Cardiopulmonary Support Research Articles

Conventional or minimized cardiopulmonary bypass support during coronary artery bypass grafting? - An analysis by means of perfusion and body mass index.

The use of minimized cardiopulmonary bypass support to reduce the side effects of extracorporeal circulation is still contradictorily discussed. This study compares perfusion operated by conventional (CCPB) and minimized (MCPB) cardiopulmonary bypass support during coronary artery bypass grafting (CABG). This study includes the data of 5164 patients treated at our department between 2004 and 2014. Tissue perfusion during cardiopulmonary bypass support and cardiac arrest was assessed by means of body mass index, hemodilution, blood pressure with corresponding pump flow and venous oxygen saturation, serum lactate, and serum pH. Hemodilution was more pronounced after CCPB: hemoglobin had dropped to 4.47±0.142g/dL after CCPB and to 2.77±0.148 g/dL after MCPB (P=0.0022). Despite the higher pump flow in conventional circuits (4.86-4.95L/min vs. 4.1-4.18L/min), mean blood pressure was higher during minimized bypass support (53±10 vs. 56±13mmHg [aortic clamping], 57±9 vs. 61±12mmHg [34°C], 55±9 vs.59±11mmHg [aortic clamp removal], P<0.0001) at all time points. Venous oxygen saturation remained on comparable levels of >70% during both conventional and minimized cardiopulmonary bypass support. The increase in serum lactate was more pronounced after CCPB (8.98±1.28 vs. 3.66±1.25mg/dL, P=0.0079), corresponding to a decrease in serum pH to acidotic levels (7.33±0.06 vs. 7.35±0.06, P<0.0001). These effects were evident in all BMI ranges. Minimized cardiopulmonary bypass support provides efficient perfusion in all BMI ranges and is thus equivalent to conventional circuits.

Extracorporeal membrane oxygenation with prone position ventilation successfully rescues infantile pertussis: a case report and literature review

BackgroundBordetella pertussis can cause fatal illness with severe acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT).Case presentationA 6-month-old non-vaccinated boy with B. pertussis infection who developed ARDS was treated by extracorporeal membrane oxygenation (ECMO). During his ECMO support stage, sudden occurred decreasing of ECMO flow implied increasing intrathoracic pressure. The airway spasm followed caused sudden drop of ventilator tidal volume as well as poor lung compliance. Prone position ventilation and bundle care were conducted as lung protection ventilator strategy. After 297-h of ECMO support, the patient was weaned off ECMO, and extubated one week later.ConclusionsIn this patient with severe ARDS caused by Bordetella pertussis, ECMO was performed for cardiopulmonary support and rescued the infant with severe pertussis. During ECMO support period, prone position ventilation and care bundle nursing strategy contributed to the relief of continuous airway spasm.

Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism.

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

Detection of patients at high risk for nonocclusive mesenteric ischemia after cardiovascular surgery

ObjectivesNonocclusive mesenteric ischemia (NOMI) is a rare but life-threatening complication after cardiovascular surgery. Early diagnosis and treatment is essential for a chance to cure. The aim of this study is to identify the independent risk factors for NOMI based on the evaluation of 12 cases of NOMI after cardiovascular surgery.MethodsWe retrospectively analyzed 12 patients with NOMI and 674 other patients without NOMI who underwent cardiovascular surgery in our hospital. We reviewed the clinical data on NOMI patients, including their characteristics and the clinical course. In addition, we performed a statistical comparison of each factor from both NOMI and non-NOMI groups to identify the independent risk factors for NOMI.ResultsThe median duration between the cardiac surgery and the diagnosis of NOMI was 14.0 (10.3–20.3) days. The in-hospital mortality of NOMI patients was 75.0%. Age (p < 0.05), peripheral arterial disease (p < 0.001), postoperative hemodialysis (p < 0.001), intraaortic balloon pump (p < 0.05), norepinephrine (NOE) > 0.10γ (p < 0.0001), percutaneous cardiopulmonary support (p < 0.001), sepsis (p < 0.05), loss of sinus rhythm (p < 0.05), prolonged ventilation (p < 0.0001), and resternotomy for bleeding (p < 0.05) showed significant differences between NOMI and non-NOMI groups. In the multivariate logistic regression model, prolonged ventilation [odds ratio (OR) = 18.1, p < 0.001] and NOE > 0.10 μg/kg/min (OR = 130.0, p < 0.0001) were detected as independent risk factors for NOMI.ConclusionsWe have identified the risk factors for NOMI based on the evaluation of the 12 cases of NOMI after cardiovascular surgery. This result may be useful in predicting NOMI, which is considered difficult in clinical practice. For the patient with suspected of NOMI who has these risk factors, early CT scan and surgical exploration should be performed without delay.

Abstract 16915: Extracorporeal Membrane Oxygenation for Pulmonary Embolism With Acute Right Ventricular Failure and Shock: National Trends of Use, Demographics and In-Patient Mortality in the United States 2011-2014

Background: Extracorporeal membrane oxygenation (ECMO) is an emerging option for cardio-pulmonary support for patients with massive pulmonary emboli (PE) as a bridge to definitive treatments. Goal of this study is to assess the national trends of use, demographics and in-patient mortality of patients managed with ECMO for PE associated with acute right ventricular failure and shock. Methods: The National Inpatient Sample database was queried for patients above 18 years of age hospitalized between 2011-2014 with pulmonary emboli (ICD diagnoses codes 415.1, 415.11, 415.19). Patients with acute right ventricular failure and shock with hemodynamic instability were identified (ICD diagnoses codes 415.0, 785.59, 785.51, 785.50). Patients treated with ECMO were identified using the procedure code 39.65. SPSS version 24 was used for statistical analysis. Results: During the study period, there were 1,262,542 admissions with pulmonary emboli, out of which 32,978 had acute right ventricular failure and shock. ECMO was used in 450 patients and that showed an increasing trend over the years (figure 1), with an in-patient mortality rate of 59.2%. Mean length of stay was 23 days. More than 90% of these patients were managed in large urban teaching hospitals with bed-size more than 500. Around half (43%) of these were in the Southern US hospitals. Factors associated with higher mortality were male sex (68.8%), age &gt;80 years (100%), Hispanic race (65%), lack of insurance (71.4%) and low socio-economic strata (income quartile 1st, 74.4%), p&lt;0.05. Conclusion: Use of ECMO for cardio-pulmonary support in patients hospitalized for PE with acute right ventricular failure and shock is increasing over the years. Among these patients, male sex, age &gt;80 years, Hispanic race, lack of insurance and lower socio-economic strata are associated with higher mortality.

VA-ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre-Implant Outcome Predictors.

Refractory cardiogenic shock (RCS) is associated with a high mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as acute cardiopulmonary support but selection of VA-ECMO candidates remains challenging. There are limited data on which pre-VA-ECMO variables that predict outcome. The aim of this study was to identify pre-VA-ECMO predictors of 90-day mortality. We retrospectively analyzed 76 consecutive patients (median age 52; interquartile range [IQR]: 37-60) supported with VA-ECMO due to RCS. The association between pre-implant variables and all-cause mortality at 90 days was analyzed with multivariable logistic regression. Main etiologies of RCS were acute myocardial infarction 51% and other AHF etiologies 49%. Cardiopulmonary resuscitation was performed in 54% of patients before initiation of VA-ECMO. Median duration of VA-ECMO was 5 days (IQR: 2-11). The 90-day overall mortality was 49% and in-hospital mortality was 50%; 46% died on VA-ECMO, 37% were successfully weaned, 13% were bridged to heart transplantation, and 4% to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio [OR] per mmol/L: 1.15; 95% confidence interval [CI]: 1.06-1.24; P=0.001) and number of inotropes and vasopressors (OR per agent: 2.14; 95% CI: 1.26-3.63; P=0.005) as independent predictors of 90-day mortality. In RCS patients arterial lactate level and number of inotropes and vasopressors were identified as independent pre-VA-ECMO predictors of 90-day mortality. Thus, the severity of cardiogenic shock expressed as levels of lactate and vasoactive agents just before start of VA-ECMO may be more predictive of outcome than the specific etiology of cardiogenic shock.

Liver Transplant Listing in Pediatric Acute Liver Failure: Practices and Participant Characteristics.

Liver transplant (LT) decisions in pediatric acute liver failure (PALF) are complex. Three phases of the PALF registry, containing data on 1,144 participants over 15 years, were interrogated to characterize clinical features associated with listing status. A decrease in the cumulative incidence of listing (P < 0.005) and receiving (P < 0.05) LT occurred without an increase in the cumulative incidence of death (P = 0.67). Time to listing was constant and early (1 day; quartiles 1-3 = 0-2; P = 0.88). The most frequent reasons for not listing were "not sick enough" and "medically unsuitable." Participants listed for LT were more likely male, with coma grade scores >0; had higher international normalized ratio, bilirubin, lactate, and venous ammonia; and had lower peripheral lymphocytes and transaminase levels compared to those deemed "not sick enough." Participants listed versus those deemed "medically unsuitable" were older; had higher serum aminotransferase levels, bilirubin, platelets, and albumin; and had lower lactate, venous ammonia, and lymphocyte count. An indeterminate diagnosis was more prevalent in listed participants. Ventilator (23.8%) and vasopressor (9.2%) support occurred in a significant portion of listed participants but less frequently than in those who were not "medically suitable." Removal from the LT list was a rare event. Conclusion: The cumulative incidence of listing for and receiving LT decreased throughout the PALF study without an increase in the cumulative incidence of death. While all participants fulfilled entry criteria for PALF, significant differences were noted between participants listed for LT and those deemed "not sick enough" as well as those who were "medically unsuitable." Having an indeterminate diagnosis and a requirement for cardiopulmonary support appeared to influence decisions toward listing; optimizing listing decisions in PALF may reduce the frequency of LT without increasing the frequency of death.

Utility and limitations of perimortem cesarean section: A nationwide survey in Japan

Perimortem cesarean section (PCS) is a procedure performed as part of cardiopulmonary resuscitation (CPR). This study aims to clarify maternal and neonatal prognosis and establish PCS's utility and limitations. We sent structured questionnaires to obstetrics facilities regarding the cases of PCS performed in Japan between April 2010 and April 2015. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values of the time from cardiopulmonary arrest (CPA) to return of spontaneous circulation to predict the onset of disseminated intravascular coagulation (DIC). PCS was performed for 18 patients. Out of 18 patients, 12 were resuscitated. The women who were discharged without major sequelae (n = 6) were compared with the non-discharged women who were dead or in persistent vegetative state (n = 12), and median interval time from arrest to PCS was significantly shorter in the former group (P = 0.002). Median interval time from CPA to PCS in the cases in which the neonates survived without major morbidities was significantly shorter than that in the cases of neonatal death and hypoxic encephalopathy (P = 0.01). DIC was observed in 8/9 (89%) patients whose resuscitation took more than 20 min from the diagnosis of CPA. Percutaneous cardiopulmonary support (PCPS) was introduced in 4/9 patients. However, more cases with uncontrolled bleeding, possibly caused by a sudden increase in blood flow and DIC after resuscitation, were observed in the PCPS group compared to the non-PCPS group. PCS can be an effective CPR procedure. However, if PCS is not performed within 20 min from CPA, starting PCPS before PCS is an option.

Extracorporeal cardiopulmonary support in acute high-risk pulmonary embolism: still waiting for solid evidence

Extracorporeal cardiopulmonary support in acute high-risk pulmonary embolism: still waiting for solid evidence

Flipped-classroom training in advanced cardiopulmonary life support.

BackgroundThe effects of the flipped classroom have been demonstrated in various fields of education in recent years. Training in emergency medicine is also beginning to gradually implement the flipped classroom; however, its practical effect in emergency medicine contexts is not yet clear.ObjectiveThe present study investigates the effects of the flipped classroom on advanced cardiopulmonary life support (ACLS) training implemented among practicum students in emergency medicine.MethodsThe study randomly assigned into control and experimental conditions 108 fourth year students in the College of Medicine at Yonsei University, in Seoul, who were scheduled to take clinical practice in emergency medicine between March and July 2017. Students were taught about ACLS in either a traditional lecture-based classroom (control condition) or a flipped classroom (experimental condition); then, simulation training with ACLS scenarios was carried out. Finally, each student was rated on performance using a rating form developed in advance.ResultsACLS simulation scores of the students in the flipped classroom were 70.9±10.9, which was higher than those of the students in the traditional classroom (67.1±11.3); however, this difference was not statistically significant (p = 0.339). In addition, the difference in student satisfaction as measured on a survey was statistically insignificant (p = 0.655).ConclusionsCompetency assessment after simulation-based training in ACLS undergone by senior medical students randomly assigned to flipped and traditional classrooms showed no statistical difference in competency between the two groups.

Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation.

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is the preferred configuration for bridging respiratory failure patients while awaiting lung transplantation. However, there is no consensus on intraoperative extracorporeal cardiopulmonary support during lung transplantation in these patients. The configuration of the intraoperative extracorporeal circuit after VV ECMO bridge was reviewed and correlated with clinical outcomes. This retrospective cohort study performed at our university hospital included 34 patients who were successfully bridged solely with VV ECMO to lung transplantation during the period 2007 to 2016. Indications to switch to intraoperative venoarterial (VA) ECMO were hemodynamic compromise (systemic hypotension or mean pulmonary artery pressure >40 mm Hg) or when this scenario was thought to be highly likely. The median duration of bridging was 12 (IQR 7 to 19) days. Intraoperatively, 3 patients (8.8%) required cardiopulmonary bypass. Twenty patients (58.8%) stayed on VV ECMO and 11 (32.3%) were switched to central VA ECMO. Between the 2 types of intraoperative ECMO (VV vs VA), there were no significant differences in post-operative ECMO duration, chest reopening for bleeding, or renal replacement therapy. There was no significant difference in 90-day mortality (0% and 9.0%, p = 0.35) or in long-term survival (p = 0.59). The intraoperative transfusion of red blood cells tended to be higher in the VA group (5 [4 to 9] vs 8 [6 to 13] units, p = 0.06). Use of intraoperative VA ECMO was associated with the use of low-flow VV device bridging and lobar transplantation. Using the existing VV ECMO bridge intraoperatively during lung transplantation is feasible and provides comparable outcomes to patients converted to central VA ECMO for compromised hemodynamics.

Extracorporeal support, during and after lung transplantation: the history of an idea.

During recent years, continuous technological innovation has provoked an increase of extracorporeal life support (ECLS) use for perioperative cardiopulmonary support in lung transplantation. Initial results were disappointing, due to ECLS-specific complications and high surgical risk of the supported patients. However, the combination of improved patient management, multidisciplinary team work and standardization of ECLS protocols has recently yielded excellent results in several case series from high-volume transplant centres. Therein, it was demonstrated that, although the prevalence of complications remains higher in supported patients, there may be no difference in long-term graft function between supported and non-supported patients. These results are important, because most of the patients who require ECLS support in lung transplantation are young and have no other chance to survive, but to be transplanted. Moreover, there is no device for "bridging to destination" therapy in lung transplantation. Of note, the evidence in favour of ECLS support in lung transplantation was never validated by randomized controlled trials, but by everyday experience at the patient bed-side. Here, we review the state-of-the-art ECLS evidence for intraoperative and postoperative cardiopulmonary support in lung transplantation.

胸骨圧迫が原因による著明な縦隔血腫から閉塞性ショックを来した1例(A case of obstructive shock from a severe mediastinal hematoma induced by chest compression)

心肺蘇生時の胸骨圧迫による合併症は比較的経験し，症例報告も散見される。しかし，胸骨圧迫によって縦隔血腫を合併し，閉塞性ショックにまで至った症例は非常に稀である。我々は胸骨骨折と内胸動脈損傷による縦隔血腫が原因で，閉塞性ショックを来した症例を救命したので報告する。症例は70歳の男性で，心肺停止状態で来院した。胸骨圧迫を継続しながら経皮的心肺補助装置を導入した。冠動脈造影検査で右冠動脈の閉塞を認め，閉塞部位に金属ステントを留置した。冠動脈カテーテル治療終了後に，単純CT検査を施行したところ，著明な縦隔血腫を認めた。縦隔血腫によって右心房が虚脱し，経皮的心肺補助装置の脱血が不良となった。緊急で剣状突起下からドレナージカテーテルを留置したが500mL/時の持続的な出血を認めたため，止血術を施行した。胸骨正中切開を行い，胸骨骨折部と左内胸動脈分枝部からの出血部をそれぞれ止血した。第4病日に経皮的心肺補助装置を離脱した。最終的に神経学的後遺症なく，長期臥床による廃用のリハビリテーション目的で転院した。 Complications due to chest compressions administered during cardiopulmonary resuscitation are relatively common. Only very rarely, however, does an obstructive shock resulting from a mediastinal hematoma occur. A 70–year–old male in cardiopulmonary arrest was admitted to the hospital. Percutaneous cardiopulmonary support was initiated as the chest compressions were continued. Coronary angiography showed occlusion of the right coronary artery, and a bare metal stent was placed at the occluded site. The patient was examined by CT after the percutaneous coronary intervention to check for complications from the percutaneous cardiopulmonary support. The CT images revealed a severe mediastinal hematoma. The percutaneous cardiopulmonary support had impeded the blood flow due to a compression of the right cardiac atrium and ventricle by the severe mediastinal hematoma. A trocar catheter was emergently inserted from below the xiphoid process. Continuous bleeding from the trocar catheter necessitated immediate hemostasis surgery. After a midline sternotomy, hemostatic treatment was applied to bleeding from the sternal fracture and branch of the left internal thoracic artery. The percutaneous cardiopulmonary support was removed on the fourth day after the surgery. The patient was ultimately transferred to another hospital for rehabilitation without neurologic deficits. CT examination can be useful for searching for fatal complications caused by chest compressions. 心肺蘇生時は質の高い胸骨圧迫を直ちに行うことが強く推奨されている 1。しかし一方で，胸骨圧迫による合併症も多数報告されている 2, 3。今回我々は，心肺蘇生時の胸骨圧迫によって胸骨骨折と内胸動脈損傷を合併し，縦隔血腫による閉塞性ショックを来した症例を救命したので報告する。 なお，倫理規定に関する事項は次の通りである。 ①倫理委員会が審査・承認すべき事項には該当しない。 ②個人情報保護に基づき，匿名化している。 ③患者および家族より論文の掲載に関して同意を得ている。 症 例：70歳の男性 主 訴：来院時心肺停止 既往歴：なし 現病歴：受診日の17時30分，商業店舗で商談中に卒倒し，17時32分から非番の消防職員によって胸骨圧迫が開始された。救急隊接触後の17時42分に心室細動が確認された。計5回のAEDによる除細動が施行されたが，自己心拍は再開しないまま，当院救命救急センターへ搬送された。 受診時現症：GCS（Glasgow coma scale）E1V1M1，心肺停止，瞳孔5mm/5mm，対光反射なし/なし 胸部単純レントゲン初見：心胸郭比48%，両側上肺野の透過性低下 II 誘導モニター心電図：心室細動 入院後経過：17時55分に当院救命救急センターに搬送された。初期波形が心室細動であり，アミオダロン300mg投与後の除細動でも効果を認めず難治性心室細動と診断した。当院での経皮的心肺補助装置（percutaneous cardiopulmonary support: PCPS）を用いた心肺蘇生術（extracorporeal cardiopulmonary resuscitation: ECPR）の導入基準に則り，心臓カテーテル室へ入室した。18時26分にPCPSを導入した（発症からPCPS導入まで56分）。PCPS回路はヘパリンコーティングされたものを使用し，3L/分の流量を保つように適時輸液負荷した。18時34分にヘパリン6,000単位を投与した。18時46分に150Jで除細動し洞調律を得た。12誘導心電図検査のII III aVf誘導でST–Tの上昇を認め，急性心筋梗塞と診断した。18時50分にACTを測定し283秒と延長していることを確認後，冠動脈造影検査（coronary angiography: CAG）を施行し，引き続き冠動脈カテーテル治療（percutaneous coronary intervention: PCI）を施行した。 CAG所見：右冠動脈（right coronay artery: RCA）（#2）の完全閉塞を認めた。左冠動脈に有意狭窄は認めなかった。 PCI所見：RCA（#2）部分の血栓を吸引し，血流が再開した。同部位にベアメタルステント（3.5×22mm）を留置し，TIMI（Thrombolysis in Myocardial Infarction Trial Grade）分類3の再灌流を得た（Fig. 1）。 Coronary angiography. a) Left anterior oblique view of the right coronary artery on coronary angiogrm. The right coronary artery was occluded (arrow). b) Left anterior oblique cranial view of the right coronary artery on angiogrm. A bare metal stent was placed in the right coronary artery (arrow heads). The right coronary flow improved. PCI終了後（20時30分頃）よりPCPSの流量が安定せず，乳酸リンゲル液やアルブミン製剤を急速投与した。PCI終了後に全身検索目的で，頭部から骨盤部までの単純CT検査を施行し，前縦隔に著明な縦隔血腫を認めた（Fig. 2）。また肺動脈，右房および右心室が壁外圧迫により虚脱していた。CT検査開始直後の20時55分頃からPCPSの脱血が不良となり，1L/分まで血液流量が低下した。右房が虚脱したため，脱血不良になったと判断した。輸液負荷によって2L/分まで血液流量が改善したため，そのままCT検査を施行した。集中治療センターに入室後，直ちに剣状突起下を小切開し前縦隔に16Frドレナージカテーテルを留置した（21時50分頃）。また，濃厚赤血球液および新鮮凍結血漿の輸血を開始した。ドレナージカテーテルによって閉塞性ショックから離脱し，十分な脱血が可能となったため脱血管の位置調整は施行しなかった。しかし，ドレナージカテーテルから500mL/時の持続的な出血を認め，断続的に濃厚赤血球および新鮮凍結血漿の輸血が必要な状態であった。23時00分に心臓血管外科に緊急開胸止血術を依頼し，24時00分から開胸手術を開始した。ヘパリン投与は初回6,000単位のみで，硫酸プロタミンは使用しなかった。 Plain CT performed after percutaneous coronary intervention. a) The pulmonary artery was compressed by a severe mediastinal hematoma (arrow head). b) Sternal bone fracture (arrow). The right atrium and right ventricle were compressed by the severe mediastinal hematoma (arrow heads). 手術所見：全身麻酔下で胸骨正中切開し，出血源を検索した。胸骨体の下1/3での骨折と，左内胸動脈の分枝からの拍動性の出血を認めた。胸骨骨折部からの出血は，挫滅も強く止血に難渋したが，電気メスによる焼灼と酸化セルロースで止血した。内胸動脈の分枝からの出血は止血クリップで止血した。また前縦隔部の血腫を除去し，心膜に損傷のないことを確認し，縦隔ドレーンを留置し閉創した。また，集中治療センターへ帰室後より，ヘパリンの持続投与を開始し，ACTが180–200秒前後になるよう，3時間ごとにモニタリングした。 術後経過：縦隔ドレーンからの排液は，術後第2病日に減少し抜去した。第4病日にはPCPSを離脱した。第6病日に胸部単純CT検査を撮影し，縦隔血腫は残存していたものの，右心系の圧排が解除されていることを確認した（Fig. 3）。神経学的後遺症は認めなかったが，長期臥床による廃用症候群を合併した。リハビリテーションによってADLは改善して，来院日から約6か月後にリハビリテーション目的で転院となった。 Plain CT was performed 6 days after operation. a) The mediastinal hematoma remained, however the pulmonary artery was not compressed. b) The mediastinal hematoma remained but the right atrium and right ventricle were not compressed. 心肺停止状態の患者に対する胸骨圧迫は，躊躇することなく行うべきであり，医療従事者のみならず，市民によっても行われている普遍的な手技である 1。一方で胸骨圧迫による合併症も多数報告されている 2, 3。本邦での胸骨圧迫の合併症に関するアンケート調査 4では，85.4%の医師が何らかの合併症を経験し，32.3%が胸骨骨折を経験している。しかし，心肺停止患者に対する胸骨圧迫が原因となり閉塞性ショックにまで至った報告は，我々の検索し得た範囲では4編5症例のみであった。うち3症例は本症例のように外科的止血術を施行し，2症例は血管内治療を施行している 5, 6, 7, 8。 本症例を救命することができた要因は，冠動脈カテーテル治療直後の単純CT検査で，縦隔血腫を早期に診断したことである。当院救命救急センターでは院外心肺停止症例に対して，積極的にPCPSを用いた心肺蘇生術（ECPR） 9を施行している。PCPS挿入時や管理中の出血合併症は致死的経過に至る可能性がある 10。そこで，PCPS挿入に伴う出血合併症の危険性を低減させるために，心臓血管カテーテル室に移動し透視下で挿入している。また，穿刺部や後腹膜の血腫の有無を確認する目的で，PCPSを挿入しCAG・PCIが終了した直後に，胸腹部単純CT検査を施行している。同時に低酸素脳症の評価目的に，頭部CT検査も施行している。当院は初療室・心臓血管カテーテル室・CT室が同一階に配置されているため移動時間が短いこと，ベッドではなくストレッチャーを用いてスペースを確保するなどの工夫によって，PCPS挿入中でも移動が可能となっている。 一般的にPCPSの脱血不良が発生した場合には，循環血漿量の不足を考える。しかし，充分な乳酸リンゲル液やアルブミン製剤の投与によっても改善を認めない場合は，PCIの合併症である冠動脈穿孔 11や，急性心筋梗塞自体の合併症である心破裂 12による心タンポナーデを疑い，経胸壁心臓超音波検査を施行することが考えられる。本症例ではCT検査を施行し縦隔血腫と診断できたため経胸壁心臓超音波検査を施行していないが，現在はECPR症例に対してはCAG・PCI終了後に心臓カテーテル室内で経胸壁心臓超音波検査を施行している。しかし，単純CT検査は簡便に縦隔血腫の有無を診断することができるため，経胸壁心臓超音波施行と併せて施行することが有用と考える。本症例はCT室内で脱血不良となり，縦隔血腫による右房の圧迫と診断が可能であった。脱血不良に対して輸液負荷で対応したが，CT室内で脱血管を下大静脈まで下げることによって，より早期に脱血不良から離脱する可能性があった。また，山岸ら 13は心肺停止の原因検索で冠動脈造影検査を行う症例では，事前にCTで出血性合併症の有無と出血源の同定をすることによって，冠動脈造影検査時にそのまま血管内治療に移行できるため有用であると報告している。当院では心臓血管カテーテル室でPCPSを挿入しているため，PCI終了後にCT室へ移動し出血性合併症の有無を検索している。 また，本症例を救命することができたもう一つの要因は，外科的治療を選択したことである。閉塞性ショックを呈していたため，早急に縦隔血腫をドレナージする必要があり，前縦隔にドレナージカテーテルを留置した 5。仮に閉塞性ショックを呈していなければ，保存的に経過観察する選択肢もある 8。出血性合併症に対する止血の方法として，血管内治療と外科的治療に分けられる。内胸動脈損傷に対しても血管内治療 13, 14と外科的治療 15の報告例がある。胸骨圧迫による縦隔血腫で出血源となり得るのは，内胸動脈や肋間動脈およびその分枝血管，胸骨や肋骨骨折からの出血である 16。血管内治療は低侵襲であるが，損傷部位が複数ある場合には出血源の検索に時間を要する。また，胸骨骨折の出血には対応できない。外科的治療は直視下で観察できるため，複数の出血源を同時に検索しやすく，止血処置も直視下で行えるため止血が得られやすい。しかし，血管内治療に比べると高侵襲である。本症例は持続する出血量を認め，出血源として胸骨骨折部分も考えられたため，直視下で観察できる外科的治療を選択した。実際，胸骨骨折からの出血も持続的に認めた。また，術中に止血を確認できたことによって，ヘパリンを早期に再開することができた。本症例のようなPCPS使用下では抗凝固療法を長期間中止しにくく，縦隔血腫によって閉塞性ショックにまで至るような場合には，緊急開胸止血術を施行し，確実な止血を得ることが有用である。 蘇生において最も基本的な手技である胸骨圧迫ではあるが，少なからず合併症を経験する。我々は胸骨圧迫によって，致死的な合併症にまで至る可能性があることを認識しておく必要がある。単純CT検査は胸骨圧迫による致死的合併症の縦隔血腫の有無を，簡便かつ迅速に検索でき有用である。 本論文に関連して開示すべき利益相反はない。

2995Risk prediction in patients with venoarterial extracorporeal membrane oxygenation for cardiopulmonary support: insights from a German registry

2995Risk prediction in patients with venoarterial extracorporeal membrane oxygenation for cardiopulmonary support: insights from a German registry

The impact of preoperative sarcopenia, defined based on psoas muscle area, on long-term outcomes of heart valve surgery

ObjectiveSarcopenia, age-related loss of muscle mass, is an objective and comprehensive marker of frailty. We aimed to clarify the influence of sarcopenia on the outcomes after heart valve surgery. MethodsWe retrospectively reviewed 1119 patients who underwent valve surgery via median sternotomy at our institution from June 2009 to December 2013. Patients aged <70 years, urgent/emergent cases, and patients without preoperative computed tomography of the abdomen were excluded. The remaining 428 patients were included in this study. Psoas muscle area, a validated measure of sarcopenia, was measured on preoperative computed tomography. Sarcopenia was defined as the lowest sex-specific quartile in psoas muscle area. The mean follow-up period was 3.4 years. ResultsOverall in-hospital mortality did not differ between the sarcopenia and nonsarcopenia patient groups. However, the incidence of stroke and intra-aortic balloon pump/percutaneous cardiopulmonary support use was greater in the sarcopenia group than in the nonsarcopenia group. The patients with sarcopenia had significantly decreased long-term survival and decreased freedom from major adverse cardiac and cerebrovascular events. Multivariable analysis and inverse probability weighting revealed that sarcopenia was an independent predictor for decreased survival (hazard ratio, 2.22; 95% confidence interval, 1.26-3.92; P = .006). ConclusionsPreoperative sarcopenia defined from the psoas muscle area was associated with long-term outcomes after valve surgery. Thus, the measurement of psoas muscle area can help facilitate more accurate risk scoring in elderly patients.

Tuberculous pneumonia-induced severe ARDS complicated with DIC in a female child: a case of successful treatment

BackgroundTuberculous (TB) pneumonia can induce acute respiratory distress syndrome (ARDS). Although TB pneumonia is one of the causes of disease and death among children worldwide, the literature on TB pneumonia-induced ARDS is limited. We report herein on the successful treatment of a two-year-old female child with TB pneumonia-induced severe ARDS complicated with disseminated intravascular coagulation (DIC).Case presentationA two-year-old Vietnamese female child with sustained fever and cough for 20 days was transferred to our hospital. She had severe dyspnea and a chest X-ray showed bilateral infiltration without findings of heart failure. After tracheal intubation, her oxygenation index (OI) and PaO2/FiO2 (PF) ratio were 29 and 60 mmHg, respectively. Mycobacterium tuberculosis was detected by real-time polymerase chain reaction (rPCR) assay of tracheal lavage fluid. She was diagnosed as having severe ARDS that developed from TB pneumonia. Anti-tuberculous therapy and cardiopulmonary support were started. However, her respiratory condition deteriorated despite treatment with high-frequency oscillating ventilation (HFO), vasopressor support, and 1 g/kg of immunoglobulin. On the third day after admission, her International Society on Thrombosis and Hemostasis DIC score had increased to 5. Recombinant human soluble thrombomodulin (rTM) was administered to treat the DIC. After the administration of rTM was completed, OI gradually decreased, after which the mechanical ventilation mode was changed from HFO to synchronized intermittent mandatory ventilation. The DIC score also gradually decreased. Plasma levels of soluble receptor for advanced glycan end products (sRAGE) and high mobility group box 1 (HMGB-1), which are reported to be associated with ARDS severity, also decreased. In addition, inflammatory biomarkers, including interferon-gamma (IFN-γ) and interleukin-6 (IL-6), decreased after the administration of rTM. Although severe ARDS (P/F ratio ≦ 100 mmHg) continued for 19 days, the patient’s OI and P/F ratio improved gradually, and she was extubated on the 27th day after admission. The severe ARDS with DIC was successfully treated, and she was discharged from hospital on day 33 post-admission.ConclusionsWe successfully treated a female child suffering from TB pneumonia-induced severe ARDS complicated with DIC using multimodal interventions. (338/350).

Influences on a Culture that Supports Organ Donation After Circulatory Death

Organ donation remains rare, particularly in Australia where various initiatives attempt to bolster donation rates including a renewed interest in Donation after Circulatory Death (DCD). DCD reintroduction has been accompanied by increased donor numbers and organs transplanted, with associated favourable short- and long-term transplant outcomes. However, reintroduction has been met with variable institutional and individual support. Ethical concerns are often raised, particularly surrounding how a clinician’s decision to palliate and withdraw cardiopulmonary support may be influenced by the desire for DCD. The current study aims for a greater understanding of DCD perceptions among staff involved. Materials and Methods This qualitative study utilised semi-structured interviews with intensive care staff at the Alfred Hospital ICU in Melbourne. Staff participants were recruited through email invitation, and a trained interviewer used a semi-structured interview guide to explore perceptions surrounding DCD. Twelve staff participants were interviewed based on reaching a data saturation point. Several 10-point Likert scales were included. Interviews were digitally recorded and transcribed verbatim for thematic analysis. Results Twelve participants were interviewed; eight intensive care physicians, three donation coordinators and one bedside nurse. Responses to the Likert scale questions were averaged (n=12). Donation after brain death was unanimously accepted (Average=10.0), whereas DCD acceptance was lower but remained supported (Average=8.8). Interview responses generated five themes, each containing subthemes. Themes included: 1) Logistical and circumstantial obstacles surrounding DCD implementation; 2) Cultural and environmental influences on DCD decision making; 3) Influence of personal factors on DCD implementation; and 4) Influence of families of potential donors on DCD. Discussion Respondents had concerns with DCD where perceptions existed that DCD would increase family distress, either from timeframes not being met or logistical delays. A second major source of concern stemmed from personal conflict relating to their role. There was difficulty transitioning from primarily sustaining life or facilitating palliation alone to advocating for DCD, especially where there was perceived potential for deviations from standard palliation in analgesia, sedation and investigations. Overall, concerns were overcome by reliance on a supportive work environment, rationalisation of concerns over time and reliance on protocols. Conclusion A supportive culture within the Alfred Hospital ICU meant DCD occurred with minimal institutional resistance. However, some individual concerns surrounding DCD were identified. These may be present and amplified in other centers. More study is required in centers where institutional resistance to DCD is identified that DCD may be further promoted to expand the donor pool.

Epidemiology of Lower Extremity Deep Venous Thrombosis in Critically Ill Adolescents

To determine the epidemiology of lower extremity deep venous thrombosis (DVT) in critically ill adolescents, which currently is unclear. We performed a multicenter, prospective, cohort study. Adolescents aged 13-17 years who were admitted to 6 pediatric intensive care units and were anticipated to receive cardiopulmonary support for at least 48 hours were eligible, unless they were admitted with DVT or pulmonary embolism or were receiving or anticipated to receive therapeutic anticoagulation. While patients were in the unit, serial sonograms of the lower extremities were performed, then centrally adjudicated. Bayesian statistics were used to leverage the similarities between adults and adolescents. A total of 88 adolescents were enrolled, from whom 184 lower extremity sonograms were performed. Of these, 9 adolescents developed DVT, with 1 having bilateral DVT. The frequency of DVT was 12.4% (95% credible interval: 6.1%, 20.1%), which ranged from 6.3% to 19.8% with a variability of 41.0% across units. All cases of DVT occurred in adolescents who received invasive mechanical ventilation (frequency: 16.5%; 95% credible interval 8.1%, 26.6%). DVT was associated with femoral central venous catheterization (OR 15.44; 95% credible interval 1.62, 69.05) and severe illness (OR for every 0.1 increase in risk of mortality 3.11; 95% credible interval 1.19, 6.85). DVT appears to be associated with prolonged days on support. Our findings highlight the similarities and differences in the epidemiology of DVT between adults and adolescents. They support the conduct and inform the design of a trial of pharmacologic prophylaxis in critically ill adolescents.

In utero transmission of Influenza AH1N1

Influenza A pandemic (H1N1) 2009 was first detected in United States in April 2009. It is associated with high risk of complications in pregnant women and children. Transplacental infection of influenza A is rare. We report a case of in utero transmission of Influenza A (H1N1) infection in a newborn whose mother was seriously ill with Influenza A (H1N1) during the perinatal period. Our patient was likely infected in utero because he was delivered by cesarean section and was never exposed to his mother, who required intensive cardiopulmonary support at the time of delivery.

Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality

ObjectivesRefractory postcardiotomy cardiogenic shock is associated with a high mortality, and venoarterial extracorporeal membrane oxygenation can offer acute cardiopulmonary life support. The aim of this study was to identify pre–venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. MethodsWe retrospectively analyzed 105 consecutive patients supported with venoarterial extracorporeal membrane oxygenation due to refractory postcardiotomy cardiogenic shock. The association between preimplant variables and all-cause mortality at 90 days was analyzed with univariable and multivariable logistic regression. ResultsMain surgical subgroups were single noncoronary artery bypass grafting (29%), isolated coronary artery bypass grafting (20%), and 2 and 3 concomitant surgical procedures (31% and 20%, respectively). The median age of patients was 62 years (interquartile range, 52-68 years), and 76% were men. Cardiopulmonary resuscitation was performed in 30% of patients before venoarterial extracorporeal membrane oxygenation initiation. The median duration of venoarterial extracorporeal membrane oxygenation was 7 days (interquartile range, 3-14). The 90-day overall mortality was 57%, and in-hospital mortality was 56%. Forty-seven percent of patients died on venoarterial extracorporeal membrane oxygenation, 51% of patients were successfully weaned, 1% of patients were bridged to heart transplantation, and 1% of patients were bridged to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio per unit, 1.22; 95% confidence interval, 1.07-14.0; P = .004) and ischemic heart disease (odds ratio, 7.87; 95% confidence interval, 2.55-24.3; P < .001) as independent risk factors of 90-day mortality. ConclusionsIn patients with postcardiotomy cardiogenic shock, ischemic heart disease and level of arterial lactate before venoarterial extracorporeal membrane oxygenation initiation were identified as independent pre–venoarterial extracorporeal membrane oxygenation risk factors of 90-day mortality. These risk factors are easily available for pre–venoarterial extracorporeal membrane oxygenation risk prediction and may improve patient selection for this resource-intensive therapy.