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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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Simons J, Di Mauro M, Mariani S, Ravaux J, van der Horst ICC, Driessen RGH, Sels JW, Delnoij T, Brodie D, Abrams D, Mueller T, Taccone FS, Belliato M, Broman ML, Malfertheiner MV, Boeken U, Fraser J, Wiedemann D, Belohlavek J, Barrett NA, Tonna JE, Pappalardo F, Barbaro RP, Ramanathan K, MacLaren G, van Mook WNKA, Mees B, Lorusso R. Bilateral Femoral Cannulation Is Associated With Reduced Severe Limb Ischemia-Related Complications Compared With Unilateral Femoral Cannulation in Adult Peripheral Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Registry. Crit Care Med 2024; 52:80-91. [PMID: 37678211 DOI: 10.1097/ccm.0000000000006040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 09/09/2023]
Abstract
OBJECTIVES Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable. DESIGN A retrospective cohort study based on the Extracorporeal Life Support Organization registry. SETTING ECMO centers worldwide included in the Extracorporeal Life Support Organization registry. PATIENTS All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020. INTERVENTIONS Unilateral or bilateral femoral cannulation. MEASUREMENTS AND MAIN RESULTS The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral ( n = 11,965) or bilateral ( n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82-1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66-0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76-0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38-0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81-0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching. CONCLUSIONS This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality.
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Affiliation(s)
- Jorik Simons
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of UOC Anestesia e Rianimazione 2, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria
- 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Department of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
- Cardiothoracic Intensive Care, National University Health System, Singapore
- Department of School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Justine Ravaux
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Rob G H Driessen
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of UOC Anestesia e Rianimazione 2, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria
- 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Department of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
- Cardiothoracic Intensive Care, National University Health System, Singapore
- Department of School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Jan Willem Sels
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of UOC Anestesia e Rianimazione 2, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria
- 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Department of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
- Cardiothoracic Intensive Care, National University Health System, Singapore
- Department of School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Thijs Delnoij
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of UOC Anestesia e Rianimazione 2, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria
- 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- Department of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
- Cardiothoracic Intensive Care, National University Health System, Singapore
- Department of School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY
| | - Thomas Mueller
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mirko Belliato
- Department of UOC Anestesia e Rianimazione 2, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mike Lars Broman
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian V Malfertheiner
- Department of Intensive Care Medicine and Pneumology, University Hospital Regensburg, Regensburg, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria
| | - Jan Belohlavek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Joseph E Tonna
- Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
- Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Ryan P Barbaro
- Department of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
| | | | - Graeme MacLaren
- Cardiothoracic Intensive Care, National University Health System, Singapore
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Department of Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend Mees
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Rali AS, Abbasi A, Alexander PMA, Anders MM, Arachchillage DJ, Barbaro RP, Fox AD, Friedman ML, Malfertheiner MV, Ramanathan K, Riera J, Rycus P, Schellongowski P, Shekar K, Tonna JE, Zaaqoq AM. Adult Highlights From the Extracorporeal Life Support Organization Registry: 2017-2022. ASAIO J 2024; 70:1-7. [PMID: 37755405 DOI: 10.1097/mat.0000000000002038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/28/2023] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) registry captures clinical data and outcomes on patients receiving extracorporeal membrane oxygenation (ECMO) support across the globe at participating centers. It provides a very unique opportunity to benchmark outcomes and analyze the clinical course to help identify ways of improving patient outcomes. In this review, we summarize select adult ECMO articles published using the ELSO registry over the past 5 years. These articles highlight innovative utilization of the registry data in generating hypotheses for future clinical trials. Members of the ELSO Scientific Oversight Committee can be found here: https://www.elso.org/registry/socmembers.aspx .
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Affiliation(s)
- Aniket S Rali
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adeel Abbasi
- Division of Pulmonary Critical Care and Sleep, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Marc M Anders
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Deepa J Arachchillage
- Center for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Alexander D Fox
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, Indiana
| | - Maximilian V Malfertheiner
- Department of Internal Medicine, Cardiology and Pneumology, University Medical Center, Regensburg, Germany
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Center, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jordi Riera
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain
- SODIR, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Peter Schellongowski
- ICU 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah
| | - Akram M Zaaqoq
- Division of Critical Care, Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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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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Drewitz KP, Hasenpusch C, Bernardi C, Brandstetter S, Fisser C, Pielmeier K, Rohr M, Brunnthaler V, Schmidt K, Malfertheiner MV, Apfelbacher CJ. Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): feasibility of a pragmatic randomised controlled trial. BMC Anesthesiol 2023; 23:344. [PMID: 37838669 PMCID: PMC10576359 DOI: 10.1186/s12871-023-02255-1] [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: 11/21/2022] [Accepted: 08/24/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND ICU survivors often suffer from prolonged physical and mental impairments resulting in the so called "Post-Intensive Care Syndrome" (PICS). The aftercare of former ICU patients affected by PICS in particular has not been addressed sufficiently in Germany so far. The aim of this study was to evaluate the feasibility of a pragmatic randomised trial (RCT) comparing an intensive care unit (ICU) follow-up clinic intervention to usual care. METHODS This pilot study in a German university hospital evaluated the feasibility of a pragmatic RCT. Patients were assigned in a 1:1 ratio to an ICU follow-up clinic intervention or to usual care. The concept of this follow-up clinic was previously developed in a participatory process with patients, next of kin, health care professionals and researchers. We performed a process evaluation and determined acceptability, fidelity, completeness of measurement instruments and practicality as feasibility outcomes. The RCT's primary outcome (health-related quality of life) was assessed six months after ICU discharge by means of the physical component scale of the Short-Form-12 self-report questionnaire. RESULTS The pilot study was conducted from June 2020 to May 2021 with 21 and 20 participants in the intervention and control group. Principal findings related to feasibility were 85% consent rate (N = 48), 62% fidelity rate, 34% attrition rate (N = 41) and 77% completeness of outcome measurements. The primary effectiveness outcome (health-related quality of life) could be measured in 93% of participants who completed the study (N = 27). The majority of participants (85%) needed assistance with follow-up questionnaires (practicality). Median length of ICU stay was 13 days and 85% (N = 41) received mechanical ventilation, median Sequential Organ Failure Assessment Score was nine. Six-month follow-up assessment was planned for all study participants and performed for 66% (N = 41) of the participants after 197 days (median). CONCLUSION The participatory developed intervention of an ICU follow-up clinic and the pragmatic pilot RCT both seem to be feasible. We recommend to start a pragmatic RCT on the effectiveness of the ICU follow-up clinic. TRIAL REGISTRATION ClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468.
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Affiliation(s)
- Karl Philipp Drewitz
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto von Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Claudia Hasenpusch
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto von Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Christine Bernardi
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Susanne Brandstetter
- University Children's Hospital Regensburg, University of Regensburg, Klinik St. Hedwig, Steinmetzstr. 1-3, 93049, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Katharina Pielmeier
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Magdalena Rohr
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
- University Children's Hospital Regensburg, University of Regensburg, Klinik St. Hedwig, Steinmetzstr. 1-3, 93049, Regensburg, Germany
| | - Vreni Brunnthaler
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
- Caritas-Krankenhaus St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Konrad Schmidt
- Institute of General Practice and Family Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstr. 18, 07743, Jena, Germany
| | - Maximilian V Malfertheiner
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
- Klinik Donaustauf, Ludwigstr. 68, 93093, Donaustauf, Germany
| | - Christian J Apfelbacher
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto von Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 50 Nanyang Avenue, Singapore, 639798, Singapore
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Malfertheiner MV, Garrett A, Passmore M, Haymet AB, Webb RI, Von Bahr V, Millar JE, Schneider BA, Obonyo NG, Black D, Bouquet M, Bartnikowski N, Suen JY, Fraser JF. The effects of nitric oxide on coagulation and inflammation in ex vivo models of extracorporeal membrane oxygenation and cardiopulmonary bypass. Artif Organs 2023; 47:1581-1591. [PMID: 37395735 DOI: 10.1111/aor.14608] [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: 03/10/2023] [Revised: 05/11/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Extracorporeal life support (ECLS) has extensive applications in managing patients with acute cardiac and pulmonary failure. Two primary modalities of ECLS, cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), include several similarities in their composition, complications, and patient outcomes. Both CPB and ECMO pose a high risk of thrombus formation and platelet activation due to the large surface area of the devices and bleeding due to system anticoagulation. Therefore, novel methods of anticoagulation are needed to reduce the morbidity and mortality associated with extracorporeal support. Nitric oxide (NO) has potent antiplatelet properties and presents a promising alternative or addition to anticoagulation with heparin during extracorporeal support. METHODS We developed two ex vivo models of CPB and ECMO to investigate NO effects on anticoagulation and inflammation in these systems. RESULTS Sole addition of NO as an anticoagulant was not successful in preventing thrombus formation in the ex vivo setups, therefore a combination of low-level heparin with NO was used. Antiplatelet effects were observed in the ex vivo ECMO model when NO was delivered at 80 ppm. Platelet count was preserved after 480 min when NO was delivered at 30 ppm. CONCLUSION Combined delivery of NO and heparin did not improve haemocompatibility in either ex vivo model of CPB and ECMO. Anti-inflammatory effects of NO in ECMO systems have to be evaluated further.
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Affiliation(s)
- Maximilian V Malfertheiner
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Ashlen Garrett
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Margaret Passmore
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Andrew B Haymet
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Richard I Webb
- The Centre for Microscopy and Microanalysis, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Viktor Von Bahr
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Department of Physiology and Pharmacology, The Section for Anesthesiology and Intensive Care Medicine, The Karolinska Institutet, Stockholm, Sweden
| | - Jonathan E Millar
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Bailey A Schneider
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Nchafatso G Obonyo
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
- Initiative to Develop African Research Leaders (IDeAL), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, UK
| | - Debra Black
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Mahe Bouquet
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Nicole Bartnikowski
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - Jacky Y Suen
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - John F Fraser
- The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- The Faculty of Medicine, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
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7
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Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lo Coco V, Van der Horst ICC, Van Bussel BCT, Schnabel RM, Delnoij T, Bolotin G, Lorini L, Schmiady MO, Schibilsky D, Kowalewski M, Pinto LF, Silva PE, Kornilov I, Blandino Ortiz A, Vercaemst L, Finney S, Roeleveld PP, Di Nardo M, Hennig F, Antonini MV, Davidson M, Jones TJ, Staudinger T, Mair P, Kilo J, Krapf C, Erbert K, Peer A, Bonaros N, Kotheletner F, Krenner Mag N, Shestakova L, Hermans G, Dauwe D, Meersseman P, Stockman B, Nobile L, Lhereux O, Nrasseurs A, Creuter J, De Backer D, Giglioli S, Michiels G, Foulon P, Raes M, Rodrigus I, Allegaert M, Jorens P, Debeucklare G, Piagnarelli M, Biston P, Peperstraete H, Vandewiele K, Germay O, Vandeweghe D, Havrin S, Bourgeois M, Lagny MG, Alois G, Lavios N, Misset B, Courcelle R, Timmermans PJ, Yilmaz A, Vantomout M, Lehaen J, Jassen A, Guterman H, Strauven M, Lormans P, Verhamme B, Vandewaeter C, Bonte F, Vionne D, Balik M, Blàha J, Lips M, Othal M, Bursa F, Spacek R, Christensen S, Jorgensen V, Sorensen M, Madsen SA, Puss S, Beljantsev A, Saiydoun G, Fiore A, Colson P, Bazalgette F, Capdevila X, Kollen S, Muller L, Obadia JF, Dubien PY, Ajrhourh L, Guinot PG, Zarka J, Besserve P, Malfertheiner MV, Dreier E, Heinze B, Akhyari P, Lichtenberg A, Aubin H, Assman A, Saeed D, Thiele H, Baumgaertel M, Schmitto JD, Ruslan N, Haverich A, Thielmann M, Brenner T, Ruhpawar A, Benk C, Czerny M, Staudacher DL, Beyersdorf F, Kalbhenn J, Henn P, Popov AF, Iuliu T, Muellenbach R, Reyher C, Rolfes C, Lotz G, Sonntagbauer M, Winkels H, Fichte J, Stohr R, Kalverkamp S, Karagiannidis C, Schafer S, Svetlitchny A, Fichte J, Hopf HB, Jarczak D, Groesdonk H, Rommer M, Hirsch J, Kaehny C, Soufleris D, Gavriilidis G, Pontikis K, Kyriakopoulou M, Kyriakoudi A, O'Brien S, Conrick-Martin I, Carton E, Makhoul M, Ben-Ari J, Hadash A, Kogan A, Kassif Lerner R, Abu-Shakra A, Matan M, Balawona A, Kachel E, Altshuler R, Galante O, Fuchs L, Almog Y, Ishay YS, Lichter Y, Gal-oz A, Carmi U, Nini A, Soroksky A, Dekel H, Rozman Z, Tayem E, Ilgiyaev E, Hochman Y, Miltau D, Rapoport A, Eden A, Kompanietz D, Yousif M, Golos M, Grazioli L, Ghitti D, Loforte A, Di Luca D, Baiocchi M, Pacini D, Cappai A, Meani P, Mondino M, Russo CF, Ranucci M, Fina D, Cotza M, Ballotta A, Landoni G, Nardelli P, Fominski EV, Brazzi L, Montrucchio G, Sales G, Simonetti U, Livigni S, Silengo D, Arena G, Sovatzis SS, Degani A, Riccardi M, Milanesi E, Raffa G, Martucci G, Arcadipane A, Panarello G, Chiarini G, Cattaneo S, Puglia C, Benussi S, Foti G, Giani M, Bombino M, Costa MC, Rona R, Avalli L, Donati A, Carozza R, Gasparri F, Carsetti A, Picichè M, Marinello A, Danzi V, Zanin A, Condello I, Fiore F, Moscarelli M, Nasso G, Speziale G, Sandrelli L, Montalto A, Musumeci F, Circelli A, Russo E, Agnoletti V, Rociola R, Milano AD, Pilato E, Comentale G, Montisci A, Alessandri F, Tosi A, Pugliese F, Giordano G, Carelli S, Grieco DL, Dell'Anna AM, Antonelli M, Ramoni E, Zulueta J, Del Giglio M, Petracca S, Bertini P, Guarracino F, De Simone L, Angeletti PM, Forfori F, Taraschi F, Quintiliani VN, Samalavicius R, Jankuviene A, Scupakova N, Urbonas K, Kapturauskas J, Soerensen G, Suwalski P, Linhares Santos L, Marques A, Miranda M, Teixeira S, Salgueiro A, Pereira F, Ketskalo M, Tsarenko S, Shilova A, Afukov I, Popugaev K, Minin S, Shelukhin D, Malceva O, Gleb M, Skopets A, Kornelyuk R, Kulikov A, Okhrimchuk V, Turchaninov A, Shelukhin D, Petrushin M, Sheck A, Mekulov A, Ciryateva S, Urusov D, Gorjup V, Golicnik A, Goslar T, Ferrer R, Martinez-Martinez M, Argudo E, Palmer N, De Pablo Sanchez R, Juan Higuera L, Arnau Blasco L, Marquez JA, Sbraga F, Fuset MP, De Gopegui PR, Claraco LM, De Ayala JA, Peiro M, Ricart P, Martinez S, Chavez F, Fabra M, Sandoval E, Toapanta D, Carraminana A, Tellez A, Ososio J, Milan P, Rodriguez J, Andoni G, Gutierrez C, Perez de la Sota E, Eixeres-Esteve A, Garcia-Maellas MT, Gutierrez-Gutierrez J, Arboleda-Salazar R, Santa Teresa P, Jaspe A, Garrido A, Castaneda G, Alcantara S, Martinez N, Perez M, Villanueva H, Vidal Gonzalez A, Paez J, Santon A, Perez C, Lopez M, Rubio Lopez MI, Gordillo A, Naranjo-Izurieta J, Munoz J, Alcalde I, Onieva F, Gimeno Costa R, Perez F, Madrid I, Gordon M, Albacete Moreno CL, Perez D, Lopez N, Martinenz D, Blanco-Schweizer P, Diez C, Perez D, Prieto A, Renedo G, Bustamante E, Cicuendez R, Citores R, Boado V, Garcia K, Voces R, Domezain M, Nunez Martinez JM, Vicente R, Martin D, Andreu A, Gomez Casal V, Chico I, Menor EM, Vara S, Gamacho J, Perez-Chomon H, Javier Gonzales F, Barrero I, Martin-Villen L, Fernandez E, Mendoza M, Navarro J, Colomina Climent J, Gonzales-Perez A, Muniz-Albaceita G, Amado L, Rodriguez R, Ruiz E, Eiras M, Grins E, Magnus R, Kanetoft M, Eidevald M, Watson P, Vogt PR, Steiger P, Aigner T, Weber A, Grunefelder J, Kunz M, Grapow M, Aymard T, Reser D, Agus G, Consiglio J, Haenggi M, Hansjoerg J, Iten M, Doeble T, Zenklusen U, Bechtold X, Faedda G, Iafrate M, Rohjer A, Bergamaschi L, Maessen J, Reis Miranda D, Endeman H, Gommers D, Meuwese C, Maas J, Van Gijlswijk MJ, Van Berg RN, Candura D, Van der Linden M, Kant M, Van der Heijden JJ, Scholten E, Van Belle-van Haren N, Lagrand WK, Vlaar AP, De Jong S, Cander B, Sargin M, Ugur M, Kaygin MA, Daly K, Agnew N, Head L, Kelly L, Anoma G, Russell C, Aquino V, Scott I, Flemming L, Gillon S, Moore O, Gelandt E, Auzinger G, Patel S, Loveridge R. In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study. Lancet Respir Med 2023; 11:151-162. [PMID: 36402148 PMCID: PMC9671669 DOI: 10.1016/s2213-2600(22)00403-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/18/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. METHODS EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. FINDINGS Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. INTERPRETATION Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. FUNDING None.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Thierry Folliguet
- Department of Cardiac Surgery, Assistance Publique–Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Justyna Swol
- Department of Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University Hospital of Vienna, Vienna, Austria
| | - Mirko Belliato
- Anestesia e Rianimazione II Cardiopolmonare, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Matteo, Pavia, Italy
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Alain Vuylsteke
- ECMO Retrieval Service & Critical Care, Royal Papworth Hospital, NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Yigal Kassif
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Ramat Gan, Israel
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, Anesthesia and Intensive Care Medicine, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Centre Hospitalier Universitaire Montpellier, Montpellier, France,Le laboratoire de Physiologie et Médecine Expérimentale du Coeur et des Muscles (PhyMedExp), Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stephane Ledot
- Intensive Care Unit, Royal Brompton & Harefield hospitals, London, UK
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Whythenshawe Hospital, Manchester, UK
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Bad Krozingen, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Kersten
- Medizinische Klinik, Uniklinik Rheinisch-Westfälische Technische Hochschule, Aachen, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, Universitair Ziekenhuis Leuven Gasthuisberg University Hospital, Leuven, Belgium
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Hospital, Lyon, France
| | - Finn M Pedersen
- Cardiothoracic Intensive Care Unit, University Hospital, Copenhagen, Denmark
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Kaan Kirali
- Cardiovascular Surgery Department, Kosuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
| | - Nicholas Barrett
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Jordi Riera
- Critical Care Department, Val d'Hebron Research Institute, Barcelona, Spain
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, Prague, Czech Republic,1st Faculty of Medicine, Charles University, Prague, Czech Republic
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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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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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10
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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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11
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Dres M, de Abreu MG, Merdji H, Müller-Redetzky H, Dellweg D, Randerath WJ, Mortaza S, Jung B, Bruells C, Moerer O, Scharffenberg M, Jaber S, Besset S, Bitter T, Geise A, Heine A, Malfertheiner MV, Kortgen A, Benzaquen J, Nelson T, Uhrig A, Moenig O, Meziani F, Demoule A, Similowski T. Randomized Clinical Study of Temporary Transvenous Phrenic Nerve Stimulation in Difficult-to-Wean Patients. Am J Respir Crit Care Med 2022; 205:1169-1178. [PMID: 35108175 PMCID: PMC9872796 DOI: 10.1164/rccm.202107-1709oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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] [Indexed: 01/27/2023] Open
Abstract
Rationale: Diaphragm dysfunction is frequently observed in critically ill patients with difficult weaning from mechanical ventilation. Objectives: To evaluate the effects of temporary transvenous diaphragm neurostimulation on weaning outcome and maximal inspiratory pressure. Methods: Multicenter, open-label, randomized, controlled study. Patients aged ⩾18 years on invasive mechanical ventilation for ⩾4 days and having failed at least two weaning attempts received temporary transvenous diaphragm neurostimulation using a multielectrode stimulating central venous catheter (bilateral phrenic stimulation) and standard of care (treatment) (n = 57) or standard of care (control) (n = 55). In seven patients, the catheter could not be inserted, and in seven others, pacing therapy could not be delivered; consequently, data were available for 43 patients. The primary outcome was the proportion of patients successfully weaned. Other endpoints were mechanical ventilation duration, 30-day survival, maximal inspiratory pressure, diaphragm-thickening fraction, adverse events, and stimulation-related pain. Measurements and Main Results: The incidences of successful weaning were 82% (treatment) and 74% (control) (absolute difference [95% confidence interval (CI)], 7% [-10 to 25]), P = 0.59. Mechanical ventilation duration (mean ± SD) was 12.7 ± 9.9 days and 14.1 ± 10.8 days, respectively, P = 0.50; maximal inspiratory pressure increased by 16.6 cm H2O and 4.8 cm H2O, respectively (difference [95% CI], 11.8 [5 to 19]), P = 0.001; and right hemidiaphragm thickening fraction during unassisted spontaneous breathing was +17% and -14%, respectively, P = 0.006, without correlation with changes in maximal inspiratory pressure. Serious adverse event frequency was similar in both groups. Median stimulation-related pain in the treatment group was 0 (no pain). Conclusions: Temporary transvenous diaphragm neurostimulation did not increase the proportion of successful weaning from mechanical ventilation. It was associated with a significant increase in maximal inspiratory pressure, suggesting reversal of the course of diaphragm dysfunction. Clinical trial registered with www.clinicaltrials.gov (NCT03096639) and the European Database on Medical Devices (CIV-17-06-020004).
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Affiliation(s)
- Martin Dres
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, R3S Department, Sorbonne University, Paris, France
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany;,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio;,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hamid Merdji
- Université de Strasbourg, Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - Holger Müller-Redetzky
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dominic Dellweg
- Department of Pulmonary and Critical Care Medicine, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg, Germany
| | - Winfried J. Randerath
- Institute for Pneumology at the University of Cologne Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Satar Mortaza
- Département de Médecine Intensive, Réanimation et Médecine Hyperbare, CHU d’Angers, Faculté de Santé, Université d’Angers, Angers, France
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital and PhyMedExp, University of Montpellier, Montpellier, France
| | - Christian Bruells
- Department of Anesthesiology, Aachen University Hospital of the RWTH Aachen, Aachen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Martin Scharffenberg
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, France
| | - Sébastien Besset
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Thomas Bitter
- Clinic for General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Arnim Geise
- Department of Respiratory Medicine, Allergology and Sleep Medicine/Nuremberg Lung Cancer Center, Paracelsus Medical University, General Hospital Nuremberg, Nuremburg, Germany
| | - Alexander Heine
- Department of Internal Medicine B, Cardiology, Pneumology, Weaning, Infectious Diseases, Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Maximilian V. Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Kortgen
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Jonathan Benzaquen
- Department of Pulmonary Medicine and Oncology, Université Côte d'Azur, CHU de Nice, University Hospital Federation OncoAge, Nice, France
| | - Teresa Nelson
- Technomics Research, LLC, Minneapolis, Minnesota; and
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Olaf Moenig
- Department of Pulmonary and Critical Care Medicine, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg, Germany
| | - Ferhat Meziani
- Université de Strasbourg, Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - Alexandre Demoule
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, R3S Department, Sorbonne University, Paris, France
| | - Thomas Similowski
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitie-Salpêtrière Hospital, R3S Department, Sorbonne Université, Paris, France
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Malfertheiner SF, Brodie D, Burrell A, Taccone FS, Broman LM, Shekar K, Agerstrand CL, Serra AL, Fraser J, Malfertheiner MV. Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study. Perfusion 2022:2676591221090668. [PMID: 35549557 DOI: 10.1177/02676591221090668] [Citation(s) in RCA: 3] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. METHODS A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. RESULTS A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). CONCLUSIONS Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed.
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Affiliation(s)
- S Fill Malfertheiner
- Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, Regensburg University, Regensburg, Germany
| | - D Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - L M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - K Shekar
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - C L Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A L Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - J Fraser
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - M V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
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Belliato M, Cremascoli L, Epis F, Ferrari F, Quattrone MG, Malfertheiner MV, Broman LM, Aliberti A, Taccone FS, Iotti GA, Lorusso R. Carbon Dioxide Elimination During Veno-Venous Extracorporeal Membrane Oxygenation Weaning: A Pilot Study. ASAIO J 2021; 67:700-708. [PMID: 33074866 DOI: 10.1097/mat.0000000000001282] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.
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Affiliation(s)
- Mirko Belliato
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fiorenza Ferrari
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria G Quattrone
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Maximilian V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Medical Center Regensburg, Regensburg, Germany
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Aliberti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Bruxelles (CUB) Erasme, Brussels, Belgium
| | - Giorgio A Iotti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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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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15
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Rohr M, Brandstetter S, Bernardi C, Fisser C, Drewitz KP, Brunnthaler V, Schmidt K, Malfertheiner MV, Apfelbacher CJ. Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial. Pilot Feasibility Stud 2021; 7:90. [PMID: 33785064 PMCID: PMC8007452 DOI: 10.1186/s40814-021-00796-1] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy. Methods/design Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. Participants: 100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months. Intervention: The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU. Discussion The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT. Trial registration ClinicalTrials.gov, NCT04186468. Submitted 2 December 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00796-1.
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Affiliation(s)
- M Rohr
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.
| | - S Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.,University Children's Hospital Regensburg, University of Regensburg, Klinik St. Hedwig, Steinmetzstr., 1-3, 93049, Regensburg, Germany
| | - C Bernardi
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - C Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - K P Drewitz
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - V Brunnthaler
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - K Schmidt
- Institute of General Practice and Family Medicine, Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany.,Institute of General Practice and Family Medicine, Jena University Hospital, Bachstr. 18, 07743, Jena, Germany
| | - M V Malfertheiner
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - C J Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.,Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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16
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Passmore MR, Ki KK, Chan CHH, Lee T, Bouquet M, Wood ES, Raman S, Rozencwajg S, Burrell AJC, McDonald CI, Langguth D, Shekar K, Malfertheiner MV, Fraser JF, Suen JY. The effect of hyperoxia on inflammation and platelet responses in an ex vivo extracorporeal membrane oxygenation circuit. Artif Organs 2020; 44:1276-1285. [PMID: 32644199 DOI: 10.1111/aor.13771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/14/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) is expanding, however, it is still associated with significant morbidity and mortality. Activation of inflammatory and innate immune responses and hemostatic alterations contribute to complications. Hyperoxia may play a role in exacerbating these responses. Nine ex vivo ECMO circuits were tested using fresh healthy human whole blood, with two oxygen levels: 21% inspired fraction of oxygen (FiO2 ; mild hyperoxia; n = 5) and 100% FiO2 (severe hyperoxia; n = 4). Serial blood samples were taken for analysis of platelet aggregometry, leukocyte activation, inflammatory, and oxidative stress markers. ECMO resulted in reduced adenosine diphosphate- (P < .05) and thrombin receptor activating peptide-induced (P < .05) platelet aggregation, as well as increasing levels of the neutrophil activation marker, neutrophil elastase (P = .013). Additionally, levels of the inflammatory chemokine interleukin-8 were elevated (P < .05) and the activity of superoxide dismutase, a marker of oxidative stress, was increased (P = .002). Hyperoxia did not augment these responses, with no significant differences detected between mild and severe hyperoxia. Our ex vivo model of ECMO revealed that the circuit itself triggers a pro-inflammatory and oxidative stress response, however, exposure to supra-physiologic oxygen does not amplify that response. Extended-duration studies and inclusion of an endothelial component could be beneficial in characterizing longer term changes.
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Affiliation(s)
- Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, Australia
| | - Chris H H Chan
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Department of Engineering and Built Environment, Griffith University, Gold Coast, Australia
| | - Talvin Lee
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Mahé Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Emily S Wood
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sainath Raman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Medical Intensive Care Unit, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpetrière, Hôpitaux de Paris, Assistance Publique, Paris, France
| | - Aidan J C Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Charles I McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Brisbane, Australia
| | - Daman Langguth
- Department of Immunology, Sullivan and Nicolaides Pathology, Brisbane, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | | | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
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17
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De Piero ME, Lo Coco V, Taccone FS, Belliato M, Broman LM, Malfertheiner MV, Lorusso R. Has Venoarterial ECMO Been Underutilized in COVID-19 Patients? Innovations (Phila) 2020; 15:317-321. [PMID: 32634058 DOI: 10.1177/1556984520939076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Maria Elena De Piero
- 199236 Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital, The Netherlands.,Anestesia e Rianimazione 2, San Giovanni Bosco Hospital, Turin, Italy
| | - Valeria Lo Coco
- 199236 Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital, The Netherlands
| | - Fabio Silvio Taccone
- 70496 Department of Intensive Care, Erasme Hospital, Universite' Libre de Bruxelles, Belgium
| | - Mirko Belliato
- 18631 U.O.C. Anestesia e Rianimazione 2 Cardiopolmonare, IRCCS, Policlinico San Matteo Foundation Hospital, Pavia, Italy
| | - Lars M Broman
- 59562 ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian V Malfertheiner
- 39070 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Germany
| | - Roberto Lorusso
- 199236 Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
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18
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Broman LM, Westlund CJ, Gilbers M, Perry da Câmara L, Prahl Wittberg L, Taccone FS, Malfertheiner MV, Di Nardo M, Swol J, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Belliato M, Lorusso R. Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation. Perfusion 2020; 35:736-744. [PMID: 32500818 DOI: 10.1177/0267659120926009] [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: 11/15/2022]
Abstract
INTRODUCTION In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure-flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. METHODS We performed a study evaluating pressure-flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer's corresponding curves obtained from the public domain. RESULTS The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain same drainage flow (hematocrit of 26%) compared with manufacturer's water charts in 13-31 Fr bi-caval dual-lumen cannulae. The same net difference was found in cavo-atrial cannulae (16-32 Fr), where a lower drainage pressure was required (Hct of 26%) compared with the manufacturer's test using blood with an Hct of 33%. Return pressure-flow data were similar, independent whether pumping blood or water, to the data reported by manufacturers. CONCLUSION Non-standardized testing of pressure-flow properties of extracorporeal membrane oxygenation dual-lumen cannulae prevents an adequate prediction of pressure-flow results when these cannulae are used in patients. Properties of dual-lumen cannulae may vary between sizes within same cannula family, in particular concerning the drainage flow.
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Affiliation(s)
- Lars Mikael Broman
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - C Jerker Westlund
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Martijn Gilbers
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Lisa Prahl Wittberg
- The Linné Flow Centre and BioMEx Centre, Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Maximilian V Malfertheiner
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Matteo Di Nardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Leen Vercaemst
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Perfusion, University Hospital Gasthuisberg, Louvain, Belgium
| | - Nicholas A Barrett
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College, London, UK
| | - Federico Pappalardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Belohlavek
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Mirko Belliato
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Lorusso
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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19
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von Bahr V, Kalzén H, Frenckner B, Hultman J, Frisén KG, Lidegran MK, Diaz S, Malfertheiner MV, Millar JE, Dobrosavljevic T, Eksborg S, Holzgraefe B. Long-term pulmonary function and quality of life in adults after extracorporeal membrane oxygenation for respiratory failure. Perfusion 2020; 34:49-57. [PMID: 30966900 DOI: 10.1177/0267659119830244] [Citation(s) in RCA: 13] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a significant long-term burden on survivors after acute respiratory distress syndrome, even 5 years after discharge. This is not well investigated in patients treated with extracorporeal membrane oxygenation. The objective of this study was to describe very-long-term (⩾3 years) disability in lung function and morphology, quality of life, mood disorders, walking capacity, and return to work status in extracorporeal membrane oxygenation survivors. METHODS Single-center retrospective cohort study on long-term survivors treated with extracorporeal membrane oxygenation for respiratory failure between 1995 and 2010 at a tertiary referral center in Sweden. Eligible patients were approached, and those who consented were interviewed and investigated during a day at the hospital. RESULTS A total of 38 patients were investigated with a median follow-up time of 9.0 years. Quality of life was reduced in several Short form 36 (SF-36) subscales and all domains of the St George's Respiratory Questionnaire, similar to previous studies in conventionally managed acute respiratory distress syndrome survivors. A reduced diffusion capacity of carbon monoxide was seen in 47% of patients, and some degree of residual lung parenchymal pathology was seen in 82%. Parenchymal pathology correlated with reductions in quality of life and diffusion capacity. Symptoms of anxiety and depression were seen in 22% and 14%, respectively. CONCLUSION A significant long-term burden remains even 3-17 years after extracorporeal membrane oxygenation treatment, similar to conventionally managed acute respiratory distress syndrome survivors. Future prospective studies are needed to elucidate risk factors for these sequelae.
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Affiliation(s)
- Viktor von Bahr
- 1 Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Kalzén
- 1 Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Frenckner
- 2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.,3 Division of Pediatric Surgery, Department of Women's and Children's Health, Karolinska Institutet and Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Jan Hultman
- 1 Section for Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - K Gunilla Frisén
- 2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marika K Lidegran
- 4 Department of Pediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Diaz
- 4 Department of Pediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.,5 Department of Radiology and Translational Medicine, Lund University and Skane University Hospital, Lund, Sweden
| | - Maximilian V Malfertheiner
- 6 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Jonathan E Millar
- 7 Department of Anaesthesia, Critical Care & Pain, School of Medicine, University of Glasgow, Glasgow, UK
| | - Tanja Dobrosavljevic
- 2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Eksborg
- 8 Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet and Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Bernhard Holzgraefe
- 2 Department of Pediatric Anaesthesia, Intensive Care and ECMO Services, Astrid Lindgren Children's Hospital, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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20
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Broman LM, Prahl Wittberg L, Westlund CJ, Gilbers M, Perry da Câmara L, Swol J, Taccone FS, Malfertheiner MV, Di Nardo M, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Müller T, Belliato M, Lorusso R. Pressure and flow properties of cannulae for extracorporeal membrane oxygenation I: return (arterial) cannulae. Perfusion 2020; 34:58-64. [PMID: 30966910 DOI: 10.1177/0267659119830521] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adequate extracorporeal membrane oxygenation support in the adult requires cannulae permitting blood flows up to 6-8 L/minute. In accordance with Poiseuille's law, flow is proportional to the fourth power of cannula inner diameter and inversely proportional to its length. Poiseuille's law can be applied to obtain the pressure drop of an incompressible, Newtonian fluid (such as water) flowing in a cylindrical tube. However, as blood is a pseudoplastic non-Newtonian fluid, the validity of Poiseuille's law is questionable for prediction of cannula properties in clinical practice. Pressure-flow charts with non-Newtonian fluids, such as blood, are typically not provided by the manufacturers. A standardized laboratory test of return (arterial) cannulae for extracorporeal membrane oxygenation was performed. The aim was to determine pressure-flow data with human whole blood in addition to manufacturers' water tests to facilitate an appropriate choice of cannula for the desired flow range. In total, 14 cannulae from three manufacturers were tested. Data concerning design, characteristics, and performance were graphically presented for each tested cannula. Measured blood flows were in most cases 3-21% lower than those provided by manufacturers. This was most pronounced in the narrow cannulae (15-17 Fr) where the reduction ranged from 27% to 40% at low flows and 5-15% in the upper flow range. These differences were less apparent with increasing cannula diameter. There was a marked disparity between manufacturers. Based on the measured results, testing of cannulae including whole blood flows in a standardized bench test would be recommended.
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Affiliation(s)
- Lars Mikael Broman
- 1 ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,2 Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK
| | - Lisa Prahl Wittberg
- 4 The Linné Flow Centre and BioMEx Centre, Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - C Jerker Westlund
- 1 ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Martijn Gilbers
- 5 Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands.,6 Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Justyna Swol
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,8 Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Fabio S Taccone
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,9 Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Maximilian V Malfertheiner
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,10 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Matteo Di Nardo
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,11 Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Leen Vercaemst
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,12 Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nicholas A Barrett
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,13 Department of Critical Care and Severe Respiratory Failure Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Federico Pappalardo
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,14 Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Jan Belohlavek
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,15 2nd Department of Medicine-Department of Cardiovascular Medicine, General University Hospital in Prague and First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Thomas Müller
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,10 Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Mirko Belliato
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,16 U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Lorusso
- 3 Working Group on Innovation and Technology, EuroElso, Newcastle upon Tyne, UK.,5 Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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21
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Conrad SA, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Grazioli L, Barbaro RP, McMullan DM, Pellegrino V, Brodie D, Bembea MM, Fan E, Mendonca M, Diaz R, Bartlett RH. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med 2019; 198:447-451. [PMID: 29614239 DOI: 10.1164/rccm.201710-2130cp] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal life support (ECLS) was developed more than 50 years ago, initially with venoarterial and subsequently with venovenous configurations. As the technique of ECLS significantly improved and newer skills developed, complexity in terminology and advances in cannula design led to some misunderstanding of and inconsistency in definitions, both in clinical practice and in scientific research. This document is a consensus of multispecialty international representatives of the Extracorporeal Life Support Organization, including the North America, Latin America, EuroELSO, South West Asia and Africa, and Asia-Pacific chapters, imparting a global perspective on ECLS. The goal is to provide a consistent and unambiguous nomenclature for ECLS and to overcome the inconsistent use of abbreviations for ECLS cannulation. Secondary benefits are ease of multicenter collaboration in research, improved registry data quality, and clear communication among practitioners and researchers in the field.
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Affiliation(s)
- Steven A Conrad
- 1 Department of Medicine.,2 Department of Emergency Medicine, and.,3 Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - L Mikael Broman
- 4 ECMO Center, Karolinska University Hospital, and.,5 Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Fabio S Taccone
- 6 Department of Intensive Care, Hôpital Erasme, Brussels, Belgium
| | - Roberto Lorusso
- 7 Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Federico Pappalardo
- 9 Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Matteo Di Nardo
- 10 Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Mirko Belliato
- 11 U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lorenzo Grazioli
- 12 Department of Anesthesiology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - D Michael McMullan
- 14 Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Vincent Pellegrino
- 15 Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Daniel Brodie
- 16 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Melania M Bembea
- 17 Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eddy Fan
- 18 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Malaika Mendonca
- 19 Division of Pediatric Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; and
| | - Rodrigo Diaz
- 20 Division of Cardiovascular Anesthesiology, Clinica las Condes, Santiago, Chile
| | - Robert H Bartlett
- 21 Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Millar JE, Bartnikowski N, von Bahr V, Malfertheiner MV, Obonyo NG, Belliato M, Suen JY, Combes A, McAuley DF, Lorusso R, Fraser JF. Extracorporeal membrane oxygenation (ECMO) and the acute respiratory distress syndrome (ARDS): a systematic review of pre-clinical models. Intensive Care Med Exp 2019; 7:18. [PMID: 30911932 PMCID: PMC6434011 DOI: 10.1186/s40635-019-0232-7] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/03/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is an increasingly accepted means of supporting those with severe acute respiratory distress syndrome (ARDS). Given the high mortality associated with ARDS, numerous animal models have been developed to support translational research. Where ARDS is combined with ECMO, models are less well characterized. Therefore, we conducted a systematic literature review of animal models combining features of experimental ARDS with ECMO to better understand this situation. DATA SOURCES MEDLINE and Embase were searched between January 1996 and December 2018. STUDY SELECTION Inclusion criteria: animal models combining features of experimental ARDS with ECMO. EXCLUSION CRITERIA clinical studies, abstracts, studies in which the model of ARDS and ECMO has been reported previously, and studies not employing veno-venous, veno-arterial, or central ECMO. DATA EXTRACTION Data were extracted to fully characterize models. Variables related to four key features: (1) study design, (2) animals and their peri-experimental care, (3) models of ARDS and mechanical ventilation, and (4) ECMO and its intra-experimental management. DATA SYNTHESIS Seventeen models of ARDS and ECMO were identified. Twelve were published after 2009. All were performed in large animals, the majority (n = 10) in pigs. The median number of animals included in each study was 17 (12-24), with a median study duration of 8 h (5-24). Oleic acid infusion was the commonest means of inducing ARDS. Most models employed peripheral veno-venous ECMO (n = 12). The reporting of supportive measures and the practice of mechanical ventilation were highly variable. Descriptions of ECMO equipment and its management were more complete. CONCLUSION A limited number of models combine the features of experimental ARDS with ECMO. Among those that do, there is significant heterogeneity in both design and reporting. There is a need to standardize the reporting of pre-clinical studies in this area and to develop best practice in their design.
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Affiliation(s)
- Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia. .,Faculty of Medicine, University of Queensland, Brisbane, Australia. .,Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, Australia
| | - Viktor von Bahr
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian V Malfertheiner
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,Wellcome Trust Centre for Global Health Research, Imperial College London, London, UK
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, IRCCS, Policlinico San Matteo Foundation, Pavia, Italy
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Alain Combes
- Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institute of Cardiometabolism and Nutrition, Sorbonne University, Paris, France
| | - Daniel F McAuley
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Hospital, Maastricht, Netherlands
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, 4035 QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
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Di Nardo M, Vercaemst L, Swol J, Barret N, Taccone FS, Malfertheiner MV, Broman LM, Pappalardo F, Belohlavek J, Mueller T, Lorusso R, Lonero M, Belliato M. A narrative review of the technical standards for extracorporeal life support devices (pumps and oxygenators) in Europe. Perfusion 2018; 33:553-561. [DOI: 10.1177/0267659118772452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This review summarizes the European rules to control the market when introducing new products. In particular, it shows all the steps to achieve the European Conformity (CE Mark), a certification that all new medical products must achieve before being used in Europe. Extracorporeal membrane oxygenation (ECMO) devices are exposed to the same procedures. Hereby, we present some regulatory issues regarding pumps and oxygenators, providing technical details as released by the manufacturers on their websites and information charts.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Louvain, Belgium
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Nicholas Barret
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Lars M. Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Belohlavek
- Second Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Margherita Lonero
- Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, IRCCS, Policlinico San Matteo Foundation, Pavia, Italy
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Broman LM, Malfertheiner MV, Montisci A, Pappalardo F. Weaning from veno-venous extracorporeal membrane oxygenation: how I do it. J Thorac Dis 2018; 10:S692-S697. [PMID: 29732188 PMCID: PMC5911556 DOI: 10.21037/jtd.2017.09.95] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [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: 09/04/2017] [Accepted: 09/06/2017] [Indexed: 11/06/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a rescue treatment for acute respiratory distress syndrome (ARDS) failing protective mechanical ventilation. It temporarily provides proper gas exchange: hypoxia is treated by adjusting the blood flow rate and fraction in spired oxygen over the ventilator (FiO2) on the extracorporeal membrane oxygenation (ECMO) circuit while CO2 removal is regulated by the ECMO fresh gas flow. Therefore, ventilator settings can be gradually reduced allowing the lungs to rest and recover. Nowadays, indications for ECMO referral and implantation are clearly formulated; on the contrary, little evidence currently exists to guide the process of weaning from ECMO support, especially concerning the timing during the course of lung healing. Therefore, indications to stop ECMO are less well standardized so that in clinical trials extracorporeal assistance is generally continued until lung recovery, with neither specific nor homogenous criteria for withdrawal. Notably, in almost all papers dealing with data on VV ECMO support, the management of weaning and the weaning procedure itself are not described. The aim of this paper is to make a picture of VV ECMO weaning, as it is performed in three European large volume intensive care units (ICUs) which represent referral centers for VV ECMO treatment. We focused on data concerning the timing of VV ECMO weaning and parameters at the time of weaning, in order to assess adequacy and safety of VV ECMO removal.
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Affiliation(s)
- Lars M. Broman
- European ECMO Advisory Board
- ECMO Centre Karolinska, Karolinska University Hospital, and Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian V. Malfertheiner
- European ECMO Advisory Board
- Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Andrea Montisci
- Cardiothoracic Centre, Instituto Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
| | - Federico Pappalardo
- European ECMO Advisory Board
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Burrell AJC, Lubnow M, Enger TB, Nanjayya VB, Philipp A, Malfertheiner MV, Lunz D, Bein T, Pellegrino VA, Müller T. The impact of venovenous extracorporeal membrane oxygenation on cytokine levels in patients with severe acute respiratory distress syndrome: a prospective, observational study. CRIT CARE RESUSC 2017; 19:37-44. [PMID: 29084500] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The immunoinflammatory response is central to the pathogenesis of acute respiratory distress syndrome (ARDS). However, little is known how this is affected by venovenous (VV) extracorporeal membrane oxygenation (ECMO). Our objective was to investigate the factors that influence the inflammatory response of patients with ARDS undergoing VV ECMO, and to analyse the impact of this response on hospital mortality. DESIGN AND SETTING A prospective observational study of all consecutive patients with severe ARDS who had VV ECMO at a tertiary German ECMO centre from 2009 to 2015. Patients without complete datasets were excluded. Cytokines (interleukin [IL]6, IL8 and tissue necrosis factor [TNF]α) and inflammatory markers (white cell count and C-reactive protein) were assessed before ECMO initiation and on Days 1, 5 and 10, before explantation and at explantation. RESULTS A total of 262 adult patients undergoing VV ECMO were analysed. Their median Sequential Organ Failure Assessment score was 12, PaO2/FiO2 ratio was 64 mmHg, and overall in-hospital mortality was 34%. Cytokine levels fell quickly within 24 hours and fell further over the first 5 days. Extra-pulmonary ARDS was associated with higher IL6 and IL8 levels compared with pulmonary ARDS. Mechanical ventilation with positive end-expiratory pressure ≥ 15 cmH2O before ECMO was associated with higher IL6, IL8 and TNFα levels. Driving pressures ≥ 19 cmH2O before ECMO were associated with higher IL8 levels. Non-survivors had higher IL6 and IL8 levels for the duration of ECMO. CONCLUSION Cytokine levels, on average, fall rapidly after initiation of VV ECMO, which may be related to the reduction of invasiveness of mechanical ventilation. Higher cytokine levels are associated with extrapulmonary causes of ARDS, more aggressive mechanical ventilation before VV ECMO, and mortality.
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Affiliation(s)
- A J C Burrell
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.
| | - M Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - T B Enger
- Department of Intensive Care Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - V B Nanjayya
- Department of Anaesthesia, Alfred Hospital, Melbourne, Australia
| | - A Philipp
- Department of Cardiothoracic and Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M V Malfertheiner
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - D Lunz
- Department of Intensive Care Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - T Bein
- Department of Cardiothoracic and Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - V A Pellegrino
- Department of Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - T Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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26
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Malfertheiner MV, Pimenta LP, Bahr VV, Millar JE, Obonyo NG, Suen JY, Pellegrino V, Fraser JF. Acquired von Willebrand syndrome in respiratory extracorporeal life support: a systematic review of the literature. CRIT CARE RESUSC 2017; 19:45-52. [PMID: 29084501] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Venovenous extracorporeal membrane oxygenation (VV ECMO) and extracorporeal CO2 removal (ECCO2R) are increasingly used in the management of severe respiratory failure. With bleeding complications being one of the major risks of these techniques, our aim in this systematic review was to assess the available literature on acquired von Willebrand syndrome (AvWS) and extracorporeal support. AvWS has previously been associated with bleeding and shear stress. DESIGN AND DATA SOURCES A systematic review, using Medline via PubMed, was performed to identify eligible studies up to January 2017. RESULTS AND CONCLUSION The prevalence of AvWF among patients on VV ECMO or ECCO2R is high, but only a limited number of studies are reported in the literature. AvWS testing should be performed, including vWF multimer analysis, vWF activity and vWF antigen concentration. The extent to which vWF contributes to bleeding during ECMO, or how much changes in ECMO management can influence high molecular weight vWF multimer levels, cannot be answered from the currently available evidence and there remains a need for future studies.
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Affiliation(s)
- M V Malfertheiner
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia.
| | - L P Pimenta
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - V von Bahr
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - J E Millar
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - N G Obonyo
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - J Y Suen
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - V Pellegrino
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - J F Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
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27
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Malfertheiner MV, Broman LM, Belliato M, Venti A, Bader A, Taccone FS, Di Nardo M, Maj G, Pappalardo F. Management strategies in venovenous extracorporeal membrane oxygenation: a retrospective comparison from five European centres. CRIT CARE RESUSC 2017; 19:76-81. [PMID: 29084505] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate contemporary clinical practice in the management of venovenous (VV) extracorporeal membrane oxygenation (ECMO) in critically ill patients with bacterial pneumonia. METHODS In this multicentre retrospective study, 48 patients with severe respiratory failure due to bacterial pneumonia receiving VV ECMO therapy in five experienced European ECMO centres were included. Ventilator and ECMO settings were analysed. RESULTS Ventilator settings showed great variability between participating centres, particularly relating to positive end-expiratory pressure, peak inspiratory pressure and driving pressure. Different strategies in cannulation, ECMO setting and weaning procedures were also observed. CONCLUSION There is great diversity in management modalities for ventilator and ECMO settings for patients with bacterial pneumonia. Our study emphasises the lack of clinical consensus in VV ECMO management.
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Affiliation(s)
- M V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - L M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital; and Department of Physiology and Pharamacology, Karolinska Institutet, Stockholm, Sweden
| | - M Belliato
- UOC Anestesia e Rianimazione, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Venti
- UOC Anestesia e Rianimazione, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Bader
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Belgium
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Belgium
| | - M Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - G Maj
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - F Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
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Taccone FS, Malfertheiner MV, Ferrari F, Di Nardo M, Swol J, Broman LM, Vercaemst L, Barrett N, Pappalardo F, Belohlavek J, Mueller T, Lorusso R, Belliato M. Extracorporeal CO2 removal in critically ill patients: a systematic review. Minerva Anestesiol 2017; 83:762-772. [PMID: 28402093 DOI: 10.23736/s0375-9393.17.11835-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of extracorporeal CO2 removal (ECCO2R) is increasingly employed in critically ill patients. However, the clinical evidence supporting its efficacy remains currently poor. EVIDENCE ACQUISITION A systematic review using MEDLINE via PubMed was performed to identify eligible studies (until 30th September 2016). The amount of CO2 reduction, the effect on the duration of mechanical ventilation and weaning, the impact on patients' outcome and the occurrence of complications were evaluated. The quality of evidence was evaluated according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. EVIDENCE SYNTHESIS Six studies were included (three evaluating patients with chronic obstructive pulmonary disease [COPD]; three evaluating patients with acute respiratory distress syndrome [ARDS]), involving 279 adult patients; 142 treated with ECCO2R and 137 controls. No study on pediatric population met the inclusion criteria for analysis. The overall quality of evidence of the two randomized trials and four case-control studies varied from moderate to very low. PaCO2 was generally reduced by 25-33% within a few hours following ECCO2R initiation. One ARDS study showed a significant decrease in the duration of mechanical ventilation, although this result was only found by post-hoc analysis. The three studies on COPD demonstrated that some patients supported by ECCO2R devices could avoid endotracheal intubation, however the ICU-LOS and survival was not influenced by ECCO2R when compared to controls. CONCLUSIONS In COPD patients, a significantly reduced need for endotracheal intubation was reported. However, the use of ECCO2R has not shown significant improvement on the outcome of critically ill patients in the reviewed studies. Therefore appropriately powered, randomized, controlled studies are urgently needed.
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Affiliation(s)
- Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Fiorenza Ferrari
- Intensive Care Unit and International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Department of Intensive Care and Emergency Medicine, HELIOS Frankenwaldklinik Kronach, Kronach, Germany
| | - Lars M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Louvain, Belgium
| | - Nicholas Barrett
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Belohlavek
- Second Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Mirko Belliato
- Second ICU, S.C. Anestesia e Rianimazione 2, IRCCS Policlinico San Matteo Foundation, Pavia, Italy -
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30
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Malfertheiner SF, Malfertheiner MV, Kropf S, Costa SD, Malfertheiner P. A prospective longitudinal cohort study: evolution of GERD symptoms during the course of pregnancy. BMC Gastroenterol 2012; 12:131. [PMID: 23006768 PMCID: PMC3499455 DOI: 10.1186/1471-230x-12-131] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 08/31/2012] [Indexed: 12/29/2022] Open
Abstract
Background Symptoms of gastro-esophageal reflux disease (GERD) in pregnancy are reported with a prevalence of 30–80%. The aim of this study was to assess the prevalence and severity of GERD symptoms during the course of pregnancy. Furthermore current practice in medical care for GERD during pregnancy was assessed. Methods We performed a prospective longitudinal cohort study on 510 pregnant women (mean age 28.12, SD 5.3). Investigations for reflux symptoms where based on the use of validated reflux-disease questionnaire (RDQ). Additional information was collected about the therapy. A group of non-pregnant women (mean age 24.56, SD 5.7) was included as controls. Frequency and severity of reflux symptoms were recorded in each trimester of pregnancy. Results The prevalence of GERD symptoms in pregnant women increased from the first trimester with 26.1 to 36.1% in the second trimester and to 51.2% in the third trimester of pregnancy. The prevalence of GERD symptoms in the control group was 9.3%. Pregnant women received medication for their GERD symptoms in 12.8% during the first, 9.1% during the second and 15.7% during the third trimester. Medications used >90% antacids, 0% PPI. Conclusion GERD symptoms occur more often in pregnant women than in non-pregnant and the frequency rises in the course of pregnancy. Medical therapy is used in a minority of cases and often with no adequate symptom relief.
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Affiliation(s)
- Sara Fill Malfertheiner
- Department of Obstetrics and Gynecology, Medical Faculty of Otto von Guericke University, Gerhart-Hauptmann-Str, 35, 39108, Magdeburg, Germany.
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Malfertheiner MV, Kandulski A, Schreiber J, Malfertheiner P. Helicobacter pylori infection and the respiratory system: a systematic review of the literature. Digestion 2012; 84:212-20. [PMID: 21757913 DOI: 10.1159/000329351] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent studies suggest an increased Helicobacter pylori prevalence in patients with various extradigestive inflammatory diseases. Similar to H. pylori infection, many respiratory diseases are characterized by chronic inflammation as well as increased immune response. Recent studies have evaluated the relation between various respiratory disorders and H. pylori infection. The aim of this systematic review was to scrutinize the relevant literature and the mechanisms that could underlie a role for H. pylori infection in respiratory diseases. METHODS Relevant literature regarding pathophysiological mechanisms and clinical epidemiology of H. pylori and different respiratory diseases has been systematically identified and analyzed by two independent reviewers according to a PubMed search for English language (until week 14, April 2010). CONCLUSIONS At present, there is no definite proof of a causal relationship between H. pylori and respiratory diseases. Both H. pylori and various respiratory diseases are characterized by the release of proinflammatory cytokines and attraction of granulocytes as well as B- and T-cell-mediated response, though a pathophysiological association has not been proven. Neither the role of genetic predisposition of the host nor the presence of virulence factors nor the impact of H. pylori eradication have been studied in detail and definitely need further evaluation.
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Malfertheiner MV, Kandulski A, Malfertheiner P, Schreiber J. [Bronchopulmonary manifestations of gastroesophageal reflux disease]. Internist (Berl) 2010; 51 Suppl 1:246-54. [PMID: 20098976 DOI: 10.1007/s00108-009-2506-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common disease in the western world. Usually it occurs with typical symptoms like heartburn and regurgitation, but almost every third GERD-patient presents with extraesophageal symptoms and diseases in which a causal relation with GERD is discussed. The extraesophageal symptoms possibly associated with GERD are chronic cough, bronchial asthma, sleep disturbances including obstructive sleep apnea, hoarseness, dental erosions, non-cardiac chest pain and idiopathic pulmonary fibrosis. This article gives an overview of the reflux-associated diseases of the airways as well as the proposed pathomechanisms and therapeutic options.
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Affiliation(s)
- M V Malfertheiner
- Fachbereich für Pneumologie, Otto-von-Guericke-Universität Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Deutschland
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Malfertheiner MV, Bönigk H, Hundack L, Schreiber J. Nasale „High-flow“-Sauerstoffzufuhr – Eine Alternative bei respiratorischer Insuffizienz? Erste Fallbeispiele. Pneumologie 2009. [DOI: 10.1055/s-2009-1242164] [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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Malfertheiner MV, Fill S, Kidd M, Modlin IM. The elucidation of peptic esophagitis: from Hamperl to heartburn. Z Gastroenterol 2007; 45:1164-8. [PMID: 18027318 DOI: 10.1055/s-2007-963476] [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] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although the esophagus was initially considered as the "humble" organ, it has in recent times evoked both substantial interest and considerable controversy as esophagitis becomes a global pandemic and the debate over the causes of esophagitis and the management of Barrett's has escalated. The esophagus has always defied easy understanding and the origins of its name and its symptomatology continue to confound those who address them. Esophagitis is increasing relentlessly on a global scale and the challenge of defining its symptomatology remains today as great a problem as when initially identified by Herwig Hamperl and Asher Winkelstein. Their identification of the entity they called "peptic esophagitis" in 1934, while initially for the most part overlooked, has today become one of the centers of gastroenterological focus. Although the initial symptomatology of esophagitis was limited to heartburn, it has more recently become apparent that a diverse group of symptoms is produced by the inflammation associated with intermittent reflux of gastric acid. Of interest is the nature of the original observations that led to the identification of the physiopathology of esophagitis and the elucidation of the relationship between symptomatology, acid reflux and inflammation. Although Asher Winkelstein of New York has long been considered the first to define the relationship of acid peptic reflux, esophageal ulceration and reflux symptomatology, it is of note to consider the seminal role of Herwig Hamperl, an Austrian pathologist in the elucidation of acid peptic esophagitis. Indeed, a careful consideration of the relative contributions of these two pioneers suggests that both deserve credit for identifying a disease process that, although initially for the most part ignored by clinicians, has now become one of the most fundamental problems faced by both gastroenterologists and pathologists.
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Affiliation(s)
- M V Malfertheiner
- Gastrointestinal Pathobiology Research Group, Yale University School of Medicine, New Haven, Connecticut 06520-8062, USA
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