Percutaneous Cardiopulmonary Support System Research Articles

489. Risk Factors for Mortality in Patients with Elizabethkingia and Clinical Impact of Antimicrobial Susceptibility Patterns

Background Elizabethkingia spp. is a non-fermenting, non-motile, oxidase-positive gram-negative aerobic bacilli that is ubiquitous in the environment, found in freshwater, saltwater and soil. Nowadays, they are emerging as nosocomial pathogens. In this study, we analyzed Elizabethkingia spp infected cases clinically and microbiologically.MethodsThis study was performed to evaluate the risk factors for mortality and to study the impact of microbiologic response on clinical outcomes in patient with Elizabethkingia spp Data on 210 patient of Elizabethkingia pneumonia and bacteremia that have occurred between November 1, 2005, and May 31, 2016, in a teaching hospital (2000 beds) in Seoul, Korea, were analyzed. Furthermore, antimicrobial susceptibility testing of Elizabethkingia from sputum and blood cultures was performed by E test for rifampin, moxifloxacin and vancomycin.ResultsAmong 210 patients, there were 157(74.8%) survivor and 53(25.2%) non-survivor. Among these patients, 129 patients (61.4%) were male and the median age was 66.5 years. There were no significant differences in the Charlson comorbidity index between survivor and non-survivor groups (P = 0.413). In the multivariate logistic regression, microbiologic failure (odds ratio [OR], 7.862; 95% confidence interval [CI], 3.448–17.931; pElizabethkingia infection (OR, 1.032; 95% CI, 1.013–1.051; P = 0.001), previous use of immunosuppressants (OR, 3.309; 95% CI, 1.334–8.210; P = 0.010), and Percutaneous cardiopulmonary support system use at the time of Elizabethkingia infection (OR, 7.439; 95% CI,1.180–46.900; P = 0.033) were significantly associated with 28day mortality. Patients with moxifloxacin-resistant and vancomycin-resistant showed higher mortality rate but no statistically significant difference.ConclusionThe early identification of these clinical factors in patients with Elizabethkingia infection is important to improve prognosisDisclosures All authors: No reported disclosures.

PCPS (経皮的心肺補助装置)により安全にステント留置できた症例

PCPS (経皮的心肺補助装置)により安全にステント留置できた症例

経皮的心肺補助法(PCPS)合併症を含めた，全身管理に苦慮した劇症型心筋炎の1例

経皮的心肺補助法(PCPS)合併症を含めた，全身管理に苦慮した劇症型心筋炎の1例

Clinical outcomes of patients with acute myocardial infarction complicated by severe refractory cardiogenic shock assisted with percutaneous cardiopulmonary support.

PurposeLimited data are available on the role of percutaneous cardiopulmonary support (PCPS) for the treatment of acute myocardial infarction (AMI) patients with cardiogenic shock. We investigated the clinical outcomes and predictors of in-hospital mortality after PCPS in patients with AMI complicated by severe refractory cardiogenic shock.Materials and MethodsFrom January 2004 to December 2011, we analyzed data from 96 consecutive AMI patients with cardiogenic shock assisted by a PCPS system. The primary outcome was in-hospital mortality. The predictors of in-hospital mortality were determined by a Cox proportional-hazards model.ResultsIn-hospital mortality occurred in 51 (53.1%) patients and 58 (60.4%) patients were able to be weaned from PCPS. Cardiopulmonary resuscitation (CPR) was performed in 61 (63.5%) patients before PCPS initiation. On multivariate analysis, age ≥67 years [adjusted hazard ratio (HR), 4.74; 95% confidence interval (CI), 2.27-9.93; p<0.001], CPR (adjusted HR, 2.32; 95% CI, 1.11-4.85; p=0.03), lactate clearance for 48 hours <70% (adjusted HR, 2.50; 95% CI, 1.04-6.05; p=0.041), and unsuccessful revascularization (adjusted HR, 3.57; 95% CI, 1.85-6.90; p=0.002) were independent predictors of in-hospital mortality after PCPS in patients with AMI complicated by cardiogenic shock.ConclusionIn spite of PCPS management, AMI patients complicated by severe refractory cardiogenic shock demonstrated high mortality. Older age, CPR, lower lactate clearance for 48 hours, and unsuccessful revascularization were independent predictors of in-hospital mortality.

Application of percutaneous cardiopulmonary support system in critically ill patients

To summarize the experiences of percutaneous cardiopulmonary support system (PCPS) for critically ill patients and examine the risk factors associated with prognosis. The clinical data of 22 patients with acute severe cardiorespiratory failure on PCPS at intensive care unit of Zhejiang Provincial People's Hospital from September 2006 to February 2013 were retrospectively collected and analyzed. According to the prognosis, they were divided into the survival and mortality groups. And their risk factors of prognosis were analyzed. The PCPS support time was 2-334 (75 ± 10) hours, 14 cases (63.6%) were successfully weaned and 12 cases (54.6%) discharged. The inter-group differences of blood lactic acid level before PCPS, heart ejection fraction, sequential organ failure assessment (SOFA) score and number of multiple organ failure (> 3) were statistically significant (P < 0.05). PCPS is an effective approach for severe acute patients with cardiopulmonary failure. And blood lactic acid level before PCPS, heart ejection fraction, SOFA score and number of multiple organ failure (>3) may be the risk factors related with prognosis.

Prompt institution of percutaneous cardiopulmonary support managed perioperative refractory vascular spasm after isolated coronary artery bypass grafting surgery

A 51-year-old Japanese male underwent on-pump coronary artery bypass grafting surgery. After weaning from cardiopulmonary bypass (348min), sudden bradycardia and hypotension occurred, followed by ventricular fibrillation. Although defibrillation and infusion of catecholamine restored sinus rhythm, transesophageal echocardiography demonstrated severely reduced contraction of both ventricles, and perioperative vascular spasm was suspected. As vascular spasm was refractory to medications, percutaneous cardiopulmonary support (PCPS) system was quickly instituted under cardiac massage. Coronary angiography revealed vascular spasm of not only the native coronary arteries but also the implanted left internal thoracic artery. After 3days of full hemodynamic assist, PCPS was withdrawn with no obvious abnormalities in regional wall motion by transesophageal echocardiography. The patient was extubated on postoperative day 6 with no impaired brain function. In this case, the immediate diagnosis of refractory vascular spasm by transesophageal echocardiography and full cardiocirculatory assistance by PCPS helped to save the life of the patient.

人工血管を介した経皮的心肺補助装置からの送血により救命したアナフィラキシーショックによる心停止例

人工血管を介した経皮的心肺補助装置からの送血により救命したアナフィラキシーショックによる心停止例

A Case of Primary Tracheal Pleomorphic Adenoma Resected Bronchoscopically Using a Percutaneous Cardiopulmonary Support System and Tracheostomy

A Case of Primary Tracheal Pleomorphic Adenoma Resected Bronchoscopically Using a Percutaneous Cardiopulmonary Support System and Tracheostomy

Myocarditis in a pediatric case of pandemic 2009H1N1 influenza

We report a 6-year-old boy with no major disease history or allergic conditions initially presented with pneumonia, progressed to acute respiratory distress syndrome and acute myocarditis caused by pandemic 2009H1N1 influenza diagnosed with RT-PCR testing, successfully managed with mechanical ventilation and percutaneous cardiopulmonary support system. Marked transient elevation of IgE in acute phase of the disease and the subsequent diagnosis of atopic asthma in our patient suggested a possible role of an underlying allergic condition in the clinicopathological process. Critically ill 2009H1N1-infected patient with acute respiratory failure should carefully be physiologically monitored together with serial assessment of biomarkers aiming at a favorable cardiac outcome by giving the timely diagnosis and intervention.

Successful esophageal bypass surgery in a patient with a large tracheoesophageal fistula following endotracheal stenting and chemoradiotherapy for advanced esophageal cancer: case report

A 63-year-old man with esophageal achalasia for more than 20 years complained of respiratory distress. He was admitted as an emergency to the referral hospital three months previously. Computed tomography revealed tracheobronchial stenosis due to advanced esophageal cancer with tracheal invasion. He underwent tracheobronchial stenting and chemoradiotherapy. A large tracheoesophageal fistula (TEF) developed after irradiation (18 Gy) and chemotherapy, and he was unable to eat. Thereafter, he was referred to our hospital, where we performed esophageal bypass surgery using a gastric conduit. A percutaneous cardiopulmonary support system was prepared due to the risk of airway obstruction during anesthesia. A small-diameter tracheal tube inserted into the stent achieved ordinary respiratory management. No anesthesia-related problems were encountered. Oral intake commenced on postoperative day 9. He was discharged on postoperative day 23 and was able to take in sustenance orally right up to the last moment of his life. Esophageal bypass under general anesthesia can be performed in patients with large TEF with sufficient preparation for anesthetic management.

Associations Between the Use of Critical Care Procedures and Change in Functional Status at Discharge

Quality improvement initiatives in intensive care units (ICUs) have increased survival rates. Changes in functional status following ICU care have been studied, but results are inconclusive because of insufficient consideration of the combinations of critical care procedures used. Using the Japanese administrative database including the Barthel Index (BI) at admission and discharge, we measured the changes in functional status among the adult patients and determined whether longer ICU stay or use of various critical care procedures was associated with functional deterioration. Of the 12502528 patients admitted to 1206 hospitals over 5 consecutive years from 2006, we analyzed data from patients aged 15 years or older who survived ICU admission in 320 hospitals. Critical care procedures evaluated were ventilation, blood purification (hemodialysis, hemodiafiltration, or hemadsorption), and cardiac support devices (intra-aortic balloon pump or percutaneous cardiopulmonary support system). Functional outcomes were determined by the difference between BI at admission and at discharge and were divided into improvement, no change, or deterioration. We compared patient characteristics, principal diagnosis, comorbidities, timing of surgical procedure, complications, days in ICU, and use of critical care procedures among the 3 categories. Associations between critical care procedures and functional deterioration were identified using multivariate analysis. Of 234209 patients with complete BI information, 7137 (3.1%) received blood purification, 27100 (11.7%) received ventilation, 2888 (1.2%) received blood purification and ventilation, 5613 (2.4%) received a cardiac support device, 247 (0.1%) received a cardiac support device and blood purification, 10444 (4.5%) received a cardiac support device and ventilation, and 1110 (0.5%) received a cardiac support device, ventilation, and blood purification. Longer use of blood purification or ventilation and a longer ICU stay were associated with functional deterioration. Intensivists should be aware of the effects of critical care procedures on functional deterioration and advance the appropriate use of functional support according to each patient's condition.

Contralateral pneumothorax in bullous lung after pneumonectomy: report of two cases

Contralateral pneumothorax after pneumonectomy is potentially fatal. We experienced two cases of right pneumothorax after left pneumonectomy in which the patients had multiple bullae in the right lung. Case 1 involved a 49-year-old man with non-small-cell lung cancer (NSCLC) who underwent left pneumonectomy after induction chemoradiotherapy. Eleven months after surgery, he had pneumothorax and was treated with chest tube drainage and pleurodesis. He was discharged but died of recurrent pneumothorax 1month later. Case 2 involved a 57-year-old man with NSCLC who had left pneumonectomy. Five months after surgery, he had pneumothorax and was treated with chest tube drainage. Because of prolonged air leak, ligation of the ruptured bulla was performed with a percutaneous cardiopulmonary support system on standby. No pneumothorax recurrence occurred for 2years. Although management of pneumothorax after pneumonectomy is challenging, surgical intervention may be useful and necessary especially when there is high risk of recurrent pneumothorax.

A Survival Case of Cardiogenic Shock due to Left Main Coronary Artery Myocardial Infarction: Successful Cooperation with On-Site Percutaneous Coronary Intervention and Helicopter Emergency Medical Service

A 54-year-old man was referred to a local hospital, located about 90 km from our hospital, with cardiogenic shock due to left main coronary artery infarction (LMCA-MI). Percutaneous coronary intervention (PCI) was performed under intra-aortic balloon pumping (IABP) support, but resulted in insufficient reperfusion and his condition worsened. The helicopter emergency medical service (HEMS) rapidly transported the patient to our hospital. After percutaneous cardio-pulmonary support system (PCPS) insertion, PCI could establish the coronary flow. A series of intensive therapies saved the patient. The cooperation of medical and emergency service system following revascularization and intensive care saved the patient with LMCA-MI accompanied by cardiogenic shock.

人工心肺を使用し救命した食道癌術後気管支膜様部壊死の1例

人工心肺を使用し救命した食道癌術後気管支膜様部壊死の1例

A Operation Case of Surgery for Adenoid Cystic Carcinoma of the Cervical Trachea Using a Percutaneous Cardiopulmonary Support System

頸部気管に発生した腺様嚢胞癌に対して，PCPS (経皮的体外循環システム) 下に摘出術を施行した症例を経験した。症例は69歳女性。咽頭の違和感と嗄声を主訴に初診。咽頭および喉頭に特記すべき所見を認めず，内科にて経過観察された。しかし喘鳴および呼吸苦が増悪し，2カ月後に当科にも再診した。上気道病変を疑い検索したCTと気管支鏡にて声門直下の気管内に腫瘍を認め，前壁から発生し内腔の4/5径を占拠していた。気管内挿管および気管切開は困難と考え，PCPSを使用した。手術は，第5気管輪で気管を横切開し，下方から腫瘍を確認した。術中迅速病理診断で腺様嚢胞癌の診断を得た。気管前壁側約1/3周を摘出・第1-5気管輪の高さで気管皮膚瘻とした。上方前壁側で断端陽性であった。術後放射線治療の後局所皮弁および右耳介軟骨にて硬性再建し，現在再発を認めない。気管腫瘍は比較的まれな疾患であるが，呼吸苦が増強し発見された折には既に増大しており対応に苦慮することがある。本症例も同様であり，教訓とすべきと考える。また部位によって治療法の綿密な計画と工夫が不可欠であるが，本例ではPCPSにより安全で確実な操作が可能であり有用であったと考えられた。

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST-T wave depression in leads V4-V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra-aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross-over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio-pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two-stent deployment strategy may assure a higher rate of safety in such cases.

緊急循環補助に対する CAPIOX EBS (EMERSAVE) の使用経験

緊急循環補助に対する CAPIOX EBS (EMERSAVE) の使用経験

Outcome of in-hospital adult cardiopulmonary resuscitation assisted with portable auto-priming percutaneous cardiopulmonary support

BackgroundOutcome from in-hospital cardiopulmonary resuscitation (CPR) is still unsatisfactory. CPR assisted with percutaneous cardiopulmonary support (PCPS) is expected to improve the outcome of in-hospital CPR. MethodsWe retrospectively analyzed 83 consecutive cases of adult in-hospital CPR assisted by a portable pre-assembled auto-priming PCPS system (EBS, Terumo, Japan) from January 2004 to December 2007. ResultsPCPS was successfully performed in 97.6% of the patients and could be weaned in 57.8% of the patients. The survival-to-discharge rate was 41.0% with an acceptable neurological status in 85.3% of the patients. The 6-month survival was 38.6%. Survival-to-discharge decreased about 1% for each 1min increase in the duration of CPR. The probability of survival was about 65%, 45%, and 19% when the duration of CPR was 10, 30, or 60min, respectively. Multivariate analysis adjusted with clinical factors including organ dysfunction severity scores revealed that defibrillation and CPR duration less than 35min were independent predictors for both survival-to-discharge (odds ratio=8.0, 95% CI=2.8–23.0, p<0.001) and 6-month survival (hazard ratio=3.3, 95% CI=1.9–5.9, p<0.001). ConclusionsOur results showed that CPR assisted with PCPS results in an acceptable survival-to-discharge rate and mid-term prognosis.

Knotting of two central venous catheters: a rare complication of pulmonary artery catheterization

To the Editor: A unique complication of pulmonary artery (PA) catheter use is knotting. We describe a case of a knot between a central venous catheter and a PA catheter, and the successful nonsurgical unknotting and removal of the catheter. A 31-year-old pregnant woman in cardiogenic shock resulting from a tachycardia-induced cardiomyopathy was transferred to the intensive care unit. On admission, a triple-lumen central venous catheter was introduced via the right internal jugular vein. Despite sufficient hydration and continuous infusion of inotropic agents, her blood pressure was unstable. Circulatory supports by intraaortic balloon pump (IABP) and percutaneous cardiopulmonary support system (PCPS) were introduced for severe heart failure (ejection fraction was 10%). On the 6th ICU day, a PA catheter was inserted through the left internal jugular vein to monitor hemodynamic status during weaning from PCPS. The catheter was inserted without difficulty and advanced easily, and the correct position was confirmed on the chest X-ray. Weaning from the PCPS was completed on the 6th ICU day, and the IABP was removed on the 7th ICU day because her hemodynamic status became relatively stable. However, as she still had multiple organ failure, we retained the PA catheter. Although a chest X-ray showed normal configuration of the catheters on the morning of the 11th ICU day, monitoring failure of pulmonary arterial pressure happened abruptly about 9 p.m. without any catheter manipulations. We attempted to remove the PA catheter in the usual manner. However, resistance was felt during withdrawal of the catheter, and repeated traction was unsuccessful. Then, we confirmed a loose knot between the central venous catheter and the PA catheter in the superior vena cava on the chest X-ray (Fig. 1). As the knotting was relatively loose, we pushed the PA catheter forward to unknot the catheters, and then the catheter was successfully removed. The case of knotting of two catheters is rare [1–3]. Cases of knotted catheters functioning normally for several days have not been previously reported. We suspected that the catheter knotted when sudden malfunction of the catheter was found; in fact, the catheter was in normal configuration in the morning. The cause of knotting was not clear, and the catheter was not manipulated before discovery of the knotting. Several technical methods for removal of the knotting have been developed in cases that are more difficult to handle. One approach is to tighten the knot as much as possible so that it may be removed through the vein insertion site. Alternative approaches are to use a retrieval basket, a loop snare formed by a double-over guide wire or loop snares, endomyocardial biopsy forceps, or an inflated angiography balloon to expand the diameter of the knot [4]. Open surgical removal of knotted catheters is reserved for large, multiple loop knots or knots that are fixed within the cardiac chamber. In summary, we experienced a case of a spontaneous knotting between a central venous catheter and a PA catheter several days after placement. A catheter knotting should be considered when malfunction of the catheter is encountered. Withdrawal of a PA catheter should be performed cautiously, and a chest X-ray should be taken S. Hida (&) S. Ohashi H. Kinoshita T. Honda S. Yamamoto J. Kazama H. Endoh Department of Emergency and Critical Care Medicine, Niigata University Faculty of Medicine, 1-757 Asahimachi, Niigata 951-8510, Japan e-mail: ukhida@med.niigata-u.ac.jp

Percutaneous cardiopulmonary support(PCPS)system for rescuing dogs with acute cardiogenic shock

Objective To evaluate the effects of PCPS on life-support of dogs with acute cardingenic shock (CS).Method Twenty healthy hybrid dogs were randomly(random number)divided into two groups.The acute CS canine model was established by ligature of the lAD coronary artery via open-chest surgery.The criteria of successful model were blood pressure dropped to 70%of the MAP or cardiac output dropped 30%.Dogs in the experimental group were treated with routine treatment including mechanical ventilation,intravenous injection of vasoucfive drugs such as dopamine,dobutamine and norepinephrine,and 5%bicarbonate as well as defibrillation along with PCPS.While dogs in control group were treated with routine treatment alone.Before modeling and at the beginning of modeling,15 rain,30 rain,60 rain and 90 rain after routine treatment,the hemodynamic variables including pH,PaO_2 and PaCO_2 were measured.The differences between two groups were compared using t-test and ANOVA.Results Eighteen(25 models were successfully made.(1)In the control group,MAP,CO deceased significantly(P＜0.05)and CVP increased significandy(P＜0.05)within 30 rain after modeling,PaO_2 decreased significantly(P＜0.05)and PaCO_2 increased significantly(P＜O.05)within 60 rain after modeling,and pH decreased significantly(P＜0.05)within 90 rain after modeling.(2)In the experimental group,MAP and PaO_2 increased significantly,and CVP decreased significantly(P＜0.05)within 15 rain after modeling,and PaCO_2 decreased significantly(P＜0.05)within 30 rain after modeling,and CO and pH remained unchanged.Compared with the control group,PaO_2 in experimental group was significantly higher(P＜0.05)and CVP was lower(P＜0.05)within 15 rain,MAP and CO were higher and PaCO_2 waa lower(P＜0.05)within 30 rain,and pH was higher(P＜0.05)within 60 min after modeling.Conclusions PCPS improves the hemodynamics and oxygen saturation in dogs with CS. Key words: Percutaneous cardio-pulmonary support; Cardiogenie shock; Animal model; Swaa-ganz vessel; Cardio-pulmonary bypass; Hemodynamics; Blood Gas analysis; Oxygen supply