Acute Cardiorespiratory Failure Research Articles

Prognostic Significance of Lactate Clearance in Cardiogenic Pulmonary Edema in the Emergency Department.

Background and Objectives: Acute cardiorespiratory failure disrupts the delicate balance of energy supply, demand, and consumption, with elevated lactate levels and decreased blood pH serving as crucial indicators. Acute cardiogenic pulmonary edema (ACPO), a common cause of acute respiratory failure, poses a substantial mortality risk. Lactate, a byproduct of pyruvate reduction, is a pertinent marker in perfusion assessment. Lactate clearance (LC) has proven prognostic efficacy in various conditions but lacks consensus on its predictive power in acute cardiogenic pulmonary edema. Materials and Methods: This prospective observational study, conducted in a metropolitan area's third-level emergency department, involved patients with cardiogenic pulmonary edema from May 2021 to August 2023. The inclusion criteria specified acute cardiogenic pulmonary edema, excluding patients with incomplete data or other respiratory conditions. Lactate clearance, calculated at presentation and after 6 h, served as the primary outcome predictor. Our data analysis employed logistic regression, the ROC curve, and statistical tests. Results: The cohort of 106 patients revealed that a lactate clearance below 14.29% was significantly associated with mortality. While 51.6% of survivors were discharged, LC's predictive success for discharge was inconclusive. Logistic regression underscored the significance of lactate clearance, with a one-unit increase yielding a 5.55-fold probability of survival. The AUC for LC was 0.759. Conclusions: This study pioneers the exploration of lactate clearance in patients with acute cardiogenic pulmonary edema. LC below 14.29% signifies a poor prognosis, emphasizing its potential as an early treatment initiation marker. While acknowledging this study's limitations, we advocate for further multicenter research to refine the understanding of lactate clearance in this context.

Neonatal cardiorespiratory failure caused by splenic hemorrhages: a case report on a fatal and a rescued case

Two cases of neonatal splenic hemorrhage with acute cardiorespiratory failure are described in this report. The first case involves a full-term neonate who was found unresponsive without any witnesses and could not be successfully resuscitated. A postmortem diagnosis revealed a splenic hemorrhage. Second case is an extremely premature neonate who experienced a witnessed cardiovascular collapse on the 14th day of life. Rapid cardiovascular support was administered, resulting in a positive outcome. While splenic hemorrhage is commonly associated with traumatic events, these cases highlight the need of considering spontaneous splenic hemorrhages as a potential cause of acute neonatal compromise, even in the absence of birth-related trauma (e.g., asphyxia, prolonged labor, clavicle fractures, brachial plexus injuries). This report emphasizes the importance of including splenic hemorrhage timely in the differential diagnosis of neonatal cardiorespiratory instability, especially in the absence of more common diagnoses, and discusses the challenges associated with its recognition and treatment.

Availability in ECMO Reduces the Failure to Rescue in Patients With Pulmonary Embolism After Major Surgery: A Nationwide Analysis of 2.4 Million Cases.

Postoperative pulmonary embolism (PE) is a rare but potentially life-threatening complication, which can be treated with extracorporeal membrane oxygenation (ECMO) therapy, a novel therapy option for acute cardiorespiratory failure. We postulate that hospitals with ECMO availability have more experienced staff, technical capabilities, and expertise in treating cardiorespiratory failure. A retrospective analysis of surgical procedures in Germany between 2012 and 2019 was performed using hospital billing data. High-risk surgical procedures for postoperative PE were analyzed according to the availability of and expertise in ECMO therapy and its effect on outcome, regardless of whether ECMO was used in patients with PE. Descriptive, univariate, and multivariate analyses were applied to identify possible associations and correct for confounding factors (complications, complication management, and mortality). A total of 13,976,606 surgical procedures were analyzed, of which 2,407,805 were defined as high-risk surgeries. The overall failure to rescue (FtR) rate was 24.4% and increased significantly with patient age, as well as type of surgery. The availability of and experience in ECMO therapy (defined as at least 20 ECMO applications per year; ECMO centers) are associated with a significantly reduced FtR in patients with PE after high-risk surgical procedures. In a multivariate analysis, the odds ratio (OR) for FtR after postoperative PE was significantly lower in ECMO centers (OR, 0.75 [0.70-0.81], P < 0.001). The availability of and expertise in ECMO therapy lead to a significantly reduced FtR rate of postoperative PE. This improved outcome is independent of the use of ECMO in these patients.

Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study.

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Myocarditis as a cause of neonate’s circulatory failure during delivery - case study

&#x0D; Myocarditis (MCI) is a heart pathology characterized by its rare occurrence and a possible fatal course. In the natural history of the disease inflammatory cell infiltrates are present. There are subtypes of MCI depending on the predominant cell type in the biopsy sampls. One of them is eosinophilic myocarditis. In eosinophilic myocarditis more that 50% of the cells are eosinophils. In the later phases of the disease the myocardium is infiltrated by fibrous tissue and the heart vessels are often affected by thrombosis. Cardiomyopathy is a common long-term complication of the MCI.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Reported case presents a death of a male neonate. The neonate was delivered by vaginal delivery. Both prenatal development and all the prenatal tests indicated proper development of the fetus. At the delivery the neonate weight was 3900 grams and was evaluated with only 1 point on the Apgar score. Moreover, the neonate presented a complete acute cardiorespiratory failure at birth. Despite the 2 hour-long cardio-pulmonary resuscitation no return of spontaneous circulation was observed. The neonate’s remains were pathologically as well as histologically examined. The microscopic examination of the neonate’s heart samples contained many inflammatory cell infiltrations. Microabscesses with Charcot-Leyden crystals inside were also observed. Furthermore, the presence of atypical, polynuclear cells was noted. On the basis of the morphological image, it was recognized as an eosinophilic MCI.&#x0D;

Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings.

Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.

Posttraumatic Stress Symptom Trajectories in Family Caregivers of Patients With Acute Cardiorespiratory Failure

Overall, 1 in 3 family caregivers of patients who require intensive care unit (ICU) admission will experience significant posttraumatic stress symptoms (PTSSs), but little is known about how PTSSs evolve over time. Measuring PTSS trajectories could facilitate the development of targeted interventions to improve mental health outcomes for family caregivers of critically ill patients. To measure 6-month PTSS trajectories among caregivers of patients with acute cardiorespiratory failure. This prospective cohort study was conducted in the medical ICU of a large academic medical center among adult patients requiring (1) vasopressors for shock, (2) high-flow nasal cannula, (3) noninvasive positive pressure ventilation, or (4) invasive mechanical ventilation. Each patient was enrolled along with their primary caregiver, ie, the unpaid individual who provided the most physical, emotional, or financial support prior to ICU admission. Family caregiver PTSSs were assessed using the Impact of Events Scale-Revised within 48 hours of ICU admission, following ICU discharge, and 3 and 6 months after enrollment. Latent class growth analysis was used to measure PTSS trajectories. Preselected patient and caregiver characteristics measured at ICU admission were analyzed for association with trajectory membership. Six-month patient and caregiver outcomes were analyzed by caregiver trajectory. Overall, 95 family caregivers were enrolled and provided baseline data; mean (SD) age was 54.2 (13.6) years, 72 (76%) were women, 22 (23%) were Black individuals, and 70 (74%) were White individuals. Three trajectories were identified: persistently low (51 caregivers [54%]), resolving (29 [31%]), and chronic (15 [16%]). Low caregiver resilience, prior caregiver trauma, high patient severity of illness, and good patient premorbid functional status were associated with the chronic trajectory. Caregivers with the chronic PTSS trajectory had worse 6-month health-related quality of life (mean [SD] total 36-item Short Form Survey score, persistently low trajectory: 104.7 [11.3]; resolving trajectory: 101.7 [10.4]; chronic trajectory: 84.0 [14.4]; P < .001) and reduced effectiveness at work (mean [SD] perceived effectiveness at work score, persistently low trajectory: 86.0 [24.2]; resolving trajectory: 59.1 [32.7]; chronic trajectory: 72.3 [18.4]; P = .009). In this study, 3 distinct PTSS trajectories among ICU family caregivers were observed, with 16% of caregivers experiencing chronic PTSSs over the subsequent 6 months. Family caregivers with persistent PTSS had lower resilience, prior trauma, higher patient severity of illness, and higher baseline patient functional status compared with family caregivers with persistently low PTSS, with adverse effects on quality of life and work. Identifying these caregivers is an essential first step to develop interventions tailored to those with the greatest need for support.

Multiparameters associated to successful weaning from VA ECMO in adult patients with cardiogenic shock or cardiac arrest: Systematic review and meta-analysis.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure, including refractory cardiogenic shock (CS) and cardiac arrest (CA). Few studies have assessed predictors of successful weaning (SW) from VA ECMO. This systematic review and meta-analysis aimed to identify a multiparameter strategy associated with SW from VA ECMO. PubMed and the Cochrane Library and the International Clinical Trials Registry Platform were searched. Studies reporting adult patients with CS or CA treated with VA ECMO published from the year 2000 onwards were included. Primary outcomes were hemodynamic, laboratory, and echocardiography parameters associated with a VA ECMO SW. A total of 11 studies (n=653) were included in this review. Pooled VA ECMO SW was 45% (95%CI: 39-50%, I2 7%) and in-hospital mortality rate was 46.6% (95%CI: 33-60%; I2 36%). In the SW group, pulse pressure [MD 12.7 (95%CI: 7.3-18) I2 = 0%] and mean blood pressure [MD 20.15 (95%CI: 13.8-26.4 I2 = 0) were higher. They also had lower values of creatinine [MD -0.59 (95%CI: -0.9 to -0.2) I2 = 7%], lactate [MD -3.1 (95%CI: -5.4 to -0.7) I2 = 89%], and creatine kinase [-2779.5 (95%CI: -5387 to -171) I2 = 38%]. And higher left and right ventricular ejection fraction, MD 17.9% (95%CI: -0.2-36.2) I2 = 91%, and MD 15.9% (95%CI 11.9-20) I2 = 0%, respectively. Different hemodynamic, laboratory, and echocardiographic parameters were associated with successful device removal. This systematic review demonstrated the relationship of multiparametric assessment on VA ECMO SW.

Clinical profile of mechanically ventilated children aged 1 month to 18 years

: Mechanical Ventilation (MV) is a life supporting device indicated in acute cardio-respiratory failure in children. A limited data is available about MV in children from India and our region too.: To study clinical profile of mechanically ventilated children aged 1 month to 18 years of age. : This retrospective study was conducted between 1 May 2014 to 30 April 2019 at Pediatric Intensive Care Unit (PICU) of D.Y.Patil Medical college and hospital, Kolhapur among 103 children who required MV. The medical records like PICU Register and case sheets were reviewed for details like age, gender, clinical diagnosis, comorbid conditions and indications , length, mode and complications of MV. The data was analyzed statistically. The incidence of MV was 13.08% (1348/103) and 54.37% patients were under-five age. The primary diagnosis was respiratory 42(40.78%), neurological 29(28.15%), and cardiac 10 (9.70%) illnesses. Pneumonia and status epilepticus were the commonest causes. The indications for MV were highest with respiratory failure 31(30.09%) and cardiorespiratory failure 23 (22.33%). The median duration of MV was 3 days. The stridor 20(19.42%) and endotracheal tube blockages 08(07.77%) were the commonest complications. The outcome of patients was improved in 60(58.25%) while death in 38(36.89%) patients. The highest deaths occurred in 9(23.68%) , 8 (21.05%) patients with sepsis and pneumonia respectively. The indication for MV was either respiratory or cardiorespiratory failure while respiratory (Pneumonia) and neurological (Status Epilepticus) were the commonest illnesses. Most of the patients were improved while deaths occurred mainly in sepsis and pneumonia patients.

Posttraumatic Stress Disorder Symptom Trajectories in ICU Family Caregivers.

Prospective cohort study. The medical ICU at a tertiary-care center in the United States. Adult patients experiencing acute cardiorespiratory failure (defined as requiring at least one of the following: 1) vasopressors, 2) noninvasive positive pressure ventilation, 3) high-flow nasal cannula, or 4) mechanical ventilation) were enrolled in a pair with their primary family caregivers. Participants were enrolled within the first 48 hours of ICU admission. Family caregiver posttraumatic stress disorder symptoms were measured using the Impact of Events Scale-Revised at four time points: at enrollment, shortly after ICU discharge, and at 3 and 6 months after ICU discharge. The data were examined using latent class growth analysis to identify posttraumatic stress disorder symptom trajectories. Two distinct symptom trajectories were identified: a persistently high trajectory, characterized by high posttraumatic stress disorder symptoms at initial assessment, which remained elevated over time, and a persistently low trajectory, characterized by low posttraumatic stress disorder symptoms at initial assessment, which remained low over time. Approximately two-thirds of caregivers belonged to the persistently high trajectory, and one-third of caregivers belonged to the persistently low trajectory. Using latent class growth analysis to measure 6-month ICU family caregiver posttraumatic stress disorder symptom trajectories, we identified two distinct trajectories (persistently low and persistently high). A larger cohort study is warranted to further delineate posttraumatic stress disorder trajectories in this population, with the ultimate goal of targeting high-risk caregivers for interventions to reduce psychologic distress and improve long-term caregiver outcomes.

Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6-7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.

Differences between public and private hospitals in complications following catheter ablation of atrial fibrillation: a cohort study in Australia

Abstract Background Comparing outcomes of care between public and private hospitals is critical to inform patients and improve care quality. Purpose To compare complication rates following catheter ablation of atrial fibrillation (AF) up to 30-days post discharge between public and private hospitals. Methods We included patients ≥18 years who underwent AF ablation in the Australian states of New South Wales, Queensland, Victoria, and Western Australia from 2010–2015. The primary outcome was the occurrence of any complication up to 30-days after discharge. The association between provider type and the risk of complications was examined using logistic regression with inverse probability of treatment weighting (IPTW) propensity scores to account for differences in measured confounders. The minimum strength of association required for an unmeasured confounder to nullify any observed association was estimated using the E value. Results We identified 18,074 AF ablations during the study period (mean age 62.3±11.4y, 28.8% female, 78.4% performed in private hospitals). Patients ablated at public hospitals were younger (59.3 vs. 63.1y, p&amp;lt;0.001) but had higher rates of heart failure (10.3% vs. 7.7%, p&amp;lt;0.001), diabetes (10.9% vs. 7.9%, p&amp;lt;0.001), chronic kidney disease (4.9% vs. 2.2%, p&amp;lt;0.001), and chronic lung diseases (4.2% vs. 3.6%, p=0.046) than those at private hospitals. The unadjusted rate of complications was higher in publics hospitals compared with private ones (7.59% vs. 5.26%, p&amp;lt;0.001). After IPTW, there was good covariate balance with a median standardised difference of 0.006 (range 0.0–0.032) and the adjusted difference in procedural complication rates between two sectors remained significant (OR=1.46, 95% CI 1.24–1.73). The difference was mainly driven by an elevated risk of complications requiring cardiac surgery (OR=3.85, 95% CI 1.35–10.98), acute kidney injury (OR=2.95, 95% CI 1.12–7.74), cardiorespiratory failure (OR=2.69, 95% CI 1.19–6.04), postprocedural infection (OR=2.50, 95% CI 1.28–4.86), and bleeding (OR=1.26, 95% CI 1.02–1.56) (Figure 1). The disparity in the complication rates persisted when in-hospital (OR=1.41, 95% CI 1.16–1.70) and post-discharge (OR=1.52, 95% CI 1.12–2.07) complications were analysed separately. The E value was 1.79, suggesting that the disparity might plausibly be explained by unmeasured confounders. Conclusion AF ablation at a public hospital was associated with a 46% higher risk of complications compared with ablation at a private hospital, mainly driven by a higher risk of complications requiring cardiac surgery, acute kidney injury, cardiorespiratory failure, infections, and bleeding. The disparity could be due to differences in care quality between two sectors or explained by unmeasured confounders such as higher procedural complexity in public hospitals. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The National Heart Foundation of Australia

Successful Establishment of the First Neonatal Respiratory Extracorporeal Membrane Oxygenation (ECMO) Program in the Middle East, in Collaboration With Pediatric Services.

Background: Extracorporeal membrane oxygenation (ECMO) is a complex life-saving support for acute cardio-respiratory failure, unresponsive to medical treatment. Starting a new ECMO program requires synergizing different aspects of organizational infrastructures and appropriate extensive training of core team members to deliver the care successfully and safely.Objectives: To describe the process of establishing a new neonatal ECMO program and to evaluate the program by benchmarking the ECMO respiratory outcomes and mechanical complications to the well-established Extracorporeal Life Support Organization (ELSO) registry data.Materials and Methods: We reviewed the processes and steps involved in planning and setting up the new ECMO program. To assess the success of the ECMO implementation program, we retrospectively reviewed data of clinical outcomes and technical complications for the first 11 patients who have received ECMO therapy for respiratory indications since program activation (July 2018–May 2020). We analyzed mechanical complications as a tool to measure infrastructures and our effective training for the core team of ECMO specialists. We also looked at all clinical complications and benchmarked these numbers with the last 10 years of ELSO registry data (2009–2019) in the corresponding categories for comparison. Chi-square test was used to compare, and outcomes are presented in percentage; a p-value of <0.05 is considered significant.Results: A total of 27 patients underwent ECMO in the hospital, out of which 11 (six neonatal and five pediatric) patients had acute respiratory failure treated with venovenous (VV) ECMO or veno-arterial (VA) ECMO over a 22-month period. We had a total of 3,360 h of ECMO run with a range from 1 day to 7 weeks on ECMO. Clinical outcomes and mechanical complications are comparable to ELSO registry data (no significant difference); there were no pump failure, oxygenator failure, or pump clots.Conclusions: Establishing the ECMO program involved a multisystem approach with particular attention to the training of ECMO team members. The unified protocols, equipment, and multistep ECMO team training increased staff knowledge, technical skills, and teamwork, allowing the successful development of a neonatal respiratory ECMO program with minimal mechanical complications during ECMO runs, showing a comparable patient flow and mechanical complications.

Assessment of Right Heart Function during Extracorporeal Therapy by Modified Thermodilution in a Porcine Model.

Veno-arterial extracorporeal membrane oxygenation therapy is a growing treatment modality for acute cardiorespiratory failure. Cardiac output monitoring during veno-arterial extracorporeal membrane oxygenation therapy remains challenging. This study aims to validate a new thermodilution technique during veno-arterial extracorporeal membrane oxygenation therapy using a pig model. Sixteen healthy pigs were centrally cannulated for veno-arterial extracorporeal membrane oxygenation, and precision flow probes for blood flow assessment were placed on the pulmonary artery. After chest closure, cold boluses of 0.9% saline solution were injected into the extracorporeal membrane oxygenation circuit, right atrium, and right ventricle at different extracorporeal membrane oxygenation flows (4, 3, 2, 1 l/min). Rapid response thermistors in the extracorporeal membrane oxygenation circuit and pulmonary artery recorded the temperature change. After calculating catheter constants, the distributions of injection volumes passing each circuit were assessed and enabled calculation of pulmonary blood flow. Analysis of the exponential temperature decay allowed assessment of right ventricular function. Calculated blood flow correlated well with measured blood flow (r2 = 0.74, P < 0.001). Bias was -6 ml/min [95% CI ± 48 ml/min] with clinically acceptable limits of agreement (668 ml/min [95% CI ± 166 ml/min]). Percentage error varied with extracorporeal membrane oxygenation blood flow reductions, yielding an overall percentage error of 32.1% and a percentage error of 24.3% at low extracorporeal membrane oxygenation blood flows. Right ventricular ejection fraction was 17 [14 to 20.0]%. Extracorporeal membrane oxygenation flow reductions increased end-diastolic and end-systolic volumes with reductions in pulmonary vascular resistance. Central venous pressure and right ventricular ejection fractions remained unchanged. End-diastolic and end-systolic volumes correlated highly (r2 = 0.98, P < 0.001). Adapted thermodilution allows reliable assessment of cardiac output and right ventricular behavior. During veno-arterial extracorporeal membrane oxygenation weaning, the right ventricle dilates even with stable function, possibly because of increased venous return.

Gender-Dependent Clinical Outcome and Other Predictors of In-Hospital Mortality Following Out-Of-Center Extracorporeal Membrane Oxygenation and Extracorporeal Life Support: A Single Center Experience.

Out-of-center extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) implantation for the treatment of acute cardiorespiratory failure with subsequent transport to a tertiary care center has been introduced successfully into the medical practice. However, due to the very specific and resource intensive nature of this therapeutic concept, it seems important to generate algorithms for adequate patient selection. The aim of our study was to analyze the impact of patients' gender on early clinical outcome in this specific therapeutic scenario. Ninety-seven consecutive patients treated by out-of-center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center within the Hallesche Extracorporeal Life Support Program (HELP) retrospectively were analyzed, regarding the impact of patients' gender on early clinical outcome. Mechanical circulatory support successfully was weaned in two-thirds of the male patients. This result was achieved in only one-third of the female patients (59.4% in male vs. 33.3% in female, P = .0267). Overall survival significantly was higher in the male group (62.5% in male versus 30.3% in female, P = .0052). In uni- and multivariate logistic regression analysis, female gender was an independent predictor of in-hospital mortality (uni: OR:3.833, CI:1.597-9.745, P = .0034; multi: OR:3.477, CI:1.146-11.494, P = .0322). Worse outcome also was associated with following independent predictors, age, SOFA score, lactate and ventilation time pre-ECMO/ECLS implantation. The current study demonstrates a worse early survival for women, following emergent out-of- center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center. Gender should be included in patient selection algorithms while basic research approaches are needed to better understand the mechanisms underlying these gender- specific outcome disparities.

Serial Arterial Lactate Clearance and Outcome in Patients with Cardio-respiratory Insufficiency Presenting in Emergency Ward at Tertiary Level Hospital

Introduction: Acute cardio-respiratory failure is one of the acute common problems encountered in emergency and which required immediately intervention. It creates an imbalance between energy supply, demand, and consumption. Earlier lactate clearance should be useful to identify patient able to reverse the metabolic derangement and failure to rapidly resolve the oxygen debt, indicated by poor lactate clearance, would be correlated with negative outcome. For this purpose lactate clearance at 2 hour is more useful. Methods: This was a prospective study conducted at B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Preliminary diagnosis was made according to clinical history, physical examination, arterial blood gas and chest radio graph. A national emergency warning system was used for patient evaluation. Gas exchange and lactate blood concentration was assessed at Emergency ward at arrival, 2 & 6 hr. Two-hour lactate clearance was calculated as (Lactate start − lactate 2 hour)/lactate start (%). Blood gas-analysis and arterial lactate was performed by intermittent blood sampling and co-oximetry. Results: Out of 74 patients the COPD was the most common co-morbidity condition (25.7%), followed by congestive heart failure (18.9%). Comprising of lactate clearance at two hours and the lactate clearance at six hours, the lactate clearance at two hours and its outcomes was more significant (P=0.001, OR=10.133) than lactate clearance at six hours (P=0.213). Conclusions: Early lactate clearance was associated with positive outcome rather than late clearance.

Evaluation of Extra Corporeal Membrane Oxygenation Support in Adult Cardio Respiratory Failure-An Observational Study.

Abstract Extracorporeal life support is a rescue therapy when mechanical ventilation is unable to maintain adequate tissue oxygenation in the setting of acute cardiac or respiratory failure. Outcome is influenced not only by factors independent of ECMO but also by the potential complications related to ECMO. The study is designed to understand the outcomes of Extracorporeal membrane oxygenation in the management of Acute Cardio Respiratory failure in adult population. The study is analytical and the data is prospectively collected from a local registry of ECMO patients and ICU clinical database. Further, clinical details were obtained from prospective review of patient medical records. The study period is from November 2013 and November 2015. A total of 30 patients were included in the study 36.7% were weaned off ECLS and 33.3% survived to hospital discharge. Incidence of Heparin Induced Thrombocytopenia was observed in 3 patients. 27 patients went into renal dysfunction. Both ICU duration (p-0.945) and duration of ECMO (0.736) support did not prove to be significant in predicting mortality. No cannula related vascular complications leading to limb ischemia or need for vascular repair were encountered in any patient. Mean number of blood transfusions required during ECMO support were 15.17 units. Infections acquired on ECMO support, p=0.052; 95% CI=0.007-1.707. Our results endorse the use of ECMO as a rescue therapy in adults, although there are some risks associated with a learning curve as well as an important increase in the days of patient stay. However, ECMO is still marred by frequent and significant complications such as renal derangement, bleeding and nosocomial infections.

Survival rate and Outcome of extracorporeal life support (ECLS) for treatment of acute cardiorespiratory failure in trauma patients

Extracorporeal life support (ECLS) remains the last option for cardiorespiratory stabilization of severe traumatic injured patients. Currently limited data are available and therefore, the current study assessed the survival rate and outcome of ECLS in a Level I trauma center. Between 2002 and 2016, 18 patients (7 females, 11 males) with an median age of 29.5 IQR 23.5 (range 1–64) years were treated with ECLS due to acute traumatic cardiorespiratory failure. Trauma mechanism, survival rate, ISS, SOFA, GCS, GOS, CPC, time to ECLS, hospital- and ICU stay, surgical interventions, complications and infections were retrospectively assessed. Veno-arterial ECLS was applied in 15 cases (83.3%) and veno-venous ECLS in 3 cases (16.6%). Survivors were significant younger than non-survivors (p = 0.0289) and had a lower ISS (23.5 (IQR 22.75) vs 38.5 (IQR 16.5), p = n.s.). The median time to ECLS cannulation was 2 (IQR 0,25) hours in survivors 2 (IQR 4) in non-survivors. Average GCS was 3 (IQR 9.25) at admission. Six patients (33.3%) survived and had a satisfying neurological outcome with a mean GOS of 5 (IQR 0.25) (p = n.s.). ECLS is a valuable treatment in severe injured patients with traumatic cardiorespiratory failure and improves survival with good neurological outcome. Younger patients and patients with a lower ISS are associated with a higher survival rate. Consideration of earlier cannulation in traumatic cardiorespiratory failure might be beneficial to improve survival.

A unique case of acute brain haemorrhage with left ventricular systolic failure requiring ECMO

BackgroundAcute left ventricular (LV) systolic failure as a consequence of acute severe brain injury with status epilepticus in a young infant is not common; managing such a patient on extracorporeal membrane oxygenation (ECMO), which requires proper anticoagulation adds further substrate to a particularly intriguing and novel case worthy of reporting. Takotsubo syndrome and its peculiar clinical presentation is not commonly reported in the paediatric population, yet the high likelihood of this diagnosis joining the dots up for this case invites our curiosity and reflection through the clinical management of this case.Case presentationA previously healthy 9-month-old local Chinese boy presented with generalised seizures secondary to acute severe brain injury, with signs of sympathetic overdrive, followed by rapidly progressive cardiogenic shock and respiratory failure, eventually requiring ECMO support. Neuroimaging at presentation revealed bilateral subdural haemorrhages. His cardiac function recovered within the next 24 h revealing the reversibility nature of Takotsubo cardiomyopathy.ConclusionsThis is a captivating case depicting a series of unfortunate and unpredictable clinical events occurring in a previously well infant, which at initial presentation challenged the managing team with regards to its exact aetiology of acute brain injury and acute cardiorespiratory failure. Consideration of various differential diagnoses and finally narrowing down to that of stress-induced reversible cardiomyopathy (Takotsubo syndrome) following his intracranial bleed, versus that of coexisting dual pathology – acute brain injury with concomitant acute viral myocarditis, deepened our understanding of the pathophysiology of each disease process, and how it possibly interlinks between different organ systems.

Inflammatory myopathy with myasthenia gravis: Thymoma association and polymyositis pathology.

ObjectiveTo provide evidence that idiopathic inflammatory myopathy (IM) with myasthenia gravis (MG) frequently shows thymoma association and polymyositis (PM) pathology and shares clinicopathologic characteristics with IM induced by immune checkpoint inhibitors (ICIs).MethodsWe analyzed the clinicopathologic features of 10 patients with idiopathic IM and MG identified in 970 consecutive patients with biopsy-proven IM.ResultsSeven patients (70%) had thymoma. IM and MG were diagnosed with more than 5-year time difference in 6 thymomatous patients and within 1 year in 1 thymomatous and 3 nonthymomatous patients. Seven thymomatous patients showed rhabdomyolysis-like features with respiratory failure (4/7), dropped head (3/7), cardiac involvement (2/7), and positive anti–acetylcholine receptor (anti-AChR) and anti-titin antibodies (7/7 and 4/6, respectively) but rarely showed ocular symptoms (2/7) or decremental repetitive nerve stimulation (RNS) responses (1/7) at IM diagnosis. Three nonthymomatous patients showed acute cardiorespiratory failure with rhabdomyolysis-like features (1/3), positive anti-AChR and anti-titin antibodies (3/2 and 2/2, respectively), and fluctuating weakness of the skeletal muscle without ocular symptoms (3/3). Muscle pathology showed a PM pathology with infiltration of CD8-positive CD45RA-negative T-lymphocytes (9/9), scattered endomysial programmed cell death 1 (PD-1)–positive cells (9/9), and overexpression of programmed cell death ligand 1 (PD-L1) on the sarcolemma of muscle fibers around the infiltrating PD-1–positive cells (7/9).ConclusionRhabdomyolysis-like features, positive anti-AChR antibody without decremental RNS responses, and PD-L1 overexpression are possible characteristics shared by ICI-induced IM. Frequent thymoma association in patients with idiopathic IM and MG may suggest thymoma-related immunopathogenic mechanisms, including dysregulation of the immune checkpoint pathway.