Extracorporeal Research Articles (Page 1)

To evaluate the impact of extracorporeal diaphragm pacing (EDP) therapy on diaphragm function in critically ill patients reliant on mechanical ventilation. Patients were randomly divided into an observation group (39 cases) and a control group (40 cases) using a random number table. Both groups received bedside rehabilitation interventions. Additionally, the observation group underwent EDP therapy 6 times weekly for 2 weeks. Diaphragm activity, diaphragm thickness, arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2), and Oxygenation Index (OI) were measured at baseline and 2 weeks postenrollment or upon extubation. Both groups showed significant improvements in diaphragm activity, PaO2, PaCO2, and OI compared to baseline (P <.05). The observation group had significantly better outcomes in diaphragm thickness (0.22 ± 0.03), diaphragm activity (13.96 ± 0.73), PaCO2 (37.59 ± 5.66), and OI (271.10 ± 17.25) compared to the control group (0.20 ± 0.02, 12.24 ± 0.99, 47.25 ± 5.64, 248.60 ± 15.26), with statistical significance (P <.05). EDP therapy offers benefits in improving diaphragm function in critically ill patients on mechanical ventilation. It enhances diaphragm strength and endurance, increases diaphragm activity, improves pulmonary ventilation, and reduces mechanical ventilation duration.

To provide a video tutorial illustrating how to place a hemodialysis catheter in the external jugular vein of a dog via a percutaneous modified Seldinger approach. Any dog requiring vascular catheter placement for extracorporeal therapy. The patient is placed under general anesthesia in left lateral recumbency. The fur is clipped, and the skin over the right lateral neck is aseptically prepared. The operators are wearing full protective barriers. A skin incision with a No. 11 blade is made over the jugular vessel, and an 18-gauge over-the-needle catheter is used for vascular access. With the use of fluoroscopic guidance, a guidewire is passed through the peripheral catheter and into the caudal vena cava. The peripheral catheter can then be removed and a dilator passed over the guidewire to stretch the size of access into the vein. The dilator is removed, and the catheter is passed over the guidewire. Fluoroscopy is used to confirm placement of the catheter tip, and both lumens are aspirated to test blood flow. The catheter lumens are then flushed with saline and capped. The catheter can then be sutured in place. An 11-French X 20-cm silicone hemodialysis catheter is placed in the right external jugular vein of a dog. Dialysis catheter placement is a key step in providing extracorporeal treatment for veterinary patients.

Background: Cardiogenic Shock (CGS) is the most common cause of death in hospitalized patients with Acute Myocardial Infarction (AMI). This study identified the characteristics of those selected and not selected to receive Mechanical Circulatory Support (MCS). We hypothesized that mortality in non-selected patients would correlate with the reason for non-support. Methods: CGS patients were identified as follows: blood pressure &lt;80 mmHg or &lt;90 mmHg on vasopressors; ICD-10 diagnosis of cardiogenic shock (R57.0); acute MI or other ischemic heart disease or heart failure; left ventricular ejection fraction &lt;40%; severe aortic stenosis patients were excluded. Results: During one year (2022) in our medical center, 211 CGS patients were treated: 95 (45%) received MCS with p-VAD, Intra-aortic Balloon Pump, or Extra Corporeal Membrane Oxygenation; 116 (55%) patients did not receive MCS. Comparing MCS to non-MCS patients, the mean age was 64 versus 70 years; underlying diagnoses were ST elevation MI in 44 (46%) versus 8 patients (7%), non-STEMI in 23 (24%) versus 35 patients (30%), other ischemic heart disease in 6 (6%) versus 19 patients (16%), heart failure in 88 (93%) versus 115 patients (99%). Shock type was defined as isolated cardiogenic shock in 74 (78%) versus 54 patients (46%), and cardiogenic with septic shock in 18 (19%) versus 60 patients (52%). Overall hospital mortality for CGS patients receiving MCS was 33 of 95 (35%). In contrast, hospital mortality for non-MCS patients was 59 of 116 patients (51%, P&lt;.01 compared to MCS patients). Reasons for electing not to place MCS were advanced co-morbidities judged to preclude survival (53 patients, mortality 60%), mixed shock (38 patients, mortality 63%) and rapid resolution of shock with pharmacological treatment (25 patients, mortality 12%). In the advanced co-morbidity group, cardiac arrest was associated with a particularly high mortality (23 of 32 arrest patients, 72% mortality). Conclusion: In a medical center that treats a high volume of CGS patients with MCS, non-selection of MCS for CGS remains relatively common (55%). Mortality in these non-MCS CGS patients is high when advanced co-morbidities or mixed etiology shock are present. Patients who have rapid resolution of shock have a substantially better course. Clinician knowledge of these different categories and outcomes for non-selection of MCS may allow clinicians to improve selection and non-selection of CGS patients for MCS and may improve outcomes.

Relevance . Pneumonia complicated by sepsis remains one of the leading causes of mortality in intensive care units. Early recognition of life-threatening conditions and the implementation of modern therapeutic strategies are crucial for improving outcomes. The aim of the research . To summarize current approaches to the diagnosis and intensive care management of community-acquired, hospital-acquired, and viral pneumonia complicated by sepsis, based on recent clinical guidelines. Materials and Methods . A literature review was conducted covering publications from 2018 to 2024, including national clinical guidelines and international recommendations (IDSA, SSC), as well as clinical studies on novel antibacterial agents, biomarkers, and extracorporeal therapies. Results . Current treatment strategies include personalized antibiotic therapy, use of prognostic and diagnostic biomarkers (PCT, MR-proADM, suPAR, presepsin), molecular diagnostics (NGS), selective hemoadsorption, and targeted immunotherapy (IL-6 and JAK/STAT inhibitors). Special attention is given to early risk stratification and timely therapeutic intervention. Discussion . Key issues remain unresalved regarding patient selection for advanced therapies, optimal timing, and criteria for treatment effectiveness. Further research is needed to refine personalized treatment approaches. Conclusion . Intensive care for pneumonia complicated by sepsis requires an integrated approach based on pathogen profile, disease severity, immune status, and prognostic markers. Incorporation of innovative treatment methods can reduce mortality and improve clinical outcomes.

Liver transplantation (LT) has been recommended for hepatoblastoma (HB) involving all four liver sectors at diagnosis (PRETEXT IV). However, recent studies question the universal indication for primary LT in PRETEXT IV HB. We reviewed 32 PRETEXT IV HB patients treated at our center from February 2007 to July 2024. A multidisciplinary team reassessed surgical resectability to evaluate treatment strategies for PRETEXT IV HB. Of 32 patients, 28 (87.5%) underwent LT, while 4 (12.5%) underwent liver resection (LR). Median follow-up was 4.6 years (IQR 2.3-8.5). The tumor, which was deemed radiologically resectable before surgery, was found pathologically unresectable in two LT patients: viable tumor microembolism at sites where the tumor was present at diagnosis in one patient and severe tumor ossification close to the major vascular system in one patient. Four patients with tumor thrombus, unresectable radiologically, were pathologically resectable using LR with extracorporeal circulation. Among the four patients undergoing LR, two patients eventually received LT. One had a recurrence at the initial tumor site, and the other developed cirrhosis post-LR. Surgical complications occurred in three LT patients and one LR patient. No complications related to long-term immunosuppression have been observed in LT patients. However, one LT patient developed portal hypertension due to chronic rejection and is awaiting a deceased donor LT. One LT patient died due to recurrence. Despite uncertainties about long-term LT outcomes, LT remains the preferred strategy for safely achieving complete resection in PRETEXT IV HB patients.

Delayed sternal closure (DSC) is a technique used in complex cardiac surgery (CCS) and is associated with an increased risk of surgical site infection (SSI). SSI increases hospital stay and healthcare costs, with an incidence ranging from 1.5% to 34%. To determine the SSI rate and associated risk factors in patients with congenital heart disease (CHD) undergoing CCS with DSC between January 2015 and December 2020, and to compare them with previous results, before the implementation of measures by the Healthcare-Associated Infections Committee (HAIC). A descriptive study was conducted in patients under 18 years of age who required DSC between 2015 and 2020 at the Hospital of Pontifical Catholic University of Chile, meeting the Chilean Ministry of Health's definition of SSI. SSI rates were compared between the periods 2009-2010 and 2015-2020 using the Poisson rate ratio. A total of 1,471 surgeries were performed, of which 138 (9.38%) required DSC and 6 (4.34%) presented SSI. 67% were males older than 7 days, with one patient premature. 66.7% had extracorporeal circulation (ECC) > 200min and 83.3% required mechanical ventilation (MV) > 5 days. Several SSI-causing microorganisms were identified. Comparing both studies, a decrease in the prevalence of SSI in DSC was found from 22% to 4.3%, with a rate ratio of 5.16 (95% IC 1.83-16.54, p = 0.001), with no significant differences in the risk factors identified in the initial study (ECC > 200min and MV > 5 days). The SSI rate was 4.34%, a significant decrease compared to the previous study, attributed to improvements in cardiovascular management and IAAS Committee measures.

BACKGROUND: Sepsis remains a critical global health issue, causing multiple organ failure and high mortality rates, despite advances in antimicrobial therapies and supportive care. Extracorporeal blood purification (EBP) techniques have emerged as promising adjunctive strategies for the management of severe infections. The Seraph® 100 Microbind® Affinity Blood Filter (Seraph 100, ExThera Medical, Martinez, CA) targets pathogens, while the Selective Cytopheretic Device (SCD, SeaStar Medical, Denver, CO) neutralizes activated leukocytes. Although individually validated, evidence of the combined use of Seraph 100 and SCD remains scarce. CASE SUMMARY: We present two cases that illustrate the combined use of Seraph 100 and SCD. The first case involves a 43-year-old woman with bacterial pneumonia, septic shock, and acute kidney injury (AKI). She underwent Seraph 100 hemoperfusion followed by SCD therapy, which improved her hemodynamics, oxygenation, and renal function, ultimately leading to full recovery. The second case involved a 31-year-old man with Influenza, severe hypoxemia, and multiorgan failure. Despite advanced therapies, including veno-arterial venous ECMO (VAV-ECMO), Seraph 100, and SCD, his condition deteriorated, resulting in multiorgan failure and eventual death. CONCLUSION: These cases highlight the potential benefits and challenges of combining EBP, such as Seraph 100 and SCD. While successful in one case, the fatal outcome in the second underscores the importance of optimal patient selection, timing, and therapeutic strategies. Further research is needed to evaluate the efficacy of combined EBP and to identify approaches for improving outcomes in critically ill patients.

Cannulae with multi-staged side holes (SHs) for venous drainage are widely used for performing extracorporeal circulation. Various types of catheters are used worldwide; however, data on the flow performance of each catheter are lacking or inaccurate. Clinical applications are often intuitive. In this study, we aimed to develop a mock circulation loop for cannula performance evaluation. We found no differences in the rate of change in the flow rate through each SH as the pump flow increased when the pump flow rate was 250 to 750 mL/min. When the pump flow rate was ≥ 750 mL/min, there was an increase in the rate of change in the flow rate through each side hole toward the proximal side hole and the percentage inflow of the proximal side hole and decrease in percentage inflow toward the distal side hole, as the pump flow increased. Thus, we believe that the desired venous drainage can be applied to patients, and the fluid dynamical structures of catheters in the human body can be estimated according to the type of catheter or its location in the human body. The findings of this study will aid in designing new catheters.

The Selective Cytopheretic Device (SCD) is a cell-directed extracorporeal therapy approved for use in children with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT) with sepsis/sepsis-like conditions. We compared outcomes for children treated with SCD to a contemporary cohort of children treated with CRRT alone. Secondary analysis and comparison of patients ≤22 years old and ≥10 kg from a multicenter registry of patients receiving CRRT for AKI and/or fluid overload (WE-ROCK; 2015-2021) to patients from two multicenter, prospective, interventional studies of children with AKI and multiple organ dysfunction (MODS) receiving SCD (SCD-PED-01/SCD-PED-02; 2016-2022). Eighteen patients in the SCD Cohort were compared to 178 in the CRRT Cohort. There were no differences between cohorts at CRRT+/-SCD initiation. SCD patients had shorter CRRT duration (6 [3,11] vs. 10 [5,18] days, p=0.013) and shorter ICU length of stay (LOS) in survivors (16 [11,25] vs. 27 [16,46] days, p=0.012). Survival to ICU discharge or Day 60 was 94% in the SCD Cohort vs. 74% in the CRRT Cohort (p=0.079). A Bayesian analysis demonstrated a >99% probability of improved survival with SCD. A sub-analysis in septic patients demonstrated greater survival (100% vs. 69%, p=0.032), shorter CRRT duration (5 [3,7] vs. 11 [6,17] days, p=0.006) and reduced ICU LOS in survivors (21 [10,25] vs. 27 [16,45] days, p=0.027) in SCD-treated patients. The addition of SCD therapy in children with AKI and MODS receiving CRRT may be beneficial, though larger prospective studies are needed.

Objectives: This study aims to compare immediate postoperative outcomes between minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) in adult patients undergoing on-pump coronary artery bypass grafting (CABG). Patients and methods: Between October 2013 and November 2013, a total of 65 adult patients (46 males, 19 females; mean age: 66.1±8.6 years; range, 34 to 84 years) who underwent isolated CABG, aortic valve replacement (AVR), or combined AVR with CABG. The patients were stratified by preoperative risk, with higher-risk patients assigned to the MiECC group (n=30) and the remaining patients to the CECC group (n=35). Intra- and postoperative parameters, including cardiopulmonary bypass (CPB) time, aortic cross-clamp time, priming and cardioplegia volumes, 24-h drainage, transfusion requirements, mechanical ventilation duration, intensive care unit (ICU) and hospital stay, and mortality were evaluated. Results: Patients in the MiECC group had higher baseline risk profiles, including older age, chronic obstructive pulmonary disease, and carotid artery stenosis. The MiECC was associated with significantly lower priming (506±54 vs. 1150±94 mL, p=0.001) and cardioplegia volumes (38±7 vs. 939±108 mL, p=0.001). Postoperatively, MiECC patients had shorter mechanical ventilation (6.4±2.0 vs. 10.2±4.9 h, p=0.001), ICU stay (24.5±4.2 vs. 45.7±6.3 h, p=0.001), and hospital stay (7.3±1.2 vs. 10.3±2.6 days, p=0.001). Blood product utilization, including red blood cells and fresh frozen plasma, was also significantly lower in the MiECC group. Mortality and major complications were comparable between the groups. Conclusion: Despite higher baseline risk, MiECC provided favorable postoperative outcomes compared to CECC, including reduced transfusion needs, shorter mechanical ventilation, and shorter ICU and hospital stays. The MiECC appears to be a safe and effective strategy even in higher-risk cardiac surgical populations, potentially reducing perioperative morbidity.

Disclosure: D. Moreno Watashi: None. D. Stasishin: None. A. Sehgal: None. W. Azzam: None. J. Ding: None. M.B. Sharma: None.Introduction: Thyroid storm is a potentially fatal condition requiring intensive care and treatment. Single Pass Albumin Dialysis (SPAD) is a highly effective but overlooked tool in the treatment of severe symptomatic thyrotoxicosis refractory to conventional therapy. However, this technique continues to be underutilized for this indication. We present a case of a patient with new-onset refractory amiodarone-induced thyrotoxicosis (AIT) precipitating thyroid storm, who was treated with SPAD. Case description: A 74-year-old male with a past medical history of coronary artery disease, ischemic cardiomyopathy, and chronic kidney disease was brought to the emergency department for shortness of breath and bilateral lower extremity swelling. He had been on amiodarone therapy for months. Labs on presentation demonstrated an undetectable TSH level, free thyroxine level of 9.68ng/dl, and a total triiodothyronine level of 309.5ng/dl. The patient was treated with maximal medical therapy including oral methimazole (120mg/day), intravenous hydrocortisone (300mg/day), Lugol’s Iodine, and Cholestyramine. Despite aggressive therapy, he showed poor response as evidenced by a slow decrease in free thyroxine levels from 10ngl/dl to 8.5ngl/dl. He then developed a non-fatal cardiac arrest due to ventricular tachycardia. Given his refractory thyroid storm, we performed SPAD daily for 5 days. Free thyroxine levels responded by decreasing over 50% from 8.5 ng/dl to 3.36 ng/dl. The patient had an improvement in symptoms as well. However, due to the protracted course of his thyroid storm and advanced ischemic cardiac disease, he eventually developed cardiogenic shock and passed away. Discussion: Extracorporeal blood purification therapies like plasmapheresis are known treatment options for hormonal removal. SPAD, most utilized for detoxification in liver failure, was introduced as a new therapy for refractory thyroid storm by Kotball et al1. Its ability to remove protein-bound toxins can provide consistent clearing of thyroid hormone, which is known to have a high binding affinity to albumin. SPAD has the advantage of not exposing patients to the risk of transfusion reactions seen in plasmapheresis. Severe thyrotoxicosis refractory to medical therapy is an indication for advanced treatment mechanisms such as SPAD. In our opinion, SPAD is a highly effective methodology and it should be utilized more frequently and earlier to reduce morbidity and mortality in thyroid storm.Presentation: Saturday, July 12, 2025

To evaluate a novel anticoagulation strategy in an extracorporeal circuit, we introduce a device that induces local hypothermia as blood flows through the circuit. Using a pig model, we assessed its technical feasibility, biocompatibility, and safety. Sixteen pigs were randomly assigned to either the cooled group or the control group and underwent midline laparotomy to establish extracorporeal circulation (blood flow 500ml/min) via the caudal vena cava for up to four hours. Blood samples were collected at baseline and at 15, 60, and 240min during the experiment. In the cooled group, blood was cooled to 20°C and then rewarmed to 37°C, while in the control group, blood was maintained at 37°C. A total of 6 cooled and 4 control pigs completed 4h of the experiment. Our findings confirm the technical feasibility of the proposed device, which effectively maintained the required temperature differentials while keeping the pressure differentials in the circuit within 150 mmHg. No issues with circuit patency were observed. Additionally, no adverse effects were detected on erythrocyte stability. Within the limitation of the short observation period, no adverse effects were observed on renal, liver, or cardiac function. Our data suggest that local hypothermia in the extracorporeal circuit may mitigate surgery-induced inflammation.

Abstract Background and Aims Damage to organs due to extracorporeal circulation is known to occur during cardiopulmonary bypass and hemodialysis. One proposed mechanism is microcirculatory impairment of various organs due to extracorporeal circulation. The objective of the present study was to develop a rat model that can be used to quantitatively analyze the effects of hemodialysis on the microcirculation by observing the surface blood flow in the tibialis anterior (TA) muscle in a rat model of hemodialysis. Method This study was conducted with the approval of the Animal Experimentation Committee of Kitasato University School of Allied Health Sciences (Approval No. 24-15-1). The animals were divided into three experimental groups: a control group that was not subjected to extracorporeal circulation, an extracorporeal circulation-alone group that was subjected to extracorporeal circulation using only a blood circuit, and a membrane contact group in which the blood came in contact with the dialysis membrane during extracorporeal circulation. During the experiment, arterial pressure changes were measured and the TA muscle of the rat was exposed for observation of the microcirculation and videocapillaroscopy to record the surface blood flow. Then, the erythrocytes were tracked in the obtained video, and the circulation in 5 capillaries in each experimental group evaluated every 30 minutes was classified into three categories (continuous flow, intermittent flow, stopped flow). Results The arterial pressure showed a 30% decrease in the membrane contact group at 30 minutes after the start of the extracorporeal circulation, while the pressure remained constant in the other two groups. The erythrocyte velocity decreased immediately after the start of circulation in both the extracorporeal circulation-alone group and the membrane contact group, to recover after approximately one hour. The decrease in erythrocyte velocity observed at 30 minutes after the start of circulation was more pronounced in the membrane contact group as compared with the extracorporeal circulation-alone group. In regard to the capillary blood flow, intermittent flow and stopped flow accounted for 20% and 80%, respectively, at 30 minutes after the start of circulation in the membrane contact group. These results showed that extracorporeal circulation, particularly when blood comes into contact with the membrane, can reduce blood flow in the capillaries, which may induce microcirculatory impairment and ischemia of various organs. Conclusion Observation of the surface blood flow utilizing the anterior tibialis muscle in a rat dialysis model permitted direct observation of microcirculation during dialysis and enabled quantitative assessment based on erythrocyte movement. We concluded that this rat dialysis model was useful for quantitative investigation of the effects of hemodialysis on the microcirculation.

Abstract Background and Aims One of the complications associated with indwelling hemodialysis catheters is circulatory failure due to thrombus formation in the catheter. To overcome this issue, a urokinase-coated catheter was developed with the expectation that the fibrinolytic properties of the urokinase immobilized on the inner and outer surfaces of the catheter would confer long-lasting antithrombotic properties on the catheter surface. Previously, we demonstrated in an in vitro experimental circulation system that has been used to evaluate the anti-thrombotic properties of catheters, that the surface coating of hemodialysis catheters with urokinase conferred antithrombogenic effects on the catheter surface lasting for at least 24 hr. In the present study, we conducted a 72-hour long-term circulation experiment using the same in vitro experimental system. We investigated thrombus formation on the inner and outer surfaces of the catheter, with the aim of investigating the long-term usefulness of urokinase-coating of hemodialysis catheters. Method Three types of catheters were used: the Blood Access UK catheter (UK), a urokinase coated catheter, manufactured by Nipro Corporation; a catheter with an identical structure to that of the UK catheter, but without any coating (non-UK); and the GamCath catheter (GamCath), manufactured by Baxter Corporation, which is different in structure from both the UK and non-UK catheters. The 72-hour circulation experiment was conducted utilizing fresh porcine blood at a flow rate of 1.5 L/min. The fresh porcine blood was divided into 3 portions so that the same blood could be used for each catheter group. During the experiment mimicking long-term systemic circulation, the circuit was flushed and the circulating fresh porcine blood was replaced every 24 hours. At the start of the systemic circulation and after 68 hours, extracorporeal circulation was performed using an indwelling dialysis catheter to simulate a four-hour dialysis treatment. After 72 hours of circulation, the thrombi that were found adhering to the outer surface of the catheter were categorized by type (no thrombus formation observed: type 0, thrombus formation observed near the withdrawing and returning blood holes: type 1, thrombus formation observed throughout the catheter: type 2). After removal of the large thrombi, the residual blood clots and adherent platelets were extracted, and the hemoglobin (Hb) level and lactate dehydrogenase (LDH) activity in the eluate were measured. Results The UK catheters predominantly exhibited type 0 thrombus formation, with only one type 1 thrombus formation. In contrast, more than a half of the catheters from the non-UK and GamCath groups were categorized as showing type 1 and type 2 thrombus formation. The UK catheter group also showed significantly lower residual blood Hb levels as compared with the non-UK and GamCath catheter groups (p = 0.047 vs.non-UK, p = 0.034 vs. GamCath), with no significant difference observed between the latter two catheter groups. The residual blood LDH activity levels were lower in the UK catheter group than in the non-UK and GamCath catheter groups. Based on the visual findings of thrombus formation and results of residual blood evaluation in the 72-hour long-term circulation experiment, we found that urokinase coating of the catheter surface inhibits thrombus formation on the inner and outer surfaces of the catheter, and that the structure of the catheter itself has little effect on the risk of thrombus formation. Conclusion This in-vitro experiment demonstrated that surface coating of hemodialysis catheters with urokinase conferred antithrombotic properties of the catheter surface for at least 72 hours of circulation.

Abstract Background and Aims Endotoxin, also referred to as lipopolysaccharide (LPS), is a major stimulus of the inflammatory response capable of leading to sepsis and septic shock. Extracorporeal blood purification therapies are increasingly employed in the treatment of sepsis. Timely and thorough removal of endotoxin and cytokines can help to mitigate the inflammatory cascade during septic shock. Hemoadsorption (HA) is a promising approach to achieve this goal. In this study, we analyzed different prototypes of a new CA cartridge: we performed in vitro circulations to define endotoxin and cytokines removal capacity. Method In vitro HA was performed using GALILEO testing platform, customized circuits with 5 mini-modules (XCA 1–5, shown in Fig. 1) containing the new CA sorbent material (Jafron Biomedical, Zhuhai, People's Republic of China) with slightly different chemical composition were prepared. A batch of 500 mL of blood pre-conditioned with LPS was utilized for each circulation. Circulation was maintained for 2 hours at a blood flow rate (QB) of 100 mL/min in a closed-loop configuration (Fig. 2). Samples (3 mL each) were taken from the experimental batch at 0, 10, 30, 60 and 120 minutes. Endotoxin activity and removal ratio (RR) of LPS, Interleukin 6 (IL-6) and Interleukin-1 beta (IL-1β) were assessed. Results The prototypes showed different performances, highlighting promising adsorption affinity towards the target molecules. Endotoxin activity values showed a significant decrease over the course of the five experiments, with an initial mean value of 3.2 ± 1.2 and a final mean value of 0.7 ± 0.2 (Fig. 3); XCA 2 and XCA 4 displayed the major reduction, 83.3% and 81.1%, respectively. All the concentrations and RRs are reported (Fig. 4). The highest LPS reductions were observed with XCA 1 and XCA 5, at the end of the experiments we found a RR of 13.2% and 13.3%, respectively (Fig. 5). Cytokine concentration over time in the five experiments showed different trends. XCA 3 obtained IL-6 RR of 80.9%; XCA 5, whereas, removed 28.2%; XCA 1, XCA 2 and XCA 4 didn't exhibit a remarkable IL-6 reduction (Fig. 6). XCA 2 displayed a relevant reduction of IL-1β concentration, we observed a RR of 61.2% after 120 minutes of circulation. XCA 1 and XCA 3 removed about 20% of IL-1β, XCA 4 and XCA 5 didn't exhibit a consistent IL-1β reduction (Fig. 7). Conclusion Our experiments allowed to characterize the prototypes in terms of adsorption capacity for both endotoxin and cytokines. Our findings represent the first evaluation of endotoxin adsorption within an in vitro blood hemoadsorption model employing the prototypes of CA cartridge. The reduction in the endotoxin activity values over time and the LPS and cytokines RRs provide useful signals indicating CA potential application in the early phases of the sepsis cascade with the possibility to target removal of endotoxin and the subsequent humoral effectors of the cascade.

Abstract Background and Aims Sepsis is one of the major causes of hospital mortality, characterized by a dysregulated immune response to infection that can lead to multiorgan failure and death. Gram-negative bacteria have emerged as primary contributors to sepsis and septic shock. Patients with sepsis induced by Gram-negative bacteria exhibit high endotoxin activity. Endotoxin, or lipopolysaccharide (LPS), is a component of the Gram-negative bacterial membrane and a potent stimulator of the inflammatory cascade. Therefore, effective strategies for LPS removal are crucial in sepsis treatment. Extracorporeal blood purification therapies, particularly hemoadsorption, have been extensively studied for their potential to modulate the immune response in septic patients. This in vitro study aimed to assess the endotoxin and cytokines removal capacity of two new cartridges. Method We studied a downscaled module of the CA and pHA cartridges (Jafron Biomedical, Zhuhai City, China) in an in vitro closed-loop hemoadsorption configuration (Fig. 1). The characteristics of the two cartridges are summarized in Fig. 2. A total of 1,300 mL of blood were inoculated with 25 mg of LPS, and each cartridge was perfused with a batch of 500 mL of blood. Two additional batches of 150 mL of blood was maintained as negative (CTR−) and positive control (CTR+). Blood was maintained at 37° and continuously stirred throughout the experiment. Circulation was performed using the GALILEO testing platform with a blood flow rate of 100 mL/min and lasted 2 hours. Solution samples were collected from the experimental batches at different time-points. Adsorption capacity towards endotoxin and inflammation factors was assessed by measuring Endotoxin Activity Assay (EAA) and the Removal Ratio (RR) of LPS, Interleukin-6 (IL-6) and Interleukin-1β (IL-1β). Results The cartridges exhibited distinct trends in removing target molecules, both effectively adsorbed endotoxin and cytokines. EAA values showed a significant decay over time: pHA and CA achieved a notable reduction of endotoxin activity, reduced by 51.2% and 65.9%, respectively (Fig. 3). CA cartridge showed a progressive and constant decrease in LPS concentration, whereas the pHA displayed a more variable pattern (Fig. 4), both cartridges achieved a similar LPS concentration, with LPS removal of about 30% at the end of the experiments. Promising results of CA cartridge were confirmed by its cytokines removal capacity. IL-6 concentration decreased exponentially with CA, reaching a RR of 49.2% within 10 minutes and 83.9% at 120 minutes. pHA instead, showed a more gradual reduction, reaching a RR of 43.5% at the end of the experiment (Fig. 5). Similarly, IL-1β decreased exponentially with CA, reaching very low levels within 30 minutes of circulation. RR obtained with pHA followed a linear trend, reaching a value of 63.9% at the end of the experiment, compared to 92.6% with CA (Fig. 6). Conclusion The reduction in endotoxin activity and concentration of LPS and cytokines represents an initial evidence of the efficacy of the two cartridges examined. This study demonstrated that both cartridges, CA and pHA, are capable of adsorbing endotoxin as well as pro-inflammatory and anti-inflammatory cytokines. These results provide a foundation for further studies aimed at more comprehensive characterization of these devices. In particular, their application in vivo will be essential to confirm the immunomodulation capacity in septic patients.

Abstract Background and Aims Extracorporeal kidney replacement therapies and plasma treatments often require anticoagulation to prevent clot formation within the extracorporeal tubing and filters. Inadequate or absent anticoagulation can lead to clotting, frequently resulting in treatment interruption and the need for a new treatment kit. This not only increases material and personnel demands but may also pose a risk to patient safety. The most commonly used anticoagulation strategy is heparin administration, which, however, carries an increased risk of bleeding complications. While regional citrate anticoagulation (RCA) has been widely established for continuous kidney replacement therapy, its application in intermittent dialysis, plasma exchange, and liver support therapies remains insufficiently studied. This study aims to evaluate the feasibility, efficacy, and safety of RCA in these intermittent extracorporeal treatment modalities. Method We report our experience with regional citrate anticoagulation (RCA) following an institution-specific protocol in 230 intermittent dialysis sessions, 165 plasma exchange treatments, and 95 liver support procedures. Anticoagulation was achieved through the infusion of ACDA solution. For intermittent dialysis, a calcium-free dialysate was used, and calcium was substituted before returning the blood to the patient. Results The treatments were successfully completed as planned in 99% of cases. In 1% of cases, clot formation occurred despite regional anticoagulation, exclusively during plasma exchange treatments. Continuous monitoring of systemic ionized calcium levels and post-filter ionized calcium levels was performed throughout the procedures. No patient-related complications were observed, including clinically symptomatic hypocalcemia, hypotension, or cardiac arrhythmias. Conclusion Regional citrate anticoagulation (RCA) is a safe and effective anticoagulation strategy for intermittent dialysis, plasma exchange, and liver support therapies when combined with close clinical and laboratory monitoring.

Poisonings can harm through their direct effect or determining organ disfunction; Extracorporeal blood purification therapies have been used for decades in case of poisonings. Although poisoning remains a major public health issue, focusing on organ dysfunction rather than the poison itself has significantly reduced mortality rates. This review explores the complex and dynamic interactions among poisons, patients and EBPT, and describes specific poisonings where EBPT may be indicated.

HighlightsWhat are the main findings?Higher spectral edge frequency (SEF) was associated with lower burst suppression (BS) throughout the surgical procedure.Children under 12 months showed a stronger SEF–BS correlation compared to those aged 12–36 months.What is the implication of the main findings?SEF appears to be an age-sensitive indicator of anesthetic depth during sevoflurane anesthesia with extracorporeal circulation.These findings underscore the importance of individualized, age-adjusted anesthesia monitoring strategies in pediatric cardiac surgery.Background/Objectives: Electroencephalography (EEG) is increasingly used in pediatric anesthesia to detect abnormal brain activity such as burst suppression (BS), a marker of profound cortical inactivation. The objective of this study was to assess anesthetic depth using bilateral spectral edge frequency (SEF) and to determine the incidence of frontal cortical BS in young children undergoing cardiac surgery with extracorporeal circulation (ECC) under sevoflurane anesthesia. Methods: Twelve children, divided into two age groups (<12 months and 12–36 months), were included. EEG sensors were placed on the forehead and continuously monitored with SedLine®. BS and SEF were analyzed using linear mixed-effects models, accounting for age group and repeated measurements across the procedure. Results: BS did not differ significantly over time. Across the full surgical procedure, higher SEF was associated with lower BS. However, children <12 months exhibited a stronger SEF–BS relationship, suggesting greater susceptibility to BS compared to older children. Before and during ECC, SEF and age group were not significantly related to BS. Random effects indicated moderate to substantial between-subject variability. Scatterplots showed a negative SEF–BS relationship overall, but weak and inconsistent associations during specific perioperative phases, underscoring the phase-dependent nature of SEF–BS dynamics. Conclusions: SEF is an age-sensitive marker of anesthetic depth during sevoflurane anesthesia with ECC, with children <12 months showing greater susceptibility to BS. These findings highlight the importance of individualized, age-adjusted anesthesia monitoring strategies in pediatric cardiac surgery.

Bisphenol (BP) compounds are widely present in the environment, primarily due to their use as plastic additives. These substances involve health risks, particularly as endocrine disruptors. While the general population is chronically exposed, patients with end-stage chronic kidney disease undergoing hemodialysis (HD-CKD) represent a particularly vulnerable group. This is due to both impaired renal clearance of circulating BPs and potential contamination from plastic-containing dialyzers used in extracorporeal blood circulation. In this longitudinal study, from the 35 HD-CKD patients initially selected, 25 changed their conventional dialyzers to BPA-free dialyzers for 6 months. Blood serum samples were collected, at baseline and after the intervention, to quantify levels of five BP analogues: Bisphenol A (BPA), Bisphenol AF (BPAF), Bisphenol F (BPF), Bisphenol B (BPB), and Bisphenol S (BPS). Genotoxicity was assessed using the comet assay and the micronucleus test on peripheral white blood cells. Among the analyzed BPs, only BPAF showed a statistically significant reduction when using BPA-free dialyzers. In terms of genotoxicity, a significant decrease was observed only in primary DNA damage (mainly DNA strand breaks), with no notable changes in chromosomal damage. This is the first study to detect multiple BP analogues in HD-CKD patients, beyond BPA, and to associate human exposure to BPs with DNA damage biomarkers. The observed reduction in DNA damage in parallel with decreased BPAF levels highlights the importance of monitoring and minimizing BP exposure of this high-risk population.