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Wiest C, Philipp A, Foltan M, Geismann F, Schneckenpointer R, Baumgartner S, Sticht F, Hitzenbichler F, Arzt M, Fisser C, Stadlbauer A, Dienemann T, Maier LS, Lunz D, Mueller T, Lubnow M. Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO a retrospective single-center experience. PLoS One 2024; 19:e0298342. [PMID: 38557873 PMCID: PMC10984404 DOI: 10.1371/journal.pone.0298342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE In this retrospective case series, survival rates in different indications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and differential diagnoses of COVID-19 associated refractory circulatory failure are investigated. METHODS Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO. All VA-ECMO's were cannulated peripherally, using a femoro-femoral cannulation. RESULTS At VA-ECMO initiation, median age was 57 years (IQR: 51-62), SOFA score 16 (IQR: 13-17) and norepinephrine dosing 0.53μg/kg/min (IQR: 0.35-0.87). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Indications for VA-ECMO support were pulmonary embolism (PE) (n = 5, survival 80%), right heart failure due to secondary pulmonary hypertension (n = 5, survival 20%), cardiac arrest (n = 4, survival 25%), acute heart failure (AHF) (n = 10, survival 40%) and refractory vasoplegia (n = 4, survival 0%). Among the patients with AHF, 4 patients suffered from COVID-19 associated heart failure (CovHF) (survival 100%) and 6 patients from sepsis associated heart failure (SHF) (survival 0%). Main Complications were acute kidney injury (AKI) 93%, renal replacement therapy was needed in 79%, intracranial hemorrhage occurred in 18%. Overall survival to hospital discharge was 39%. CONCLUSION Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decision making. A subgroup of patients suffers from acute heart failure due to inflammation, which has to be differentiated into septic or COVID-19 associated. Novel biomarkers are required to ensure reliable differentiation between these entities; a candidate might be soluble interleukin 2 receptor.
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Affiliation(s)
- Clemens Wiest
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Center for Pneumonology, Donaustauf Hospital, Donaustauf, Germany
| | | | - Simon Baumgartner
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Sticht
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Michael Arzt
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Lars Siegfried Maier
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Mueller
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department for Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Gerhardinger F, Fisser C, Malfertheiner MV, Philipp A, Foltan M, Zeman F, Stadlbauer A, Wiest C, Lunz D, Müller T, Lubnow M. Prevalence and Risk Factors for Weaning Failure From Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Insufficiency. Crit Care Med 2024; 52:54-67. [PMID: 37665263 DOI: 10.1097/ccm.0000000000006041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency. DESIGN Single-center retrospective observational study. SETTING Sixteen beds medical ICU at the University Hospital Regensburg. PATIENTS Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials. CONCLUSIONS Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure.
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Affiliation(s)
- Felix Gerhardinger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Wiest C, Müller T, Lubnow M, Fisser C, Philipp A, Foltan M, Schneckenpointner R, Malfertheiner MV. Intracranial hemorrhage in a large cohort of patients supported with veno-venous ECMO. A retrospective single-center analysis. Perfusion 2023:2676591231213514. [PMID: 37948845 DOI: 10.1177/02676591231213514] [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] [Indexed: 11/12/2023]
Abstract
BACKGROUND Intracranial bleeding (ICB) is a serious complication during veno-venous extracorporeal membrane oxygenation (V-V ECMO), with potentially fatal consequences. PURPOSE This study aimed to evaluate the incidence, time of detection of ICB among patients treated with V-V ECMO and potential risk factors for developing ICB during V-V ECMO. METHODS Five hundred fifty six patients were included in this retrospective single center analysis. RESULTS Median time on V-V ECMO was 9 (IQR 6-15) days. Intracranial bleeding during V-V ECMO was detected in 10.9% of all patients (61 patients with ICB). Only 17 patients with ICB presented obvious clinical symptoms. Intracranial bleeding was detected on cerebral imaging in median after 5 days (IQR 1-14) after starting V-V ECMO. Overall survival to hospital discharge was 63.7% (ICB: 29.5%). Risk factors of ICB before starting V-V ECMO in univariable analysis were platelets <100/nl (OR: 3.82), creatinine >1.5mg/dl (OR: 1.98), norepinephrine >2.5mg/h (OR: 2.5), ASAT >80U/L (OR: 1.86), blood-urea >100mg/dl (OR: 1.81) and LDH >550u/L (OR: 2.07). Factors associated with cannulation were rapid decrease in paCO2 >35mmHg (OR: 2.56) and rapid decrease in norepinephrine >1mg/h (OR: 2.53). Multivariable analysis revealed low platelets, high paCO2 before ECMO, and rapid drop in paCO2 after V-V ECMO initiation as significant risk factors for ICB. CONCLUSION The results emphasize that ICB is a frequent complication during V-V ECMO. Many bleedings were incidental findings, therefore screening for ICB is advisable. The univariate risk factors reflect the underlying disease severity, coagulation disorders and peri-cannulation factors, and may help to identify patients at risk.
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Affiliation(s)
- Clemens Wiest
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Roland Schneckenpointner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maximilian V Malfertheiner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
- Clinic of Pneumonology Donaustauf, Donaustauf, Germany
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Deinzer J, Philipp A, Kmiec L, Li J, Wiesner S, Blecha S, Petermichl W, Lubnow M, Camboni D, Schmid C, Stadlbauer A. Mortality on extracorporeal membrane oxygenation: Evaluation of independent risk factors and causes of death during venoarterial and venovenous support. Perfusion 2023:2676591231212997. [PMID: 37933793 DOI: 10.1177/02676591231212997] [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] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Most patients on extracorporeal membrane oxygenation (ECMO) decease during therapy on the system. However, the actual causes of death have not been studied sufficiently. This study analyses the etiology, prevalence, and risk factors for the outcome variable death during ongoing ECMO for all patients and divided according to venoarterial (VA) or venovenous (VV) support. METHODS We retrospectively analysed all patients receiving ECMO support at our institution between March 2006 to January 2021. Only the patients deceased during ongoing support were included. RESULTS 2016 patients were placed on VA (n = 1168; 58%) or VV (n = 848; 42%) ECMO; 759 patients (37.7%) deceased on support. The causes of death differed between the support types: VA ECMO patients mostly died from cerebral ischemia (34%), low-cardiac output (LCO; 24.1%) and multi-organ failure (MOF; 21.6%), whereas in VV ECMO cases, refractory respiratory failure (28.2%), and sepsis (20.4%) dominated. Multivariate regression analysis revealed cardiopulmonary resuscitation (CPR) and acidosis prior to ECMO as risk factors for dying on VA ECMO, while high inotropic doses pre-ECMO, a high fraction of inspired oxygen on day 1, elevated lactate dehydrogenase, and international normalized ratio levels lead to an unfavourable outcome in VV ECMO patients. CONCLUSION Even in highly experienced centers, ECMO mortality remains high and occurs mainly on support or 24 h after its termination. The causes of death differ between VV and VA ECMO, depending on the underlying diseases responsible for the need of extracorporeal support.
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Affiliation(s)
- Johannes Deinzer
- Department of Internal Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Lukasz Kmiec
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Sigrid Wiesner
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Walter Petermichl
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Lingel MP, Haus M, Paschke L, Foltan M, Lubnow M, Gruber M, Krenkel L, Lehle K. Clinical relevance of cell-free DNA during venovenous extracorporeal membrane oxygenation. Artif Organs 2023; 47:1720-1731. [PMID: 37525949 DOI: 10.1111/aor.14616] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Thrombosis remains a critical complication during venovenous extracorporeal membrane oxygenation (VV ECMO). The involvement of neutrophil extracellular traps (NETs) in thrombogenesis has to be discussed. The aim was to verify NETs in the form of cell-free DNA (cfDNA) in the plasma of patients during ECMO. METHODS A fluorescent DNA-binding dye (QuantifFluor®, Promega) was used to detect cell-free DNA in plasma samples. cfDNA concentrations from volunteers (n = 21) and patients (n = 9) were compared and correlated with clinical/technical data before/during support, ECMO end and time of a system exchange. RESULTS Before ECMO, patients with a median (IQR) age of 59 (51/63) years, SOFA score of 11 (10/15), and ECMO run time of 9.0 (7.0/19.5) days presented significantly higher levels of cfDNA compared to volunteers (6.4 (5.8/7.9) ng/μL vs. 5.9 (5.4/6.3) ng/μL; p = 0.044). Within 2 days after ECMO start, cfDNA, inflammatory, and hemolysis parameters remained unchanged, while platelets decreased (p = 0.005). After ECMO removal at the end of therapy, cfDNA, inflammation, and coagulation data (except antithrombin III) remained unchanged. The renewal of a system resulted in known alterations in fibrinogen, d-dimers, and platelets, while cfDNA remained unchanged. CONCLUSION Detection of cfDNA in plasma of ECMO patients was not an indicator of acute and circuit-induced thrombogenesis.
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Affiliation(s)
- Maximilian P Lingel
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Moritz Haus
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Lukas Paschke
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Krenkel
- Regensburg Center of Biomedical Engineering, Ostbayerische Technische Hochschule, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
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Lubnow M, Dreier T, Schulz C, Endres T. Water-film thickness imaging based on time-multiplexed near-infrared absorption with up to 500 Hz repetition rate. Appl Opt 2023; 62:3169-3175. [PMID: 37133165 DOI: 10.1364/ao.486206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
We demonstrate high-repetition-rate imaging of the liquid-film thickness in the 50-1000 µm range resulting from impinging water droplets on a glass surface. The pixel-by-pixel ratio of line-of-sight absorption at two time-multiplexed near-infrared wavelengths at 1440 and 1353 nm was detected with a high-frame-rate InGaAs focal-plane array camera. Frame rates of 1 kHz and thus measurement rates of 500 Hz could be achieved, well suited to capture the fast dynamics of droplet impingement and film formation. The droplets were sprayed onto the glass surface using an atomizer. Suitable absorption wavelength bands for water droplet/film imaging were determined from Fourier-transform infrared (FTIR) spectra of pure water between 298 and 338 K. At 1440 nm, the water absorption is nearly temperature-independent, making the measurements robust against temperature fluctuations. Time-resolved imaging measurements capturing the dynamics of the water droplet impingement and evolution were successfully demonstrated.
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Blecha S, Hager A, Gross V, Seyfried T, Zeman F, Lubnow M, Burger M, Pawlik MT. Effects of Individualised High Positive End-Expiratory Pressure and Crystalloid Administration on Postoperative Pulmonary Function in Patients Undergoing Robotic-Assisted Radical Prostatectomy: A Prospective Randomised Single-Blinded Pilot Study. J Clin Med 2023; 12:jcm12041460. [PMID: 36835995 PMCID: PMC9960679 DOI: 10.3390/jcm12041460] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/03/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). The aim of the study was to evaluate whether crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and post-operative pulmonary function in patients undergoing RALP. DESIGN Prospective randomised single-centre single-blinded explorative study. SETTING Patients were either allocated to a standard PEEP (5 cmH2O) group or an individualised high PEEP group. Furthermore, each group was divided into a liberal and a restrictive crystalloid group (8 vs. 4 mL/kg/h predicted body weight). Individualised PEEP levels were determined by means of preoperative recruitment manoeuvre and PEEP titration in STP. PARTICIPANTS Informed consent was obtained from 98 patients scheduled for elective RALP. INTERVENTIONS The following intraoperative parameters were analysed in each of the four study groups: ventilation setting (peak inspiratory pressure [PIP], plateau pressure, driving pressure [Pdriv], lung compliance [LC] and mechanical power [MP]) and postoperative pulmonary function (bed-side spirometry). The spirometric parameters Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25-75) were measured pre- and post-operatively. Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A p-value of <0.05 was considered significant. RESULTS The two individualised high PEEP groups (mean PEEP 15.5 [±1.71 cmH2O]) showed intraoperative significantly higher PIP, plateau pressure and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualised high PEEP levels had a significantly higher mean Tiffeneau index and FEF25-75. Perioperative oxygenation and ventilation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two respective PEEP groups. CONCLUSIONS Individualised high PEEP levels (≥14 cmH2O) during RALP improved intraoperative blood oxygenation and resulted in more lung-protective ventilation. Furthermore, postoperative pulmonary function was improved for up to 48 h after surgery in the sum of the two individualised high PEEP groups. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and post-operative oxygenation and pulmonary function.
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
- Correspondence: ; Tel.: +49-941-944-7801; Fax: +49-941-944-7802
| | - Anna Hager
- Department of Anaesthesiology, Caritas St. Josef Medical Centre, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Verena Gross
- Department of Anaesthesiology, Caritas St. Josef Medical Centre, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Timo Seyfried
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Michael T. Pawlik
- Department of Anaesthesiology, Caritas St. Josef Medical Centre, University Medical Centre Regensburg, 93053 Regensburg, Germany
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Wiest C, Philipp A, Lunz D, Steinmann JF, Eissnert C, Kees M, Kieninger M, Dienemann T, Ritzka M, Schweinger S, Pross A, Fisser C, Malfertheiner MV, Schneckenpointner R, Lange TJ, Schulz C, Geismann F, Foltan M, Schettler F, Salzberger B, Hitzenbichler F, Hanses F, Schmidt B, Arzt M, Sinner B, Graf B, Maier LS, Müller T, Lubnow M. The Long-Term Support of COVID-19 Patients With Veno-Venous Extracorporeal Membrane Oxygenation. Dtsch Arztebl Int 2023; 120:56-57. [PMID: 36949640 DOI: 10.3238/arztebl.m2022.0354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/11/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
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Kieninger B, Kilger M, Foltan M, Gruber M, Lunz D, Dienemann T, Schmid S, Graf B, Wiest C, Lubnow M, Müller T, Salzberger B, Schneider-Brachert W, Kieninger M. Prognostic factors for favorable outcomes after veno-venous extracorporeal membrane oxygenation in critical care patients with COVID-19. PLoS One 2023; 18:e0280502. [PMID: 36662898 PMCID: PMC9858373 DOI: 10.1371/journal.pone.0280502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Patients with COVID-19 and severe acute respiratory failure may require veno-venous extracorporeal membrane oxygenation (VV ECMO). Yet, this procedure is resource-intensive and high mortality rates have been reported. Thus, predictors for identifying patients who will benefit from VV ECMO would be helpful. METHODS This retrospective study included 129 patients with COVID-19 and severe acute respiratory failure, who had received VV ECMO at the University Medical Center Regensburg, Germany, between 1 March 2020 and 31 December 2021. Patient-specific factors and relevant intensive-care parameters at the time of the decision to start VV ECMO were investigated regarding their value as predictors of patient survival. In addition, the intensive-care course of the first 10 days of VV ECMO was compared between survivors and patients who had died in the intensive care unit. RESULTS The most important parameters for predicting outcome were patient age and platelet count, which differed significantly between survivors and non-survivors (age: 52.6±8.1 vs. 57.4±10.1 years, p<0.001; platelet count before VV ECMO: 321.3±132.2 vs. 262.0±121.0 /nL, p = 0.006; average on day 10: 199.2±88.0 vs. 147.1±57.9 /nL, p = 0.002). A linear regression model derived from parameters collected before the start of VV ECMO only included age and platelet count. Patients were divided into two groups by using receiver operating characteristics (ROC) analysis: group 1: 78% of patients, mortality 26%; group 2: 22% of patients, mortality 75%. A second linear regression model included average blood pH, minimum paO2, and average pump flow on day 10 of VV ECMO in addition to age and platelet count. The ROC curve resulted in two cut-off values and thus in three groups: group 1: 25% of patients, mortality 93%; group 2: 45% of patients, mortality 31%; group 3: 30% of patients, mortality 0%.
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Affiliation(s)
- Bärbel Kieninger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Magdalena Kilger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiac, Thoracic and Cardiovascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Wulf Schneider-Brachert
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
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Dzemali O, Starck C, Wessel L, Miera O, Werdan K, Burckhardt M, Muellenbach R, Jaksties R, Schmidt F, Wiebe K, Schmid C, Kluge S, Pilarczyk K, Haake N, Schaible T, Flemmer A, Klotz S, Assmann A, Janssens U, Lubnow M, Herber-Jonat S, Ferrari M, Buchwald D, Ensminger S, Zausig Y, Beckmann A, Rosenberg M, Kelm M, Hennersdorf M, Hartog C, Fischer S, Rastan A, Zimpfer D, Frnd A, Maier S, Ruttmann-Ulmer E, Groesdonk H, Schlensak C, Nothacker M, Buerke M, Kditz H, Michels G, Krger L, Boeken U. Extracorporeal Life Support Use in Cardiac and Circulatory Failure: A Summary of Recently Published S3 Guidelines. Cardiovasc Med 2022. [DOI: 10.4414/cvm.2022.02234] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Omer Dzemali
- Municipal Hospital Triemli: Stadtspital Triemli
- Zurich
- SWITZERLAND
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Fisser C, Palmér O, Sallisalmi M, Paulus M, Foltan M, Philipp A, Malfertheiner MV, Lubnow M, Müller T, Broman LM. Corrigendum: Recirculation in single lumen cannula venovenous extracorporeal membrane oxygenation: A non-randomized bi-centric trial. Front Med (Lausanne) 2022; 9:1045207. [PMID: 36267622 PMCID: PMC9577499 DOI: 10.3389/fmed.2022.1045207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Christoph Fisser
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany,*Correspondence: Christoph Fisser
| | - Oscar Palmér
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Marko Sallisalmi
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Paulus
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Fischer S, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan AJ, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Goesdonk H, Ferrari MW, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel LM, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Ensminger S, Kelm M, Boeken U. Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“. Zentralbl Chir 2022. [DOI: 10.1055/a-1918-1999] [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: 10/14/2022]
Abstract
ZusammenfassungIn den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile
jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter
Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und
Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit
Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter
Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf
klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht
zu der Methodik und den konsentierten Empfehlungen.
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Affiliation(s)
- Stefan Fischer
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Ibbenbüren, Deutschland
| | - Alexander Assmann
- Herzchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Andreas Beckmann
- Klinik für Herz- und Gefäßchirurgie, Herzzentrum Duisburg, Duisburg, Deutschland
| | - Christof Schmid
- Klinik und Poliklinik für Herz-, Thorax- und herznahe Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Halle, Deutschland
| | - Guido Michels
- Akut- und Notfallmedizin, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Oliver Miera
- Klinik für Angeborene Herzfehler – Kinderkardiologie, Deutsches Herzzentrum Berlin, Berlin, Deutschland
| | | | - Stefan Klotz
- Herzchirurgie, Segeberger Kliniken GmbH, Bad Segeberg, Deutschland
| | - Christoph Starck
- Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin, Deutschland
| | - Kevin Pilarczyk
- Klinik für Intensivmedizin, imland Klinik Rendsburg, Rendsburg, Deutschland
| | | | - Marion Burckhardt
- Angewandte Gesundheitswissenschaften für Pflege, insbes. Pflegewissenschaften u. klinische Praxis, DHBW, Stuttgart, Deutschland
| | - Monika Nothacker
- Philipps-Universität Marburg, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften eV, Marburg, Deutschland
| | - Ralf Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Kassel GmbH, Kassel, Deutschland
| | - York Zausig
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Deutschland
| | - Nils Haake
- Klinik für Intensivmedizin, imland Klinik Rendsburg, Rendsburg, Deutschland
| | - Heinrich Goesdonk
- Klinik für Interdisz. Intensivmedizin und Intermediate Care, HELIOS Klinikum Erfurt, Erfurt, Deutschland
| | - Markus Wolfgang Ferrari
- Klinik für Innere Medizin I: Kardiologie und konservative Intensivmedizin, DKD HELIOS Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Michael Buerke
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Marien Kliniken Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Klinik für Innere Medizin I: Kardiologie, Angiologie, Pneumologie, Internistische Intensivmedizin, SLK-Kliniken Heilbronn GmbH, Heilbronn, Deutschland
| | - Mark Rosenberg
- Medizinische Klinik I, Kardiologie, Nephrologie, Pneumologie, Rhythmologie, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Deutschland
| | - Thomas Schaible
- Klinik für Neonatologie, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Harald Köditz
- Klinik für Pädiatrische Kardiologie und Pädiatrische Intensivmedizin, Medizinische Hochschule Hannover Klinikum, Hannover, Deutschland
| | - Stefan Kluge
- Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Innere Medizin und Internistische Intensivmedizin, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Matthias Lubnow
- Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Leiter der Neonatologie am Perinatalzentrum Großhadern, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Susanne Herber-Jonat
- Kinder- und Jugendmedizin, Neonatologie, Dr von Haunersches Kinderspital Kinderklinik und Kinderpoliklinik der Ludwig Maximilian Universitat Munchen, Munchen,
Deutschland
| | - Lucas M Wessel
- Zentrums für Kinder-, Jugend- und rekonstruktive Urologie, Universitätsklinikum Mannheim Klinik für Kinder- und Jugendmedizin, Mannheim, Deutschland
| | - Dirk Buchwald
- Herz- und Thoraxchirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Sven Maier
- Herz- und Gefäßchirurgie, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Deutschland
| | - Lars Krüger
- Pflegeentwicklung, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Andreas Fründ
- Physiotherapie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Rolf Jaksties
- Ehrenamtlicher Beauftragter, Deutsche Herzstiftung e.V., Frankfurt am Main, Deutschland
| | - Karsten Wiebe
- Herz-und Thoraxchirurgie, Sektion Thoraxchirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Christiane Hartog
- Versorgungsforschung, Charité Universitätsmedizin Berlin CVK, Berlin, Deutschland
| | - Omer Dzemali
- Klinik für Herzchirurgie, Stadtspital Triemli, Zürich, Schweiz
| | - Daniel Zimpfer
- Kinder- und Jugendheilkunde, Meduni Graz, Graz, Österreich
| | - Elfriede Ruttmann-Ulmer
- Klinik für Herzchirurgie, Medizinische Universität Innsbruck Universitätsklinik für Herzchirurgie, Innsbruck, Österreich
| | - Christian Schlensak
- Universitätsklinik für Herz, Thorax- und Gefäßchirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Stephan Ensminger
- Klinik für Herz- und thorakale Gefäßchirurgie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Malte Kelm
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Udo Boeken
- Klinik für Herzchirurgie/Leiter des Transplantationsprogramms, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Deutschland
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Madurka I, Vishnevsky A, Soriano JB, Gans SJ, Ore DJS, Rendon A, Ulrik CS, Bhatnagar S, Krishnamurthy S, Mc Harry K, Welte T, Fernandez AA, Mehes B, Meiser K, Gatlik E, Sommer U, Junge G, Rezende E, Fernandez AA, Bagu AM, Amido FH, Costa MB, Brigante JA, Franco G, Ahmed NJ, Zerega N, Bacci MR, Fernandes CC, Ragognete HG, de Carvalho Rezende EA, Jaoude CVG, de Olivera EP, Malacize VQ, Stadnik CMB, Ramos EA, Kist GR, Barbosa GR, Filik H, Nalin S, Ulrik CS, Tidemandsen C, Hakansson K, Benfield T, Pedersen KBH, Welte T, Bachman M, Stoll M, Olzik I, Scharf N, Shearman N, Pink I, Frey A, Schulze P, Sayehli CM, Weismann D, Klinker H, Goebeler ME, Maier L, Geismann F, Hanses F, Zeller J, Hupf J, Lubnow M, Sag S, Ripfel S, Pabel S, Bauernfeind S, Leisner U, Hitzenbichler F, Madurka I, Iharos D, Toth KK, Hejja M, Esze T, Bhatnagar S, Mohan A, Pandit A, Kumar B, Ratre BK, Tiwari P, Singh R, Vig S, Bhopale S, Bhan S, Budhraja A, Agrawal A, Krishnamurthy S, Srikanth A, Kaneesan K, Unnithan MRJ, Srinivasan N, Velayuthaswamy N, Gounder SKM, Vaidyanathan V, Saha A, Bhattacharjee A, Datta A, Rendon A, Ortiz AC, Moncivais BS, Rodriguez BNL, Ramirez EJR, Perez ROF, Perez DLC, Osornio JS, Ortega MLM, Medina MAJ, Gans SJ, VanDen Berg JW, Boom L, Panhuis E, Lancee G, Lammens M, Boeve-Epping N, Ore DJS, Bustios ERM, Flores EMZ, Farronay MIM, Orihuela BG, del Pino RM, Vishnevsky AY, Morozov E, Repnikov I, Kiseleva M, Kotov ME, Terskikh MM, Zykov VA, Smolyarchuk EA, Kurguzova D, Garkavi DA, Messnikov O, Kharlamova S, Bondareva YA, Sementsov KV, Katagarov DN, Belekhov GA, Alferov SP, Martynenko TI, Vasileva E, Lazarenko IV, Gatalsky KK, Rudikh OV, Ganova OS, Paraeva OS, Pashkevich VV, Vishneva EM, Martynov AV, Isakova AP, Egorova EA, Gaygolnik TV, Pinzhina VN, Hinovker VV, Abramov VG, Ignatova GL, Blinova EV, Grebneva IV, Rodionova OV, Antonov VN, Trufanov KV, Krylov AA, Radchenko EN, McHarry K, Snyman E, Soriano J, Serrano DR, Vergara AM, Marcos MC, Viladomiu AS, Cardozo C, Garcia F. DFV890: a new oral NLRP3 inhibitor—tested in an early phase 2a randomised clinical trial in patients with COVID-19 pneumonia and impaired respiratory function. Infection 2022; 51:641-654. [PMID: 36104613 PMCID: PMC9473473 DOI: 10.1007/s15010-022-01904-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/27/2022] [Indexed: 01/08/2023]
Abstract
Background Coronavirus-associated acute respiratory distress syndrome (CARDS) has limited effective therapy to date. NLRP3 inflammasome activation induced by SARS-CoV-2 in COVID-19 contributes to cytokine storm. Methods This randomised, multinational study enrolled hospitalised patients (18–80 years) with COVID-19-associated pneumonia and impaired respiratory function. Eligible patients were randomised (1:1) via Interactive Response Technology to DFV890 + standard-of-care (SoC) or SoC alone for 14 days. Primary endpoint was APACHE II score at Day 14 or on day-of-discharge (whichever-came-first) with worst-case imputation for death. Other key assessments included clinical status, CRP levels, SARS-CoV-2 detection, other inflammatory markers, in-hospital outcomes, and safety. Findings Between May 27, 2020 and December 24, 2020, 143 patients (31 clinical sites, 12 countries) were randomly assigned to DFV890 + SoC (n = 71) or SoC alone (n = 72). Primary endpoint to establish clinical efficacy of DFV890 vs. SoC, based on combined APACHE II score, was not met; LSM (SE), 8·7 (1.06) vs. 8·6 (1.05); p = 0.467. More patients treated with DFV890 vs. SoC showed ≥ 1-level improvement in clinical status (84.3% vs. 73.6% at Day 14), earlier clearance of SARS-CoV-2 (76.4% vs. 57.4% at Day 7), and mechanical ventilation-free survival (85.7% vs. 80.6% through Day 28), and there were fewer fatal events in DFV890 group (8.6% vs. 11.1% through Day 28). DFV890 was well tolerated with no unexpected safety signals. Interpretation DFV890 did not meet statistical significance for superiority vs. SoC in primary endpoint of combined APACHE II score at Day 14. However, early SARS-CoV-2 clearance, improved clinical status and in-hospital outcomes, and fewer fatal events occurred with DFV890 vs. SoC, and it may be considered as a protective therapy for CARDS. Trial registration ClinicalTrials.gov, NCT04382053. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-022-01904-w.
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Fisser C, Palmér O, Sallisalmi M, Paulus M, Foltan M, Philipp A, Malfertheiner MV, Lubnow M, Müller T, Broman LM. Recirculation in single lumen cannula venovenous extracorporeal membrane oxygenation: A non-randomized bi-centric trial. Front Med (Lausanne) 2022; 9:973240. [PMID: 36117961 PMCID: PMC9470851 DOI: 10.3389/fmed.2022.973240] [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: 06/19/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRecirculation is a common problem in venovenous (VV) extracorporeal membrane oxygenation (ECMO). The aims of this study were to compare recirculation fraction (Rf) between femoro-jugular and jugulo-femoral VV ECMO configurations, to identify risk factors for recirculation and to assess the impact on hemolysis.MethodsPatients in the medical intensive care unit (ICU) at the University Medical Center Regensburg, Germany receiving VV ECMO with femoro-jugular, and jugulo-femoral configuration at the ECMO Center Karolinska, Sweden, were included in this non-randomized prospective study. Total ECMO flow (QEC), recirculated flow (QREC), and recirculation fraction Rf = QREC/QEC were determined using ultrasound dilution technology. Effective ECMO flow (QEFF) was defined as QEFF = QEC * (1–Rf). Demographics, cannula specifics, and markers of hemolysis were assessed. Survival was evaluated at discharge from ICU.ResultsThirty-seven patients with femoro-jugular configuration underwent 595 single-point measurements and 18 patients with jugulo-femoral configuration 231 measurements. Rf was lower with femoro-jugular compared to jugulo-femoral configuration [5 (0, 11) vs. 19 (13, 28) %, respectively (p < 0.001)], resulting in similar QEFF [2.80 (2.21, 3.39) vs. 2.79 (2.39, 3.08) L/min (p = 0.225)] despite lower QEC with femoro-jugular configuration compared to jugulo-femoral [3.01 (2.40, 3.70) vs. 3.57 (3.05, 4.06) L/min, respectively (p < 0.001)]. In multivariate regression analysis, the type of configuration, distance between the two cannula tips, ECMO flow, and heart rate were significantly associated with Rf [B (95% CI): 25.8 (17.6, 33.8), p < 0.001; 960.4 (960.7, 960.1), p = 0.009; 4.2 (2.5, 5.9), p < 0.001; 960.1 (960.2, 0.0), p = 0.027]. Hemolysis was similar in subjects with Rf > 8 vs. ≤ 8%. Explorative data on survival showed comparable results in the femoro-jugular and the jugulo-femoral group (81 vs. 72%, p = 0.455).ConclusionVV ECMO with femoro-jugular configuration caused less recirculation. Further risk factors for higher Rf were shorter distance between the two cannula tips, higher ECMO flow, and lower heart rate. Rf did not affect hemolysis.
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Affiliation(s)
- Christoph Fisser
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
- *Correspondence: Christoph Fisser
| | - Oscar Palmér
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Marko Sallisalmi
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Paulus
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Lubnow M, Berger J, Schneckenpointner R, Zeman F, Lunz D, Philipp A, Foltan M, Lehle K, Heimerl S, Hart C, Schmid C, Fisser C, Müller T. Prevalence and outcomes of patients developing heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. PLoS One 2022; 17:e0272577. [PMID: 35939484 PMCID: PMC9359525 DOI: 10.1371/journal.pone.0272577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/21/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Unfractionated heparin (UFH) is the commonly used anticoagulant to prevent clotting of the ECMO circuit and thrombosis of the cannulated vessels. A side effect of UFH is heparin-induced thrombocytopenia (HIT). Little is known about HIT during ECMO and the impact of changing anticoagulation in ECMO patients with newly diagnosed HIT. The aim of the study was to determine the prevalence, complications, impact of switching anticoagulation to argatroban and outcomes of patients developing heparin-induced thrombocytopenia (HIT) during either veno-venous (VV) or veno-arterial (VA) ECMO. Methods Retrospective observational single centre study of prospectively collected data of consecutive patients receiving VV ECMO therapy for severe respiratory failure and VA ECMO for circulatory failure from January 2006 to December 2016 of the Medical intensive care unit (ICU) of the University Hospital of Regensburg. Treatment of HIT on ECMO was done with argatroban. Results 507 patients requiring ECMO were included. Further HIT-diagnostic was conducted if HIT-4T-score was ≥4. The HIT-confirmed group had positive HIT-enzyme-linked-immunosorbent-assay (ELISA) and positive heparin-induced-platelet-activation (HIPA) test, the HIT-suspicion group a positive HIT-ELISA and missing HIPA but remained on alternative anticoagulation until discharge and the HIT-excluded group a negative or positive HIT-ELISA, however negative HIPA. These were compared to group ECMO-control without any HIT suspicion. The prevalence of HIT-confirmed was 3.2%, of HIT-suspicion 2.0% and HIT-excluded 10.8%. Confirmed HIT was trendwise more frequent in VV than in VA (3.9 vs. 1.7% p = 0.173). Compared to the ECMO control group, patients with confirmed HIT were longer on ECMO (median 13 vs. 8 days, p = 0.002). Different types of complications were higher in the HIT-confirmed than in the ECMO-control group, but in-hospital mortality was not different (31% vs. 41%, p = 0.804). Conclusion HIT is rare on ECMO, should be suspected, if platelets are decreasing, but seems not to increase mortality if treated promptly.
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Affiliation(s)
- Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
- * E-mail:
| | - Johannes Berger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Roland Schneckenpointner
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Bavaria, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Susanne Heimerl
- Department of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christina Hart
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
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Fisser C, Armbrüster C, Wiest C, Philipp A, Foltan M, Lunz D, Pfister K, Schneckenpointner R, Schmid C, Maier LS, Müller T, Lubnow M. Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:960716. [PMID: 35966879 PMCID: PMC9365977 DOI: 10.3389/fmed.2022.960716] [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: 06/03/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe aim of this study was to investigate the prevalence of arterial and venous complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) and its risk factors at the time of cannulation and during extracorporeal membrane oxygenation (ECMO) support and to assess vascular complications in association with decannulation.Material and methodsBetween January 2010 to January 2020, out of 1,030 eligible patients requiring VA-ECMO, 427 with analyzable vascular screening were included. Duplex sonography and/or CT scan after decannulation were used to screen for thrombosis and pulmonary embolism as well as arterial complications. Near-infrared spectrometry (NIRS) was established at the time of cannulation and was continuously monitored during the ECMO therapy.ResultsThe prevalence of venous complications was 27%. Thrombosis and pulmonary embolism were observed in 21 and 7% of patients, respectively. Pulmonary embolism was more frequently diagnosed in patients with thrombosis (22 vs. 3%, p < 0.001). In multivariate analysis, cannulation in the jugular vein was determined as a risk factor for venous thrombosis in contrast to the extent of anticoagulation. The prevalence of arterial complications was 37%, mainly ischemia followed by bleeding, dissection, and compartment syndrome. Vascular surgery was necessary for 19% of the patients, of whome 1% required major amputations. A distal perfusion cannula (DPC) was implanted at cannulation in 24% of patients and secondarily in 16% of patients after cannulation as required during ECMO support. In the multivariate analysis, risk factors for leg ischemia at the time of cannulation were elevated D-dimers, lower NIRS on the cannulated leg, and lack of a DPC. The best discriminative parameter was the difference in NIRS between the non-cannulated leg and the cannulated leg. In contrast, during ECMO support, only the lack of a DPC was associated with leg ischemia. A similar rate of complications associated with decannulation, mainly arterial thrombosis, ischemia, or bleeding, was seen with percutaneous and surgical approaches (18 vs. 17%, p = 0.295).ConclusionPatients requiring VA ECMO should be routinely screened for vascular complications. The decision to insert a DPC should be evaluated individually. However, NIRS monitoring of the cannulated leg and the non-cannulated leg is essential to identify the legs at risk for critical ischemia. As complications associated with decannulation were equally distributed between percutaneous and surgical approaches, the applied method may be chosen according to local experience.
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Affiliation(s)
- Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
- *Correspondence: Christoph Fisser,
| | - Corina Armbrüster
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Lars S. Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Buder F, Bauswein M, Magnus CL, Audebert F, Lang H, Kundel C, Distler K, Reuschel E, Lubnow M, Müller T, Lunz D, Graf B, Schmid S, Müller M, Poeck H, Hanses F, Salzberger B, Peterhoff D, Wenzel JJ, Schmidt B, Lampl BMJ. Correction to: Contribution of High Viral Loads, Detection of Viral Antigen and Seroconversion to Severe Acute Respiratory Syndrome Coronavirus 2 Infectivity. J Infect Dis 2022; 227:605. [PMID: 35869700 PMCID: PMC9384479 DOI: 10.1093/infdis/jiac123] [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: 11/25/2022] Open
Affiliation(s)
- Felix Buder
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Markus Bauswein
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Clara L Magnus
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | | | | | - Christof Kundel
- Medizinische Klinik 1, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Karin Distler
- Medizinische Klinik 1, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Edith Reuschel
- University Department of Obstetrics and Gynecology at the Hospital St Hedwig of the Order of St John, University of Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Hendrik Poeck
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Emergency Department, University Hospital Regensburg, Regensburg, Germany,Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Jürgen J Wenzel
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany,Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Benedikt M J Lampl
- Correspondence: Benedikt M. J. Lampl, Public Health Department Regensburg, Altmühlstraße 3, 93059 Regensburg, Germany ()
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Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Ensminger S, Kelm M, Boeken U. Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen. Aktuelle Kardiologie 2022. [DOI: 10.1055/a-1734-4157] [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: 10/18/2022]
Abstract
ZusammenfassungIn den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland
mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der
Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der
Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und
der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der
extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen.
Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.
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Affiliation(s)
- Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St. Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken Bad Segeberg, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic & Vascular Surgery, German Heart Centre, Berlin, Deutschland
| | - Kevin Pilarczyk
- Department for Intensice Care Medicine, Imland Hospital Rendsburg, Rendsburg, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Germany
| | - Nils Haake
- Department for Intensice Care Medicine, Imland Hospital Rendsburg, Rendsburg, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Medizinische Klinik I, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Harald Köditz
- Medical University Children's Hospital Hannover, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, München, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, München, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University Bochum, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University Bochum, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Zürich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
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Kieninger M, Dietl S, Sinning A, Gruber M, Gronwald W, Zeman F, Lunz D, Dienemann T, Schmid S, Graf B, Lubnow M, Müller T, Holzmann T, Salzberger B, Kieninger B. Evaluation of models for prognosing mortality in critical care patients with COVID-19: First- and second-wave data from a German university hospital. PLoS One 2022; 17:e0268734. [PMID: 35617276 PMCID: PMC9135305 DOI: 10.1371/journal.pone.0268734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/07/2022] [Indexed: 12/15/2022] Open
Abstract
Background In a previous study, we had investigated the intensive care course of patients with coronavirus disease 2019 (COVID-19) in the first wave in Germany by calculating models for prognosticating in-hospital death with univariable and multivariable regression analysis. This study analyzed if these models were also applicable to patients with COVID-19 in the second wave. Methods This retrospective cohort study included 98 critical care patients with COVID-19, who had been treated at the University Medical Center Regensburg, Germany, between October 2020 and February 2021. Data collected for each patient included vital signs, dosage of catecholamines, analgosedation, anticoagulation, and antithrombotic medication, diagnostic blood tests, treatment with extracorporeal membrane oxygenation (ECMO), intensive care scores, ventilator therapy, and pulmonary gas exchange. Using these data, expected mortality was calculated by means of the originally developed mathematical models, thereby testing the models for their applicability to patients in the second wave. Results Mortality in the second-wave cohort did not significantly differ from that in the first-wave cohort (41.8% vs. 32.2%, p = 0.151). As in our previous study, individual parameters such as pH of blood or mean arterial pressure (MAP) differed significantly between survivors and non-survivors. In contrast to our previous study, however, survivors and non-survivors in this study showed significant or even highly significant differences in pulmonary gas exchange and ventilator therapy (e.g. mean and minimum values for oxygen saturation and partial pressure of oxygen, mean values for the fraction of inspired oxygen, positive expiratory pressure, tidal volume, and oxygenation ratio). ECMO therapy was more frequently administered than in the first-wave cohort. Calculations of expected mortality by means of the originally developed univariable and multivariable models showed that the use of simple cut-off values for pH, MAP, troponin, or combinations of these parameters resulted in correctly estimated outcome in approximately 75% of patients without ECMO therapy.
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Affiliation(s)
- Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
- * E-mail:
| | - Sarah Dietl
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Annemarie Sinning
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Wolfram Gronwald
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Holzmann
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Bärbel Kieninger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
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20
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Kozakov K, Philipp A, Lunz D, Lubnow M, Provaznik Z, Keyser A, Rupprecht L, Schmid C, Schopka S. Multi-organ dysfunction syndrome in patients undergoing extracorporeal life support. Artif Organs 2022; 46:1912-1922. [PMID: 35470442 DOI: 10.1111/aor.14272] [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: 12/03/2021] [Revised: 01/30/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple organ failure is a common complication in patients undergoing ECLS significantly affecting patient outcomes. Gaining knowledge about the mechanisms of onset, clinical course, risk factors, and potential therapeutic targets is highly desirable. METHODS Data of 354 patients undergoing ECLS with one-, two, three-, and four organ failures were retrospectively analyzed. Incidence of multiple organ dysfunction (MODS), its impact on survival, risk factors for its occurrence, and the impact of proinflammatory mediators on the occurrence of MODS in patients undergoing ECLS were investigated. RESULTS The median follow-up was 66 (IQR 6; 820) days. 245 (69.2%) patients could be weaned from ECLS, 30-day survival and 1-year survival were 194 (54.1%) and 157 (44.4%), respectively. The duration of mechanical support was 4 (IQR 2; 7) days in the median. Increasing severity of MODS resulted in significant prolongation of mechanical circulatory support and worsening of the outcome. Liver dysfunction had the strongest impact on patient mortality (OR = 2.5) and survival time (19 vs 367 days). The serum concentration of analyzed interleukins rose significantly with each, additional organ affected by dysfunction (p < 0.001). All analyzed proinflammatory cytokines showed significant predictivity relative to the occurrence of MODS with interleukin 8 serum level prior to ECLS showing the strongest predictive potential for the occurrence of MODS (AUC 0.78). CONCLUSION MODS represents a frequent complication in patients undergoing ECLS with a significant impact on survival. Proinflammatory cytokines show prognostic capacity regarding the occurrence and severity of multi-organ dysfunction.
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Affiliation(s)
- Kostiantyn Kozakov
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Keyser
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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21
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Lehle K, Philipp A, Foltan M, Schettler F, Ritzka M, Müller T, Lubnow M. Coagulation abnormalities in patients with COVID-19 on venovenous ECLS increased risk for technical complications and support times but had no impact on survival. Artif Organs 2022; 46:1669-1681. [PMID: 35192198 PMCID: PMC9111222 DOI: 10.1111/aor.14218] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with severe coronavirus disease-19 (COVID-19)-associated acute respiratory distress on venovenous extracorporeal lung support (V-V ECLS) showed high incidence of vascular as well as ECLS-related thrombotic complications. The latter may influence the outcome of the patients. METHODS This is a retrospective monocentric study on prospectively collected data of technical complications including 69 adult COVID-19 patients on V-V ECLS (ECLS Registry, March 2020 until April 2021) without and with system exchanges. Alterations in ECLS-specific data, hemolysis, coagulation and hemostasis parameters were analyzed. RESULTS Every second COVID-19 patient on V-V ECLS developed technical complications. Optimized ECLS management at our ECLS center reduced cases of acute clot formation (pump head thrombosis, acute oxygenator thrombosis) (17%), and allowed early identification of progressive clotting processes (worsened gas transfer, coagulation disorder) (14%, 54%) with a significant overhang of hyperfibrinolysis (37%). Although COVID-19 disease and technical complications caused prolonged length of stay at the intensive care unit and ECLS support times, the proportion of successful weaning and survival rates were comparable with patients without system exchange. CONCLUSION The survival of ECLS patients with COVID-19 was independent of the requirement for system exchange due to technical-induced coagulation disorders. Close monitoring for circuit clotting is mandatory in COVID-19 patients and is one prerequisite for successful organ support in these difficult patients.
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Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Frank Schettler
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Ritzka
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Stadlbauer A, Philipp A, Blecha S, Lubnow M, Lunz D, Li J, Terrazas A, Schmid C, Lange TJ, Camboni D. Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock. Ann Intensive Care 2021; 11:181. [PMID: 34951692 PMCID: PMC8709804 DOI: 10.1186/s13613-021-00975-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 08/12/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Since 2019, European guidelines recommend considering extracorporeal life support as salvage strategy for the treatment of acute high-risk pulmonary embolism (PE) with circulatory collapse or cardiac arrest. However, data on long-term survival, quality of life (QoL) and cardiopulmonary function after extracorporeal membrane oxygenation (ECMO) are lacking. Methods One hundred and nineteen patients with acute PE and severe cardiogenic shock or in need of mechanical resuscitation (CPR) received venoarterial or venovenous ECMO from 2007 to 2020. Long-term data were obtained from survivors by phone contact and personal interviews. Follow-up included a QoL analysis using the EQ-5D-5L questionnaire, echocardiography, pulmonary function testing and cardiopulmonary exercise testing. Results The majority of patients (n = 80, 67%) were placed on ECMO during or after CPR with returned spontaneous circulation. Overall survival to hospital discharge was 45.4% (54/119). Nine patients died during follow-up. At a median follow-up of 54.5 months (25–73; 56 ± 38 months), 34 patients answered the QoL questionnaire. QoL differed largely and was slightly reduced compared to a German reference population (EQ5D5L index 0.7 ± 0.3 vs. 0.9 ± 0.04; p < 0.01). 25 patients (73.5%) had no mobility limitations, 22 patients (65%) could handle their activities, while anxiety and depression were expressed by 10 patients (29.4%). Return-to-work status was 33.3% (average working hours: 36.2 ± 12.5 h/per week), 15 (45.4%) had retired from work early. 12 patients (35.3%) expressed limited exercise tolerance and dyspnea. 59% (20/34) received echocardiography and pulmonary function testing, 50% (17/34) cardiopulmonary exercise testing. No relevant impairment of right ventricular function and an only slightly reduced mean peak oxygen uptake (76.3% predicted) were noted. Conclusions Survivors from severe intractable PE in cardiogenic shock or even under CPR with ECMO seem to recover well with acceptable QoL and only minor cardiopulmonary limitations in the long term. To underline these results, further research with larger study cohorts must be obtained.
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Affiliation(s)
- Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Armando Terrazas
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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23
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen. Z Herz- Thorax- Gefäßchir 2021. [DOI: 10.1007/s00398-021-00465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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24
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Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S, Boeken U. Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice Guideline Level 3. ESC Heart Fail 2021; 9:506-518. [PMID: 34811959 PMCID: PMC8788014 DOI: 10.1002/ehf2.13718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/23/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022] Open
Abstract
Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment. Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements. Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.
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Affiliation(s)
- Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Moorenstr. 5, Düsseldorf, 40225, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, Germany
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshader, LMU Munich, Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa, Germany
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Moorenstr. 5, Düsseldorf, 40225, Germany
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25
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Siska PJ, Decking SM, Babl N, Matos C, Bruss C, Singer K, Klitzke J, Schön M, Simeth J, Köstler J, Siegmund H, Ugele I, Paulus M, Dietl A, Kolodova K, Steines L, Freitag K, Peuker A, Schönhammer G, Raithel J, Graf B, Geismann F, Lubnow M, Mack M, Hau P, Bohr C, Burkhardt R, Gessner A, Salzberger B, Wagner R, Hanses F, Hitzenbichler F, Heudobler D, Lüke F, Pukrop T, Herr W, Wolff D, Spang R, Poeck H, Hoffmann P, Jantsch J, Brochhausen C, Lunz D, Rehli M, Kreutz M, Renner K. Metabolic imbalance of T cells in COVID-19 is hallmarked by basigin and mitigated by dexamethasone. J Clin Invest 2021; 131:148225. [PMID: 34779418 DOI: 10.1172/jci148225] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 02/01/2021] [Accepted: 09/28/2021] [Indexed: 12/15/2022] Open
Abstract
Metabolic pathways regulate immune responses and disrupted metabolism leads to immune dysfunction and disease. Coronavirus disease 2019 (COVID-19) is driven by imbalanced immune responses, yet the role of immunometabolism in COVID-19 pathogenesis remains unclear. By investigating 87 patients with confirmed SARS-CoV-2 infection, 6 critically ill non-COVID-19 patients, and 47 uninfected controls, we found an immunometabolic dysregulation in patients with progressed COVID-19. Specifically, T cells, monocytes, and granulocytes exhibited increased mitochondrial mass, yet only T cells accumulated intracellular reactive oxygen species (ROS), were metabolically quiescent, and showed a disrupted mitochondrial architecture. During recovery, T cell ROS decreased to match the uninfected controls. Transcriptionally, T cells from severe/critical COVID-19 patients showed an induction of ROS-responsive genes as well as genes related to mitochondrial function and the basigin network. Basigin (CD147) ligands cyclophilin A and the SARS-CoV-2 spike protein triggered ROS production in T cells in vitro. In line with this, only PCR-positive patients showed increased ROS levels. Dexamethasone treatment resulted in a downregulation of ROS in vitro and T cells from dexamethasone-treated patients exhibited low ROS and basigin levels. This was reflected by changes in the transcriptional landscape. Our findings provide evidence of an immunometabolic dysregulation in COVID-19 that can be mitigated by dexamethasone treatment.
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Affiliation(s)
- Peter J Siska
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Sonja-Maria Decking
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Nathalie Babl
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Carina Matos
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Christina Bruss
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Katrin Singer
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg
| | - Jana Klitzke
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Marian Schön
- Department of Statistical Bioinformatics, Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Jakob Simeth
- Department of Statistical Bioinformatics, Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Josef Köstler
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Heiko Siegmund
- Institute of Pathology, University of Regensburg, Regensburg, Germany.,Central Biobank Regensburg, University Hospital and University of Regensburg, Regensburg, Germany
| | - Ines Ugele
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg
| | | | | | - Kristina Kolodova
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | | | - Katharina Freitag
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Alice Peuker
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Gabriele Schönhammer
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Johanna Raithel
- Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | | | | | | | | | - Peter Hau
- Wilhelm Sander-NeuroOncology Unit and Department of Neurology
| | - Christopher Bohr
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg
| | | | - Andre Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | | | - Ralf Wagner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Department of Infection Prevention and Infectious Diseases, and.,Emergency Department, University Hospital Regensburg, Regensburg, Germany
| | | | - Daniel Heudobler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Bavarian Cancer Research Center, Regensburg, Germany
| | - Florian Lüke
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Bavarian Cancer Research Center, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Rainer Spang
- Department of Statistical Bioinformatics, Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Hendrik Poeck
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Petra Hoffmann
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Jonathan Jantsch
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University of Regensburg, Regensburg, Germany.,Central Biobank Regensburg, University Hospital and University of Regensburg, Regensburg, Germany
| | | | - Michael Rehli
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Marina Kreutz
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Kathrin Renner
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
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26
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Lubnow M, Dreier T, Schulz C, Endres T. Simultaneous measurement of liquid-film thickness and solute concentration of aqueous solutions of two urea derivatives using NIR absorption. Appl Opt 2021; 60:10087-10093. [PMID: 34807113 DOI: 10.1364/ao.440465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 06/13/2023]
Abstract
We present a method to simultaneously measure the film thickness and individual concentrations of two urea derivates (urea CH4N2O and dimethylurea C3H8N2O) mixed in an aqueous solution at constant temperature using near-infrared (NIR) absorption at multiple specific wavelengths. Fourier transform infrared (FTIR) spectra of aqueous mixtures of urea and dimethylurea solutions were recorded in the 1250-2500 nm wavelength range in thin-layer quartz cuvettes at room temperature. The spectra reveal suitable detection wavelengths, i.e., 1450, 1933, 2200, and 2270 nm, for which both the absorption coefficient and its variation with the species concentration are large enough to achieve satisfactory detection sensitivity and selectivity. For validation measurements, samples were prepared in thin-layer quartz transmission cells with known path lengths and mixture compositions in the range 100-1000 µm and 0-40 wt.%, respectively. Film thickness and mass fractions of both species were determined from measured absorbance ratios in the determined characteristic wavelength bands.
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27
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. [Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. Med Klin Intensivmed Notfmed 2021; 116:678-686. [PMID: 34665281 DOI: 10.1007/s00063-021-00868-3] [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] [Indexed: 11/26/2022]
Abstract
In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.
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Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Deutschland
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle-Wittenberg, Deutschland
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Deutschland
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Deutschland
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Deutschland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Deutschland
| | - Kevin Pilarczyk
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps University Hospital Marburg, Marburg, Deutschland
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Deutschland
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Deutschland
| | - Ralf Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Deutschland
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Deutschland
| | - Nils Haake
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, 99089, Erfurt, Deutschland
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Deutschland
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Deutschland
| | - Mark Rosenberg
- Department of Internal Medicine I, Hospital Aschaffenburg-Alzenau, Aschaffenburg-Alzenau, Deutschland
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Deutschland
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Deutschland
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Deutschland
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr University, Bochum, Deutschland
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Deutschland
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University, Bochum, Deutschland
| | - Andreas Fründ
- Department of Physiotherapy, Heart and Diabetes Center NRW, Ruhr University, Bochum, Bochum, Deutschland
| | - Rolf Jaksties
- German Heart Foundation, Frankfurt am Main, Deutschland
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Deutschland
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Deutschland
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstraße 497, 8063, Zurich, Schweiz
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Österreich
| | - Elfriede Ruttmann-Ulmer
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Deutschland
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical School, Moorenstraße 5, Duesseldorf, Deutschland
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Luisenstraße 58/59, Berlin, Deutschland
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28
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. [Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. Anaesthesist 2021; 70:942-950. [PMID: 34665266 DOI: 10.1007/s00101-021-01058-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.
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Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Deutschland
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle-Wittenberg, Deutschland
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Deutschland
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Deutschland
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Deutschland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Deutschland
| | - Kevin Pilarczyk
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps University Hospital Marburg, Marburg, Deutschland
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Deutschland
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Deutschland
| | - Ralf Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Deutschland
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Deutschland
| | - Nils Haake
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, 99089, Erfurt, Deutschland
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Deutschland
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Deutschland
| | - Mark Rosenberg
- Department of Internal Medicine I, Hospital Aschaffenburg-Alzenau, Aschaffenburg-Alzenau, Deutschland
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Deutschland
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Deutschland
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Deutschland
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr University, Bochum, Deutschland
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Deutschland
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University, Bochum, Deutschland
| | - Andreas Fründ
- Department of Physiotherapy, Heart and Diabetes Center NRW, Ruhr University, Bochum, Bochum, Deutschland
| | - Rolf Jaksties
- German Heart Foundation, Frankfurt am Main, Deutschland
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Deutschland
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Deutschland
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstraße 497, 8063, Zurich, Schweiz
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Österreich
| | - Elfriede Ruttmann-Ulmer
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Deutschland
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical School, Moorenstraße 5, Duesseldorf, Deutschland
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Luisenstraße 58/59, Berlin, Deutschland
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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30
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Seidel D, Simon M, Sprute R, Lubnow M, Evert K, Speer C, Seeßle J, Khatamzas E, Merle U, Behrens C, Blau IW, Enghard P, Haas CS, Steinmann J, Kurzai O, Cornely OA. Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals. Mycoses 2021; 65:103-109. [PMID: 34655486 PMCID: PMC8662289 DOI: 10.1111/myc.13379] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 09/27/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Most COVID-19-associated mucormycosis (CAM) cases are reported from India and neighbouring countries. Anecdotally cases from Europe have been presented. OBJECTIVE To estimate the disease burden and describe the clinical presentation of CAM in Germany. METHODS We identified cases through German mycology networks and scientific societies, and collected anonymised clinical information via FungiScope®. RESULTS We identified 13 CAM cases from six tertiary referral hospitals diagnosed between March 2020 and June 2021. Twelve patients had severe or critical COVID-19, eleven were mechanically ventilated for a median of 8 days (range 1-27 days) before diagnosis of CAM. Eleven patients received systemic corticosteroids. Additional underlying medical conditions were reported for all but one patient, five were immunocompromised because of malignancy or organ transplantation, three were diabetic. Eleven patients developed pneumonia. Mortality was 53.8% with a median time from diagnosis of mucormycosis to death of 9 days (range 0-214 days) despite treatment with liposomal amphotericin B and/or isavuconazole in 10 of 13 cases. CAM prevalence amongst hospitalised COVID-19 patients overall (0.67% and 0.58% in two centres) and those admitted to the intensive care unit (ICU) (1.47%, 1.78% and 0.15% in three centres) was significantly higher compared to non-COVID-19 patients (P < .001 for respective comparisons). CONCLUSION COVID-19-associated mucormycosis is rare in Germany, mostly reported in patients with comorbidities and impaired immune system and severe COVID-19 treated in the ICU with high mortality compared to mainly rhino-orbito-cerebral CAM in patients with mild COVID-19 in India. Risk for CAM is higher in hospitalised COVID-19 patients than in other patients.
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Affiliation(s)
- Danila Seidel
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Michaela Simon
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Rosanne Sprute
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Matthias Lubnow
- Department of Anesthesiology and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Claudius Speer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Jessica Seeßle
- Department of Gastroenterology and Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Elham Khatamzas
- Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology and Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Christopher Behrens
- Department Medizinische Mikrobiologie und Technische Hygiene, Medizet, Städtisches Klinikum München GmbH, Munich, Germany
| | - Igor Wolfgang Blau
- Department of Hematology, Oncology and Cancer Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Christian S Haas
- Department of Internal Medicine, Nephrology and Intensive Care Medicine, University of Marburg, Marburg, Germany
| | - Joerg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany.,Institute of Medical Microbiology, University Hospital Essen, Essen, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany.,Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Cologne, Germany
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31
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Kieninger M, Sinning A, Vadász T, Gruber M, Gronwald W, Zeman F, Lunz D, Dienemann T, Schmid S, Graf B, Lubnow M, Müller T, Holzmann T, Salzberger B, Kieninger B. Lower blood pH as a strong prognostic factor for fatal outcomes in critically ill COVID-19 patients at an intensive care unit: A multivariable analysis. PLoS One 2021; 16:e0258018. [PMID: 34587211 PMCID: PMC8480873 DOI: 10.1371/journal.pone.0258018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Data of critically ill COVID-19 patients are being evaluated worldwide, not only to understand the various aspects of the disease and to refine treatment strategies but also to improve clinical decision-making. For clinical decision-making in particular, prognostic factors of a lethal course of the disease would be highly relevant. METHODS In this retrospective cohort study, we analyzed the first 59 adult critically ill Covid-19 patients treated in one of the intensive care units of the University Medical Center Regensburg, Germany. Using uni- and multivariable regression models, we extracted a set of parameters that allowed for prognosing in-hospital mortality. RESULTS Within the cohort, 19 patients died (mortality 32.2%). Blood pH value, mean arterial pressure, base excess, troponin, and procalcitonin were identified as highly significant prognostic factors of in-hospital mortality. However, no significant differences were found for other parameters expected to be relevant prognostic factors, like low arterial partial pressure of oxygen or high lactate levels. In the multivariable logistic regression analysis, the pH value and the mean arterial pressure turned out to be the most influential prognostic factors for a lethal course.
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Affiliation(s)
- Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Annemarie Sinning
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Timea Vadász
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Wolfram Gronwald
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Holzmann
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
| | - Bärbel Kieninger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Regensburg, Germany
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32
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. Extracorporeal Circulation (ECLS/ECMO) for Cardio-circulatory Failure-Summary of the S3 Guideline. Thorac Cardiovasc Surg 2021; 69:483-489. [PMID: 34547801 DOI: 10.1055/s-0041-1735464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University, Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | | | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetes Centre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetes Centre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Buder F, Bauswein M, Magnus CL, Audebert F, Lang H, Kundel C, Distler K, Reuschel E, Lubnow M, Müller T, Lunz D, Graf B, Schmid S, Müller M, Poeck H, Hanses F, Salzberger B, Peterhoff D, Wenzel JJ, Schmidt B, Lampl BMJ. SARS-CoV-2 infectivity correlates with high viral loads and detection of viral antigen and is terminated by seroconversion. J Infect Dis 2021; 225:190-198. [PMID: 34427652 PMCID: PMC8513404 DOI: 10.1093/infdis/jiab415] [Citation(s) in RCA: 9] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background From a public health perspective, effective containment strategies for SARS-CoV-2 should be balanced with individual liberties. Methods We collected 79 respiratory samples from 59 patients monitored in an outpatient center or in the intensive care unit of the University Hospital Regensburg. We analyzed viral load by quantitative real-time PCR, viral antigen by point-of-care assay, time since onset of symptoms and presence of SARS-CoV-2 IgG antibodies in the context of virus isolation from respiratory specimen. Results The odds ratio for virus isolation increased 1.9-fold for each log10 level of SARS-CoV-2 RNA and 7.4-fold with detection of viral antigen, while it decreased 6.3-fold beyond 10 days of symptoms and 20.0-fold with presence of SARS-CoV-2 antibodies. The latter was confirmed for B.1.1.7 strains. The positive predictive value for virus isolation was 60.0% for viral loads above 10 7 RNA copies/mL and 50.0% for the presence of viral antigen. Symptom onset before 10 days and seroconversion predicted lack of infectivity with 93.8% and 96.0%. Conclusions Our data support quarantining patients with high viral load and detection of viral antigen, and lifting restrictive measures with increasing time to symptom onset and seroconversion. Delay of antibody formation may prolong infectivity.
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Affiliation(s)
- Felix Buder
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Markus Bauswein
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Clara L Magnus
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | | | | | - Christof Kundel
- Medizinische Klinik 1, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Karin Distler
- Medizinische Klinik 1, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Edith Reuschel
- University Department of Obstetrics and Gynecology At The Hospital St. Hedwig of The Order of St. John, University of Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Hendrik Poeck
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Emergency Department, University Hospital Regensburg, Regensburg, Germany.,Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Jürgen J Wenzel
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany.,Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
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Schmidt M, Fisser C, Martucci G, Abrams D, Frapard T, Popugaev K, Arcadipane A, Bromberger B, Lino G, Serra A, Rozencwajg S, Lubnow M, Petrikov S, Mueller T, Combes A, Pham T, Brodie D. Tracheostomy management in patients with severe acute respiratory distress syndrome receiving extracorporeal membrane oxygenation: an International Multicenter Retrospective Study. Crit Care 2021; 25:238. [PMID: 34233748 PMCID: PMC8261805 DOI: 10.1186/s13054-021-03649-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/21/2021] [Indexed: 01/19/2023]
Abstract
Background Current practices regarding tracheostomy in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. Our objectives were to assess the prevalence and the association between the timing of tracheostomy (during or after ECMO weaning) and related complications, sedative, and analgesic use. Methods International, multicenter, retrospective study in four large volume ECMO centers during a 9-year period. Results Of the 1,168 patients treated with ECMO for severe ARDS (age 48 ± 16 years, 76% male, SAPS II score 51 ± 18) during the enrollment period, 353 (30%) and 177 (15%) underwent tracheostomy placement during or after ECMO, respectively. Severe complications were uncommon in both groups. Local bleeding within 24 h of tracheostomy was four times more frequent during ECMO (25 vs 7% after ECMO, p < 0.01). Cumulative sedative consumption decreased more rapidly after the procedure with sedative doses almost negligible 48–72 h later, when tracheostomy was performed after ECMO decannulation (p < 0.01). A significantly increased level of consciousness was observed within 72 h after tracheostomy in the “after ECMO” group, whereas it was unchanged in the “during-ECMO” group. Conclusion In contrast to patients undergoing tracheostomy after ECMO decannulation, tracheostomy during ECMO was neither associated with a decrease in sedation and analgesia levels nor with an increase in the level of consciousness. This finding together with a higher risk of local bleeding in the days following the procedure reinforces the need for a case-by-case discussion on the balance between risks and benefits of tracheotomy when performed during ECMO. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03649-8.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Université, Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France. .,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Gennaro Martucci
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Darryl Abrams
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas Frapard
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Konstantin Popugaev
- Sklifosovsky Research Institute of Emergency Medicine, Bolshaya Sukharevskaya squire, 3, Moscow, Russia
| | - Antonio Arcadipane
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Bianca Bromberger
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Giovanni Lino
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Alexis Serra
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Sacha Rozencwajg
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Sergey Petrikov
- Sklifosovsky Research Institute of Emergency Medicine, Bolshaya Sukharevskaya squire, 3, Moscow, Russia
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alain Combes
- Sorbonne Université, Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Tài Pham
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Poschenrieder F, Meiler S, Lubnow M, Zeman F, Rennert J, Scharf G, Schaible J, Stroszczynski C, Pfeifer M, Hamer OW. Severe COVID-19 pneumonia: Perfusion analysis in correlation with pulmonary embolism and vessel enlargement using dual-energy CT data. PLoS One 2021; 16:e0252478. [PMID: 34101734 PMCID: PMC8186798 DOI: 10.1371/journal.pone.0252478] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Gas exchange in COVID-19 pneumonia is impaired and vessel obstruction has been suspected to cause ventilation-perfusion mismatch. Dual-energy CT (DECT) can depict pulmonary perfusion by regional assessment of iodine uptake. OBJECTIVE The purpose of this study was the analysis of pulmonary perfusion using dual-energy CT in a cohort of 27 consecutive patients with severe COVID-19 pneumonia. METHOD We retrospectively analyzed pulmonary perfusion with DECT in 27 consecutive patients (mean age 57 years, range 21-73; 19 men and 8 women) with severe COVID-19 pneumonia. Iodine uptake (IU) in regions-of-interest placed into normally aerated lung, ground-glass opacifications (GGO) and consolidations was measured using a dedicated postprocessing software. Vessel enlargement (VE) within opacifications and presence of pulmonary embolism (PE) was assessed by subjective analysis. Linear mixed models were used for statistical analyses. RESULTS Compared to normally aerated lung 106/151 (70.2%) opacifications without upstream PE demonstrated an increased IU, 9/151 (6.0%) an equal IU and 36/151 (23.8%) a decreased IU. The estimated mean iodine uptake (EMIU) in opacifications without upstream PE (GGO 1.77 mg/mL; 95%-CI: 1.52-2.02; p = 0.011, consolidations 1.82 mg/mL; 95%-CI: 1.56-2.08, p = 0.006) was significantly higher compared to normal lung (1.22 mg/mL; 95%-CI: 0.95-1.49). In case of upstream PE, EMIU of opacifications (combined GGO and consolidations) was significantly decreased compared to normal lung (0.52 mg/mL; 95%-CI: -0.07-1.12; p = 0.043). The presence of VE in opacifications correlated significantly with iodine uptake (p<0.001). CONCLUSIONS DECT revealed the opacifications in a subset of patients with severe COVID-19 pneumonia to be perfused non-uniformly with some being hypo- and others being hyperperfused. Mean iodine uptake in opacifications (both ground-glass and consolidation) was higher compared to normally aerated lung except for areas with upstream pulmonary embolism. Vessel enlargement correlated with iodine uptake: In summary, in a cohort of 27 consecutive patients with severe COVID-19 pneumonia, dual-energy CT demonstrated a wide range of iodine uptake in pulmonary ground-glass opacifications and consolidations as a surrogate marker for hypo- and hyperperfusion compared to normally aerated lung. Applying DECT to determine which pathophysiology is predominant might help to tailor therapy to the individual patient´s needs.
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Affiliation(s)
| | - Stefanie Meiler
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, Regensburg University Medical Center, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, Regensburg University Medical Center, Regensburg, Germany
| | - Janine Rennert
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Gregor Scharf
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Jan Schaible
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | | | - Michael Pfeifer
- Department of Internal Medicine II, Regensburg University Medical Center, Regensburg, Germany
- Department of Pneumology, Donaustauf Hospital, Donaustauf, Germany
| | - Okka W. Hamer
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
- Department of Radiology, Donaustauf Hospital, Donaustauf, Germany
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Malfertheiner MV, Koch A, Fisser C, Millar JE, Maier LS, Zeman F, Poschenrieder F, Lubnow M, Philipp A, Müller T. Incidence of early intra-cranial bleeding and ischaemia in adult veno-arterial extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation patients: a retrospective analysis of risk factors. Perfusion 2021; 35:8-17. [PMID: 32397881 DOI: 10.1177/0267659120907438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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
BACKGROUND Cerebral complications in veno-arterial extracorporeal membrane oxygenation are known to have a strong impact on mortality and morbidity. Aim of this study is to investigate the early incidence, risk factors and in-hospital mortality of intra-cranial ischaemia and haemorrhage in adults undergoing veno-arterial extracorporeal membrane oxygenation treatment. METHODS This study is a single-centre retrospective analysis on adult patients undergoing veno-arterial extracorporeal membrane oxygenation for different indications. The inclusion criterion included patients with early routine cerebral computed tomography imaging during extracorporeal membrane oxygenation, with no clinical evidence of cerebral pathology prior to cannulation. Cerebral complications were grouped by aetiology and the territories of the brain's supplying arteries. RESULTS One hundred eighty-seven adult patients with a total of 190 veno-arterial extracorporeal membrane oxygenation treatments were included. A total of 16.3% (n = 31) had evidence of either cerebral ischaemia (11.1%) or haemorrhage (5.8%); one patient suffered from both. Cerebral computed tomography scans were performed early in median on the first day after extracorporeal membrane oxygenation cannulation; in-hospital mortality of intra-cranial ischaemia and haemorrhage was 71.4% and 45.5%, respectively. Associated with an increased risk for ischaemic lesions were cannulation of the ascending aorta, higher age, presence of an autoimmune disease and cardiac surgery prior to veno-arterial extracorporeal membrane oxygenation. An association with haemorrhagic lesions was found for a lower blood PaCO2 at 2 hours, lower blood flow through the extracorporeal membrane oxygenation device at 2 hours, higher international normalized ratio and constantly higher activated partial thromboplastin time values as well as higher mean arterial pressures until haemorrhagic lesions were evident. CONCLUSION Cerebral complications are frequent in patients on veno-arterial extracorporeal membrane oxygenation and may be clinically silent events. Careful monitoring with routine neuroimaging seems to be the most appropriate diagnostic approach at present. Intra-cranial ischaemia occurs more frequent than haemorrhage and is associated with cannulation of the aorta ascendens.
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Affiliation(s)
| | - Andrea Koch
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jonathan Edward Millar
- Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Lars Sigfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Fisser C, Winkler M, Malfertheiner MV, Philipp A, Foltan M, Lunz D, Zeman F, Maier LS, Lubnow M, Müller T. Argatroban versus heparin in patients without heparin-induced thrombocytopenia during venovenous extracorporeal membrane oxygenation: a propensity-score matched study. Crit Care 2021; 25:160. [PMID: 33910609 PMCID: PMC8081564 DOI: 10.1186/s13054-021-03581-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/19/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND During venovenous extracorporeal membrane oxygenation (vvECMO), direct thrombin inhibitors are considered by some potentially advantageous over unfractionated heparin (UFH). We tested the hypothesis that Argatroban is non-inferior to UFH regarding thrombosis and bleeding during vvECMO. METHODS We conducted a propensity-score matched observational non-inferiority study of consecutive patients without heparin-induced-thrombocytopenia (HIT) on vvECMO, treated between January 2006 and March 2019 in the medical intensive care unit at the University Hospital Regensburg. Anticoagulation was realized with UFH until August 2017 and with Argatroban from September 2017 onwards. Target activated partial thromboplastin time was 50 ± 5seconds in both groups. Primary composite endpoint was major thrombosis and/or major bleeding. Major bleeding was defined as a drop in hemoglobin of ≥ 2 g/dl/day or in transfusion of ≥ 2 packed red cells/24 h, or retroperitoneal, cerebral, or pulmonary bleeding. Major thrombosis was defined as obstruction of > 50% of the vessel lumen diameter by means of duplex sonography. We also assessed technical complications such as oxygenator defects or pump head thrombosis, the time-course of platelets, and the cost of anticoagulation (including HIT-testing). RESULTS Out of 465 patients receiving UFH, 78 were matched to 39 patients receiving Argatroban. The primary endpoint occurred in 79% of patients in the Argatroban group and in 83% in the UFH group (non-inferiority for Argatroban, p = 0.026). The occurrence of technical complications was equally distributed (Argatroban 49% vs. UFH 42%, p = 0.511). The number of platelets was similar in both groups before ECMO therapy but lower in the UFH group after end of ECMO support (median [IQR]: 141 [104;198]/nl vs. 107 [54;171]/nl, p = 0.010). Anticoagulation costs per day of ECMO were higher in the Argatroban group (€26 [13.8;53.0] vs. €0.9 [0.5;1.5], p < 0.001) but not after accounting for blood products and HIT-testing (€63 [42;171) vs. €40 [17;158], p = 0.074). CONCLUSION In patients without HIT on vvECMO, Argatroban was non-inferior to UFH regarding bleeding and thrombosis. The occurrence of technical complications was similarly distributed. Argatroban may have less impact on platelet decrease during ECMO, but this finding needs further evaluation. Direct drug costs were higher for Argatroban but comparable to UFH after accounting for HIT-testing and transfusions.
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Affiliation(s)
- Christoph Fisser
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Maren Winkler
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Maximilian V Malfertheiner
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Schießer S, Hitzenbichler F, Kees MG, Kratzer A, Lubnow M, Salzberger B, Kees F, Dorn C. Measurement of Free Plasma Concentrations of Beta-Lactam Antibiotics: An Applicability Study in Intensive Care Unit Patients. Ther Drug Monit 2021; 43:264-270. [PMID: 33086362 DOI: 10.1097/ftd.0000000000000827] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The antibacterial effect of antibiotics is linked to the free drug concentration. This study investigated the applicability of an ultrafiltration method to determine free plasma concentrations of beta-lactam antibiotics in ICU patients. METHODS Eligible patients included adult ICU patients treated with ceftazidime (CAZ), meropenem (MEM), piperacillin (PIP)/tazobactam (TAZ), or flucloxacillin (FXN) by continuous infusion. Up to 2 arterial blood samples were drawn at steady state. Patients could be included more than once if they received another antibiotic. Free drug concentrations were determined by high-performance liquid chromatography with ultraviolet detection after ultrafiltration, using a method that maintained physiological conditions (pH 7.4/37°C). Total drug concentrations were determined to calculate the unbound fraction. In a post-hoc analysis, free concentrations were compared with the target value of 4× the epidemiological cut-off value (ECOFF) for Pseudomonas aeruginosa as a worst-case scenario for empirical therapy with CAZ, MEM or PIP/tazobactam and against methicillin-sensitive Staphylococcus aureus for targeted therapy with FXN. RESULTS Fifty different antibiotic treatment periods in 38 patients were evaluated. The concentrations of the antibiotics showed a wide range because of the fixed dosing regimen in a mixed population with variable kidney function. The mean unbound fractions (fu) of CAZ, MEM, and PIP were 102.5%, 98.4%, and 95.7%, with interpatient variability of <6%. The mean fu of FXN was 11.6%, with interpatient variability of 39%. It was observed that 2 of 12 free concentrations of CAZ, 1 of 40 concentrations of MEM, and 11 of 23 concentrations of PIP were below the applied target concentration of 4 × ECOFF for P. aeruginosa. All concentrations of FXN (9 samples from 6 patients) were >8 × ECOFF for methicillin-sensitive Staphylococcus aureus. CONCLUSIONS For therapeutic drug monitoring purposes, measuring total or free concentrations of CAZ, MEM, or PIP is seemingly adequate. For highly protein-bound beta-lactams such as FXN, free concentrations should be favored in ICU patients with prevalent hypoalbuminemia.
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Affiliation(s)
- Selina Schießer
- Departments of Infection Prevention and Infectious Diseases and
| | | | | | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg
| | | | - Frieder Kees
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
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Steiger T, Philipp A, Hiller KA, Müller T, Lubnow M, Lehle K. Different mechanisms of oxygenator failure and high plasma von Willebrand factor antigen influence success and survival of venovenous extracorporeal membrane oxygenation. PLoS One 2021; 16:e0248645. [PMID: 33735282 PMCID: PMC7971568 DOI: 10.1371/journal.pone.0248645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Failure of membrane oxygenator (MO) function of venovenous extracorporeal membrane oxygenators (VV ECMO) remains problematic. The development of device-induced coagulation disorder (COD) or worsened gas transfer (WGT) necessitates a system exchange. The aim was to correlate von Willebrand factor antigen (vWF:Ag) with the predisposition to MO failure and mortality. METHODS Laboratory parameters (inflammation, coagulation) and ECMO-related data from 31 VV ECMO patients were analyzed before and after the first MO exchange. Study groups were identified according to the exchange reasons (COD, WGT) and the extent of vWF:Ag (low, ≤425%; high, >425%). RESULTS vWF:Ag remained unchanged after system exchange. High vWF:Ag was associated with systemic endothelial activation of older and obese patients with elevated SOFA score, increased norepinephrine and higher requirement of continuous renal replacement therapy without an effect on MO runtime and mortality. Including the mechanism of MO failure (COD, WGT), various patient group emerged. COD/low vWF:Ag summarized younger and less critically ill patients that benefit mainly from ECMO by a significant improvement of their inflammatory and coagulation status (CRP, D-dimers, fibrinogen) and highest survival rate (91%). Instead, WGT/high vWF:Ag presented older and more obese patients with a two-digit SOFA score, highest norepinephrine, and aggravated gas transfer. They benefited temporarily from system exchange but with worst survival (33%). CONCLUSIONS vWF:Ag levels alone cannot predict early MO failure and outcome in VV ECMO patients. Probably, the mechanism of clotting disorder in combination with the vWF:Ag level seems to be essential for clot formation within the MO. In addition, vWF:Ag levels allows the identification different patient populations In particular, WGT/high vWF:Ag represented a critically ill population with higher ECMO-associated mortality.
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Affiliation(s)
- Tamara Steiger
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Karl-Anton Hiller
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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Dreier E, Malfertheiner MV, Dienemann T, Fisser C, Foltan M, Geismann F, Graf B, Lunz D, Maier LS, Müller T, Offner R, Peterhoff D, Philipp A, Salzberger B, Schmidt B, Sinner B, Lubnow M. ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors. Perfusion 2021. [PMID: 33612020 DOI: 10.1177/0267659121995997]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy. METHODS A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed. RESULTS Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8-32.1) ml/cmH2O vs 18.7 (17.7-25.0) ml/cmH2O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16-23) days vs 5 (5-9) days, p = 0.002) and SOFA score was higher (12.0 (10.5-17.0) vs 10.0 (9.0-10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome. CONCLUSIONS VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.
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Affiliation(s)
- Esther Dreier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Siegfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Sinner
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Dreier E, Malfertheiner MV, Dienemann T, Fisser C, Foltan M, Geismann F, Graf B, Lunz D, Maier LS, Müller T, Offner R, Peterhoff D, Philipp A, Salzberger B, Schmidt B, Sinner B, Lubnow M. ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors. Perfusion 2021; 36:582-591. [PMID: 33612020 PMCID: PMC8369905 DOI: 10.1177/0267659121995997] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [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] [Indexed: 12/14/2022]
Abstract
Background: The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy. Methods: A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed. Results: Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8–32.1) ml/cmH2O vs 18.7 (17.7–25.0) ml/cmH2O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16–23) days vs 5 (5–9) days, p = 0.002) and SOFA score was higher (12.0 (10.5–17.0) vs 10.0 (9.0–10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome. Conclusions: VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.
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Affiliation(s)
- Esther Dreier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Siegfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Sinner
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Peterhoff D, Glück V, Vogel M, Schuster P, Schütz A, Neubert P, Albert V, Frisch S, Kiessling M, Pervan P, Werner M, Ritter N, Babl L, Deichner M, Hanses F, Lubnow M, Müller T, Lunz D, Hitzenbichler F, Audebert F, Hähnel V, Offner R, Müller M, Schmid S, Burkhardt R, Glück T, Koller M, Niller HH, Graf B, Salzberger B, Wenzel JJ, Jantsch J, Gessner A, Schmidt B, Wagner R. A highly specific and sensitive serological assay detects SARS-CoV-2 antibody levels in COVID-19 patients that correlate with neutralization. Infection 2021; 49:75-82. [PMID: 32827125 PMCID: PMC7441844 DOI: 10.1007/s15010-020-01503-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic challenges national health systems and the global economy. Monitoring of infection rates and seroprevalence can guide public health measures to combat the pandemic. This depends on reliable tests on active and former infections. Here, we set out to develop and validate a specific and sensitive enzyme linked immunosorbent assay (ELISA) for detection of anti-SARS-CoV-2 antibody levels. METHODS In our ELISA, we used SARS-CoV-2 receptor-binding domain (RBD) and a stabilized version of the spike (S) ectodomain as antigens. We assessed sera from patients infected with seasonal coronaviruses, SARS-CoV-2 and controls. We determined and monitored IgM-, IgA- and IgG-antibody responses towards these antigens. In addition, for a panel of 22 sera, virus neutralization and ELISA parameters were measured and correlated. RESULTS The RBD-based ELISA detected SARS-CoV-2-directed antibodies, did not cross-react with seasonal coronavirus antibodies and correlated with virus neutralization (R2 = 0.89). Seroconversion started at 5 days after symptom onset and led to robust antibody levels at 10 days after symptom onset. We demonstrate high specificity (99.3%; N = 1000) and sensitivity (92% for IgA, 96% for IgG and 98% for IgM; > 10 days after PCR-proven infection; N = 53) in serum. CONCLUSIONS With the described RBD-based ELISA protocol, we provide a reliable test for seroepidemiological surveys. Due to high specificity and strong correlation with virus neutralization, the RBD ELISA holds great potential to become a preferred tool to assess thresholds of protective immunity after infection and vaccination.
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Affiliation(s)
- David Peterhoff
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany.
| | - Vivian Glück
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Vogel
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Philipp Schuster
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Anja Schütz
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Philip Neubert
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Veruschka Albert
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Stefanie Frisch
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Mara Kiessling
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Philip Pervan
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Maren Werner
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Nicole Ritter
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Leon Babl
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Maria Deichner
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
- Emergency Department, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Florian Hitzenbichler
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | | | - Viola Hähnel
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | | | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Hans Helmut Niller
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Jürgen J Wenzel
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Jonathan Jantsch
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - André Gessner
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany.
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany.
| | - Ralf Wagner
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany.
- Institute for Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany.
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Evert K, Dienemann T, Brochhausen C, Lunz D, Lubnow M, Ritzka M, Keil F, Trummer M, Scheiter A, Salzberger B, Reischl U, Boor P, Gessner A, Jantsch J, Calvisi DF, Evert M, Schmidt B, Simon M. Autopsy findings after long-term treatment of COVID-19 patients with microbiological correlation. Virchows Arch 2021; 479:97-108. [PMID: 33471172 PMCID: PMC7816067 DOI: 10.1007/s00428-020-03014-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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: 11/18/2020] [Revised: 12/22/2020] [Accepted: 12/27/2020] [Indexed: 12/11/2022]
Abstract
Between April and June 2020, i.e., during the first wave of pandemic coronavirus disease 2019 (COVID-19), 55 patients underwent long-term treatment in the intensive care unit at the University Hospital of Regensburg. Most of them were transferred from smaller hospitals, often due to the need for an extracorporeal membrane oxygenation system. Autopsy was performed in 8/17 COVID-19-proven patients after long-term treatment (mean: 33.6 days). Autopsy revealed that the typical pathological changes occurring during the early stages of the disease (e.g., thrombosis, endothelitis, capillaritis) are less prevalent at this stage, while severe diffuse alveolar damage and especially coinfection with different fungal species were the most conspicuous finding. In addition, signs of macrophage activation syndrome was detected in 7 of 8 patients. Thus, fungal infections were a leading cause of death in our cohort of severely ill patients and may alter clinical management of patients, particularly in long-term periods of treatment.
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Affiliation(s)
- Katja Evert
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Dirk Lunz
- Department of Medicine II, University Medical Centre, Regensburg, Germany
| | - Matthias Lubnow
- Department of Anesthesiology and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Markus Ritzka
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Felix Keil
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Matthias Trummer
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Alexander Scheiter
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Udo Reischl
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Peter Boor
- Institute of Pathology, University Hospital Aachen, RWTH Aachen, Aachen, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Jonathan Jantsch
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Diego F Calvisi
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Matthias Evert
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Michaela Simon
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
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Lubnow M, Schmidt B, Fleck M, Salzberger B, Müller T, Peschel G, Schneckenpointner R, Lange T, Hitzenbichler F, Kieninger M, Lunz D, Graf B, Brochhausen C, Weber F, Lüke F, Peterhoff D, Schuster P, Hiergeist A, Offner R, Hehr U, Wallner S, Hanses F, Schmid S, Weigand K, Geismann F, Poeck H, Pukrop T, Evert M, Gessner A, Burkhardt R, Herr W, Maier LS, Heudobler D. Secondary hemophagocytic lymphohistiocytosis and severe liver injury induced by hepatic SARS-CoV-2 infection unmasking Wilson's disease: Balancing immunosuppression. Int J Infect Dis 2021; 103:624-627. [PMID: 33412272 PMCID: PMC7781512 DOI: 10.1016/j.ijid.2020.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/05/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 11/12/2022] Open
Abstract
A 21-year-old woman was hospitalized due to coronavirus disease 2019 (COVID-19)-associated respiratory and hepatic impairment concomitant with severe hemolytic anemia. Upon diagnosis of secondary hemophagocytic lymphohistiocytosis, immunosuppression with anakinra and steroids was started, leading to a hepatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and viremia. Subsequent liver biopsy revealed virus particles in hepatocytes by electron microscopy and SARS-CoV-2 virus could be isolated and cultured. Immunosuppression was stopped and convalescent donor plasma given. In the differential diagnosis, an acute crisis of Wilson’s disease was raised by laboratory and genetic testing. This case highlights the complexity of balancing immunosuppression to control hyperinflammation versus systemic SARS-CoV-2 dissemination.
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Affiliation(s)
- Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.
| | - Barbara Schmidt
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany; Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Martin Fleck
- Department of Rheumatology, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Georg Peschel
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | | | - Tobias Lange
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Florian Weber
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Florian Lüke
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Philipp Schuster
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Andreas Hiergeist
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Ute Hehr
- Institute for Human Genetics, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Wallner
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany; Department of Emergency Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Kilian Weigand
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Hendrik Poeck
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany; Bavarian Center for Cancer Research, Regensburg, Germany
| | - Matthias Evert
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Andre Gessner
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Heudobler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany; Bavarian Center for Cancer Research, Regensburg, Germany.
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45
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Lassen CL, Philipp A, Akyol D, Brueckner K, Judemann K, Lubnow M, Lunz D. Out-of-center Initiation of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients. ASAIO J 2021; 67:4-6. [PMID: 33346987 DOI: 10.1097/mat.0000000000001271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Christoph L Lassen
- From the Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
| | - Derya Akyol
- From the Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
| | - Kerstin Brueckner
- From the Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
| | - Katrin Judemann
- From the Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center of Regensburg, Regensburg, Germany
| | - Dirk Lunz
- From the Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
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46
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Fisser C, Wiest C, Hamer OW, Müller T, Lubnow M, Pfeifer M, Lerzer C, Dvorak I. Die Diagnose liegt auf der Hand. Pneumologie 2020; 74:780-786. [DOI: 10.1055/a-1177-4209] [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: 10/23/2022]
Abstract
ZusammenfassungEine seltene Form der Dermatomyositis ist die klinische amyopathische Dermatomyositis (CADM). Charakterisiert ist sie durch das Fehlen einer bzw. durch eine nur sehr gering ausgeprägte Muskelbeteiligung. Dementsprechend sind die Kreatinkinase-Werte meist im Normalbereich. Typische Hautmanifestationen sind Gottron-Papeln und Mechanikerhände. Bei Nachweis eines MDa5 (Melanoma-differentiation-associated gene 5 intracellular pathogen sensor)-Antikörpers ist die CADM häufig mit einer rasch progredienten und schweren Verlaufsform einer interstitiellen Lungenerkrankung assoziiert. In der Lungenfunktion lässt sich eine Restriktion und eine Hypoxämie unterschiedlichen Ausmaßes nachweisen. Die HRCT-Bildgebung ist nicht spezifisch. Es lassen sich u. a. Milchglas, Retikulationen und Konsolidierungen beobachten. In der bronchioloalveolären Lavage zeigen sich gelegentlich vermehrt Lymphozyten. Histologisch ähnelt das Bild einer nicht-spezifischen interstitiellen Pneumonie oder einer organisierenden Pneumonie. Die Therapie richtet sich nach der Schwere der Ausprägung der klinischen Manifestation. Im Allgemeinen ist eine ausgeprägte immunsuppressive Therapie notwendig. Meist müssen verschiedene Immunsuppressiva kombiniert werden. Ein neuer Therapieansatz stellt die Verwendung des Januskinase-Inhibitors Tofacitinib dar. Zur Therapiekontrolle können der Ferritinspiegel und der MDa5-Antikörper-Titer verwendet werden. Es besteht eine hohe Mortalität von bis zu 84 %.
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Affiliation(s)
- C. Fisser
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - C. Wiest
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - O. W. Hamer
- Institut für Röntgendiagnostik, Universitätsklinik Regensburg, Regensburg
- Abteilung für Radiologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - T. Müller
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Lubnow
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
| | - M. Pfeifer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
- Abteilung für Pneumologie, Krankenhaus der Barmherzigen Brüder Regensburg, Regensburg
| | - C. Lerzer
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
| | - I. Dvorak
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
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47
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Lüke F, Orsó E, Kirsten J, Poeck H, Grube M, Wolff D, Burkhardt R, Lunz D, Lubnow M, Schmidt B, Hitzenbichler F, Hanses F, Salzberger B, Evert M, Herr W, Brochhausen C, Pukrop T, Reichle A, Heudobler D. Coronavirus disease 2019 induces multi-lineage, morphologic changes in peripheral blood cells. ACTA ACUST UNITED AC 2020; 1:376-383. [PMID: 32838398 PMCID: PMC7361732 DOI: 10.1002/jha2.44] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 06/07/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023]
Abstract
The clinical course of coronavirus disease 2019 (COVID‐19) varies from mild symptoms to acute respiratory distress syndrome, hyperinflammation, and coagulation disorder. The hematopoietic system plays a critical role in the observed hyperinflammation, particularly in severely ill patients. We conducted a prospective diagnostic study performing a blood differential analyzing morphologic changes in peripheral blood of COVID‐19 patients. COVID‐19 associated morphologic changes were defined in a training cohort and subsequently validated in a second cohort (n = 45). Morphologic aberrations were further analyzed by electron microscopy (EM) and flow cytometry of lymphocytes was performed. We included 45 COVID‐19 patients in our study (median age 58 years; 82% on intensive care unit). The blood differential showed a specific pattern of pronounced multi‐lineage aberrations in lymphocytes (80%) and monocytes (91%) of patients. Overall, 84%, 98%, and 98% exhibited aberrations in granulopoiesis, erythropoiesis, and thrombopoiesis, respectively. Electron microscopy revealed the ultrastructural equivalents of the observed changes and confirmed the multi‐lineage aberrations already seen by light microscopy. The morphologic pattern caused by COVID‐19 is characteristic and underlines the serious perturbation of the hematopoietic system. We defined a hematologic COVID‐19 pattern to facilitate further independent diagnostic analysis and to investigate the impact on the hematologic system during the clinical course of COVID‐19 patients.
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Affiliation(s)
- Florian Lüke
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Evelyn Orsó
- Institute for Clinical Chemistry and Laboratory Medicine University Hospital Regensburg Regensburg Germany
| | - Jana Kirsten
- Institute for Clinical Chemistry and Laboratory Medicine University Hospital Regensburg Regensburg Germany
| | - Hendrik Poeck
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Matthias Grube
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Daniel Wolff
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Ralph Burkhardt
- Institute for Clinical Chemistry and Laboratory Medicine University Hospital Regensburg Regensburg Germany
| | - Dirk Lunz
- Department of Anesthesiology University Hospital Regensburg Regensburg Germany
| | - Matthias Lubnow
- Department of Internal Medicine II University Hospital Regensburg Regensburg Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene University Hospital Regensburg Germany
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases University Hospital Regensburg Regensburg Germany
| | - Frank Hanses
- Department of Infection Prevention and Infectious Diseases University Hospital Regensburg Regensburg Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases University Hospital Regensburg Regensburg Germany
| | - Matthias Evert
- Institute of Pathology University of Regensburg Regensburg Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | | | - Tobias Pukrop
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Albrecht Reichle
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
| | - Daniel Heudobler
- Department of Internal Medicine III, Haematology and Oncology University Hospital Regensburg Regensburg Germany
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48
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Schopka S, Philipp A, Müller T, Lubnow M, Lunz D, Unterbuchner C, Rupprecht L, Keyser A, Schmid C. The impact of interleukin serum levels on the prognosis of patients undergoing venoarterial extracorporeal membrane oxygenation. Artif Organs 2020; 44:837-845. [PMID: 32043591 DOI: 10.1111/aor.13666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 10/23/2019] [Revised: 12/31/2019] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
Abstract
Extracorporeal life support is increasingly used in the treatment of patients presenting with cardiogenic shock or in need of cardiopulmonary resuscitation. Identifying therapeutic targets and factors associated with the prognosis are highly desirable. The present study analyzed the impact of interleukin 6 and 8 on the outcome of patients undergoing venoarterial extracorporeal membrane oxygenation (VA ECMO). Interleukin 6 and 8 serum levels of 329 patients were analyzed prior to, on days 1 and 5 of VA ECMO therapy. Interleukin 6 and 8 serum levels of surviving and nonsurviving patients were compared. At time points with significant differences, receiver operating characteristics and cutoff levels were analyzed to determine the prognostic value of interleukin serum levels. Survival analysis was performed to compare patients above and below cutoff levels. Interleukin 6 serum levels were significantly elevated in nonsurviving patients prior to VA ECMO initiation. Interleukin 6 and 8 serum levels in nonsurviving patients were significantly elevated on day 1 of VA ECMO. Receiver operating characteristics analysis revealed significant prognostic impact of interleukin 6 and 8 on day 1 of VA ECMO (AUC 0.70 and 0.72). Survival analysis comparing patients above and below the cutoff showed a 1-year survival of 32.6% for IL6 and 20.8% for IL8 above, as well as 66.9% for IL6 and 61.9% for IL8 below the cutoff (P < .05). Interleukin 6 and 8 serum levels demonstrated prognostic value early in VA ECMO therapy. The technical applicability of interleukin reduction raises interest in interleukins 6 and 8 as therapeutic targets.
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Affiliation(s)
- Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Christoph Unterbuchner
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Keyser
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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49
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Appelt H, Philipp A, Mueller T, Foltan M, Lubnow M, Lunz D, Zeman F, Lehle K. Factors associated with hemolysis during extracorporeal membrane oxygenation (ECMO)-Comparison of VA- versus VV ECMO. PLoS One 2020; 15:e0227793. [PMID: 31986168 PMCID: PMC6984694 DOI: 10.1371/journal.pone.0227793] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022] Open
Abstract
Venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) are effective support modalities to treat critically ill patients. ECMO-associated hemolysis remains a serious complication. The aim was to disclose similarities and differences in VA- and VV ECMO-associated hemolysis. This is a retrospective single-center analysis (January 2012 to September 2018) including 1,063 adult consecutive patients (VA, n = 606; VV, n = 457). Severe hemolysis (free plasma hemoglobin, fHb > 500 mg/l) during therapy occurred in 4% (VA) and 2% (VV) (p≤0.001). VV ECMO showed significantly more hemolysis by pump head thrombosis (PHT) compared to VA ECMO (9% vs. 2%; p≤0.001). Pretreatments (ECPR, cardiac surgery) of patients who required VA ECMO caused high fHb pre levels which aggravates the proof of ECMO-induced hemolysis (median (interquartile range), VA: fHb pre: 225.0 (89.3–458.0); VV: fHb pre: 72.0 (42.0–138.0); p≤0.001). The survival rate to discharge from hospital differed depending on ECMO type (40% (VA) vs. 63% (VV); p≤0.001). Hemolysis was dominant in VA ECMO patients, mainly caused by different indications and not by the ECMO support itself. PHT was the most severe form of ECMO-induced hemolysis that occurs in both therapies with low frequency, but more commonly in VV ECMO due to prolonged support time.
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Affiliation(s)
- Hannah Appelt
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
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50
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Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2019; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [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: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
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Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium.,Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland.,UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
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