Extracorporeal Life Support System Research Articles

Development of regional extracorporeal life support system: The importance of innovative simulation training

BackgroundDespite advances in mechanical ventilation, severe acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality rates ranging from 30% to 60%. Extracorporeal Membrane Oxygenation (ECMO) can be used as a “bridge to recovery”. ECMO is a complex network that provides oxygenation and ventilation and allows the lungs to rest and recover from respiratory failure, while minimizing iatrogenic ventilator-induced lung injury. In the critical care settings, ECMO is shown to improve survival rates and outcomes in patients with severe ARDS. The primary objective was to present an innovative approach for using high-fidelity medical simulation before setting ECMO program for reversible respiratory failure (RRF) in Poland's first unique regional program “ECMO for Greater Poland”, covering a total population of 3.5 million inhabitants in the Greater Poland region (Wielkopolska). Aim and methodsBecause this organizational model is complex and expensive, we use advanced high-fidelity medical simulation to prepare for the real-life implementation. The algorithm was proposed for respiratory treatment by veno-venous (VV) Extracorporeal Membrane Oxygenation (ECMO). The scenario includes all critical stages: hospital identification (Regional Department of Intensive Care) - inclusion and exclusion criteria matching using an authorship protocol; ECMO team transport; therapy confirmation; veno-venous cannulation of mannequin's artificial vessels and implementation of perfusion therapy and transport with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the VV ECMO therapy was performed in the next 48 h, as training platform. ResultsThe total time, by definition, means the time from the first contact with the mannequin to the cannulation of artificial vessels and starting VV perfusion on ECMO, did not exceed 3 h – including 75 min of transport (the total time of simulation with first call from provincial hospital to admission to the Clinical Intensive Care department was 5 h). The next 48 h for perfusion simulation “in situ” generated a specific learning platform for intensive care personnel. Shortly after this simulation, we performed, the first in the region: ECMO used for RRF treatment. The transport was successful and exceeded 120 km. During first year of Program duration we performed 6 successful ECMO transports (5 adult and 1 paediatric) with 60% of adult patient survival of ECMO therapies. Three patients in good condition were discharged to home. Two years old patient was successfully disconnected from ECMO and in stabile condition is treated in Paediatric Department. ConclusionsWe discovered the important role of medical simulation, not only as an examination for testing the medical professional's skills, but also as a mechanism for creating non-existent procedures. During debriefing, it was found that the previous simulation-based training allowed to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation and providing ECMO perfusion therapy.

Extracorporeal resuscitation as a further modifier of clinical outcome in patients with left ventricular assist device implantation and Interagency Registry for Mechanically Assisted Circulatory Support level 1.

In cardiogenic shock patients with Interagency Registry for Mechanical Circulatory Support (INTERMACS) level 1, the need for temporary circulatory support is a predictor and modifier of patient outcome. Because this group includes patients with and without cardiopulmonary resuscitation (CPR) and is thus very heterogeneous, we investigated whether a further subclassification is useful. We compared 30-day and 1-year mortality of patients who underwent left ventricular assist device implantation after extracorporeal CPR with the aid of an extracorporeal life support system (CPR+ group; n = 40) with cardiogenic shock patients in which the extracorporeal life support system was implanted under non-CPR conditions (CPR- group, n = 68). In the CPR+ and CPR- groups, 30-day mortality was 27.5% (n = 11) and 8.8% (n = 6), respectively (P = 0.014). The values for 1-year mortality were 57.5% (n = 23) and 36.8% (n = 25), respectively (P = 0.023). The age- and gender-adjusted hazard ratios of 30-day and 1-year mortality for the CPR+ group versus the CPR- group were 3.88 (95% confidence interval 1.29-11.7; P = 0.016) and 1.79 (95% confidence interval 1.01-3.17; P = 0.045), respectively. In conclusion, our data show that left ventricular assist device implantation with extracorporeal life support following CPR is associated with high 30-day and 1-year mortality. Further multicentre studies are needed to confirm these results and potentially add CPR as a new modifier to the INTERMACS profile.

Local and Lower Limb Complications during and after Femoral Cannulation for Extracorporeal Life Support.

The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation. Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016. In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) (p = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients (p = 0.45). Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut-down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled.

Twenty minutes of normothermic cardiac arrest in a pig model: the role of short-term hypothermia for neurological outcome.

Cardiopulmonary resuscitation restores circulation, but with inconsistent blood-flow and pressures. Our recent approach using an extracorporeal life support system, named "controlled integrated resuscitation device" (CIRD), may lead to improved survival and neurological recovery after cardiac arrest (CA). The basic idea is to provide a reperfusion tailored to the individual patient by control of the conditions of reperfusion and the composition of the reperfusate. Hypothermia is one aspect of this concept. Here, we investigated the role of immediate short-term blood cooling after experimental CA and its influence on survival and neurological recovery. Twenty-one pigs were exposed to 20 minutes of normothermic CA. Afterwards, CIRD was immediately started for 60 minutes in all animals and the heart was converted to a sinus rhythm. The pigs either received normothermic reperfusion (37°C, n=11) or the temperature was maintained at 32°C for the first 30 minutes (n=10). Thermometric, hemodynamic and serologic data were collected during the experiment. After weaning from CIRD, neurological recovery was assessed daily by a species-specific neurological deficit score (NDS; 0: normal; 500: brain death). One pig in each group could not be successfully resuscitated. Due to severe neurological deficits, only 6/11 animals in the normothermic group finished the observation time of seven days with an NDS of 37±34. In the hypothermic group, all nine surviving animals reached day seven with an NDS of 16±13. Analogous to the lower NDS, animals in the hypothermic group also showed lower neuron-specific enolase end values as a marker of brain injury. Within this experimental setting, immediate moderate and short-term hypothermia after CA improves survival and seems to result in statistically non-significant better neurological recovery.

Notice of Retraction.

[This retracts the article on p. 661 in vol. 38.].

Erratum to: "Bivalirudin anticoagulation for left ventricular assist device implantation on an extracorporeal life support system in patients with heparin-induced thrombocytopenia antibodies" [Interact CardioVasc Thorac Surg 2017:1-7; doi:10.1093/icvts/ivx251

Erratum to: "Bivalirudin anticoagulation for left ventricular assist device implantation on an extracorporeal life support system in patients with heparin-induced thrombocytopenia antibodies" [Interact CardioVasc Thorac Surg 2017:1-7; doi:10.1093/icvts/ivx251

Evaluation of Combined Extracorporeal Life Support and Continuous Renal Replacement Therapy on Hemodynamic Performance and Gaseous Microemboli Handling Ability in a Simulated Neonatal ECLS System.

The objective of this study was to evaluate the hemodynamic performance and gaseous microemboli (GME) handling ability of a simulated neonatal extracorporeal life support (ECLS) circuit with an in-line continuous renal replacement therapy (CRRT) device. The circuit consisted of a Maquet RotaFlow centrifugal pump or HL20 roller pump, Quadrox-iD Pediatric diffusion membrane oxygenator, 8-Fr arterial cannula, 10-Fr venous cannula, and Better-Bladder (BB) with "Y" connector. A second Quadrox-I Adult oxygenator was added postarterial cannula for GME experiments. The circuit and pseudo-patient were primed with lactated Ringer's solution and packed human red blood cells (hematocrit 40%). All hemodynamic trials were conducted at ECLS flow rates ranging from 200 to 600 mL/min and CRRT flow rate of 75 mL/min at 36°C. Real-time pressure and flow data were recorded with a data acquisition system and GME were detected and characterized using the Emboli Detection and Classification Quantifier System. CRRT was added at distinct locations such that blood entered CRRT between the pump and oxygenator (A), recirculated through the pump (B), or bypassed the pump (C). With the centrifugal pump, all CRRT positions had similar flow rates, mean arterial pressure (MAP), and total hemodynamic energy (THE) loss. With the roller pump, C demonstrated increased flow rates (293.2-686.4 mL/min) and increased MAP (59.4-75.5 mmHg) (P < 0.01); B had decreased flow rates (129.7-529.7 mL/min), and MAP (34.2-45.0 mmHg) (P < 0.01); A maintained the same when compared to without CRRT. At 600 mL/min C lost more THE (81.4%) (P < 0.01) with a larger pressure drop across the oxygenator (95.6 mmHg) (P < 0.01) than without CRRT (78.3%; 49.1 mmHg) (P < 0.01). C also demonstrated a poorer GME handling ability using the roller pump, with 87.1% volume and 17.8% count reduction across the circuit, compared to A and B with 99.9% volume and 65.8-72.3% count reduction. These findings suggest that, in contrast to A and B, adding CRRT at position C is unsafe and not advised for clinical use.

Thigh compartment syndrome during extracorporeal life support.

The aim of this study was to report our experience with patients on the extracorporeal life support system (ECLS) who presented with thigh compartment syndrome, a yet unreported complication. A retrospective analysis was performed from April 2003 to April 2017 to identify patients who presented to our department for treatment of acute compartment syndrome of the thigh after cannulation of the ECLS through the femoral artery and vein. Five patients, aged 30 to 84years, who developed thigh compartment syndrome during ECLS therapy were identified. In three patients, the cause was arterial malperfusion; in one patient, the cause was venous malfunction and arterial malperfusion due to malposition of the arterial distal leg perfusion cannula in the femoral vein. The fifth patient suffered impaired venous drainage. Patients were on ECLS for 4± 2days, and decompressive fasciotomy was performed in all patients 1± 1days after ECLS commencement. Thigh compartment syndrome was responsible for significant morbidity, including prolonged open wound therapy, hospitalization, and leg amputation in one patient. Compartment syndrome of the thigh is a limb- and life-threatening complication and may occur in patients on ECLS. Angiographic or duplex ultrasound control of adequate limb perfusion and correct placement of the perfusion cannulas is recommended. Also, awareness of and close clinical observation for thigh perfusion and compartment syndrome are essential in patients during ECLS therapy.

Initial Clinical Experiences With Novel Diagonal ECLS System in Pediatric Cardiac Patients.

Extracorporeal life support (ECLS) provides mechanical support following cardiac surgery when respiratory or cardiac failure occurs. The aim of this study was to analyze the safety and feasibility of the Medos Deltastream diagonal pump (DP3) ECLS system in pediatric cardiac patients. We described the technical considerations and risk factors related to the survival outcomes in 102 pediatric cardiac patients who received ECLS support between March 2011 and April 2016. We switched from the DP2 system, which was used for the initial 25 patients, to the DP3 system after November 2012. The DP3 was then used in a consecutive series of 77 patients (4.5% of all pediatric patients who underwent congenital heart surgery during the same time period). The patients' median age was 90 days (range: 2 days-12 years), while their median weight was 4 kg (range: 2.1-40 kg). Fifty four patients (70%) were weaned off ECLS, while 28 patients (36.3%) were successfully discharged from the hospital by means of the DP3 system. The median ECLS duration for survivors was 8.2 days (range: 4-14.5 days). The ECLS indications, durations, and initiation times had no statistical significance in terms of survival. Renal, hemorrhagic, and neurologic complications were all associated with decreased hospital discharge rates (P = 0.003, P = 0.045, and P < 0.001 respectively). Higher lactate levels (P = 0.009) and longer duration for normalization (P < 0.001) were both associated to failure to wean off ECLS support and, hence, to hospital deaths. The weaning rate was 36% prior to November 2012. It increased to 70.3% after that time (P = 0.009). The mechanical complication rate was 9% with the DP3 system and 32% with the DP2, which was statistically significant (P = 0.009). Additionally, the lactate levels were higher and decreased more slowly in the patients supported by the DP2. As a result of the shift to the DP3 system, a revised ECLS protocol, and increased ECLS experience, a significant improvement was observed in our clinical outcomes. The results of this study suggested that the combination of a DP3 pump and a Hilite oxygenator in pediatric ECLS circuits may improve durability and reduce circuit-induced complications.

P3020Real-world clinical experience with percutaneous extracorporeal life support system (ECLS): analysis of the German Lifebridge registry

P3020Real-world clinical experience with percutaneous extracorporeal life support system (ECLS): analysis of the German Lifebridge registry

Thromboprophylaxis in Extracorporeal Circuits: Current Pharmacological Strategies and Future Directions.

The development of extracorporeal devices for organ support has been a part of medical history and progression since the late 1900s. These types of technology are primarily used and developed in the field of critical care medicine. Unfractionated heparin, discovered in 1916, has really been the only consistent form of thromboprophylaxis for attenuating or even preventing the blood-biomaterial reaction that occurs when such technologies are initiated. The advent of regional anticoagulation for procedures such as continuous renal replacement therapy and plasmapheresis have certainly removed the risks of systemic heparinization and heparin effect, but the challenges of the blood-biomaterial reaction and downstream effects remain. In addition, regional anticoagulation cannot realistically be applied in a system such as extracorporeal membrane oxygenation because of the high blood flow rates needed to support the patient. More recently, advances in the technology itself have resulted in smaller, more compact extracorporeal life support (ECLS) systems that can-at certain times and in certain patients-run without any form of anticoagulation. However, the majority of patients on ECLS systems require some type of systemic anticoagulation; therefore, the risks of bleeding and thrombosis persist, the most devastating of which is intracranial hemorrhage. We provide a concise overview of the primary and alternate agents and monitoring used for thromboprophylaxis during use of ECLS. In addition, we explore the potential for further biomaterial and technologic developments and what they could provide when applied in the clinical arena.

Novel ECG-Synchronized Pulsatile ECLS System With Various Heart Rates and Cardiac Arrhythmias: An In Vitro Study.

The objective of this study is to evaluate electrocardiography (ECG)-synchronized pulsatile flow under varying heart rates and different atrial and ventricular arrhythmias in a simulated extracorporeal life support (ECLS) system. The ECLS circuit consisted of an i-cor diagonal pump and console, an iLA membrane ventilator, and an 18 Fr arterial cannula. The circuit was primed with lactated Ringer's solution and packed red blood cells (hematocrit 35%). An ECG simulator was used to trigger pulsatile flow and to generate selected cardiac rhythms. All trials were conducted at a flow rate of 2.5 L/min at room temperature for normal sinus rhythm at 45-180 bpm under non-pulsatile and pulsatile modes. Various atrial and ventricular arrhythmias were also tested. Real-time pressure and flow data were recorded using a custom-based data acquisition system. The energy equivalent pressure (EEP) generated by pulsatile flow was always higher than the mean pressure. No surplus hemodynamic energy (SHE) was recorded under non-pulsatile mode. Under pulsatile mode, SHE levels increased with increasing heart rates (45-120 bpm). SHE levels under a 1:2 assist ratio were higher than the 1:1 and 1:3 assist ratios with a heart rate of 180 bpm. A similar trend was recorded for total hemodynamic energy levels. There was no statistical difference between the two perfusion modes with regards to pressure drops across the ECLS circuit. The main resistance and energy loss came from the arterial cannula. The i-cor console successfully tracked electrocardiographic signals of 12 atrial and ventricular arrhythmias. Our results demonstrated that the i-cor pulsatile ECLS system can be synchronized with a normal heart rate or with various atrial/ventricular arrhythmias. Further in vivo studies are warranted to confirm our findings.

Extracorporeal Membrane Oxygenation in Adults - Variants, Complications during Therapy, and the Role of Radiological Imaging.

Background Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) as respiratory and circulatory assist therapies are gaining in importance in the treatment of critically ill patients. Depending on the place of cannulation - veno-venous for ECMO and veno-arterial for ECLS - distinct changes in hemodynamics will occur. In this review we describe the different types of ECMO and ECLS systems, the typical cannula placement and frequent complications under therapy. The most suitable imaging modalities will be presented and typical hemodynamic pitfalls in contrast-enhanced computed tomography or angiography will be elucidated. Methods The review is based on a literature search in PubMed with the terms "ECMO" and/or "ECLS" and/or "extracorporeal life support" and/or "imaging" and/or "complications". Statistical data was taken from the ECMO register of the "Extracorporeal Life Support Organization (ELSO)". Results Critical illness- and therapy-associated complications are common so that imaging, particularly computed tomography, becomes increasingly important. Following veno-venous cannulation in ECMO, the normal sequential blood flow is preserved, so that no contrast enhancement irregularities should be expected when the right timing and an adequate amount of contrast agent are selected. After veno-arterial cannulation in ECLS, different artifacts like pseudo-filling defects, pseudomembranes and irregular/low contrast enhancement of heart and pulmonary vessels can be found, depending on the site of cannulation and the residual cardiac function. Key points · Cannula placement is usually documented by radiography.. · Computed tomography is appropriate in the face of inconclusive cannula placement and probable complications.. · In veno-venous ECMO, no contrast enhancement artifacts are to be expected.. · Veno-arterial ECLS leads to pseudo-filling defects, pseudomembranes and irregular contrast enhancement of heart and pulmonary vessels.. Citation Format · Beck L, Burg MC, Heindel W et al. Extracorporeal Membrane Oxygenation in Adults - Variants, Complications during Therapy, and the Role of Radiological Imaging. Fortschr Röntgenstr 2017; 189: 119 - 127.

Does Flexible Arterial Tubing Retain More Hemodynamic Energy During Pediatric Pulsatile Extracorporeal Life Support?

The objective of this study was to evaluate the hemodynamic performance and energy transmission of flexible arterial tubing as the arterial line in a simulated pediatric pulsatile extracorporeal life support (ECLS) system. The ECLS circuit consisted of a Medos Deltastream DP3 diagonal pump head, Medos Hilite 2400 LT oxygenator, Biomedicus arterial/venous cannula (10 Fr/14 Fr), 3 feet of polyvinyl chloride (PVC) arterial tubing or latex rubber arterial tubing, primed with lactated Ringer's solution and packed red blood cells (hematocrit 40%). Trials were conducted at flow rates of 300 to 1200 mL/min (300 mL/min increments) under nonpulsatile and pulsatile modes at 36°C using either PVC arterial tubing (PVC group) or latex rubber tubing (Latex group). Real-time pressure and flow data were recorded using a custom-based data acquisition system. Mean pressures and energy equivalent pressures (EEP) were the same under nonpulsatile mode between the two groups. Under pulsatile mode, EEPs were significantly great than mean pressure, especially in the Latex group (P < 0.05). There was no difference between the two groups with regards to pressure drops across ECLS circuit, but pulsatile flow created more pressure drops than nonpulsatile flow (P < 0.05). Surplus hemodynamic energy (SHE) levels were always higher in the Latex group than in the PVC group at all sites. Although total hemodynamic energy (THE) losses were higher under pulsatile mode compared to nonpulsatile mode, more THE was delivered to the pseudopatient, particularly in the Latex group (P < 0.05). The results showed that the flexible arterial tubing retained more hemodynamic energy passing through it under pulsatile mode while mean pressures and pressure drops across the ECLS circuit were similar between PVC and latex rubber arterial tubing. Further studies are warranted to verify our findings.

Does an Open Recirculation Line Affect the Flow Rate and Pressure in a Neonatal Extracorporeal Life Support Circuit With a Centrifugal or Roller Pump?

The objective of this study is to evaluate the impact of an open or closed recirculation line on flow rate, circuit pressure, and hemodynamic energy transmission in simulated neonatal extracorporeal life support (ECLS) systems. The two neonatal ECLS circuits consisted of a Maquet HL20 roller pump (RP group) or a RotaFlow centrifugal pump (CP group), Quadrox-iD Pediatric oxygenator, and Biomedicus arterial and venous cannulae (8 Fr and 10 Fr) primed with lactated Ringer's solution and packed red blood cells (hematocrit 35%). Trials were conducted at flow rates ranging from 200 to 600 mL/min (200 mL/min increments) with a closed or open recirculation line at 36°C. Real-time pressure and flow data were recorded using a custom-based data acquisition system. In the RP group, the preoxygenator flow did not change when the recirculation line was open while the prearterial cannula flow decreased by 15.7-20.0% (P < 0.01). Circuit pressure, total circuit pressure drop, and hemodynamic energy delivered to patients also decreased (P < 0.01). In the CP group, the prearterial cannula flow did not change while preoxygenator flow increased by 13.6-18.8% (P < 0.01). Circuit pressure drop and hemodynamic energy transmission remained the same. The results showed that the shunt of an open recirculation line could decrease perfusion flow in patients in the ECLS circuit using a roller pump, but did not change perfusion flow in the circuit using a centrifugal pump. An additional flow sensor is needed to monitor perfusion flow in patients if any shunts exist in the ECLS circuit.

The use of neonatal extracorporeal life support in pediatric cardiac intensive care unit

Aim: The aim of the study is to evaluate extracorporeal life support system (ECLS) employed in neonates in pediatric cardiac intensive care unit.Material and methods: Twenty-five neonates that required ECLS in between November 2010 and November 2015 were evaluated.Results: The median age was 12 days (range 3–28 days) and the median body weight was 3 kg (range 2.5–5 kg). Venoarterial ECLS was performed in all of the cases. Ascendan aorta-right atrial cannulation in 22 patients and neck cannulation in three patients were performed. The reason for ECLS was E-CPR in two patients, inability to wean from cardiopulmonary bypass (CPB) in seven patients, respiratory insufficiency and hypoxia in nine patients, low cardiac output (LCOS) in seven patients. Median duration of ECLS was four days (range 1–15). Hemorrhagic complications developed in 15, renal complications in 13, pulmonary complications in 12, infectious complications in 11, neurologic complications in three and mechanical complications in two of the patients. Weaning was successful in 15 of the patients. Eleven patients were successfully discharged.Conclusion: ECLS is an important treatment option that is performed successfully in many centers around the world to maintain life support in patients unresponsive to medical treatment. The utilization of this modality especially in newborns with congenital heart disease should be taken into consideration.

Extracorporeal carbon dioxide removal (ECCO2R) in respiratory deficiency and current investigations on its improvement: a review

The implementation of extracorporeal carbon dioxide removal (ECCO2R) as one of the extracorporeal life support system is getting more attention today. Thus, the objectives of this paper are to study the clinical practice of commercial ECCO2R system, current trend of its development and also the perspective on future improvement that can be done to the existing ECCO2R system. The strength of this article lies in its review scope, which focuses on the commercial ECCO2R therapy in the market based on membrane lung and current investigation to improve the efficiency of the ECCO2R system, in terms of surface modification by carbonic anhydrase (CA) immobilization technique and respiratory electrodialysis (R-ED). Our methodology approach involves the identification of relevant published literature from PubMed and Web of Sciences search engine using the terms Extracorporeal Carbon Dioxide Removal (ECCO2R), Extracorporeal life support, by combining terms between ECCO2R and CA and also ECCO2R with R-ED. This identification only limits articles in English language. Overall, several commercial ECCO2R systems are known and proven safe to be used in patients in terms of efficiency, safety and risk of complication. In addition, CA-modified hollow fiber for membrane lung and R-ED are proven to have good potential to be applied in conventional ECCO2R design. The detailed technique and current progress on CA immobilization and R-ED development were also reviewed in this article.

The Use of Extracorporeal Membrane Oxygenation Systems in Severe Accidental Hypothermia After Drowning: A Centre Experience.

Cardiopulmonary failure because of drowning with accidental hypothermia (AH) remains a major task for emergency care physicians. In this case series, we describe our experience in nine patients with cardiopulmonary failure after drowning with AH less than 35°C, who were provided on an emergency basis with extracorporeal life support (ECLS) system or extracorporeal membrane oxygenation (ECMO). Conservative rewarming methods are not considered for this study. Preclinical conditions and protocols were gathered. Surgical reports and clinical data sets were collected. Median age was 24 years (range, 6-75 years). Six patients were male. Climatic conditions mostly showed cold to frosty weather. All cases had different preclinical rescue procedures. They reached the emergency department under cardiopulmonary resuscitation (CPR). Indications for ECLS were cardiac arrest, and in one case, pulmonary failure. Mean CPR duration was 60 min (range: 15-120 min). Before implantation, the median pH value was 6.9. Two patients could be successfully weaned from the systems. Cause of death was severe neurologic damage in six patients and cardiac failure in one patient. The use of ECLS/ECMO is a therapy option for a small range of patients with cardiopulmonary failure because of drowning with AH. Nevertheless, the interval of preclinical rescue remains extensively long.

Implementation of a Weaning-protocol for Extracorporeal Life Support Systems in Patients with Postcardiotomy Failure is accompanied with Decrease of 30-day Mortality

Objectives: In recent years, Extracorporeal Life Support Systems (ECLS) have become an established tool in the therapy of postcardiotomy failure. Despite the increasing use in cardiovascular surgery, there are currently no guidelines suggesting key-parameters like therapeutic goals, duration of ECLS support or weaning strategies. For this reason, an appropriate protocol was implemented to supervise this important therapeutic process.

A Parallelized Pumpless Artificial Placenta System Significantly Prolonged Survival Time in a Preterm Lamb Model.

An artificial placenta (AP) is an arterio-venous extracorporeal life support system that is connected to the fetal circulation via the umbilical vasculature. Previously, we published an article describing a pumpless AP system with a small priming volume. We subsequently developed a parallelized system, hypothesizing that the reduced circuit resistance conveyed by this modification would enable healthy fetal survival time to be prolonged. We conducted experiments using a premature lamb model to test this hypothesis. As a result, the fetal survival period was significantly prolonged (60.4 ± 3.8 vs. 18.2 ± 3.2 h, P < 0.01), and circuit resistance and minimal blood lactate levels were significantly lower in the parallel circuit group, compared with our previous single circuit group. Fetal physiological parameters remained stable until the conclusion of the experiments. In summary, parallelization of the AP system was associated with reduced circuit resistance and lactate levels and allowed preterm lamb fetuses to survive for a significantly longer period when compared with previous studies.