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Damlakhy A, Barham H, Omar M, Khan Z, Elkholy M. Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature. Cureus 2024; 16:e54421. [PMID: 38510887 PMCID: PMC10954315 DOI: 10.7759/cureus.54421] [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] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.
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Affiliation(s)
- Ahmad Damlakhy
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
| | - Husam Barham
- Internal Medicine, Balqa Applied University, Al-Salt, JOR
| | - Mohammad Omar
- Internal Medicine, Balqa Applied University, Al-Salt, JOR
| | - Zohaib Khan
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
| | - Montaser Elkholy
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
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2
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Hurtado S, Sepulveda V, Godoy C, Bahamondes R, Kattan E, Mendez M, Besa S. Parallel oxygenators in the same circuit for refractory hypoxemia on veno-venous extracorporeal membrane oxygenation. A 3-patient series. Perfusion 2023:2676591231220315. [PMID: 38050813 DOI: 10.1177/02676591231220315] [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: 12/07/2023]
Abstract
Extracorporeal membrane oxygenator (ECMO) is a well-established therapy for respiratory failure. Refractory hypoxemia, despite the use of ECMO, remains a challenging problem. The ECMO circuit may not provide enough oxygenation support in the presence of high cardiac output, increased physiologic demand, and impaired gas exchange. Adding a second ECMO oxygenator using the same pump (sometimes needing a second drainage cannula) can improve oxygenation and facilitate lung-protective ventilation in selected patients. We describe a 3-patient series with severe ARDS secondary to SARS-CoV-2 infection and refractory hypoxemia during ECMO support successfully treated with this approach.
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Affiliation(s)
- Sebastian Hurtado
- Division de Cirugia, Pontificia Universidad Católica, Santiago, Chile
| | | | - Cesar Godoy
- Division de Anestesia, Pontificia Universidad Católica, Santiago, Chile
| | | | - Eduardo Kattan
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica, Santiago, Chile
| | - Magdalena Mendez
- Division de Cirugia, Pontificia Universidad Católica, Santiago, Chile
| | - Santiago Besa
- Division de Cirugia, Pontificia Universidad Católica, Santiago, Chile
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3
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Akopyan K, Golubykh K, Freitas J, Mehrad B. A Chest Pain Conundrum: Dapsone-Induced Methemoglobinemia in a Heart Transplant Patient. Cureus 2023; 15:e46690. [PMID: 37942387 PMCID: PMC10629810 DOI: 10.7759/cureus.46690] [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] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
We present the case of a 39-year-old male with a past medical history of orthotopic heart transplantation who presented with chest pain and dyspnea on exertion. He was diagnosed with dapsone-induced methemoglobinemia toward the end of his hospital course, and his condition clinically improved with the discontinuation of the offending agent. This case highlights the importance of medication review and history-taking. Clinicians should be mindful of dapsone-induced methemoglobinemia, especially when encountering patients with dyspnea and a history of dapsone intake.
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Affiliation(s)
| | | | - Jared Freitas
- Pulmonology and Critical Care, University of Florida, Gainesville, USA
| | - Borna Mehrad
- Pulmonary and Critical Care Medicine, University of Florida, Gainesville, USA
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Omlor AJ, Caspari S, Omlor LS, Jungmann AM, Krawczyk M, Schmoll N, Mang S, Seiler F, Muellenbach RM, Bals R, Lepper PM. Comparison of Serial and Parallel Connections of Membrane Lungs against Refractory Hypoxemia in a Mock Circuit. Membranes (Basel) 2023; 13:809. [PMID: 37887981 PMCID: PMC10608735 DOI: 10.3390/membranes13100809] [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] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an important rescue therapy method for the treatment of severe hypoxic lung injury. In some cases, oxygen saturation and oxygen partial pressure in the arterial blood are low despite ECMO therapy. There are case reports in which patients with such instances of refractory hypoxemia received a second membrane lung, either in series or in parallel, to overcome the hypoxemia. It remains unclear whether the parallel or serial connection is more effective. Therefore, we used an improved version of our full-flow ECMO mock circuit to test this. The measurements were performed under conditions in which the membrane lungs were unable to completely oxygenate the blood. As a result, only the photometric pre- and post-oxygenator saturations, blood flow and hemoglobin concentration were required for the calculation of oxygen transfer rates. The results showed that for a pre-oxygenator saturation of 45% and a total blood flow of 10 L/min, the serial connection of two identical 5 L rated oxygenators is 17% more effective in terms of oxygen transfer than the parallel connection. Although the idea of using a second membrane lung if refractory hypoxia occurs is intriguing from a physiological point of view, due to the invasiveness of the solution, further investigations are needed before this should be used in a wider clinical setting.
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Affiliation(s)
- Albert J. Omlor
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Stefan Caspari
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Leonie S. Omlor
- Department of Anaesthesiology and Critical Care, University Hospital of Saarland, 66424 Homburg, Germany
| | - Anna M. Jungmann
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Marcin Krawczyk
- Department of Internal Medicine II, University Hospital of Saarland, 66424 Homburg, Germany
- Laboratory of Metabolic Liver Diseases, Department of General, Transplant and Liver Surgery, Centre for Preclinical Research, Medical University of Warsaw, 02091 Warsaw, Poland
| | - Nicole Schmoll
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Sebastian Mang
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Ralf M. Muellenbach
- Department of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Robert Bals
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI), 66123 Saarbrücken, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
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Simioli F, Annunziata A, Coppola A, Imitazione P, Mirizzi AI, Marotta A, D’Angelo R, Fiorentino G. The role of dexmedetomidine in ARDS: an approach to non-intensive care sedation. Front Med (Lausanne) 2023; 10:1224242. [PMID: 37720511 PMCID: PMC10502206 DOI: 10.3389/fmed.2023.1224242] [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: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Severe COVID-19 is a life-threatening condition characterized by complications such as interstitial pneumonia, hypoxic respiratory failure, and acute respiratory distress syndrome (ARDS). Non-pharmacological intervention with mechanical ventilation plays a key role in treating COVID-19-related ARDS but is influenced by a high risk of failure in more severe patients. Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that provides sedative effects with preservation of respiratory function. The aim of this study is to assess how dexmedetomidine influences gas exchange during non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) in moderate to severe ARDS caused by COVID-19 in a non-intensive care setting. Methods This is a single center retrospective cohort study. We included patients who showed moderate to severe respiratory distress. All included subjects had indication to NIV and were suitable for a non-intensive setting of care. A total of 170 patients were included, divided in a control group (n = 71) and a treatment group (DEX group, n = 99). Results A total of 170 patients were hospitalized for moderate to severe ARDS and COVID-19. The median age was 71 years, 29% females. The median Charlson comorbidity index (CCI) was 2.5. Obesity affected 21% of the study population. The median pO2/FiO2 was 82 mmHg before treatment. After treatment, the increase of pO2/FiO2 ratio was clinically and statistically significant in the DEX group compared to the controls (125 mmHg [97-152] versus 94 mmHg [75-122]; ***p < 0.0001). A significative reduction of NIV duration was observed in DEX group (10 [7-16] days vs. 13 [10-17] days; *p < 0.02). Twenty four patients required IMV in control group (n = 71) and 16 patients in DEX group (n = 99) with a reduction of endotracheal intubation of 62% (OR 0.38; **p < 0.008). A higher incidence of sinus bradycardia was observed in the DEX group. Conclusion Dexmedetomidine provides a "calm and arousal" status which allows spontaneous ventilation in awake patients treated with NIV and HFNC. The adjunctive therapy with dexmedetomidine is associated with a higher pO2/FiO2, lower duration of NIV, and a lower risk of NIV failure. A higher incidence of sinus bradycardia needs to be considered.
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Affiliation(s)
- Francesca Simioli
- Department of Respiratory Pathophysiology and Rehabilitation, Monaldi Hospital, A.O. dei Colli, Naples, Italy
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Bajon F, Gauthier V. Management of refractory hypoxemia using recruitment maneuvers and rescue therapies: A comprehensive review. Front Vet Sci 2023; 10:1157026. [PMID: 37065238 PMCID: PMC10098094 DOI: 10.3389/fvets.2023.1157026] [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: 02/02/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Refractory hypoxemia in patients with acute respiratory distress syndrome treated with mechanical ventilation is one of the most challenging conditions in human and veterinary intensive care units. When a conventional lung protective approach fails to restore adequate oxygenation to the patient, the use of recruitment maneuvers and positive end-expiratory pressure to maximize alveolar recruitment, improve gas exchange and respiratory mechanics, while reducing the risk of ventilator-induced lung injury has been suggested in people as the open lung approach. Although the proposed physiological rationale of opening and keeping open previously collapsed or obstructed airways is sound, the technique for doing so, as well as the potential benefits regarding patient outcome are highly controversial in light of recent randomized controlled trials. Moreover, a variety of alternative therapies that provide even less robust evidence have been investigated, including prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and unconventional ventilatory modes such as airway pressure release ventilation. With the exception of prone positioning, these modalities are limited by their own balance of risks and benefits, which can be significantly influenced by the practitioner's experience. This review explores the rationale, evidence, advantages and disadvantages of each of these therapies as well as available methods to identify suitable candidates for recruitment maneuvers, with a summary on their application in veterinary medicine. Undoubtedly, the heterogeneous and evolving nature of acute respiratory distress syndrome and individual lung phenotypes call for a personalized approach using new non-invasive bedside assessment tools, such as electrical impedance tomography, lung ultrasound, and the recruitment-to-inflation ratio to assess lung recruitability. Data available in human medicine provide valuable insights that could, and should, be used to improve the management of veterinary patients with severe respiratory failure with respect to their intrinsic anatomy and physiology.
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Muacevic A, Adler JR, Shrestha S, Basnet A, Seitllari A. Shunting Across a Latent Patent Foramen Ovale (PFO) in a Patient With Right Ventricular (RV) Infarction Improved With Impella. Cureus 2023; 15:e34302. [PMID: 36860226 PMCID: PMC9969903 DOI: 10.7759/cureus.34302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 01/29/2023] Open
Abstract
The right-to-left shunt (RTLS) through a latent patent foramen ovale (PFO) is a rare complication of right ventricle myocardial infarction (MI). Though a rare complication, the development of refractory hypoxemia after right ventricular MI should always alert clinicians to consider the possibility of shunting across PFO. Right-sided Impella (Impella RP) can be considered in such patients, which helps to decrease the elevated right heart pressure reducing the shunt, thereby providing a bridge to recovery.
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Phan AT, Hu J, Hasan M. Diffuse Alveolar Hemorrhage in the Setting of Cytarabine Therapy in a Critically Ill Patient. Cureus 2021; 13:e19575. [PMID: 34926047 PMCID: PMC8671050 DOI: 10.7759/cureus.19575] [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] [Accepted: 11/14/2021] [Indexed: 11/05/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening pulmonary condition characterized by hypoxemia with progression to respiratory failure, rapid onset of dyspnea, and blood loss anemia. While hemoptysis may be present and corroborates the diagnosis, it is absent in about half of the cases, resulting in a diagnostic challenge with variable presenting symptoms. Imaging findings on chest x-ray or computed tomography (CT) scans are also non-specific, often showing diffuse bilateral alveolar opacities. Because DAH is an under-recognized diagnosis, physicians should maintain a degree of clinical suspicion for DAH in patients with unexplained airspace opacities and no signs of an infectious etiology. This is especially important in higher-risk populations such as patients with hematological malignancies, who have a propensity for thrombocytopenia and coagulopathy compounded by the use of anticoagulants. Patients with hematological malignancies, namely acute myeloid leukemia (AML), are also at risk for drug-induced DAH due to the use of cytotoxic medications like cytarabine. Here, we present the case of a 48-year-old male with a past medical history of AML and myeloid sarcoma who developed shortness of breath after receiving cytarabine chemotherapy. Chest radiography revealed diffuse bilateral infiltrates. He was intubated and underwent flexible bronchoscopy, which resulted in a bloody effluent consistent with DAH. After ruling out infectious etiologies, we reached a final diagnosis of DAH and started the patient on corticosteroid therapy.
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Affiliation(s)
- Alexander T Phan
- Internal Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Janie Hu
- Internal Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Mufadda Hasan
- Pulmonary and Critical Care Medicine, Arrowhead Regional Medical Center, Colton, USA
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Tongyoo S, Permpikul C, Sucher S, Thomrongpairoj P, Poompichet A, Ratanarat R, Chierakul N. Venovenous extracorporeal membrane oxygenation versus conventional mechanical ventilation to treat refractory hypoxemia in patients with acute respiratory distress syndrome: a retrospective cohort study. J Int Med Res 2021; 48:300060520935704. [PMID: 32603248 PMCID: PMC7328063 DOI: 10.1177/0300060520935704] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective To compare the treatment outcome of venovenous extracorporeal membrane
oxygenation (VV-ECMO) versus mechanical ventilation in hypoxemic patients
with acute respiratory distress syndrome (ARDS) at a referral center that
started offering VV-EMCO support in 2010. Methods This retrospective cohort study enrolled adults with severe ARDS
(PaO2/FiO2 ratio of <100 with FiO2
of ≥90 or Murray score of ≥3) who were admitted to the intensive care unit
of Siriraj Hospital (Bangkok, Thailand) from January 2010 to December 2018.
All patients were treated using a low tidal volume (TV) and optimal positive
end-expiratory pressure. The primary outcome was hospital mortality. Results Sixty-four patients (ECMO, n = 30; mechanical ventilation, n = 34) were
recruited. There was no significant difference in the baseline
PaO2/FiO2 ratio (67.2 ± 25.7 vs.
76.6 ± 16.0), FiO2 (97 ± 9 vs. 94 ± 8), or
Murray score (3.4 ± 0.5 vs. 3.3 ± 0.5) between the ECMO and
mechanical ventilation groups. The hospital mortality rate was also not
significantly different between the two groups (ECMO, 20/30 [66.7%]
vs. mechanical ventilation, 24/34 [70.6%]). Patients
who underwent ECMO were ventilated with a significantly lower TV than
patients who underwent mechanical ventilation (3.8 ± 1.8
vs. 6.6 ± 1.4 mL, respectively). Conclusion Although VV-ECMO promoted lower-TV ventilation, it did not improve the
in-hospital mortality rate. Trial registration:www.clinicaltrials.gov (NCT 04031794).
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Affiliation(s)
- Surat Tongyoo
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chairat Permpikul
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Siwalai Sucher
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Preecha Thomrongpairoj
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Akekarin Poompichet
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ranistha Ratanarat
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nitipatana Chierakul
- Division of Respiratory Disease, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Zhou Y, Holets SR, Li M, Meyer TJ, Rangel Latuche LJ, Oeckler RA, Bohman JK. The Impact of a Standardized Refractory Hypoxemia Protocol on Outcome of Subjects Receiving Venovenous Extracorporeal Membrane Oxygenation. Respir Care 2021; 66:837-844. [PMID: 33653908 PMCID: PMC9994113 DOI: 10.4187/respcare.08584] [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: 02/05/2023]
Abstract
BACKGROUND Current mechanical ventilation practice and the use of treatment adjuncts in patients requiring extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia (RH) vary widely and their impact on outcomes remains unclear. In 2015, we implemented a standardized approach to protocolized ventilator settings and guide the escalation of adjunct therapies in patients with RH. This study aimed to investigate ICU mortality, its associated risk factors, and mechanical ventilation practice before and after the implementation of a standardized RH guideline in patients requiring venovenous ECMO (VV-ECMO). METHODS This was a single-center, retrospective cohort study of patients undergoing VV-ECMO due to RH respiratory failure between January 2008 and March 2015 (before RH protocol implementation) and between April 2015 and October 2019 (after RH protocol implementation). RESULTS A total of 103 subjects receiving VV-ECMO for RH were analyzed. After implementation of the RH protocol, more subjects received prone positioning (6.7% vs 23.3%, P = .02), and fewer received high-frequency oscillatory ventilation than before launching the RH protocol (0% vs 13.3%, P = .01). Plateau pressure was also lower before initiation of ECMO (P = .04) and at day 1 during ECMO (P = .045). Driving pressure was consistently lower at days 1, 2, and 3 after ECMO initiation: median 13.0 (interquartile range [IQR] 10.6-18.0) vs 16.0 (IQR 14.0-20.0) cm H2O at day 1 (P = .003); 13.0 (IQR 11.0-15.9) vs 15.5 (IQR 12.0-20.0) cm H2O at day 2 (P = .03); and 12.0 (IQR 10.0-14.5) vs 15.0 (IQR 12.0-19.0) cm H2O at day 3 (P = .005). CONCLUSIONS The implementation of a standardized RH guideline improved compliance with a lung-protective ventilation strategy and utilization of the prone position and was associated with lower driving pressure during the first 3 days after ECMO initiation in subjects with refractory hypoxemia.
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Affiliation(s)
- Yongfang Zhou
- Department of Critical Care Medicine, West China Hospital, Chengdu, Sichuan, China
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Respiratory Therapy, Mayo Clinic, Rochester, Minnesota
| | - Steven R Holets
- Department of Respiratory Therapy, Mayo Clinic, Rochester, Minnesota
| | - Man Li
- Department of Information Technology, Mayo Clinic, Rochester, Minnesota
| | - Todd J Meyer
- Department of Respiratory Therapy, Mayo Clinic, Rochester, Minnesota
| | | | - Richard A Oeckler
- Department of Critical Care Medicine, West China Hospital, Chengdu, Sichuan, China
| | - John K Bohman
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota.
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DeGrado JR, Szumita PM, Schuler BR, Dube KM, Lenox J, Kim EY, Weinhouse GL, Massaro AF. Evaluation of the Efficacy and Safety of Inhaled Epoprostenol and Inhaled Nitric Oxide for Refractory Hypoxemia in Patients With Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0259. [PMID: 33134949 PMCID: PMC7581066 DOI: 10.1097/cce.0000000000000259] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate the efficacy and safety of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019. DESIGN Retrospective single-center study. SETTING ICUs at a large academic medical center in the United States. PATIENTS Thirty-eight adult critically ill patients with coronavirus disease 2019 and refractory hypoxemia treated with either inhaled epoprostenol or inhaled nitric oxide for at least 1 hour between March 1, 2020, and June 30, 2020. INTERVENTIONS Electronic chart review. MEASUREMENTS AND MAIN RESULTS Of 93 patients screened, 38 were included in the analysis, with mild (4, 10.5%), moderate (24, 63.2%), or severe (10, 26.3%), with acute respiratory distress syndrome. All patients were initiated on inhaled epoprostenol as the initial pulmonary vasodilator and the median time from intubation to initiation was 137 hours (68-228 h). The median change in Pao2/Fio2 was 0 (-12.8 to 31.6) immediately following administration of inhaled epoprostenol. Sixteen patients were classified as responders (increase Pao2/Fio2 > 10%) to inhaled epoprostenol, with a median increase in Pao2/Fio2 of 34.1 (24.3-53.9). The mean change in Pao2 and Spo2 was -0.55 ± 41.8 and -0.6 ± 4.7, respectively. Eleven patients transitioned to inhaled nitric oxide with a median change of 11 (3.6-24.8) in Pao2/Fio2. A logistic regression analysis did not identify any differences in outcomes or characteristics between the responders and the nonresponders. Minimal adverse events were seen in patients who received either inhaled epoprostenol or inhaled nitric oxide. CONCLUSIONS We found that the initiation of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019, on average, did not produce significant increases in oxygenation metrics. However, a group of patients had significant improvement with inhaled epoprostenol and inhaled nitric oxide. Administration of inhaled epoprostenol or inhaled nitric oxide may be considered in patients with severe respiratory failure secondary to coronavirus disease 2019.
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Affiliation(s)
| | - Paul M. Szumita
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Brian R. Schuler
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Kevin M. Dube
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA
| | - Jesslyn Lenox
- Department of Respiratory Therapy, Brigham and Women’s Hospital, Boston, MA
| | - Edy Y. Kim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Gerald L. Weinhouse
- Department of Respiratory Therapy, Brigham and Women’s Hospital, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Anthony F. Massaro
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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12
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Wang X, Tu Y, Huang B, Li Y, Li Y, Zhang S, Lin Y, Huang L, Zhang W, Luo H. Pulmonary vascular endothelial injury and acute pulmonary hypertension caused by COVID-19: the fundamental cause of refractory hypoxemia? Cardiovasc Diagn Ther 2020; 10:892-897. [PMID: 32968645 PMCID: PMC7487391 DOI: 10.21037/cdt-20-429] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 04/11/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
Coronavirus disease (COVID-19) is a severe infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that binds to the cells; angiotensin converting enzyme 2 (ACE2) receptor. In the first severe case of COVID-19 in Shenzhen city, we found that in addition to the typical clinical manifestations, our patient presented hemoptysis, refractory hypoxemia and pulmonary fibrosis-like changes on computed tomography (CT) involving alveoli and pulmonary interstitium in the early stage and acute pulmonary hypertension and right heart failure in the later stage, which were not completely justified by myocarditis, acute respiratory distress syndrome (ARDS), pulmonary fibrosis and high PEEP level. The lung compliance deterioration of this patient was not as serious as we expected, indicating classic ARDS was not existed. Simultaneously, the first autopsy report of COVID-19 in China showed normal-structured alveoli and massive thick excretion in the airway. Then, we speculated that the virus not only attacked alveolar epithelial cells, but also affected pulmonary vascular endothelial cells. Imbalance in the ACE2-RAAS- bradykinin axis and the cytokine storm could be an important mechanism leading to pathophysiological changes in pulmonary vascular and secondary refractory hypoxemia. Pulmonary vasculitis or capillaritis associated to immune damage and an inflammatory storm could exist in COVID-19 because of ground-glass opacities in the subpleural area, which are similar to connective tissue disease associated interstitial lung disease (CTD-ILD). Thus, this case elucidates new treatment measures for COVID-19.
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Affiliation(s)
- Xinxin Wang
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Yunliang Tu
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Bin Huang
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Yinfeng Li
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Yanyan Li
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Sheng Zhang
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Yingxin Lin
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Lei Huang
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Weixing Zhang
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
| | - Hua Luo
- ICU of Peking University Shenzhen Hospital, Shenzhen, China
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13
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Gallo de Moraes A, Holets SR, Tescher AN, Elmer J, Arteaga GM, Schears G, Patch RK, Bohman JK, Oeckler RA. The Clinical Effect of an Early, Protocolized Approach to Mechanical Ventilation for Severe and Refractory Hypoxemia. Respir Care 2020; 65:413-419. [PMID: 31992664 DOI: 10.4187/respcare.07243] [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] [Indexed: 11/05/2022]
Abstract
BACKGROUND ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened. METHODS Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed. RESULTS Baseline characteristics, tidal volumes, PaO2 /FIO2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H2O [IQR 6.5-19.4] vs 18 cm H2O [IQR 10-22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H2O [IQR 13-36.2] vs 12 cm H2O [IQR 9-19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83-347.2] vs 16.3 h [IQR 1-99.7], I = .02), and PaO2 /FIO2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation. CONCLUSIONS Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Steven R Holets
- Department of Respiratory Care, Mayo Clinic, Rochester, Minnesota
| | - Ann N Tescher
- Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Elmer
- Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Grace M Arteaga
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Gregory Schears
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Richard K Patch
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.,Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - John K Bohman
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Richard A Oeckler
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.
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14
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van Meenen DM, Roozeman JP, Serpa Neto A, Pelosi P, Gama de Abreu M, Horn J, Cremer OL, Paulus F, Schultz MJ. Associations between changes in oxygenation, dead space and driving pressure induced by the first prone position session and mortality in patients with acute respiratory distress syndrome. J Thorac Dis 2019; 11:5004-5013. [PMID: 32030216 DOI: 10.21037/jtd.2019.12.38] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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 Outcome prediction in acute respiratory distress syndrome (ARDS) is challenging, especially in patients with severe hypoxemia. The aim of the current study was to determine the prognostic capacity of changes in PaO2/FiO2, dead space fraction (VD/VT) and respiratory system driving pressure (ΔPRS) induced by the first prone position (PP) session in patients with ARDS. Methods This was a post hoc analysis of the conveniently-sized 'Molecular Diagnosis and Risk Stratification of Sepsis' study (MARS). The current analysis included ARDS patients who were placed in the PP. The primary endpoint was the prognostic capacity of the PP-induced changes in PaO2/FiO2, VD/VT, and ΔPRS for 28-day mortality. PaO2/FiO2, VD/VT, and ΔPRS was calculated using variables obtained in the supine position before and after completion of the first PP session. Receiving operator characteristic curves (ROC) were constructed, and sensitivity, specificity positive and negative predictive value were calculated based on the best cutoffs. Results Ninety patients were included; 28-day mortality was 46%. PP-induced changes in PaO2/FiO2 and VD/VT were similar between survivors vs. non-survivors [+83 (+24 to +137) vs. +58 (+21 to +113) mmHg, and -0.06 (-0.17 to +0.05) vs. -0.08 (-0.16 to +0.08), respectively]. PP-induced changes in ΔPRS were different between survivors vs. non-survivors [-3 (-7 to 2) vs. 0 (-3 to +3) cmH2O; P=0.03]. The area under the ROC of PP-induced changes in ΔPRS for mortality, however, was low [0.63 (95% confidence interval (CI), 0.50 to 0.75]; PP-induced changes in ΔPRS had a sensitivity and specificity of 76% and 56%, and a positive and negative predictive value of 60% and 73%. Conclusions Changes in PaO2/FiO2, VD/VT, and ΔPRS induced by the first PP session have poor prognostic capacities for 28-day mortality in ARDS patients.
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Affiliation(s)
- David M van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan-Paul Roozeman
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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15
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Abstract
ARDS is characterized by a non-cardiogenic pulmonary edema with bilateral chest radiograph opacities and hypoxemia refractory to oxygen therapy. It is a common cause of admission to the ICU due to hypoxemic respiratory failure requiring mechanical ventilation. Corticosteroids are not recommended in ARDS patients. Rescue therapies alleviate hypoxemia in patients unable to maintain reasonable oxygenation: recruitment maneuvers, prone positioning, inhaled nitric oxide, high-frequency oscillatory ventilation, and extracorporeal membrane oxygenation improve oxygenation, but their impact on mortality remains unproven. Restrictive fluid management seems to be a favorable strategy with no significant reduction in 60-d mortality. Future studies are needed to clarify the efficacy of these therapies on outcomes in patients with severe ARDS, and institution of these therapies may be considered on a case-by-case basis.
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Affiliation(s)
- Francesco Alessandri
- Sapienza University of Rome, Department of Anesthesia and Critical Care Medicine, Policlinico Umberto I, Rome, Italy.
| | - Francesco Pugliese
- Sapienza University of Rome, Department of Anesthesia and Critical Care Medicine, Policlinico Umberto I, Rome, Italy
| | - V Marco Ranieri
- Sapienza University of Rome, Department of Anesthesia and Critical Care Medicine, Policlinico Umberto I, Rome, Italy
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16
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Abstract
For the past 4 decades, the prone position has been employed as an occasional rescue option for patients with severe hypoxemia unresponsive to conventional measures applied in the supine orientation. Proning offers a high likelihood of significantly improved arterial oxygenation to well selected patients, but until the results of a convincing randomized trial were published, its potential to reduce mortality risk remained in serious doubt. Proning does not benefit patients of all disease severities and stages but may be life-saving for others. Because it requires advanced nursing skills and escalation of monitoring surveillance to deploy safely, its place as an early stage standard of care depends on the definition of that label.
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Affiliation(s)
- John J Marini
- University of Minnesota, Minneapolis, Minnesota and with the Pulmonary and Critical Care Department of Regions Hospital, St. Paul, Minnesota.
| | - Sean A Josephs
- Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio
| | - Maggie Mechlin
- Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio
| | - William E Hurford
- Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio
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17
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Abstract
INTRODUCTION Severe acute respiratory distress syndrome (ARDS) has a high mortality, and there is limited knowledge about management of severe ARDS refractory to standard therapy. Early evidence suggests that therapeutic hypothermia (TH) could be a viable treatment for acute respiratory failure. We present 2 cases where TH was successfully used to manage refractory ARDS on extracorporeal membrane oxygenation (ECMO) and a review of the literature around TH and acute respiratory failure. RESULTS We present 2 cases of ARDS secondary to H1N1 influenza and human metapneumovirus. Both patients were treated with the current evidence-based therapy for ARDS. Venovenous ECMO was used in both patients for refractory hypoxemia. Therapeutic hypothermia was applied for 24 hours with improved oxygenation. We did a review of the literature summarizing 38 patients in 10 publications where TH was successfully utilized in the treatment of acute respiratory failure. CONCLUSION Therapeutic hypothermia may be a viable salvage therapy for ARDS refractory to the current evidence-based therapy but needs further evaluation.
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Affiliation(s)
- Adam J Hayek
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Heath D White
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Shekhar Ghamande
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Christopher Spradley
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Alejandro C Arroliga
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
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18
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Abstract
In this article we propose a practical approach to the use of prone therapy for acute respiratory distress syndrome (ARDS). We have attempted to provide information to improve the understanding and implementation of prone therapy based on the literature available and our own experience. We review the basic physiology behind ARDS and the theoretical mechanism by which prone therapy can be of benefit. The findings of the most significant studies regarding prone therapy in ARDS as they pertain to its implementation are summarized. Also provided is a discussion of the nuances of utilizing prone therapy, including potential pitfalls, complications, and contraindications. The specific considerations of prone therapy in open abdomens and traumatic brain injuries are discussed as well. Finally, we supply suggested protocols for the implementation of prone therapy discussing criteria for initiation and cessation of therapy as well as addressing issues such as the use of neuromuscular blockade and nutritional supplementation.
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Affiliation(s)
- Krishna P Athota
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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19
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Patel JJ, Lipchik RJ. Systemic lupus-induced diffuse alveolar hemorrhage treated with extracorporeal membrane oxygenation: a case report and review of the literature. J Intensive Care Med 2012; 29:104-9. [PMID: 23753220 DOI: 10.1177/0885066612464335] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [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
OBJECTIVES We report the case of a 28-year-old patient with systemic lupus erythematosus (SLE) with rapid onset of dyspnea and hemoptysis found to have diffuse alveolar hemorrhage (DAH) with refractory hypoxemia successfully treated with venovenous extracorporeal membrane oxygenation (ECMO). The discussion includes clinical presentation, diagnosis, management, outcome, and a review of the available adult literature on the use of ECMO in patients with DAH. DESIGN Case report. SETTING Froedtert Hospital and the Medical College of Wisconsin. DATA SOURCES Data were collected from the patient's electronic medical record and the hospital radiology database. CONCLUSIONS Diffuse alveolar hemorrhage secondary to SLE is quite rare. The adult literature on the utilization of ECMO for DAH is limited mostly to antineutrophil cytoplasmic antibody (ANCA)-associated alveolar hemorrhage and a few reports of nonvasculitis DAH. Bleeding has been a contraindication to ECMO due to the need for systemic anticoagulation. Our case, along with a review of the literature, indicates that ECMO with anticoagulation can be safely utilized in patients with DAH. To our knowledge, this is the first reported adult case of DAH due to SLE successfully treated with ECMO.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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