RESUMO
Backgroundï¼This study reports experience of wound care at the site of cannulation in the case of a patient with dilated cardiomyopathy (DCM) weaned from extracorporeal membrane oxygenation (ECMO). PURPOSE: To describe the use of a self-made vacuum-sealing drainage device with constant-temperature flushing to manage wound exudates in the cannulation site, aiming to create an environment conducive to wound healing. MATERIALS AND METHODS: Exudates from the wound were processed using the vacuum-sealing drainage technique combined with constant-temperature flushing. Anti-infective agents were systemically administered to control infection and promote wound healing. Additionally, the patient's nutritional status, pain management, psychological well-being, and rehabilitation were assessed and managed as part of the comprehensive care approach. RESULTS: The wound exhibited gradual healing under this multifaceted care strategy. After 48 days of treatment, the patient demonstrated stable disease conditions and achieved wound closure. The patient was subsequently transferred to a general ward for further care. CONCLUSION: The use of a self-made vacuum-sealing drainage device with constant-temperature flushing, along with comprehensive patient management, proved effective in wound care for a critically ill patient with ECMO cannulation. This approach fosters an optimal environment for wound healing and contributes to patient recovery and stability.
Assuntos
Oxigenação por Membrana Extracorpórea , Cicatrização , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/instrumentação , Cicatrização/fisiologia , Masculino , Tratamento de Ferimentos com Pressão Negativa/métodos , Tratamento de Ferimentos com Pressão Negativa/instrumentação , Tratamento de Ferimentos com Pressão Negativa/normas , Pessoa de Meia-Idade , Drenagem/métodos , Drenagem/instrumentação , Cateterismo/métodos , Cateterismo/instrumentação , Cateterismo/efeitos adversos , Cardiomiopatia Dilatada/terapia , Cardiomiopatia Dilatada/fisiopatologia , Cardiomiopatia Dilatada/complicações , VácuoRESUMO
Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation are critical tools in contemporary cardiac surgery and intensive care, respectively. While these techniques share similar components, their application contexts differ, leading to distinct immune dysfunctions which could explain the higher incidence of nosocomial infections among ECMO patients compared to those undergoing CPB. This review explores the immune modifications induced by these techniques, comparing their similarities and differences, and discussing potential treatments to restore immune function and prevent infections. The immune response to CPB and ECMO involves both humoral and cellular components. The kinin system, complement system, and coagulation cascade are rapidly activated upon blood contact with the circuit surfaces, leading to the release of pro-inflammatory mediators. Ischemia-reperfusion injury and the release of damage-associated molecular patterns further exacerbate the inflammatory response. Cellular responses involve platelets, neutrophils, monocytes, dendritic cells, B and T lymphocytes, and myeloid-derived suppressor cells, all of which undergo phenotypic and functional alterations, contributing to immunoparesis. Strategies to mitigate immune dysfunctions include reducing the inflammatory response during CPB/ECMO and enhancing immune functions. Approaches such as off-pump surgery, corticosteroids, complement inhibitors, leukocyte-depleting filters, and mechanical ventilation during CPB have shown varying degrees of success in clinical trials. Immunonutrition, particularly arginine supplementation, has also been explored with mixed results. These strategies aim to balance the inflammatory response and support immune function, potentially reducing infection rates and improving outcomes. In conclusion, both CPB and ECMO trigger significant immune alterations that increase susceptibility to nosocomial infections. Addressing these immune dysfunctions through targeted interventions is essential to improving patient outcomes in cardiac surgery and critical care settings. Future research should focus on refining these strategies and developing new approaches to better manage the immune response in patients undergoing CPB and ECMO.
Assuntos
Ponte Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodosRESUMO
Blastomycosis can result in lung injury with high mortality rates. The literature on veno-venous extracorporeal membrane oxygenation (VV-ECMO) used as a rescue therapy is limited to case reports and small case series collected over extended time periods. This report describes the clinical course and post-hospitalization outcomes among patients with blastomycosis-induced respiratory failure requiring VV-ECMO in the most recent time frame. The data were collected retrospectively from the health records of eight patients with blastomycosis-induced respiratory failure admitted to a tertiary care center between 2019 and 2023. The mean time from the start of mechanical ventilation to ECMO initiation was 57 h. All patients survived to ECMO decannulation, and seven of them survived to hospital discharge. All six patients whose post-discharge follow-up information was available were weaned from mechanical ventilation and lived at home while two required supplemental oxygen. This includes a case where the provision of adequate ECMO support was challenging due to the patient's morbid obesity. The most common residual imaging abnormalities included pulmonary infiltrates and pneumatoceles. The study demonstrates the feasibility of VV-ECMO as a rescue therapy in patients with blastomycosis-related refractory respiratory failure. Rapid initiation of ECMO support in eligible patients may have contributed to the good outcomes.
Assuntos
Blastomicose , Oxigenação por Membrana Extracorpórea , Insuficiência Respiratória , Humanos , Masculino , Insuficiência Respiratória/terapia , Insuficiência Respiratória/etiologia , Estudos Retrospectivos , Blastomicose/terapia , Blastomicose/complicações , Blastomicose/diagnóstico , Adulto , Feminino , Pessoa de Meia-Idade , Resultado do Tratamento , Respiração Artificial , Fatores de Tempo , Adulto JovemRESUMO
The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly, driven by the COVID-19 pandemic. Despite its widespread adoption, neurological complications pose a significant risk, impacting both mortality and survivors' quality of life. Detecting these complications is challenging due to sedation and the heterogeneous nature of ECMO-associated neurological injury. Still, consensus of neurologic monitoring during ECMO is lacking since utilization and effectiveness of current neuromonitoring methods are limited. Especially in view of the heterogeneous nature of neurological injury during ECMO support an easily acquirable biomarker tracing neuronal damage independently from the underlying pathomechanism would be favorable. In a single-center prospective study on 34 severe acute respiratory distress syndrome (ARDS) patients undergoing ECMO, we explored the potential of serum neurofilament light chain levels (NfL) as a biomarker for neurological complications and its predictive power towards the overall outcome of ECMO patients. Individuals experiencing neurological complications (41%) demonstrated a notable rise in NfL levels (Tbaseline median 92.95 pg/ml; T24h median 132 pg/ml (IQR 88.6-924 pg/ml), p = 0.008; T7d median 248 pg/ml (IQR 157-1090 pg/ml), p = 0.001). Moreover, under ECMO therapy, these patients exhibited markedly elevated concentrations compared to those without neurological complications (T24h median 70.75 pg/ml (IQR 22.2-290 pg/ml), p = 0.023; T7d median 128 pg/ml (IQR 51.8-244 pg/ml), p = 0.002). There was no significant difference in the NfL dynamics between surviving patients and those who died during or shortly after ECMO therapy. While NfL indicates neuro-axonal damage during intensive care with ECMO therapy, we could not identify any correlation between survival outcome and the levels of NfL, indicating that NfL may not serve as a prognostic marker for survival. Nevertheless, additional studies involving a larger patient cohort are required.
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Biomarcadores , COVID-19 , Oxigenação por Membrana Extracorpórea , Proteínas de Neurofilamentos , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Biomarcadores/sangue , Masculino , Feminino , Pessoa de Meia-Idade , Proteínas de Neurofilamentos/sangue , Estudos Prospectivos , COVID-19/sangue , COVID-19/terapia , Adulto , Síndrome do Desconforto Respiratório/sangue , Síndrome do Desconforto Respiratório/terapia , Idoso , SARS-CoV-2RESUMO
BACKGROUND: The study objective was to characterize compliance with Standardized Therapy after ECMO Program (STEP), an intentional discharge pathway for extracorporeal membrane oxygenation (ECMO) survivors in a US pediatric hospital. METHODS: The program identified pediatric ECMO survivors before discharge, appropriate consultations were reviewed and requested, families were educated on ECMO sequelae, and ECMO summaries were sent to pediatricians. Compliance with institutional post-ECMO guidelines was evaluated before and after STEP implementation. RESULTS: We identified 77 ECMO survivors to hospital discharge (36 [46.8%] before and 41 [53.2%] after STEP implementation). There was a significant increase in complete (38.8% vs. 74.2%, p < 0.001) and time-appropriate neurodevelopmental testing (71.4% vs. 95.6%, p = 0.03). Significant increase in inpatient evaluations by neurology (52.7% vs. 75.6%, p = 0.03) and audiology (66.7% vs. 87.8%, p = 0.02), and in referrals for outpatient audiology (66.6 vs. 95.1%, p = 0.002), physical therapy (P.T.) (63.8% vs. 95.1%, p = 0.001), occupational therapy (O.T.) (63.8% vs. 95.1%, p = 0.001) and speech-language pathology (S.L.P.) (55.5% vs. 95.1%, p < 0.001) were noted. CONCLUSION: Implementing an intentional discharge pathway for pediatric ECMO survivors (STEP) successfully increases inpatient and outpatient compliance with hospital and Extracorporeal life support organization (ELSO) follow-up guidelines. It leads to timely and complete neurodevelopmental evaluation.
Assuntos
Oxigenação por Membrana Extracorpórea , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Masculino , Lactente , Criança , Pré-Escolar , Fidelidade a Diretrizes/estatística & dados numéricos , Recém-Nascido , Alta do Paciente/estatística & dados numéricos , Adolescente , Sobreviventes/estatística & dados numéricosRESUMO
BACKGROUND: Patients supported with extracorporeal life support (ECLS) circuits such as ECMO and CRRT often require high doses of sedatives and analgesics, including ketamine and dexmedetomidine. Concentrations of many medications are affected by ECLS circuits through adsorption to the circuit components, dialysis, as well as the large volume of blood used to prime the circuits. However, the impact of ECLS circuits on ketamine and dexmedetomidine pharmacokinetics has not been well described. This study determined ketamine and dexmedetomidine extraction by extracorporeal circuits in an ex-vivo system. METHODS: Medication was administered at therapeutic concentration to blood-primed, closed-loop ex-vivo ECMO and CRRT circuits. Drug concentrations were measured in plasma, hemofiltrate, and control samples at multiple time points throughout the experiments. At each sample time point, the percentage of drug recovery was calculated. RESULTS: Ketamine plasma concentration in the ECMO and CRRT circuits decreased rapidly, with 43.8% recovery (SD = 0.6%) from ECMO circuits after 8 h and 3.3% (SD = 1.8%) recovery from CRRT circuits after 6 h. Dexmedetomidine was also cleared from CRRT circuits, with 20.3% recovery (SD = 1.8%) after 6 h. Concentrations of both medications were very stable in the control experiments, with approximately 100% drug recovery of both ketamine and dexmedetomidine after 6 h. CONCLUSION: Ketamine and dexmedetomidine concentrations are significantly affected by ECLS circuits, indicating that dosing adjustments are needed for patients supported with ECMO and CRRT.
Assuntos
Dexmedetomidina , Oxigenação por Membrana Extracorpórea , Ketamina , Ketamina/administração & dosagem , Ketamina/farmacocinética , Ketamina/sangue , Dexmedetomidina/administração & dosagem , Dexmedetomidina/farmacocinética , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Hipnóticos e Sedativos/farmacocinética , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/sangueRESUMO
BACKGROUND: This retrospective observational study aimed to examine whether clinical inflammatory parameters were associated with the requirement dosage of unfractionated heparin (UFH) to maintain the range of ACT in veno-arterial extracorporeal membrane oxygenation (V-A ECMO) during lung transplantation surgery. METHODS: Among all patients who underwent lung transplantation using V-A ECMO from January 2021 to May 2022, 27 patients were included. These patients were divided into two groups based on whether the infusion rate of UFH was increased from the initial infusion rate (7-8 units/kg/h) (increased group, n = 10) or the infusion rate was maintained or decreased (non-increased group, n = 17). The infusion rate was adjusted with an activated clotting time (ACT) target of 160-200 s. RESULTS: At 1-2 h after starting ECMO, ACT was significantly lower (179.0 (166.5-188.5) versus 224.0 (193.0-242.0) sec, p = 0.006) and white blood cell (WBC) counts were higher in the increased group (12.6 ± 3.3 versus 9.5 ± 4.0 × 103/µL, p = 0.046). The UFH infusion rates were higher in the increased group during the surgery. The cutoff value of WBC count at 1-2 h after starting ECMO for discriminating the need for increasing the UFH dosage was determined as 10.2 × 103/µL (sensitivity 90.0%, specificity 58.8%, area under the curve 0.712) and discrimination of this cut-off value was confirmed as statistically significant (p = 0.018). CONCLUSION: These data suggested that WBC count was associated with the requirement of an increase in the UFH infusion rate of V-A ECMO during lung transplantation surgery. Further evaluation is necessary to clarify the role of WBC count in determining the optimal UFH dosage.
Assuntos
Oxigenação por Membrana Extracorpórea , Heparina , Transplante de Pulmão , Humanos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Heparina/administração & dosagem , Heparina/uso terapêutico , Feminino , Estudos Retrospectivos , Masculino , Pessoa de Meia-Idade , Adulto , Contagem de Leucócitos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêuticoRESUMO
BACKGROUND: In the state of Kentucky, many status asthmaticus (SA) patients require care in the Pediatric Intensive Care Unit (PICU) and a fraction of these patients may receive "rescue therapies" with inhaled volatile anesthetics (IVA) and/or Extracorporeal Membrane Oxygenation (ECMO). We present a series of such patients with the objective of comparing the clinical parameters of individual patients who received inhaled volatile anesthesia and subsequently the need for ECMO. METHODS: Children between 2 and 18 years of age admitted to our PICU from January 2014 to July 2020 with SA were reviewed and categorized as 1) patients who received IVA alone, 2) patients who received IVA and then subsequently ECMO, and 3) patients on ECMO alone. RESULTS: A total of 1772 children with SA episodes were identified with a mortality of 13 patients. Seven children with SA were identified who received either IVA, ECMO, or both. One patient received only IVA, 5 received both IVA and ECMO and one received only ECMO. All received standard asthma therapies of steroids, albuterol, magnesium sulphate, and aminophylline prior to escalation. Six out of seven refractory SA received IVA, and five (83%) of those were subsequently escalated to ECMO. There was an improvement in mean pH after cannulation compared to IVA. pCO2 levels had no improvement after IVA administration but decreased by an average of 20 points after ECMO. Patients peak inspiratory pressures decreased within the 1st 24 h of ECMO cannulation from a mean of 30 to 18. There were no other complications related to ECMO placement. CONCLUSION: While we cannot decisively draw any conclusions from our study due to the small sample, it was noted that there was no clear advantage of using IVA prior to ECMO in our patients. Most patients who received IVA were escalated to ECMO indicating that early ECMO cannulation may be beneficial. Given the high cost and potential complications of both, there is a need for the development of well-defined guidelines for severe SA management in the PICU.
Assuntos
Anestésicos Inalatórios , Oxigenação por Membrana Extracorpórea , Estado Asmático , Humanos , Estado Asmático/terapia , Estado Asmático/tratamento farmacológico , Criança , Pré-Escolar , Feminino , Masculino , Adolescente , Resultado do Tratamento , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/uso terapêutico , Estudos RetrospectivosRESUMO
A case of peripheral venoarterial extracorporeal membrane oxygenation decannulation using the Teleflex Manta vascular closure device is presented.
Assuntos
Oxigenação por Membrana Extracorpórea , Dispositivos de Oclusão Vascular , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/instrumentação , Remoção de Dispositivo/métodos , Veia Femoral/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao LeitoRESUMO
Medication poisoning, resulting from the ingestion of cardiotoxic drugs, presents a significant health issue. The mortality rate remains high for patients with myocardial dysfunction refractory to conventional treatments. Venoarterial Extracorporeal Membrane Oxygenation (V-A ECMO) provides temporary support, potentially enhancing patient outcomes. This study aims to assess the efficacy of V-A ECMO in treating cardiovascular failure induced by cardiovascular medication poisoning. We utilized inpatient data from all hospitalisations in Germany from 2007 to 2022 due to cardiovascular medication poisoning treated with V-A ECMO. Patient characteristics, comorbidities, complications and application of ECMO were described descriptively and analysed for statistical significance between survivors and non-survivors. Overall, 49 patients received V-A ECMO for cardiovascular medication poisoning, with a survival rate of 63.6%. The most ingested medications were calcium-channel blockers (38.8%) and beta-adrenoceptor antagonists (34.7%). Half of non-survivors received in-hospital CPR, compared to 12.9% of survivors. Early ECMO implantation (within 24 h of admission) was common (83.7%) but did not significantly impact survival rates. A substantial number of patients presented with multiple substances ingested. V-A ECMO represents a viable option for patients experiencing cardiac failure due to medication poisoning. A structured implementation of V-A ECMO for cardiovascular medication poisoning could lead to higher survival rates.
Assuntos
Oxigenação por Membrana Extracorpórea , Humanos , Masculino , Feminino , Alemanha/epidemiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto , Idoso , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/mortalidade , Bloqueadores dos Canais de Cálcio/intoxicação , Bloqueadores dos Canais de Cálcio/uso terapêutico , Fármacos Cardiovasculares/uso terapêutico , Taxa de Sobrevida , Antagonistas Adrenérgicos beta/intoxicação , Antagonistas Adrenérgicos beta/uso terapêuticoRESUMO
This study investigates the prevalence and risk factors associated with venous thrombotic events in patients receiving (ECMO) support. Systematic review and meta-analysis of case-control and cohort studies. PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, and ProQuest databases from inception through November 25, 2023.Case-control and cohort studies focusing on the prevalence and risk factors for venous thrombotic events in patients supported by ECMO. Identification of risk factors and calculation of incidence rates. Nineteen studies encompassing 10,767 participants were identified and included in the analysis. The pooled prevalence of venous thrombotic events among patients receiving ECMO support was 48% [95% confidence interval (CI) 0.37-0.60, I2 = 97.18%]. Factors associated with increased incidence rates included longer duration of ECMO support (odds ratio [OR] 1.08, 95% CI 1.07-1.09, I2 = 49%), abnormal anti-coagulation monitoring indicators (OR 1.02, 95% CI 1.00-1.04, I2 = 84%), and type of ECMO cannulation (OR 1.77, 95% CI 1.14-3.34, I2 = 64%). The pooled prevalence of venous thrombotic events in patients with ECMO support is high. Increased risk is associated with extended duration of ECMO support, abnormal anti-coagulation monitoring, and specific types of ECMO cannulation.
Assuntos
Oxigenação por Membrana Extracorpórea , Trombose Venosa , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Trombose Venosa/etiologia , Trombose Venosa/epidemiologia , Fatores de Risco , PrevalênciaRESUMO
BACKGROUND: Bacterial pneumonia is one of the most common causes of acute respiratory distress syndrome. In fulminant cases, when mechanical ventilation fails, veno-venous extracorporeal membrane oxygenation is required. However, this method is still associated with significant mortality and a wide range of potential complications. However, there are now many case reports of good outcomes even in patients with prolonged extracorporeal oxygenation, as in our rather complicated case report. CASE PRESENTATION: Our case report describes a complicated but successful treatment of a severe, devastating bacterial pneumonia in a 39-year-old European polymorbid woman with a rare form of diabetes mellitus, which had been poorly compensated for a long time with limited compliance, in the context of a combined immunodeficiency that strongly influenced the course of the disease. The patient's hospitalization required a total of 30 days of veno-venous extracorporeal membrane oxygenation therapy and more than 50 days of mechanical ventilation. Numerous complications, particularly bleeding, required seven chest drains, two extracorporeal membrane oxygenation circuit changes, and one surgical revision. The patient's mental state required repeated psychiatric intervention. CONCLUSION: It is possible that even the initially severely damaged lung parenchyma can develop its regenerative potential if suitable conditions are provided for this process, including a sufficiently long period of extracorporeal membrane oxygenation. We believe that this case report may also contribute to the consideration of the indications and contraindications of extracorporeal support. The authors also discuss the limitations and risks of prolonged veno-venous extracorporeal membrane oxygenation support and periprocedural anticoagulation strategies.
Assuntos
Oxigenação por Membrana Extracorpórea , Pneumonia Bacteriana , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Adulto , Pneumonia Bacteriana/terapia , Pneumonia Bacteriana/complicações , Respiração Artificial , Síndrome do Desconforto Respiratório/terapia , Resultado do Tratamento , Antibacterianos/uso terapêuticoRESUMO
AIMS: In a recent meta-analysis of randomized controlled trials, routine use of veno-arterial ECMO (VA-ECMO) did not improve outcomes in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS), while a microaxial flow pump reduced mortality in a selected group of patients with AMI-CS in the DanGer-Shock trial. METHODS AND RESULTS: Individual patient data of patients included in four randomized clinical trials investigating the routine use of VA-ECMO in AMI-CS were centrally analysed. For the purpose of this sub-analysis, DanGer-Shock-like patients were analysed (STEMI only, presumed low likelihood of brain injury). The primary endpoint was 180-day all-cause mortality. A total of 202 patients (106 randomized to VA-ECMO and 96 to control) were included. There were no differences in baseline characteristics, angiographic and interventional features between the two groups. Mortality after 6 months was numerically lower with VA-ECMO between the groups [45% in VA-ECMO group vs. 51% in control group; hazard ratio, 0.84; 95% confidence interval (CI), 0.56-1.26], while major bleeding (OR, 2.24; 95% CI, 1.08-4.64) and peripheral vascular complications (OR, 3.65; 95% CI, 1.15-11.56) were increased with the use of VA-ECMO. CONCLUSION: In this exploratory subgroup analysis in patients with CS, STEMI, and a low likelihood of brain injury, there was no mortality benefit with the routine use of VA-ECMO. However, as indicated by the large confidence intervals, the statistical power was limited to draw definite conclusions.
Assuntos
Oxigenação por Membrana Extracorpórea , Infarto do Miocárdio , Choque Cardiogênico , Humanos , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/etiologia , Oxigenação por Membrana Extracorpórea/métodos , Masculino , Feminino , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Infarto do Miocárdio/mortalidade , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , IdosoRESUMO
OBJECTIVES: Historically, the perfusion-guided sequence suggests to first transplant the side with lowest lung perfusion. This sequence is thought to limit right ventricular afterload and prevent acute heart failure after first pneumonectomy. As a paradigm shift, we adopted the right-first implantation sequence, irrespective of lung perfusion. The right donor lung generally accommodates a larger proportion of the cardiac output. We hypothesized that the right-first sequence reduces the likelihood of oedema formation in the firstly transplanted graft during second-lung implantation. Our objective was to compare the perfusion-guided and right-first sequence for intraoperative extracorporeal membrane oxygenation (ECMO) need and primary graft dysfunction (PGD). METHODS: A retrospective single-centre cohort study (2008-2021) including double-lung transplant cases (N = 696) started without ECMO was performed. Primary end-points were intraoperative ECMO cannulation and PGD grade 3 (PGD3) at 72 h. Secondary end-points were patient and chronic lung allograft dysfunction-free survival. In cases with native left lung perfusion ≤50% propensity score adjusted comparison of the perfusion-guided and right-first sequence was performed. RESULTS: When left lung perfusion was ≤50%, right-first implantation was done in 219 and left-first in 189 cases. Intraoperative escalation to ECMO support was observed in 10.96% of right-first versus 19.05% of left-first cases (odds ratio 0.448; 95% confidence interval 0.229-0.0.878; P = 0.0193). PGD3 at 72 h was observed in 8.02% of right-first versus 15.64% of left-first cases (0.566; 0.263-1.217; P = 0.1452). Right-first implantation did not affect patient or chronic lung allograft dysfunction-free survival. CONCLUSIONS: The right-first implantation sequence in off-pump double-lung transplantation reduces need for intraoperative ECMO cannulation with a trend towards less PGD grade 3.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Humanos , Transplante de Pulmão/métodos , Transplante de Pulmão/efeitos adversos , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Oxigenação por Membrana Extracorpórea/métodos , Adulto , Disfunção Primária do Enxerto/prevenção & controle , Disfunção Primária do Enxerto/etiologia , Pulmão/cirurgiaRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has expanded considerably, though evidence-based selection criteria and long-term outcome data are lacking. The purpose of this study was to evaluate whether risk factors often used to exclude patients from ECMO BTT-specifically older age and not yet being listed for transplant-are validated by long-term outcomes. METHODS: To ensure minimum 5-year follow-up, a retrospective cohort study was performed of adult patients actively listed for lung transplantation at a high-volume center and bridged on ECMO between January 2012 and December 2017. Data was collected through January 1, 2023. RESULTS: Among 50 patients bridged on ECMO, 25 survived to transplant. Median age at listing was 58 (interquartile range [IQR], 42-65) in the transplanted group and 65 (IQR, 56.5-69) in the deceased group (P = 0.051). One-year, 3-year, and 5-year survival were 88% (22/25), 60% (15/25), and 44% (11/25), respectively, with eight patients still living at the time of review. Median time spent at home during the year post-transplant was 340 days (IQR, 314-355). Older age at listing was a negative predictor of survival on ECMO to transplant (odds ratio 0.92 [95% confidence interval, 0.86-0.99], P = 0.01). Thirteen patients were placed on ECMO prior to being listed and three were listed the same day as ECMO cannulation, with 10/16 transplanted. No significant difference in post-transplant survival was found between patients placed on ECMO prior to listing (n = 10) and those already listed (n = 15) (P = 0.93, log-rank). Serial post-transplant spirometry up to 5 years and surveillance transbronchial biopsy demonstrated good allograft function and low rates of cellular rejection. CONCLUSIONS: In one of the oldest cohorts of ECMO BTT patients described, favorable survival outcomes and allograft function were observed up to 5 years irrespective of whether patients were previously listed or bridged to decision. Despite inherent limitations to this retrospective, single-center study, the data presented support the feasibility of ECMO BTT in older and not previously listed advanced lung disease patients.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/tendências , Oxigenação por Membrana Extracorpórea/mortalidade , Transplante de Pulmão/tendências , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Adulto , Idoso , Resultado do Tratamento , Estudos de Coortes , Fatores de Tempo , Seguimentos , Fatores Etários , Fatores de Risco , Listas de Espera/mortalidade , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND AND OBJECTIVE: Because of the pathophysiological changes associated with critical illness and the use of extracorporeal life support (ECLS) such as continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO), the pharmacokinetics of drugs are often altered. The objective of this study was to develop a physiologically based pharmacokinetic (PBPK) model for anakinra in children that accounts for the physiological changes associated with critical illness and ECLS technology to guide appropriate pharmacotherapy. METHODS: A PBPK model for anakinra was first developed in healthy individuals prior to extrapolating to critically ill children receiving ECLS. To account for the impact of anakinra clearance by the dialysis circuit, a CRRT compartment was added to the pediatric PBPK model and parameterized using data from a previously published ex-vivo study. Additionally, an ECMO compartment was added to the whole-body structure to create the final anakinra ECLS-PBPK model. The final model structure was validated by comparing predicted concentrations with observed patient data. Due to limited information in guiding anakinra dosing in this population, in-silico dose simulations were conducted to provide baseline recommendations. RESULTS: By accounting for changes in physiology and the addition of ECLS compartments, the final ECLS-PBPK model predicted the observed plasma concentrations in an adolescent receiving subcutaneous anakinra. Furthermore, dosing simulations suggest that anakinra exposure in adolescents receiving ECLS is similar to that in healthy counterparts. CONCLUSION: The anakinra ECLS-PBPK model developed in this study is the first to predict plasma concentrations in a population receiving simultaneous CRRT and ECMO. Dosing simulations provided may be used to inform anakinra use in critically ill children and guide future clinical trial planning.
Assuntos
Estado Terminal , Oxigenação por Membrana Extracorpórea , Proteína Antagonista do Receptor de Interleucina 1 , Modelos Biológicos , Humanos , Proteína Antagonista do Receptor de Interleucina 1/farmacocinética , Proteína Antagonista do Receptor de Interleucina 1/administração & dosagem , Estado Terminal/terapia , Oxigenação por Membrana Extracorpórea/métodos , Criança , Pré-Escolar , Adolescente , Masculino , Feminino , Lactente , Terapia de Substituição Renal Contínua/métodos , Simulação por ComputadorRESUMO
Myocarditis is a potentially life-threatening inflammatory disease of the myocardium, often resulting from infectious and immune-mediated responses. Clinical presentation in severe cases often results in a devastating illness requiring extracorporeal membrane oxygenation support as a result of cardiogenic shock. Although endomyocardial biopsy is still considered the gold standard for diagnosis, it often reveals nonspecific lymphocytic infiltration. Because the precise cause is usually unknown, the initial treatment typically involves immunosuppression and frequent assessment of myocardial contractility. This report presents 3 rare cases of autoimmune diseases (polymyositis, immunoglobulin G4-related disease, and systemic lupus erythematosus) that require extracorporeal membrane oxygenation support as a result of fulminant myocarditis, including their follow-up periods.
Assuntos
Oxigenação por Membrana Extracorpórea , Miocardite , Humanos , Miocardite/terapia , Miocardite/diagnóstico , Miocardite/fisiopatologia , Miocardite/imunologia , Oxigenação por Membrana Extracorpórea/métodos , Masculino , Feminino , Adulto , Biópsia , Pessoa de Meia-Idade , Doenças Autoimunes/diagnóstico , Doenças Autoimunes/terapia , Doenças Autoimunes/imunologia , Doenças Autoimunes/complicações , Miocárdio/patologia , Miocárdio/imunologia , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/terapia , Choque Cardiogênico/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/diagnóstico , Resultado do Tratamento , Doença Relacionada a Imunoglobulina G4/diagnóstico , Doença Relacionada a Imunoglobulina G4/terapia , Doença Relacionada a Imunoglobulina G4/complicaçõesRESUMO
Extracorporeal membrane oxygenation (ECMO), as an extracorporeal life support technique, can save the lives of reversible critically ill patients when conventional treatments fail. However, ECMO-related acute organ injury is a common complication that increases the risk of death in critically ill patients, including acute kidney injury, acute brain injury, acute lung injury, and so on. In ECMO supported patients, an increasing number of studies have shown that activation of the inflammatory response plays an important role in the development of acute organ injury. Cross-cascade activation of the complement system, the contact system, and the coagulation system, as well as the mechanical forces of the circuitry are very important pathophysiological mechanisms, likely leading to neutrophil activation and the production of neutrophil extracellular traps (NETs). NETs may have the potential to cause organ damage, generating interest in their study as potential therapeutic targets for ECMO-related acute organ injury. Therefore, this article comprehensively summarized the mechanism of neutrophils activation and NETs formation following ECMO treatment and their actions on acute organ injury.
Assuntos
Armadilhas Extracelulares , Oxigenação por Membrana Extracorpórea , Ativação de Neutrófilo , Neutrófilos , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Neutrófilos/imunologia , Neutrófilos/metabolismo , Armadilhas Extracelulares/imunologia , Armadilhas Extracelulares/metabolismo , Animais , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/imunologia , Insuficiência de Múltiplos Órgãos/terapia , Estado TerminalRESUMO
Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced technique using extracorporeal membrane oxygenation (ECMO) to support patients with refractory cardiac arrest. Age significantly influences ECPR outcomes, with younger patients generally experiencing better survival and neurological outcomes due to many aspects. This review explores the impact of age on ECPR effectiveness, emphasizing the need to consider age alongside other clinical factors in patient selection. Survival rates differ notably between in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA), highlighting the importance of rapid intervention. The potential of artificial intelligence to develop predictive models for ECPR outcomes is discussed, aiming to improve decision-making. Ethical considerations around age-based treatment decisions are also addressed. This review advocates for a balanced approach to ECPR, integrating clinical and ethical perspectives to optimize patient outcomes across all age groups.