RESUMEN
Extracorporeal membrane oxygenation (ECMO) is an established tool for respiratory and circulatory support. In computed tomography, altered hemodynamics in ECMO patients requires special considerations and handling in contrast injection and its timing. In this article, we demonstrate changes in hemodynamics in ECMO patients captured on contrast-enhanced CT examinations and pitfalls in strategies for contrast injection in relation to the ECMO flow, cardiac function and the placement of ECMO cannulas. Contrast-enhanced CT of patients with ECMO requires prior knowledge of the ECMO cannulas, central venous lines, changes of hemodynamics induced by low cardiac output and the influence of adjustment of ECMO on blood flow in order to optimize injection of the contrast material and timing of the scan. Special considerations include temporary reduction of the ECMO flow, selection of the injection site and increasing volume or flow rate of the contrast material.
Asunto(s)
Medios de Contraste/administración & dosificación , Oxigenación por Membrana Extracorpórea/métodos , Hemodinámica , Tomografía Computarizada por Rayos X/métodos , Adulto , Medios de Contraste/análisis , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: The aim of our study was to analyze, in a pig model of prolonged ventricular fibrillation (VF) treated by veno-arterial extracorporeal membrane oxygenation (ECMO), the time dependent changes of VF wavelet frequency obtained from intracardial signals and its relations to return of spontaneous circulation (ROSC). METHODS: 11 female pigs (50.3 ± 3.4 kg) under general anesthesia had undergone 15 min of VF with ECMO flow of 5 to 10 ml/kg per min simulating "untreated" VF followed by continued VF with full ECMO flow of 100 ml/kg per min. The median frequency (MF) of VF from right ventricular apex, coronary perfusion pressure, myocardial oxygen metabolism and resuscitability were determined. RESULTS: Median (interquartile range) of MF of fibrillatory wavelets in minute 15 of low ECMO flow [9.7 Hz (8.3; 10.1)] was not significantly changed in comparison to minute 1 [10.5 Hz (9.8; 12.4)], p = 0.12. Five minutes after full ECMO initiation MF increased [11.6 Hz (10.6; 13.5)], p = 0.04 (compared to minute 15 of VF) and did not deteriorate during the rest of ECMO treatment. Out of all subjects, three animals did not reach ROSC. Those subjects demonstrated deeper decrease of MF at the VF minute 15 as compared to others [-2.4 Hz (-2.5; -2.3) vs. -0.6 Hz (-1.6; -0.1)] and continuously significantly higher increase in MF on full ECMO support [4.3 Hz (2.9; 5.6) vs. 1.1 Hz (0.6; 1.6)] with p = 0.05 for both observations, respectively. CONCLUSIONS: The veno-arterial ECMO reperfusion influences MF of VF wavelet obtained from right ventricular apex. The course of changes in wavelet frequency corresponds to a presence of later ROSC.
Asunto(s)
Oxigenación por Membrana Extracorpórea/métodos , Fibrilación Ventricular/terapia , Animales , Presión Arterial/fisiología , Reanimación Cardiopulmonar/métodos , Modelos Animales de Enfermedad , Femenino , Recuperación de la Función/fisiología , Porcinos , Fibrilación Ventricular/fisiopatologíaRESUMEN
BACKGROUND: ECMO (extracorporeal membrane oxygenation) is increasingly used in severe hemodynamic compromise and cardiac arrest (CA). Pulmonary infections are frequent in these patients. Venoarterial (VA) ECMO decreases pulmonary blood flow and antibiotic availability in lungs during VA ECMO treated CA is not known. We aimed to assess early vancomycin, amikacin and gentamicin concentrations in the pulmonary artery as well as tracheal aspirate and to determine penetration ratios of these antibiotics to lung tissue in a pig model of VA ECMO treated CA. METHODS: Twelve female pigs, body weight 51.5 ± 3.5 kg, were subjected to prolonged CA managed by different modes of VA ECMO. Anesthetized animals underwent 15 min of ventricular fibrillation (VF) followed by continued VF with ECMO flow of 100 mL/kg/min. Immediately after institution of ECMO, a 30 min vancomycin infusion (10 mg/kg) was started and amikacin and gentamicin boluses (7.5 and 3 mg/kg, respectively) were administered. ECMO circuit, aortic, pulmonary arterial, and tracheal aspirate concentrations of antibiotics were measured at 30 and 60 min after administration; penetration ratios were calculated. RESULTS: All 30 min antibiotic concentrations and 60 min concentration for gentamicin in the pulmonary artery were no different than the aorta. However, the 60 min pulmonary artery vancomycin and amikacin values were significantly higher than aortic, 19.8 (14.3-21.6) vs. 17.6 (14.2-19.0) mg/L, p = 0.009, and 15.6 mg/L (11.0-18.6) vs. 11.2 (10.4-17.2) mg/L, p = 0.036, respectively. One hour penetration ratios were 18.5% for vancomycin, 34.9% for gentamicin and 38.8% for amikacin. CONCLUSION: In a pig model of VA ECMO treated prolonged CA, despite diminished pulmonary flow, VA ECMO does not decrease early vancomycin, gentamicin, and amikacin concentrations in pulmonary artery. Within 1 h post administration, antibiotics can be detected in tracheal aspirate in adequate concentrations.