RESUMEN
OBJECTIVE: The aim of the study was to evaluate the outcome of extracorporeal membrane oxygenation (ECMO) support in Hantavirus cardiopulmonary syndrome (HCPS) patients with a predicted mortality of 100%, and the complications associated with this treatment modality and different cannulation techniques. METHODS: A total of 51 patients with refractory HCPS were supported with ECMO between April 1994 and June 2010. They were divided into group A consisting of the 26 patients treated between 1994 and 2000 and group B consisting of 25 patients treated between 2003 and 2010. No patients were treated between September 2000 and December 2003. Patients in group A were intubated when they became hypoxic and placed on ECMO when they became hemodynamically unstable, whereas patients in group B had elective insertion of vascular sheaths and were almost concurrently intubated and placed on ECMO when they decompensated. Cannulation of the femoral vessels was performed percutaneously in 18 (35.3%) patients and with an open technique in 33 (64.7%) patients. RESULTS: Complications from percutaneous cannulation occurred in 4/18 (22.27%) patients: retroperitoneal hematoma in 2/18 (11.1%) and lower-extremity ischemia in 2/18 (11.1%) patients. Complications from open femoral cannulation occurred in 12/33 (36.3%) patients: bleeding in 10/33 (30.3%) patients and ischemia in 2/33 (6.1%) patients. The overall survival was 66.6% (34 of 51 patients); 56% (14/26) for group A and 80% (20/25) for group B (p = 0.048). There was no difference in mortality regarding the method of cannulation. A trend toward increased mortality in patients with cannulation complications was recognized, but it was not statistically significant. Mortality was not associated with ECMO duration (average 121.7h, range: 5-276h). All survivors recovered and were discharged from the hospital after a mean hospital stay of 19.8 days (range: 10-39 days). CONCLUSIONS: Two-thirds of 51 HCPS patients with a predicted mortality of 100%, who were supported with ECMO, survived and recovered completely. Survival was significantly higher in the second half of the study. Complications associated with both types of femoral cannulation were associated with a trend toward decreased survival, which was not significant.
Asunto(s)
Oxigenación por Membrana Extracorpórea/métodos , Síndrome Pulmonar por Hantavirus/terapia , Adolescente , Adulto , Anciano , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Niño , Métodos Epidemiológicos , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Síndrome Pulmonar por Hantavirus/mortalidad , Hematoma/etiología , Humanos , Isquemia/etiología , Tiempo de Internación/estadística & datos numéricos , Extremidad Inferior/irrigación sanguínea , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , New Mexico/epidemiología , Espacio Retroperitoneal , Adulto JovenRESUMEN
OBJECTIVE: The purposes of this study are to evaluate the outcome of extracorporeal membrane oxygenation support in a subgroup of patients with Hantavirus cardiopulmonary syndrome who had a predicted mortality of 100% and to assess the complications associated with this treatment modality and with different cannulation techniques. METHODS: Thirty-eight patients with severe Hantavirus cardiopulmonary syndrome were supported with extracorporeal membrane oxygenation between April 1994 and June 2006. Cannulation of the femoral vessels was performed on an emergency basis by a percutaneous approach in 15 (39.5%) and by an open technique in 23 (60.5%) patients. Duration of extracorporeal membrane oxygenation averaged 132 hours (range: 5-276 hours). RESULTS: Complications from percutaneous cannulation occurred in 4 (26.6%) of 15 patients: retroperitoneal hematoma in 2 (13.3%) and lower extremity ischemia in 2 (13.3%) patients, which resolved after insertion of a distal perfusion cannula. Complications from open femoral cannulation occurred in 8 (34.8%) of 23 patients: severe bleeding in 7 (30.4%) patients and lower extremity ischemia in 1 (4.3%) patient who required a leg amputation. The overall survival was 60.5% (23/38 patients). Six (40%) of the 15 patients cannulated percutaneously and 9 (39.1%) of 23 patients who had open cannulation died. All survivors recovered completely and were discharged from the hospital after a mean hospital stay of 20.8 days (range: 10-39 days). CONCLUSIONS: Almost two thirds of the patients with severe Hantavirus cardiopulmonary syndrome who were supported with extracorporeal circulation survived and recovered completely. The complications associated with both types of femoral cannulation may be attributed to the fact that all patients were in shock or in full cardiac arrest, and the procedure had to be done expeditiously. Earlier institution of extracorporeal membrane oxygenation may decrease the complication rates and improve the overall survival.
Asunto(s)
Causas de Muerte , Oxigenación por Membrana Extracorpórea/métodos , Síndrome Pulmonar por Hantavirus/mortalidad , Síndrome Pulmonar por Hantavirus/terapia , Insuficiencia Respiratoria/mortalidad , Insuficiencia Respiratoria/terapia , Adolescente , Adulto , Factores de Edad , Anciano , Reanimación Cardiopulmonar , Niño , Estudios de Cohortes , Femenino , Síndrome Pulmonar por Hantavirus/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Probabilidad , Pronóstico , Pruebas de Función Respiratoria , Insuficiencia Respiratoria/etiología , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Análisis de SupervivenciaRESUMEN
BACKGROUND: Sedatives are used in critically ill children to facilitate mechanical ventilation. Although tolerance and withdrawal are associated with use of sedatives, information about withdrawal from benzodiazepines in children is limited. OBJECTIVE: To document the occurrence of lorazepam withdrawal in critically ill children and identify predictors for the development of withdrawal. METHODS: This prospective, investigational, open-label study enrolled pediatric patients receiving a continuous infusion of lorazepam for at least 72 hours. The lorazepam dosage was tapered in a uniform fashion over 6 days by decreasing the total daily dose by 50% every other day on 3 occasions; it was then discontinued. The occurrence of withdrawal from lorazepam was determined by pediatric intensive care unit attending physicians based on clinical judgment. Patients were assessed for withdrawal twice daily beginning 48 hours after the initiation of the lorazepam taper. Assessments were continued for 72 hours after lorazepam discontinuation or until the patient experienced withdrawal, whichever came first. Patient demographic, sedative dosing, and lorazepam serum concentration data were collected to identify risk factors for withdrawal. RESULTS: Twenty-nine patients completed the study. They received lorazepam for a median duration of about 21 days, and withdrawal occurred in 7 patients. There were no significant differences in demographic variables, lorazepam dosage or other sedative therapy, or lorazepam serum concentrations between patients with withdrawal and those without withdrawal. No predictors of withdrawal were identified. CONCLUSIONS: Withdrawal occurred in 24% of critically ill children receiving long-term sedation from lorazepam. Risk factors for withdrawal are unknown.