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Vahedian-Azimi A, Hassan IF, Rahimi-Bashar F, Elmelliti H, Akbar A, Shehata AL, Ibrahim AS, Ait Hssain A. What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study. Int J Emerg Med 2024; 17:56. [PMID: 38632515 PMCID: PMC11022486 DOI: 10.1186/s12245-024-00608-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/22/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR. METHODS This retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests. RESULTS The mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021-3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289-4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092-3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161-0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration. CONCLUSION These findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma research center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Farshid Rahimi-Bashar
- Department of Anesthesiology and Critical Care, School of medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Anzila Akbar
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Ahmed Labib Shehata
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar.
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar.
- Medical Intensive Care Unit, ECMO team, Hamad General Hospital, Doha, Qatar.
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Vahedian-Azimi A, Hassan IF, Rahimi-Bashar F, Elmelliti H, Akbar A, Shehata AL, Ibrahim AS, Ait Hssain A. Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study. Intensive Crit Care Nurs 2024; 83:103674. [PMID: 38461711 DOI: 10.1016/j.iccn.2024.103674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest. METHODS This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed. SETTING Hamad General Hospital, Qatar. MAIN OUTCOME MEASURES Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale. RESULTS Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group. CONCLUSION This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings. IMPLICATIONS FOR CLINICAL PRACTICE The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar; Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Farshid Rahimi-Bashar
- Department of Anesthesiology and Critical Care, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran.
| | | | - Anzila Akbar
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar; Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Ahmed Labib Shehata
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar; Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar; Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar; Department of Medicine, Weill Cornell Medical College, Doha, Qatar.
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Vahedian-Azimi A, Hassan IF, Rahimi-Bashar F, Elmelliti H, Salesi M, Alqahwachi H, Albazoon F, Akbar A, Shehata AL, Ibrahim AS, Ait Hssain A. Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study. BMC Emerg Med 2024; 24:36. [PMID: 38438853 PMCID: PMC10913290 DOI: 10.1186/s12873-023-00905-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/06/2023] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO). METHODS This single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA. RESULTS The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest. CONCLUSIONS Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma research center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Farshid Rahimi-Bashar
- Department of Anesthesiology and Critical Care, School of medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Mahmood Salesi
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Fatima Albazoon
- Medical Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Anzila Akbar
- Trauma research center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ahmed Labib Shehata
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar.
- Department of Medicine, Weill Cornell Medical College, PO BOX 3050, Doha, Qatar.
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Shehatta AL, Kaddoura R, Orabi B, Ibrahim MIM, El-Menyar A, Alyafei SA, Alkhulaifi A, Ibrahim AS, Hassan IF, Omar AS. Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: A Retrospective Study from A National Center of Extracorporeal Cardiopulmonary Resuscitation. Crit Pathw Cardiol 2024:00132577-990000000-00067. [PMID: 38381697 DOI: 10.1097/hpc.0000000000000352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. METHODS A retrospective cohort study analyzing six-year data from a tertiary center, the country reference for ECPR. SETTING A national center of ECPR. PARTICIPANTS Adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. INTERVENTIONS ECPR for eligible patients as per local service protocol. RESULTS Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA), and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n=22), 19 presented with IHCA (30.6%), whilst only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (Odds Ratio 5.8, p =0.042), however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. CONCLUSION In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better under-standing and improving the outcomes.
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Affiliation(s)
- Ahmed Labib Shehatta
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Doha, Qatar; (AL); (AS) ; (IH)
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rasha Kaddoura
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (RK) ; (BO); (SA)
| | - Bassant Orabi
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (RK) ; (BO); (SA)
| | | | - Ayman El-Menyar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Department of Cardiothoracic Surgery Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (AA), (AO)
| | - Sumaya Alsaadi Alyafei
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (RK) ; (BO); (SA)
| | - Abdulaziz Alkhulaifi
- Department of Cardiothoracic Surgery Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (AA), (AO)
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Doha, Qatar; (AL); (AS) ; (IH)
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Doha, Qatar; (AL); (AS) ; (IH)
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Amr S Omar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Department of Cardiothoracic Surgery Heart Hospital, Hamad Medical Corporation, Doha, Qatar, (AA), (AO)
- Department of Critical Care Medicine, Beni Suef University, Egypt (AO)
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Eltahir M, Chaudhry H, Ibrahim EA, Mokhtar M, Jaouni H, Hassan IF, El-Menyar A, Shehatta AL. Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series. Am J Case Rep 2023; 24:e940672. [PMID: 37614021 PMCID: PMC10461322 DOI: 10.12659/ajcr.940672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/17/2023] [Accepted: 06/22/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Severe hyperthyroidism, including thyroid storm, can be precipitated by acute events, such as surgery, trauma, infection, medications, parturition, and noncompliance or stoppage of antithyroid drugs. Thyroid storm is one of the serious endocrinal emergencies that prompts early diagnosis and treatment. Early occurrence of multiorgan failure is an ominous sign that requires aggressive treatment, including the initiation of extracorporeal membrane oxygenation (ECMO) support as a bridge to stability and definitive surgical treatment. Most adverse events occur after failure of medical therapy. CASE REPORT We described 4 cases of fulminating thyroid storm that were complicated with multiple organ failure and cardiac arrest. The patients, 3 female and 1 male, were between 39 and 46 years old. All patients underwent ECMO support, with planned thyroidectomy. Three survived to discharge and 1 died after prolonged cardiac arrest and sepsis. All patients underwent peripheral, percutaneous, intensivist-led cannulation for VA-ECMO with no complications. CONCLUSIONS Early recognition of thyroid storm, identification of the cause, and proper treatment and support in the intensive care unit is essential. Patients with thyroid storm and cardiovascular collapse, who failed to improve with conventional supportive measures, had the worst prognosis, and ECMO support should be considered as a bridge until the effective therapy takes effect. Our case series showed that, in patients with life-threatening thyroid storm, VA-ECMO can be used as bridge to stabilization, definitive surgical intervention, and postoperative endocrine management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial in patients with thyroid storm after failure of conventional management.
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Affiliation(s)
- Mugahid Eltahir
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hamza Chaudhry
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ezzeddin Abdulsalam Ibrahim
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Marwa Mokhtar
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hani Jaouni
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Labib Shehatta
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
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Cvetkovic M, Antonini MV, Rosenberg A, Meadows CI, Dąbrowski M, Puslecki M, Fawzy Hassan I, Fowles JA, O'Callaghan M, Stefaniak S, Riera J, Barrett NA, Bělohlávek J, Di Nardo M, Hoskote A, Swol J. "Bridging the Gap" international ECLS training and simulation - evaluation of the 10th educational corner on EuroELSO congress 2022 in London, United Kingdom. Perfusion 2023; 38:3-12. [PMID: 37078917 DOI: 10.1177/02676591231157273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Introduction: Simulation training offers an authentic team-based learning opportunity without risk to real patients. The Educational Corner at the annual congress of the European Branch of Extracorporeal Life Support Organisation (EuroELSO) provided an opportunity for multiple simulation training sessions facilitated by experts from all over the world.Aim: We aimed to review the educational impact of EuroELSO Educational Corner and whether it provides a quality ECLS training to a wide spectrum of multidisciplinary international attendees utilising high and low fidelity simulation, workshops and hands on sessions.Methods: During the congress, 43 sessions were conducted dedicated to ECLS education with identified educational objectives. The sessions focused on management of adults and children on V-V or V-A ECMO. Adult sessions covered emergencies on mechanical circulatory support with management of LVAD and Impella, managing refractory hypoxemia on V-V ECMO, emergencies on ECMO, renal replacement therapy on ECMO, V-V ECMO, ECPR cannulation and performing perfect simulation. Paediatric sessions covered ECPR neck and central cannulation, renal replacement on ECMO, troubleshooting, cannulation workshop, V-V recirculation, ECMO for single ventricle, PIMS-TS and CDH, ECMO transport and neurological injury.Results: The Educational Corner was attended by more than 400 participants over the two congress days. Majority of responders (88%) reported that training sessions met the set educational goals and objectives and that this would change their current practice. Almost all (94%) reported that they received useful information and 95% would recommend the session to their colleagues.Conclusion: The Educational Corner, as an integral component of the annual EuroELSO congress, achieved the set educational goals and provided quality education based on the recipient survey. Structured multidisciplinary ECLS education with standardised curriculum and feedback is an important key step in delivering quality training to an international audience. Standardisation of European ECLS education remains an important focus of the EuroELSO.
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Affiliation(s)
- Mirjana Cvetkovic
- Heart and Lung Division, Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marta V Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Alex Rosenberg
- Intensive Care Unit, Royal Brompton and Harefield Hospitals, Part of Guys and St Thomas's NHS Foundation Trust, Harefield, UK
| | - Christopher Is Meadows
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Marek Dąbrowski
- Katedra i Zakład Edukacji Medycznej, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu, Poznań, Poland
- Chair and Department of Medical Education, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puslecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Ibrahim Fawzy Hassan
- Clinical Medicine, Weill Cornell Medical College, New York, NY, USA
- ECMO Program Director, Hamad Medical Corporation, Doha, Qatar
| | - Jo-Anne Fowles
- Intensive Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Maura O'Callaghan
- Heart and Lung Division, Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jordi Riera
- Critical Care Department, Vall d´Hebron University Hospital; SODIR, Vall d´Hebron Research Institute, Barcelona, Spain
| | - Nicholas A Barrett
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Jan Bělohlávek
- Second Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, IRCCS, Children's Hospital Bambino Gesù, Rome, Italy
| | - Aparna Hoskote
- Heart and Lung Division, Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University Nuremberg, Germany
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Di Nardo M, MacLaren G, Schellongowski P, Azoulay E, DeZern AE, Gutierrez C, Antonelli M, Antonini MV, Beutel G, Combes A, Diaz R, Fawzy Hassan I, Fowles JA, Jeong IS, Kochanek M, Liebregts T, Lueck C, Moody K, Moore JA, Munshi L, Paden M, Pène F, Puxty K, Schmidt M, Staudacher D, Staudinger T, Stemmler J, Stephens RS, Vande Vusse L, Wohlfarth P, Lorusso R, Amodeo A, Mahadeo KM, Brodie D. Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement. Lancet Respir Med 2023; 11:477-492. [PMID: 36924784 DOI: 10.1016/s2213-2600(22)00535-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 03/16/2023]
Abstract
Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Paediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Peter Schellongowski
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, University of Paris, Paris, France
| | - Amy E DeZern
- Division of Hematologic Malignancies, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Cristina Gutierrez
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Marta V Antonini
- Anaesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Jo-Anne Fowles
- Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology, Aachen-Bonn-Cologne-Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Catherina Lueck
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karen Moody
- Division of Pediatrics, Palliative and Supportive Care Section, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica A Moore
- Section of Integrated Ethics in Cancer Care, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matthew Paden
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre & Université Paris Cité, Paris, France
| | - Kathryn Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Dawid Staudacher
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Joachim Stemmler
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Vande Vusse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Philipp Wohlfarth
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Antonio Amodeo
- Cardiac Surgery Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kris M Mahadeo
- Pediatric Transplant and Cellular Therapy, Duke University, Durham, NC, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MA, USA
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Iqbal P, Bilal Jamshaid M, Shahzad A, Yousaf Z, Nabavi Monfared S, Sadik ND, Fawzy Hassan I. Enigma of categorizing COVID-19-related lung parenchymal diseases and management experience with follow-up outcomes in Qatar: a case series. Qatar Med J 2022; 2022:2. [PMID: 35251950 PMCID: PMC8855675 DOI: 10.5339/qmj.2022.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/24/2022] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has become one of the worst global pandemics in recent history. Post-COVID-19 interstitial lung disease is a significant concern in COVID-19 survivors. It is a disabling clinical condition for patients and a burden on the healthcare system. With time and subsequent waves of COVID-19 globally, the post-COVID-19 sequelae of lung diseases can be debilitating. We report cases of three patients with persistent hypoxia post-COVID-19, raising concerns for interstitial lung disease in Qatar. In this report, we shared our experience of the patient's clinical course, complications, and outcomes with post-COVID-19 sequelae of lung parenchymal disease. Patients were followed up during and after treatment until recovery or discharge from the hospital.
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Affiliation(s)
- Phool Iqbal
- Critical Care Department, Hamad Medical Corporation, Doha, Qatar
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar E-mail:
| | | | | | - Zohaib Yousaf
- Dresden International University, Dresden, DEU, Germany
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar E-mail:
| | - Saba Nabavi Monfared
- Trauma & Emergency Clinical Pharmacist Department, Hamad Medical Corporation, Doha, Qatar
| | - Nagham D. Sadik
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar E-mail:
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9
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Hassan IF, Alinier G. The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue - An important milestone. Qatar Med J 2019; 2019:1. [PMID: 31763204 PMCID: PMC6851948 DOI: 10.5339/qmj.2019.qccc.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 11/03/2022] Open
Abstract
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Dr. Ibrahim Fawzy Hassan Local Host and QCCC 2019 Conference Chair Dear Friends and Colleagues, It is an honour to welcome everyone to the first Qatar Critical Care Conference (QCCC). It has been a long journey to make it happen, but this event has been much awaited by the local critical care community. Over the last few years, we have hosted a number of related events of various scales, ranging from Critical Care Grand Rounds targeting Hamad Medical Corporation (HMC) critical care clinicians, ran specialised courses, through to organising an international medical conference on extracorporeal life support in 2017.1 This inaugural QCCC event is the fruit of much planning and collaboration. The programme spans from 28th to 31st October 2019 and consists of two days of pre-conference workshops and two days for the main conference. The vast majority of the pre-conference workshops will be held in the state-of-the-art ITQAN Clinical Simulation and Innovation Centre located within Hamad bin Khalifa Medical City. Although the facility is yet to be offically inaugurated and opened, we have the privilege to have been granted access to it as a way of showcasing our forthcoming continuing professional development capability. “Itqan” in Arabic means quality and striving for perfection, which is very much in line with the mission of our established Critical Care Network (CCNW).2 Simulation-based education is an area in which we have started to be very active through various immersive courses as well as innovative technological developments to train our extracorporeal membrane oxygenation (ECMO) specialists.3,4 The scientific part of the conference will be hosted in the iconic Sheraton Grand Doha Resort & Convention Hotel in the West Bay area. It includes a varied selection of topics presented by many renowned experts in their respective domain. This comprehensive programme with a line-up of lectures and workshops addressing e-CPR, ECMO simulation, ECMO cannulation, hemodynamics and so much more will facilitate the exchange of knowledge and experiences to improve patient care in Qatar and beyond. We anticipate that the programme will appeal to a broad audience and hence will bring together clinicians from all professions involved with caring for acutely ill patients. It is QCCC's aim to connect and explore new insights and expertise at a national and international level through networking with other professionals in a multidisciplinary setting. We hope that during this event many fruitful discussions will take place and that it will enhance opportunities for collaboration to develop everyone's practice in critical care. The HMC Critical Care family has a capacity of 163 and 109 intensive care unit (UCI) beds, respectively for adult and paediatric patients, across 7 hospitals spread throughout Qatar. These numbers are complemented by another 52 adult and paediatric beds from non-HMC hospitals. This gives us a national ICU bed capacity of 11.8 per 100,000 inhabitants considering a current population of nearly 2,750,000 inhabitants.5 Although this number remains below the international benchmark which can be considered to be around 15/100,000 population,6 this quota in Qatar has more than quadrupled over the last ten years, which represents a very significant improvement in the care that can be provided to acutely ill patients. Within HMC only, it is supported by a workforce of 159 intensive care physicians, 1122 intensive care nurses, and many other clinical staff, all of whom undergo a well regulated programme of continuing professional development and are licensed to practise by the Qatar Council for Healthcare Practitioners (QCHP).7 The work they do across the various sites is coordinated and monitored by the CCNW2 who ensures the best level of care, up-to-date technology, and evidence-based practices are consistently adopted for the wellbeing of our patients. Once again, on behalf of the Scientific and Organizing Committees, it is my pleasure to welcome you all to Doha and we hope that you enjoy and gain meaningful insights during the conference regarding our local critical care setting and practices, but also learn from the experiences and best practices shared by our international guest speakers. ![]()
Prof. Guillaume Alinier Guest Managing Editor, Qatar Medical Journal QCCC Special Issue and Abstracts Chair of the QCCC Scientific Committee. Dear Contributors and Conferences Delegates, Welcome to this special issue of the Qatar Medical Journal (QMJ) which has been dedicated to the inaugural conference of the Hamad Medical Corporation (HMC) Qatar Critical Care Network (QCCN) which celebrates its fifth anniversary in 2019. I would like to start by thanking everyone who has supported this arduous publication endeavour through their extended abstract submission(s) and the reviewers for the valuable feedback they have provided to the authors to ensure this publication is a representative legacy of the calibre of this conference which includes many local and international experts in their respective field of practice or interest. All the accepted abstracts are being published Open Access thanks to the support of the conference sponsors and this contributes greatly to the sharing of experiences and best practices worldwide, but also showcases the good work that is being done in Qatar in the domain of critical care thanks to the work of dedicated clinicians and the leadership of the CCNW.2 Being the Guest Managing Editor of the special issue of a journal is an honour but also an arduous task, especially when a large number of submissions from international authors needs to be handled. It is the second time that I have accepted to take on that role for Qatar Medical Journal as the previous time was in 2017 on the occasion of hosting the South West Asia and African Chapter (SWAAC) of the Extracorporeal Life Support Organisation (ELSO) in Doha.1 This was only a couple of years after HMC had established its Extracorporeal Membrane Oxygenation (ECMO) programme, and it was a very successful event with many of its associated open access publications having been downloaded hundreds of times from the QScience.com publishing platform. Working on this new Special Issue really made me reflect on how the domain of critical care is vast and encompasses so many aspects of patient care and so many professions and specialties. The topics of the abstracts published in this special issue of QMJ cover dietetics,8 sepsis,9 delirium,10,11 physical therapy,12 end of life care and organ donation,13,14 dealing with families,15 as well as education and training of clinicians,16,17 to only highlight a few. Critical care is fast moving as new clinical practices and technological innovations are adopted and contribute to continuously improving patient care. This is especially true in Qatar where significant investments are constantly made to develop and support healthcare in a strategic way.18 At HMC, the critical care phase that some patients have to go through so their medical needs can be met is well integrated across all stakeholder departments that can possibly be involved.2 The patient's journey through the healthcare system can be seen as a continuum of care facilitated by the fact that all parties involved belong to the same overarching organisation, HMC, which is the government funded main provider of secondary and tertiary healthcare in Qatar. This means that from initial contact with the Ambulance Service bringing a patient to the Emergency Department for example, right through to rehabilitation and even possible access upon discharge to a mobile healthcare service supported by family physicians, nurses, and paramedics, patients can expect the same high standards of care.19 Critical care provision relies on multidisciplinary communication during transition of care as well as during any acute episode. This needs to be underpinned by medical knowledge and understanding of the potential contributions of other professions as nothing can be left to chance when a patient's life is hanging by a thread. The present collection of editorials and abstracts brings different perspectives on a broad range of topics which should be highly relevant to all clinicians involved with critical care and contribute to improving patient outcome and satisfaction, and hence that of the multidisciplinary team members also involved in caring for them. We hope that the Qatar Medical Journal Special Issue publications on critical care meets your needs and expectations. The complete record of QCCC publications including additional open access abstracts and editorials relating to this conference will be made available in Qatar Medical Journal at the following link: https://www.qscience.com/content/journals/qmj. Thanks again to everyone for your contributions, and beyond our email communications, I now hope to meet you in person during the conference!
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Affiliation(s)
- Ibrahim Fawzy Hassan
- Director of Corporate Critical Care Centre, and Director of Critical Care ECMO programme at Hamad Medical Corporation (HMC), Doha, Qatar; Deputy Medical Director of HMC Ambulance Service, Doha, Qatar; Assistant Professor at Weill Cornell Medicine Qatar, Doha, Qatar
| | - Guillaume Alinier
- Director of Research, HMC Ambulance Service, Doha, Qatar; Professor of Simulation in Healthcare Education at the University of Hertfordshire, Hatfield, UK; Adjunct Professor of Education in Medicine at Weill Cornell Medicine Qatar, Doha, Qatar; Visiting Fellow at Northumbria University, Newcastle upon Tyne, UK
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Abstract
Critical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.1 The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.2 It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.3 Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand. Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision – namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system. The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.4 For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC. As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.5 It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.6 This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients. The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas: 1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards. 2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required. 3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects. 4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers. 5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients. 6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment4 of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.7 The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various international accreditation awards by prestigious organisations and professional bodies.
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Affiliation(s)
- Majed Hijjeh
- Corporate Nursing and Midwifery, Hamad Medical Corporation, Doha, Qatar
| | - Loua Al Shaikh
- Hamad Medical Corporation Ambulance Service, Doha, Qatar
| | | | - David Selwood
- Hamad General Hospital Administration, Hamad Medical Corporation, Doha, Qatar
| | - Faisal Malmstrom
- Department of Anaesthesia, ICU and Perioperative Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Weill Cornell Medicine Qatar, Doha, Qatar.,Corporate Critical Care Centre, Hamad Medical Corporation, Doha, Qatar
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Ibrahim AS, Akkari ARM, Raza T, Hassan IF, Akbar A, Alatoum I. Epidemiological and Clinical Profiles of Patients with Acute Respiratory Distress Syndrome Admitted to Medical Intensive Care in Qatar: A Retrospective Analysis of the Data Registry for the Year 2015. Qatar Med J 2019; 2019:3. [PMID: 31384572 PMCID: PMC6664154 DOI: 10.5339/qmj.2019.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/22/2019] [Indexed: 02/02/2023] Open
Abstract
Background: Although acute respiratory distress syndrome (ARDS) is a common reason for admission to intensive care units, limited information is available about the epidemiological and clinical characteristics of these patients in Middle Eastern countries. Qatar is a high per capita income country with a large multinational expatriate population. Hamad General Hospital is our main tertiary referral center with the largest medical intensive care unit (MICU). Method: A retrospective cross-sectional study was conducted to extract data from the MICU registry for 101 patients aged >14 years who were admitted with ARDS from January 2015 to December 2015. Results: In 2015, a total of 101 (14.8%) of 682 patients admitted to MICU were diagnosed with ARDS. Males comprised 71.3% and females 28.7%. The mean age of the study population was 44.96 ± 17.97 years. Community-acquired bacterial and viral pneumonia were the most common reasons for ARDS. Crude mortality rate was 35%. The mean age of survivors was 42.09 ± 13.58 years compared with 50.36 ± 16.84 years of non-survivors (p = 0.008). Mortality was associated with increasing age, the Acute Physiologic Assessment and Chronic Health Evaluation II severity score, lower P/F ratio, higher Murray's score, higher PCO2, lower pH, and circulatory support with vasopressors. Preexisting comorbidities did not contribute to high mortality. No difference in mortality was noted with higher versus lower positive end expiratory pressure. The prone position was used in 8% of the cases. Twenty-seven (27%) patients had undergone salvage therapy with extracorporeal membrane oxygenation (ECMO) that resulted in a survival rate of 44%. ARDS was associated with acute renal failure requiring dialysis in 28.7% of the cases, pneumothoraces in 4%, ventilator-associated pneumonia in 7.9%, and central line-associated bloodstream infection in 2%. ARDS led to a prolonged length of stay compared with the average length of stay in MICU. Conclusion: Community-acquired bacterial and viral pneumonia were the most common causes of ARDS at our center. Critical care outcome correlated with the severity of the disease. ECMO was used as salvage therapy in our center.
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Affiliation(s)
- Abdulsalam Saif Ibrahim
- Division of Medicine Critical Care, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar
| | | | - Tasleem Raza
- Division of Medicine Critical Care, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar
| | - Ibrahim Fawzy Hassan
- Division of Medicine Critical Care, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar
| | - Anzila Akbar
- Division of Medicine Critical Care, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar
| | - Ibrahim Alatoum
- Division of Medicine Critical Care, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar
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Alinier G, Hassan IF, Alsalemi A, Al Disi M, Ait Hssain A, Labib A, Alhomsi Y, Bensaali F, Amira A, Ibrahim AS. Addressing the challenges of ECMO simulation. Perfusion 2018; 33:568-576. [PMID: 29790824 DOI: 10.1177/0267659118777194] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION/AIM The patient's condition and high-risk nature of extracorporeal membrane oxygenation (ECMO) therapy force clinical services to ensure clinicians are properly trained and always ready to deal effectively with critical situations. Simulation-based education (SBE), from the simplest approaches to the most immersive modalities, helps promote optimum individual and team performance. The risks of SBE are negative learning, inauthenticity in learning and over-reliance on the participants' suspension of disbelief. This is especially relevant to ECMO SBE as circuit/patient interactions are difficult to fully simulate without confusing circuit alterations. METHODS Our efforts concentrate on making ECMO simulation easier and more realistic in order to reduce the current gap there is between SBE and real ECMO patient care. Issues to be overcome include controlling the circuit pressures, system failures, patient issues, blood colour and cost factors. Key to our developments are the hospital-university collaboration and research funding. RESULTS A prototype ECMO simulator has been developed that allows for realistic ECMO SBE. The system emulates the ECMO machine interface with remotely controllable pressure parameters, haemorrhaging, line chattering, air bubble noise and simulated blood colour change. CONCLUSION The prototype simulator allows the simulation of common ECMO emergencies through innovative solutions that enhance the fidelity of ECMO SBE and reduce the requirement for suspension of disbelief from participants. Future developments will encompass the patient cannulation aspect.
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Affiliation(s)
- Guillaume Alinier
- 1 Department of Research, Hamad Medical Corporation Ambulance Service, Medical City, Doha, Qatar & Simulation in Healthcare Education, School of Health and Social Work, Hatfield, Herts, UK.,2 Division of Critical Care, Medicine, Hamad General Hospital, Medical Intensive Care Unit, Doha, Qatar & Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- 2 Division of Critical Care, Medicine, Hamad General Hospital, Medical Intensive Care Unit, Doha, Qatar & Weill Cornell Medicine - Qatar, Doha, Qatar.,3 Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Abdullah Alsalemi
- 4 Department of Electrical Engineering, Qatar University, Doha, Qatar
| | - Mohammed Al Disi
- 4 Department of Electrical Engineering, Qatar University, Doha, Qatar
| | - Ali Ait Hssain
- 5 Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
| | - Ahmed Labib
- 3 Weill Cornell Medicine - Qatar, Doha, Qatar.,5 Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
| | - Yahya Alhomsi
- 4 Department of Electrical Engineering, Qatar University, Doha, Qatar
| | - Fayçal Bensaali
- 4 Department of Electrical Engineering, Qatar University, Doha, Qatar
| | - Abbes Amira
- 6 Department of Computer Engineering, Qatar University, Doha, Qatar
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Ali HS, Hassan IF, George S, Fadlelmula AE. Hypercapnic respiratory failure during pregnancy due to polymyositis-related respiratory muscle weakness: a case report. J Med Case Rep 2017; 11:203. [PMID: 28743311 PMCID: PMC5527389 DOI: 10.1186/s13256-017-1368-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 06/27/2017] [Indexed: 12/04/2022] Open
Abstract
Background Polymyositis is a rare medical disorder complicating pregnancy. Ventilatory muscle weakness leading to respiratory failure is an uncommon manifestation of this autoimmune disease. We report a case of life-threatening hypercapnic respiratory failure due to polymyositis-related respiratory muscle weakness in a pregnant woman. Case presentation A 31-year-old, African woman in her second trimester of pregnancy presented to the emergency department with fever, shortness of breath and muscle weakness. Initial investigations excluded pulmonary infection, thromboembolism, and cardiac dysfunction as the underlying cause of her symptoms. She developed deterioration in her level of consciousness due to carbon dioxide narcosis requiring invasive mechanical ventilation. Further workup revealed markedly elevated serum creatine kinase, abnormal electromyography and edema of her thigh muscles on magnetic resonance imaging. Diagnosis of polymyositis was confirmed by muscle biopsy. After receiving pulse steroid, intravenous immunoglobulins, and maintenance immunosuppressive therapy, our patient’s respiratory muscle function improved and she was weaned off mechanical ventilation. Despite good maternal recovery from critical illness, the fetus developed intrauterine growth retardation and distress necessitating emergency cesarian section. Conclusions New-onset polymyositis during pregnancy presenting with respiratory failure is rare. Early diagnosis and prompt initiation of therapy is necessary to improve fetal and maternal outcomes.
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Affiliation(s)
- Husain Shabbir Ali
- Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, Qatar.
| | | | - Saibu George
- Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, Qatar
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15
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Hassan IF. Acute respiratory failure: From intubation to ECMO. Qatar Med J 2017. [PMCID: PMC5474581 DOI: 10.5339/qmj.2017.swacelso.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Alinier G, Campbell C, Labib A, Mehta T, Hssain AA, Almomani EAH, Hassan IF. Qatar welcomes the Extracorporeal Life Support Organisation of the South and West Asia Chapter 2017 Conference. Qatar Med J 2017. [PMCID: PMC5474569 DOI: 10.5339/qmj.2017.swacelso.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Guillaume Alinier
- 1Hamad Medical Corporation Ambulance Service (HMCAS), PO Box 3050, Doha, Qatar. http://as.hamad.qa
- 2University of Hertfordshire, College Lane Campus, Hatfield, Hertfordshire AL10 9AB, UK. www.herts.ac.uk
- 3Northumbria University, Coach Lane Campus, Newcastle upon Tyne, NE7 7XA, UK. www.northumbria.ac.uk
| | - Craig Campbell
- 4School of Medicine, Discipline of Paramedicine, University of Tasmania, Rozelle Campus, Sydney, New South Wales 2015, Australia. www.utas.edu.au/health (Previously HMCAS)
| | - Ahmed Labib
- 5Medical Intensive Care Unit, Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar. www.hamad.qa
| | - Tejas Mehta
- 6Pediatric Intensive Care Unit, Department of Pediatrics, Hamad Medical Corporation, PO Box 3050, Doha, Qatar. www.hamad.qa
| | - Ali Ait Hssain
- 5Medical Intensive Care Unit, Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar. www.hamad.qa
| | - Emad Ali Hamad Almomani
- 7Nursing Education and Research Department, Hamad Medical Corporation, PO Box 3050, Doha, Qatar. www.hamad.qa
| | - Ibrahim Fawzy Hassan
- 1Hamad Medical Corporation Ambulance Service (HMCAS), PO Box 3050, Doha, Qatar. http://as.hamad.qa
- 5Medical Intensive Care Unit, Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar. www.hamad.qa
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Abdelaty M, Hassan IF, Abdussalam ALM, Ibrahim AS. ECMO for a polytrauma patient without systemic anticoagulation. Qatar Med J 2017. [PMCID: PMC5474638 DOI: 10.5339/qmj.2017.swacelso.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Mohamed Abdelaty
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
| | - Ibrahim Fawzy Hassan
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
| | | | - Abdulsalam Saif Ibrahim
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
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Affiliation(s)
- Ibrahim Fawzy Hassan
- Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar www.hamad.qa
- Hamad Medical Corporation Ambulance Service, PO Box 3050, Doha, Qatar http://as.hamad.qa
| | - Loua Al Shaikh
- Hamad Medical Corporation Ambulance Service, PO Box 3050, Doha, Qatar http://as.hamad.qa
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Shabbir Ali H, Hassan IF, George S. Extracorporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe pneumocystis pneumonia with pneumomediastinum. Journal of Emergency Medicine, Trauma and Acute Care 2016. [DOI: 10.5339/jemtac.2016.icepq.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Pulmonary infections caused by Pneumocystis in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraces. In such cases, it can be challenging to maintain adequate gas exchange by mechanical ventilation and at the same time prevent further barotrauma or ventilator-induced lung injury (VILI). We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis jirovecii infection, rescued with veno-venous extracorporeal membrane oxygenation (V-V ECMO).
Case: A 26-year-old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation to reduce work of breathing. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients’ pulmonary parameters worsened and he developed severe type 2 respiratory failure necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-lung protective ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus (HIV) infection. Patient was successfully treated with appropriate antibiotics and de-cannulated after six days of ECMO support.
Conclusion: ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia.
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Affiliation(s)
| | | | - Saibu George
- Medical ICU, Hamad General Hospital, Doha, Qatar
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Ali HS, Hassan IF, George S. Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review. BMC Pulm Med 2016; 16:52. [PMID: 27080997 PMCID: PMC4832462 DOI: 10.1186/s12890-016-0214-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 04/04/2016] [Indexed: 12/02/2022] Open
Abstract
Background Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). Case presentation A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients’ pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. Conclusion ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.
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Affiliation(s)
- Husain Shabbir Ali
- Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar.
| | - Ibrahim Fawzy Hassan
- Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar
| | - Saibu George
- Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar
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Abstract
A hamster model has been developed for studying desferrioxamine. The hamster shows many similarities to man in terms of plasma stability and metabolites formed from desferrioxamine. The [59Fe]ferritin derived from rats has been shown to be sequestered into liver parenchymal cells when injected intravenously into hamsters. The technique has proved sufficiently sensitive to enable detection of differences of < 1% of the radioactivity administered in the elimination of iron. Alterations in iron excretion were seen when dosing desferrioxamine via different routes. The principal route of iron excretion was into the intestines. The effectiveness of the dosing routes for desferrioxamine in removing iron were subcutaneous (10.5%) > intravenous (6.25%) > oral (3.66%) > control (2.19%). A dose-response relationship was demonstrated using the intravenous dose route. The model offers a simple method for comparing the efficacy of administration routes for determining the optimal use of desferrioxamine.
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Affiliation(s)
- A Steward
- Department of Drug Discovery, Ciba Pharmaceuticals, Horsham, West Sussex
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Nicklin PL, Irwin WJ, Hassan IF, Mackay M, Dixon HB. The transport of acidic amino acids and their analogues across monolayers of human intestinal absorptive (Caco-2) cells in vitro. Biochim Biophys Acta 1995; 1269:176-86. [PMID: 7488651 DOI: 10.1016/0167-4889(95)00118-c] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The X-AG system, a sodium-dependent, acidic amino-acid transport system has been implicated in the transport of L-aspartate and L-glutamate across monolayers of human Caco-2 cells, an in vitro model of intestinal absorption. This system, which shares many properties with the L-glutamate carrier present in the human jejunum, is highly saturable (> 95% at 50 microM), vectorial (apical-to-basolateral >> basolateral-to-apical) and sodium-, pH- and temperature-dependent. L-Aspartate was also transported against a 10-fold reverse concentration gradient. These data are consistent with a major (saturable) carrier-mediated pathway superimposed onto a minor non-saturable (diffusional) pathway. The carrier has an absolute sodium-dependence and the Michaelis constants for the sodium-dependent transport component (Km) for L-aspartate and L-glutamate were 56 +/- 3 microM and 65 +/- 6 microM, respectively. Cross-inhibition studies showed that strong interaction with the carrier was limited to close analogues of the natural substrates. Potent inhibitors included L-aspartate, D-aspartate (Ki, 70 microM), L-glutamate (Ki 180 microM) and threo-beta-hydroxy-DL-aspartate (Ki, 55 microM), while partial inhibitors included alpha-methyl-DL-aspartate, D-glutamate, L-asparagine, L-proline and L-alanine. Replacement of the side-chain -COO- group (aspartate) with -SO-3 (L-cysteate, Ki, 65 microM) or -(H)P(O)O- (DL-3-(hydroxyphosphoryl)alanine, Ki, 60 microM) maintained strong interaction with the carrier while -As(O)(OH)O- (DL-3-arsonoalanine, Ki, 1100 microM) and -P(O)(OH)O- (DL-3-phosphonoalanine, Ki, 3270 microM) were much more weakly bound, with the larger, but probably less ionised, arsono analogue being more tightly bound than the phosphono compound. The corresponding analogues of glutamate (homologous extension of the methylene chain) showed negligible interaction. We conclude that Caco-2 monolayers are a relevant experimental model for the study of the transport of acidic amino acids and their analogues in man.
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Affiliation(s)
- P L Nicklin
- Pharmaceutical Sciences Institute, Aston University, Aston Triangle, Birmingham, UK
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23
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Nicklin PL, Irwin WJ, Hassan IF, Mackay M. Proline uptake by monolayers of human intestinal absorptive (Caco-2) cells in vitro. Biochim Biophys Acta 1992; 1104:283-92. [PMID: 1547265 DOI: 10.1016/0005-2736(92)90042-k] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Monolayers of the Caco-2 human intestinal cell line exhibit active and passive uptake systems for the imino acid L-proline. The active transport component is saturable and it is responsible for about two thirds of the observed flux over the nanomolar concentration range, at 37 degrees C and pH 7.4. In contrast to L-phenylalanine, specific L-proline uptake has a high degree of sodium dependency and the efficiency of the carrier system is significantly reduced when protein synthesis (cycloheximide), Na+/K(+)-ATPase (ouabain) or cellular metabolism (sodium azide) are inhibited. The expression of the L-proline carrier by Caco-2 cells was under some degree of nutritional control. Glucose deficiency, over the time scale of the experiment, had no effect. The temperature-dependence of the specific uptake process followed the Arrhenius model with an apparent activation energy of 93.5 kJ nmol-1. This pathway also displayed Michaelis-Menten concentration-dependence with a Ksdm of 5.28 mM and a maximal transport flux (Jsdmax) of 835 pmol min-1 (10(6) cells)-1. Although the passive component was unchanged, the pH of the donor phase exerted a profound effect on the active carrier component. Within the physiological pH range a local maximum efficiency was found at pH 7.4 but dramatic increases were noted as pH 5.0 was approached. In competition studies, with 100-fold excess of a second amino acid, strong inhibition of uptake was found with alpha-aminoisobutyric acid, L-alanine and L-serine whereas moderate inhibition was observed with glycine, D-proline and gamma-aminoisobutyric acid. Aromatic and branched amino acids showed weak (L-valine) or no interaction (L-phenylalanine, L-leucine) with the carrier system. These data indicate that the carrier system for the uptake of L-proline has many features in common with the A system for amino acid transport.
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Affiliation(s)
- P L Nicklin
- Pharmaceutical Sciences Institute, Aston University, Birmingham, UK
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Abstract
Caco-2 cells grown on 0.45-micron filters, in Millicell chambers, form intact monolayers with many of the properties of polarized intestinal epithelial cells. It is reported here that these cells bind and internalize intrinsic factor-cobalamin complexes and that after 14-28 days in culture this specific binding is exclusively located on the apical membrane. Caco-2 cells also synthesize and secrete a protein with properties similar to transcobalamin II. This protein is secreted from the basolateral side of the cells after 20 days in culture. Specific apical-to-basolateral transcellular transport of [57Co]cobalamin also occurs between 20 and 28 days in culture. Thus, Caco-2 cells provide the first polarized human cell system for studying the transepithelial transport of cobalamin.
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Affiliation(s)
- C J Dix
- Advanced Drug Delivery Research Unit, Ciba-Geigy Pharmaceuticals, Horsham, West Sussex, United Kingdom
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Cushley W, Baker JR, Hassan IF, Williamson IH. On the fidelity of the lactoperoxidase method of cell membrane radioiodination: an electron microscopic autoradiographic study. J Immunol Methods 1983; 59:1-11. [PMID: 6601164 DOI: 10.1016/0022-1759(83)90139-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The radiolabelling of human peripheral blood lymphocytes by lactoperoxidase-catalysed iodination using 2 different sources of hydrogen peroxide has been compared using electron microscopic autoradiography. A method of statistical analysis of the autoradiographs has permitted precise identification of radioactive sources, in particular cellular compartments, taking into account cross-fire of Auger electrons producing silver grains in compartments other than those from which they are emitted. Our data confirm the postulates of previous investigators that the majority of radioiodine is located at the plasma membrane of cells labelled by enzymic iodination. The results further suggest that the glucose-glucose oxidase system for generation of hydrogen peroxide permits a greater degree of specific radiolabelling of plasma membrane proteins with less damage than equivalent lactoperoxidase iodination reactions promoted by exogenously added hydrogen peroxide.
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