Extracorporeal Membrane Oxygenation Implantation Research Articles

Dual titration of minute ventilation and sweep gas flow to control carbon dioxide variations in patients on venovenous extracorporeal membrane oxygenation

BackgroundThe implantation of venovenous extracorporeal membrane oxygenation (VV-ECMO) support to manage severe acute respiratory distress syndrome generates large variations in carbon dioxide partial pressure (PaCO2) that are associated with intracranial bleeding. We assessed the feasibility and efficacy of a pragmatic protocol for progressive dual titration of sweep gas flow and minute ventilation after VV-ECMO implantation in order to limit significant PaCO2 variations.Patients and methodsA protocol for dual titration of sweep gas flow and minute ventilation following VV-ECMO implantation was implemented in our unit in September 2020. In this single-centre retrospective before-after study, we included patients who required VV-ECMO from March, 2020 to May, 2021, which corresponds to two time periods: from March to August, 2020 (control group) and from September, 2020 to May, 2021 (protocol group). The primary endpoint was the mean absolute change in PaCO2 in consecutive arterial blood gases samples drawn over the first 12 h following VV-ECMO implantation. Secondary endpoints included large (> 25 mmHg) initial variations in PaCO2, intracranial bleedings and mortality in both groups.ResultsFifty-one patients required VV-ECMO in our unit during the study period, including 24 in the control group and 27 in the protocol group. The protocol was proved feasible. The 12-h mean absolute change in PaCO2 was significantly lower in patients of the protocol group as compared with their counterparts (7 mmHg [6–12] vs. 12 mmHg [6–24], p = 0.007). Patients of the protocol group experienced less large initial variations in PaCO2 immediately after ECMO implantation (7% vs. 29%, p = 0.04) and less intracranial bleeding (4% vs. 25%, p = 0.04). Mortality was similar in both groups (35% vs. 46%, p = 0.42).ConclusionImplementation of our protocol for dual titration of minute ventilation and sweep gas flow was feasible and associated with less initial PaCO2 variation than usual care. It was also associated with less intracranial bleeding.

P290 EXTRACORPOREAL MEMBRANE OXYGENATION SYSTEM AS A BRIDGE TO REPARATIVE SURGERY IN VENTRICULAR SEPTAL DEFECT COMPLICATING ACUTE MYOCARDIAL INFARCTION

Abstract Introduction Post–infarct ventricular septal defect (VSD) is a life tethering complication of acute myocardial infarction which is associated to high in–hospital mortality (90–95%). The optimal peri–operative management including timing of surgical correction is still debated. There is a large body of evidence demonstrating that surgical repair is also associated to poor post–operative outcomes due to cardiogenic shock and multiorgan failure (MOF). The use of extracorporeal membrane oxygenation (ECMO) system in adult cardiac surgery is not routine, occurring in a minority of critically ill patients, typically postoperatively. Here we present our single centre experience of patients with post–infarct VSD managed preoperatively with ECMO support as a bridge to definitive surgical closure. Materials and methods Between February 2020 to July 2021, 5 patients presented to our unit with diagnosis of post–infarct VSD and were managed with preoperative veno–arterial (V–A) ECMO implantation and enrolled in our study. Clinical parameters (such as mean arterial pressure, central venous pressure, ECG, pulmonary artery pressure), blood tests, trans–thoracic and trans–esophageal echocardiography, chest X–rays have been evaluated both before and after surgery. Primary end–point was all causes in–hospital mortality. Results Three (60%) patients were male and mean age was 70,4 (60–78) years. All patients underwent surgical repair. ECMO was positioned between 1 and 9 days prior to surgical correction, giving the chance to reduce the pharmacological inotropic support while still reverting the MOF as demonstrated by the reduction of AST, ALT, bilirubin level, decreased CVP and systemic lactate levels. Two (40%) patients were successfully weaned off from the mechanical support and discharged home in good clinical conditions. Two (40%) patients developed MOF after surgery leading to the exitus. Conclusions We postulate that the use of V–A use preoperatively in patients with cardiogenic shock secondary to post–infarct VSD is appropriate and where feasible should be considered. It allows restoration of haemodynamic stability and resolution of MOF. This provides for a delayed surgical repair with a likely higher chance of operative success and reduced mortality.

Right ventricle dysfunction does not predict mortality in patients with SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support

The prognostic role of right ventricle dilatation and dysfunction (RVDD) has not been elucidated in patients with coronavirus disease (COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation (ECMO) support. To assess whether pre veno-venous (VV) ECMO RVDD were related to in-intensive care unit (ICU) mortality. We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU (an ECMO referral center) from 31th March 2020 to 31th August 2021. An echocardiographic exam was performed immediately before VV ECMO implantation. Males were prevalent (73.8%) and patients with a body mass index > 30 kg/m2 were the majority (46/61, 75%). The overall in-ICU mortality rate was 54.1% (33/61). RVDD was detectable in more than half of the population (34/61, 55.7%) and associated with higher simplified organ functional assessment (SOFA) values (P = 0.029) and a longer mechanical ventilation duration prior to ECMO support (P = 0.046). Renal replacement therapy was more frequently needed in RVDD patients (P = 0.002). A higher in-ICU mortality (P = 0.024) was observed in RVDD patients. No echo variables were independent predictors of in-ICU death. In patients with COVID-related respiratory failure on ECMO support, RVDD (dilatation and dysfunction) is a common finding and identifies a subset of patients characterized by a more severe disease (as indicated by higher SOFA values and need of renal replacement therapy) and by a higher in-ICU mortality. RVDD (also when considered separately) did not result independently associated with in-ICU mortality in these patients.

Del-Nido cardioplegia in cardiac surgery for elderly patients: a propensity score-matched analysis

ObjectivesTo compare the safety and efficacy of del-Nido cardioplegia (DNC) with traditional 4:1 cold blood cardioplegia (CBC) in coronary artery bypass grafting and/or valve surgeries in elderly patients.MethodsThe present study is a retrospective case-series study that included 302 consecutive patients aged 70 years and over who underwent on-pump valve surgery and/or coronary artery bypass graft (CABG). DNC was administered to 90 patients and CBC to 212 patients. After propensity-score matching, 89 pairs were compared. The safety and efficacy were analyzed between the two groups.ResultsThe DNC group had a similar mortality (3.4% vs. 5.6%, OR = 0.79, P = 0.720) and extracorporeal membrane oxygenation (ECMO) implantation rate (1.1% vs. 2.2%, OR = 0.75, P = 1.000) to the CBC group, a lower incidence of postoperative intra-aortic balloon pump (IABP) implantation (1.1% vs. 9.0%, OR = 0.54, P = 0.034) and a higher left ventricular ejection fraction (LVEF) at discharge (60 (56–64) % vs. 57 (51–62)%, P = 0.007). The estimated glomerular filtration rate (eGFR) in the DNC group was higher when the patient was transferred to the intensive care unit (79.4 (65.0-94.3) ml/min/1.73m2 vs. 77.2 (59.8–88.7) ml/min/1.73m2, P = 0.014), but no significant differences were identified after 24 h. The serum lactate values of the DNC group were significantly lower than those of the CBC group (0 h: 2.7 (2.0-3.2) vs. 3.2 (2.4–4.4), P = 0.001; 3 h: 3.2 (2.0-4.8) vs. 4.8 (2.8–6.6), P < 0.001; 6 h: 3.5 (2.2–5.4) vs. 5.8 (3.4–8.4), P < 0.001; 9 h: 3.4 (2.0–7.0) vs. 5.5 (2.9–8.3), P = 0.005). There were no differences between the two groups in respect of lactate levels at 12 h and thereafter. Postoperative creatinine kinase-MB concentrations were similar between the two groups.ConclusionsDel-Nido cardioplegia is safe and effective in elderly patients undergoing CABG and/or valve surgery.

Echocardiography Before Extracorporeal Membrane Oxygenation in Refractory Respiratory Failure: SARS-CoV-2 Infection Versus Other Etiologies

The study authors hypothesized that in patients with SARS-CoV-2, COVID-19-related refractory respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support echocardiographic findings (just before ECMO implantation) would be different from those observed in patients with refractory respiratory failure from different etiologies. A single-center observational study. At an intensive care unit (ICU). A total of 61 consecutive patients with refractory COVID-19-related respiratory failure (COVID-19 series) and 74 patients with refractory acute respiratory disease syndrome from other etiologies (no COVID-19 series), all needing ECMO support. Echocardiogram pre-ECMO. Right ventricle dilatation and dysfunction were defined in the presence of the RV end-diastolic area and/or left ventricle end-diastolic area (LVEDA >0.6 and tricuspid annular plane systolic excursion [TAPSE] <15 mm. Patients in the COVID-19 series showed a higher body mass index (p < 0.001) and a lower Sequential Organ Failure Assessment score (p=0.002). In-ICU mortality rates were comparable between the 2 subgroups. Echocardiograms performed in all patients before ECMO implantation revealed an incidence of RV dilatation that was higher in patients in the COVID-19 series (p < 0.001), and they also showed higher values of systolic pulmonary artery pressure (sPAP) (p < 0.001) and lower TAPSE and/or sPAP (p < 0.001). The multivariate logistic regression analysis showed that COVID-19-related respiratory failure was not associated with early mortality. The presence of RV dilatation and the uncoupling of RV function and pulmonary circulation were associated independently with COVID-19 respiratory failure. The presence of RV dilatation and an altered coupling between RVe function and pulmonary vasculature (as indicated by TAPSE and/or sPAP) are associated strictly with COVID-19-related refractory respiratory failure needing ECMO support.

Early computed tomography after extracorporeal cardiopulmonary resuscitation on in-hospital survival: a retrospective cohort study.

The role of computed tomography (CT) scans after extracorporeal membrane oxygenation (ECMO) implantation in patients with refractory cardiac arrest has not been frequently investigated. Early CT scan findings may have many meaningful findings and contribute significantly to patients' outcome. In this study, we sought to determine whether early CT scans in such patients indirectly improved in-hospital survival. A computerized search of the electronic medical records systems of 2 ECMO centers was conducted. A total of 132 patients who had undergone extracorporeal cardiopulmonary resuscitation (ECPR) between September 2014 and January 2022 were included in the analysis. The patients were divided into 2 groups based on whether they underwent early CT scans (the treatment group) or did not undergo early CT scans (the control group). The findings of early CT scans and in-hospital survival were investigated. A total of 132 patients had undergone ECPR with 71 were male, 61were female and mean age: 48.0±14.3 years. Early CT scans did not improve patient's in-hospital survival [hazard ratio (HR): 0.705; P=0.357]. Overall, a smaller proportion of patients survived in the treatment group (22.5%) than the control group (42.6%; P=0.013). In total, 90 patients were matched in terms of age, initial shockable rhythm, Sequential Organ Failure Assessment (SOFA) score, cardiopulmonary resuscitation (CPR) duration, ECMO duration, percutaneous coronary intervention, and cardiac arrest location. In the matched cohort, fewer patients survived in the treatment group (28.9%) than the control group (37.8%; P=0.371), but the difference was not significant. According to a log-rank test, in-hospital survival did not differ significantly before and after matching (P=0.69, and P=0.63, respectively). Thirteen patients (18.3%) had complications during transportation, among which a drop in blood pressure was the most common. The in-hospital survival rate between treatment and control group was not different, however, early CT scan after ECPR could help clinicians to gain important information to guide clinical practice.

Off-Hours versus Regular-Hours Implantation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Patients with Cardiogenic Shock.

The "weekend effect" has been associated with worse clinical outcomes. Our aim was to compare off-hours vs. regular-hours peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in cardiogenic shock patients. We analyzed in-hospital and 90-day mortality among 147 consecutive patients treated with percutaneous VA-ECMO for medical reasons between July 1, 2013, and September 30, 2022, during regular-hours (weekdays 8:00 a.m.-10:00 p.m.) and off-hours (weekdays 10:01 p.m.-7:59 a.m., weekends, and holidays). The median patient age was 56 years (interquartile range [IQR] 49-64 years) and 112 (72.6%) were men. The median lactate level was 9.6 mmol/L (IQR 6.2-14.8 mmol/L) and 136 patients (92.5%) had a Society for Cardiovascular Angiography and Interventions (SCAI) stage D or E. Cannulation was performed off-hours in 67 patients (45.6%). In-hospital mortality was similar in off-hours and regular hours (55.2% vs. 56.3%, p = 0.901), as was the 90-day mortality (58.2% vs. 57.5%, p = 0.963), length of hospital stay (31 days [IQR 16-65.8 days] vs. 32 days [IQR 18-63 days], p = 0.979), and VA-ECMO related complications (77.6% vs. 70.0%, p = 0.305). Off-hours and regular-hours percutaneous VA-ECMO implantation in cardiogenic shock of medical cause have similar results. Our results support well-designed 24/7 VA-ECMO implantation programs for cardiogenic shock patients.

Role of ECMO in E-CPR

Extracorporeal cardiopulmonary resuscitation (ECPR) is the implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a patient who experienced a sudden and unexpected pulseless condition attributable to cessation of cardiac mechanical activity. The aim of ECPR is to provide adequate perfusion to the end organs when the potentially “reversible” conditions were managed. ECPRs are mostly done in tertiary care center in India. There is little scope for out of hospital arrest as poor quality of CPR and response time exists with lack of awareness about ECPR, which hinders its wider usage even in IHCA. Emergency department doctors need to be involved to counsel, recognize candidates activate, and initiate ECPR.

Analyzing willingness for extracorporeal cardiopulmonary resuscitation in refractory ventricular fibrillation.

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia in out-of-hospital cardiac arrest has recently been recommended for selected patients with favorable prognostic features. We aimed to identify factors affecting the willingness of emergency physicians to implement extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a factorial survey with nine experimental vignettes by combining three different scene time intervals and transportation time intervals. Emergency physicians reported willingness to implement ECPR (1-100 points). Respondent characteristics that could affect the willingness were studied. Multilevel analysis of vignettes and respondent factors was conducted using a mixed-effects regression model. We obtained 486 vignette responses from 54 emergency physicians. In the case of longer scene time intervals, there was a significant difference in the willingness scores at 9 and 12 min transportation time intervals. When the pre-hospital time interval was > 40 min, emergency physicians demonstrated lower willingness to implement ECPR. Clinical experience of 15-19 years showed a significant favorable effect on willingness to implement extracorporeal membrane oxygenation (ECMO). However, the mean willingness scores of EPs for ECMO implementation were more than 75 across all vignettes. In ECPR, the prehospital time interval is an important factor, and the willingness of emergency physicians to implement ECMO could be mutually affected by scene time intervals, transportation time intervals, and total prehospital time.

Antithrombin substitution practice in pediatric cardiac surgery: A European survey.

The antithrombin concentration of neonates is approximately half that of adults. Low preoperative antithrombin concentration in this population have been associated with increased transfusion requirements.1 Similarly, low antithrombin concentration result in poor response to unfractionated heparin and inability to establish adequate anticoagulation during extracorporeal circulation (e.g., cardiopulmonary bypass, CPB), placing patients at risk for thrombosis.2 Despite obvious mode of action, there are no well-described clinical benefits of antithrombin usage in clinical practice. The aim of this survey was to identify the practice of antithrombin usage in pediatric cardiac surgery across Europe. The authors developed a 55-item electronic questionnaire to evaluate the following areas: the local practice of antithrombin management and substitution, including antithrombin monitoring and target levels, antithrombin administration techniques, and monitoring of anticoagulation. The survey was endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) and distributed among its members. Respondents had to identify themselves as pediatric cardiac anesthetists before they were allowed to enter the questionnaire. A total of 118 responses were received. The half of respondents confirmed that they were currently working as pediatric cardiac anesthesiologists and were allowed to participate in the survey. Sixty-eight percent of participants (39/57) regularly measure antithrombin concentration and 79% (31/39) regularly substitute antithrombin in different pathophysiological scenarios in pediatric congenital heart surgery (Table 1). Thirty-two percent (12/37) substitute antithrombin in all cardiac surgery cases with low antithrombin concentration. In the setting of CPB, 41% (15/37) substitute antithrombin. In patients <6 months of age scheduled for cardiac surgery, half of the respondents (54%, 20/37) not routinely substitute antithrombin. In pediatric patients with low antithrombin concentration on veno-arterial extracorporeal membrane oxygenation (ECMO), 78% (29/37) replace antithrombin. In all cardiac patients (with or without cardiac surgery), more than 65% (21/32) of respondents measure antithrombin concentration only when specifically indicated, 28% (9/32) before administration, and 25% (8/32) preoperatively (in case of cardiac surgery). In patients on veno-arterial ECMO, 50% (16/32) measure antithrombin once daily, 31% (10/32) before administration, 28% (9/32) only on specific indication, 25% (8/32) after administration or before ECMO implantation, respectively. The primary strategy for antithrombin concentration below target was immediate substitution in 54% (14/26) of respondents. Twenty-seven (7/26) percent opted for repeated measurements to make a final decision. In a situation with low antithrombin concentration and known heparin resistance, 100% (31/31) of responders substitute antithrombin. In a situation with known heparin resistance and unmeasured antithrombin concentration, half of the participants (52%, 16/31) did not substitute antithrombin. In unclear clinical situations with suspected low antithrombin concentration (e.g., disseminated intravascular coagulation), 77% (24/31) did not substitute antithrombin without a previous level measurement. Antithrombin substitution occurred in 66% (18/27) using calculations as provided by the manufacturer, in 22% (6/27) using a standard dose (e.g., 500 U antithrombin concentrate), and in 11% (3/27) using a calculation based on a custom formula. Antithrombin substitution - YES - Antithrombin substitution - NO - Antithrombin substitution - no answer - In this European survey examining the use of antithrombin in pediatric cardiac patients, we found widespread use of antithrombin measurement and substitution strategies. The most important areas for antithrombin monitoring and substitution were ECMO, in patients with inadequate elevation of activated clotting time during cardiac surgery with CPB, and in patients with known heparin resistance in combination with low antithrombin concentration. The most common consensus in the literature regarding antithrombin administration is inadequate response to heparin.3, 4 In our survey, antithrombin was substituted in all cases when a low antithrombin concentration was present in combination with detected heparin resistance. Regarding the use of antithrombin in different procedures without surgery, this study confirms large differences between institutions. One possible explanation is the lack of evidence in the literature for the use of antithrombin in specific cardiac lesions including specific cardiac surgery populations as for example cyanotic patients with high hematocrit. This survey underlines again the need for further, adequately powered studies regarding antithrombin monitoring and substitution in the pediatric cardiac patients undergoing surgery or interventions. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Implementation of Extracorporeal Membrane Oxygenation Without On-Site Cardiac Surgery or Perfusion Support: A Tale of Two County Hospitals.

Patients with refractory respiratory and cardiac failure may present to noncardiac surgery centers. Prior studies have demonstrated that acute care surgeons, intensivists, and emergency medicine physicians can safely cannulate and manage patients receiving extracorporeal membrane oxygenation (ECMO). Harborview Medical Center (Harborview) and Hennepin County Medical Center (Hennepin) are both urban, county-owned, level 1 trauma centers that implemented ECMO without direct, on-site cardiac surgery or perfusion support. Both centers 1) use an ECMO specialist model staffed by specially trained nurses and respiratory therapists and 2) developed comparable training curricula for ECMO specialists, intensivists, surgeons, and trainees. Each program began with venovenous ECMO to provide support for refractory hypoxemic respiratory failure and subsequently expanded to venoarterial ECMO support. The coronavirus disease 2019 (COVID-19) pandemic created an impetus for restructuring, with each program creating a consulting service to facilitate ECMO delivery across multiple intensive care units (ICUs) and to promote fellow and resident training and experience. Both Harborview and Hennepin, urban county hospitals 1,700 miles apart in the United States, independently implemented and operate adult ECMO programs without involvement from cardiovascular surgery or perfusion services. This experience further supports the role of ECMO specialists in the delivery of extracorporeal life support.

Takotsubo cardiomyopathy after cardiac surgery: A case-series and systematic review of literature.

Takotsubo cardiomyopathy (TTC) is a rare entity after cardiac surgery. To describe patients' profile who developed postoperative TTC after cardiac surgery, management, and outcomes. We performed a systematic literature search to extract cases of TTC after adult cardiac surgery (from 1990 to 2021). Additionally, we extracted all cases of TTC in a prospective single-center cohort database of 10,000+ patients (from 2007 to 2019). We then combined all cases in a single cohort to describe its clinical features. From 694 screened articles, we retained 71 individual cases published in 20 distinct articles (19 cases reports and 1 case-series). We combined these to 10 cases extracted from our cohort [among 10,682 patients (0.09%)]. Overall, we included 81 cases. Patients were aged 68 ± 10 years-old and 64/81 (79%) were women. Surgery procedures included mitral valve and/or tricuspid valve surgery in 70/81, 86%. TTC was diagnosed in the first days after surgery [median 4 (1-4) days]. Incidence of cardiogenic shock, defined as requirement of vasopressor and/or inotropic support was 24/29, 83% (data available on 29/81 patients). Refractory cardiogenic appeared in 5/81, 6% who required implantation of arterio-venous extra-corporeal membrane oxygenation, and 6/81, 7%, intra-aortic balloon pump. In-hospital mortality was 5/81, 6%. This systematic review, based on case reports and case series, showed that postoperative TTC appears as a rare complication after cardiac surgery and mainly occurred after mitral and/or tricuspid valve repair procedures. In this population, TTC is associated with high rate of cardiogenic shock.

Endovascular repair as a rescue strategy to restoring the extracorporeal membrane oxygenation flow

Ventricular septal defect (VSD) is a known complication after myocardial infarction associated with high mortality. Extracorporeal membrane oxygenation (ECMO) is being successfully used in patients with VSD as a bridge to definitive surgical repair. Although often the only possibility to stabilize hemodynamics and oxygenation, ECMO has many potential complications, carrying significant morbidity and mortality. Here, the patient presented with a postinfarct VSD on peripheral venoarterial ECMO who developed a dissection of the common iliac artery (CIA) on the 5th day after ECMO implantation. As a result, a sudden drop in ECMO flow has become evident along with high pressures in the arterial cannula. After a definitive diagnosis of a CIA lesion obstructing the blood flow was made, trans-ECMO endovascular repair of CIA was performed. Four days after endovascular repair, we encountered the same problem of decreased blood flow associated with stent kinking and were approached with another endovascular repair to re-establishing full ECMO flow.

Extracorporeal Membrane Oxygenation: Set-up, Indications, and Complications.

Extracorporeal membrane oxygenation (ECMO) occupies an increasingly important position in the clinic for the management of cardiac and/or pulmonary failure. As a rescue therapy, ECMO can support patients following respiratory or cardiac compromise to act as a bridge to recovery, to decision, or to transplant. This chapter reviews briefly the history of ECMO implementation as well as devicemodes, from veno-arterial, veno-venous, veno-arterial-venous, and veno-venous-arterial set-ups. The importance of acknowledging complications that can arise in each of these modes cannot be overlooked. Both bleeding and thrombosis are inherent risks to the use of ECMO and the existing strategies for management are reviewed. The device also elicits an inflammatory response, and the use of extracorporeal approaches can lead to infection, both of which are important to examine when reflecting how ECMO can be successfully implemented in patients. This chapter both discusses the understanding of these various complications and highlights the need for future research.

Risk of cannulation site bleeding during physical therapy mobilization during extracorporeal membrane oxygenation : A retrospective analysis in patients with acute respiratory failure

Patients suffering from acute respiratory distress syndrome receive extracorporeal membrane oxygenation (ECMO) as the last possible therapy. At the University Hospital Tübingen, these patients also receive physical therapy during this phase from aspecially trained team to counteract physical deconditioning. In this work, the risk of cannula site bleeding during physiotherapy mobilization is investigated and aspects regarding safety are described. From 2013 to 2018, 83patients matching the inclusion criteria were treated at the Anesthesiology Intensive Care Unit at the University Hospital Tübingen. The datasets were retrospectively analyzed by means of acase-control study. For comparison, the patients were divided into apassive and an active group according to the achieved level of mobilization. Bleeding events, ECMO implantation duration, and other aspects were taken into consideration in the analysis. There were two bleeding events in the passive and two bleeding events in the active group, but these were not related to physical therapy mobilization. The ECMO implantation duration varied between 1and 77days. Physical therapy mobilization by aspecially trained interdisciplinary team did not increase the risk of bleeding at the cannulation site.

Timing of active left ventricular unloading in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy

Abstract Aim To evaluate the impact of timing of active left ventricular (LV) unloading in relation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation on outcomes of patients with cardiogenic shock (CS). Methods and results Data from 421 patients with CS treated with active LV unloading on top of VA-ECMO at 18 tertiary-care centers in 4 countries were collected. Only patients in whom both devices were implanted within 24 hours of each other were considered and patients were stratified by timing of device implantation in early vs. delayed active LV unloading (e.g. active LV unloading before vs. after VA-ECMO). Cox and logistic regression models (adjusted for age, sex, lactate, cardiopulmonary resuscitation (CPR), VA-ECMO assisted CPR and enrollment center) were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as several safety outcomes. Overall, 310 (73.6%) patients were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (hazard ratio 0.63, 95% confidence interval 0.46–0.87) and a higher likelihood of weaning from mechanical ventilation (odds ratio 1.25, 95% confidence interval 1.03–1.52), but not with more complications. Importantly, postponing active LV unloading in these patients was associated with higher mortality risk (Figure 1), and lower likelihood of successful weaning from mechanical ventilation. Conclusion This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO as a primary treatment strategy, as opposed to a bail-out approach. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Unrestricted research grant from Abiomed

Predicting value on short-term outcome of various established risk prediction models in extracorporeal membrane oxygenation treated cardiogenic shock patients due to ST-segment elevation myocardial infarction

Objective: To investigate the predicting value of different risk prediction models for short-term death in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock and treated with extracorporeal membrane oxygenation (ECMO). Methods: This study was a retrospective case-control study. Forty patients with STEMI complicated by cardiogenic shock who hospitalized in the First Affiliated Hospital of Zhengzhou University from April 2017 to August 2021 and treated with percutaneous coronary intervention (PCI) and ECMO, were enrolled in this study. Patients were divided into survival group and death group according to their clinical outcomes at 30 days after ECMO implantation, and clinical data of the two groups were collected and analyzed. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to compare the predictive value of ACEF, AMI-ECMO, Encourage and SAVE risk scores for mortality at 30 days after ECMO implantation. According to the evaluation results of DCA, the optimal risk score was selected. Kaplan-Meier curve estimating the 30-day survival after ECMO implantation was plotted by grouping risk scores with reference to previous literatures. Results: A total of 40 patients with STEMI combined with cardiogenic shock were included, age was (57.4±16.7) years, 31 (77.5%) patients were male, there were 21 (52.5%) patients in the death group and 19 (47.5%) in the survival group. Compared with the survival group, patients in the death group had higher lactic acid values, higher proportion of anterior descending artery or left main artery lesions, and a higher proportion of acute renal failure and continuous renal replacement therapy during hospitalization (all P<0.05). Compared with survival group, ACEF, AMI-ECMO and Encourage scores were higher in death group, SAVE score was lower in death group (all P<0.05). The ROC curve analysis showed that the area under the curve (AUC) of ACEF, AMI-ECMO, Encourage and SAVE scores in predicting mortality were 0.707, 0.816, 0.757, and 0.677 respectively (P>0.05). ACEF score demonstrated the highest sensitivity (90.5%) and Encourage score exhibited the highest specificity (89.5%). DCA indicated that the AMI-ECMO and Encourage scores had the best performance in predicting the 30-day mortality after ECMO therapy. Kaplan-Meier survival curve analysis showed that the 30-day mortality after ECMO implantation increased with the increase of AMI-ECMO and Encourage scores (log-rank P≤0.001). Conclusions: The 4 scoring systems are all suitable for predicting 30-day mortality after VA-ECMO therapy in patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock. Among them, AMI-ECMO and Encourage scores have better predicting performance.

Lethal Waterhouse–Friderichsen syndrome caused by Capnocytophaga canimorsus in an asplenic patient

BackgroundCapnocytophaga canimorsus, a Gram-negative rod, belongs to the Flavobacteriaceae family and colonizes the oropharynx of dogs and cats. Infections with C. canimorsus are rare and can induce a systemic infection with a severe course of the disease. So far, only five case reports of C. canimorsus infections associated with Waterhouse–Friderichsen Syndrome (WFS) have been reported with only two of the patients having a history of splenectomy.Case presentationHere, we report a fatal case of WFS due to C. canimorsus bacteremia and mycetal superinfection in a 61-year-old female asplenic patient. Despite extensive therapy including mechanical ventilation, antibiotic coverage with meropenem, systemic corticosteroids medication, vasopressor therapy, continuous renal replacement therapy, therapeutic plasma exchange, multiple transfusions of blood products and implantation of a veno-arterial extracorporeal membrane oxygenation the patient died 10 days after a dog bite. The autopsy showed bilateral hemorrhagic necrosis of the adrenal cortex and septic embolism to heart, kidneys, and liver. Diagnosis of C. canimorsus was prolonged due to the fastidious growth of the bacteria.ConclusionsThe occurrence of a severe sepsis after dog bite should always urge the attending physician to consider C. canimorsus as the disease-causing pathogen. A therapeutic regimen covering C. canimorsus such as aminopenicillins or carbapenems should be chosen. However, despite maximum therapy, the prognosis of C. canimorsus-induced septic shock remains very poor. Asplenic or otherwise immunocompromised patients are at higher risk for a severe course of disease and should avoid exposure to dogs and cats and consider antibiotic prophylaxis after animal bite.

Determinants of survival in patients on extracorporeal membrane oxygenation therapy due to severe covid-19.

BackgroundSevere acute respiratory distress syndrome (ARDS) due to Coronavirus Disease-19 (COVID-19) is associated with high mortality. Although survival on mechanical circulatory support has improved, determinants for better prognosis are still unclear. Here, we report on the outcome of our patient population with the need for mechanical circulatory support due to severe COVID-19 (sCOVID-19) induced ARDS.MethodsAll patients treated with extracorporeal membrane oxygenation (ECMO) for severe ARDS due to sCOVID-19 were analysed. Patients > 18 years of age at the time of initiation of ECMO were included. Pre-existing comorbidities, complications during ECMO implantation, and ECMO runtime were reviewed. The latency to intubation, proning, tracheotomy, and ECMO implantation was analysed. Furthermore, the survival and non-survival population were compared to determine factors in favour of a better outcome.ResultsIn total, 85 patients were treated with veno-venous membrane oxygenation (vv-ECMO) for severe ARDS in our medical centre. The patient population was predominantly male (83.5%) with a mean patient age of 54.9 years. A history of cardiovascular disease (p = .01), smoking (p < .05), need for vasopressor- (p < .05), and renal replacement therapy (p < .001) was associated with a worse prognosis. Overall survival was 50%. The survival population was significantly younger (p = .004), had a significantly higher body weight (p = .02) and body mass index (BMI) (p = .01). Furthermore, survival was significantly better when vv-ECMO was initiated within 48 h after admission (p < .001).ConclusionsPre-existing cardiovascular disease, higher age, history of nicotine abuse, and development of renal failure are associated with poor outcome. Early start of vv-ECMO therapy may lead to better survival in sCOVID-19 patients, although complications during ECMO therapy are associated with a worse prognosis.

Implementación de membrana de oxigenación extracorpórea. Relato de experiencia

A resource that has been used for some years in Argentina was incorporated into the institution, but with the pandemic it took on vital importance; This is ECMO (extracorporeal membrane oxygenation). It is a life support modality of high complexity andcost, which is used in patients with severe respiratory or heart failure. ECMO consists of an extracorporeal circulation circuit that allows the elimination of carbon dioxide and oxygenation of the blood. There are two types of circuits: the veno-arterial, in which the circuit takes venous blood from the cavas and the right atrium, ox ygenates it and then returns it to the larger circuit through the aorta, and the veno-arterial circuit. venous, which takes venous blood from the inferior vena cava and returns it oxygenated to the right atrium. The implementation of ECMO at the Sanatorio Allende requires important changes in a structured and integrated manner with a multidisciplinary plan aimed at patient care. Where the nurse's approach to the person in a critical situation subjected to ECMO is considered decisive, this professional being essential for the process. The health team is responsible for a continuous presence to monitor, monitor and prevent complications, as well as the management and coordination of care. The protocol was developed, emphasizing the strengths, weaknesses and The importance of this new challenge in the Coronary Unit service lies in acquiring new knowledge, technologies, unifying nursing care in post-wellness, recovery and patient safety.