Search Results (401)

Background/Objectives: Multiple independent variables were analyzed to determine total nutritional intake (caloric and protein), while reviewing vasoactive inotrope scores (VISs). Methods: Retrospective data were collected for nutritional intake (N = 64), daily VISs, extracorporeal membrane oxygenation (ECMO) complications, delays in nutritional intake (>48 h), reason for delay, and interruptions in nutrition support. Results: VISs and ECMO characteristics analyzed by box–whisker plots demonstrated that ECMO complications prior to 24 h, cardiac arrest 24 h prior to ECMO, pediatric ECMO patients, venoarterial ECMO type, having a cardiac ECMO indication, and ECMO centrifugal pump had higher VISs. A regression analysis revealed that venovenous ECMO patients and the centrifugal pump type had higher caloric and protein intake; subsequently, for each increase in VIS, caloric intake decreased by −0.54. Sixteen patients did not receive nutritional support while on ECMO (9/16; 56% cardiac); 12/48 (25%) had a delay, with the cardiac patients nearing statistical significance. Conclusion: Venovenous ECMO (non-cardiac) correlated with higher nutritional intake. The enteral administration of nutrition had a lower VIS on average compared to the other three groupings, namely enteral vs. parenteral; enteral vs. both enteral and parenteral; enteral vs. no nutrition. This study provides additional clinical insight on nutritional intake in ECMO patients. Full article

ECMO is becoming widely used as a life-saving measure for critically ill patients. However, there is limited data on pharmacokinetics and the dosing of beta-lactam antibiotics in ECMO. In this study, we evaluated the serum concentrations of cefepime in patients on ECMO to determine the impact of ECMO circuitry and to guide therapeutic dosing. Methods: Patients 19 years or older admitted to the ICU, treated with ECMO and beta-lactam antibiotics for presumed or documented infection, were enrolled. Three blood samples (peak, midpoint, trough) were obtained before ECMO (pre-ECMO) and during ECMO (intra-ECMO) at a steady state. Results: Eight patients met inclusion criteria; six received cefepime. All patients were male. Average ± SD age was 45.8 ± 14.7. Four patients received ECMO for severe SARS-CoV-2 infection, and one each for Pneumocystis pneumonia and influenza A infection. Mean ± SD APACHE II and SOFA scores prior to ECMO were 24.6 ± 7.1 and 11.0 ± 3.9, respectively. All but one of the patients received venovenous (VV) ECMO. Cefepime 1 g every 6 h intravenously over 2 min was administered to all patients before and during ECMO. Cefepime concentrations were fit to non-compartment analysis (NCA) and area under the serum concentration–time curve averaged ± SE 211.9 ± 29.6 pre-ECMO and 329.6 ± 32.3 mg*h/L intra-ECMO, p = 0.023. No patients displayed signs of cefepime neurotoxicity. Patients received ECMO for 43.1± 30 days. All patients expired. Cefepime dosed at 1 g every 6 h intravenously appears to achieve therapeutic levels for critically ill patients on ECMO. Full article

Post decompression syndrome (PDS) is a rare and life-threatening complication of pericardiocentesis, especially after rapid drainage of large amounts of pericardial fluid. We present the case of a 21-year-old man who presented with cardiac tamponade of unknown etiology. After preoperative optimization, surgical drainage of the pericardial effusion was performed and approximately 2500 mL of fluid was released over 30 min. The patient rapidly developed hemodynamic collapse with severe biventricular dysfunction, with a left ventricle ejection fraction of 15%. Vasopressor and inotropic support were initiated with Noradrenaline and Dobutamine, further escalated to Adrenaline and Levosimendan with no improvement in clinical and hemodynamic parameters. Considering the high doses of vasoactive drugs, rescue veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was started within the first 24 h. After 10 days on V-A ECMO, the cardiac function slowly recovered, and the extracorporeal mechanical support was successfully weaned. The diagnosis of paraneoplastic PDS secondary to angiosarcoma was made and the patient was successfully discharged to the ward on the 24th day. In conclusion, far from being the last option in the management of PDS, V-A ECMO deserves early consideration for securing adequate myocardial and systemic perfusion, while the cardiac function recovers, but a risk-to-benefit assessment should be made by an experienced multidisciplinary team. Full article

Introduction: Angiopoietin II (Ang-II) plays a pivotal role in the development of microcirculatory dysfunction as it provokes endothelial barrier disruption in patients with sepsis or septic shock. In particular, those with acute kidney injury show high Ang-II concentrations. So far, it is unclear which covariates influence Ang-II concentration in the early phase of sepsis, especially if extracorporeal therapies also do. Methods: Ang-II concentrations were measured in 171 patients with sepsis after the first day of antibiotic treatment between 03/2013 and 01/2015. Ang-II was correlated with potential influencing factors (Spearman correlation). A multivariate model was established including the significant correlating parameters. The Mann–Whitney U test and the Kruskal–Wallis test were used to detect significant differences in Ang-II concentration. Results: The median Ang-II concentration was 8015 pg/mL (interquartile range (IQR): 5024–14,185). A total of forty patients were treated with kidney replacement therapy (KRT) and 20 were supported by venovenous extracorporeal membrane oxygenation (vv-ECMO). Sequential organ failure assessment (SOFA) score (r = 0.541), creatinine clearance (r = −0.467), urinary output (r = −0.289), interleukin (IL)-6 (r = 0.529), C-reactive protein (CRP) (r = 0.241), platelet count (r = −0.419), bilirubin (r = 0.565), lactate (r = 0.322), KRT (r = 0.451), and fluid balance (r = 0.373) significantly correlated with Ang-II concentration and were included in the multivariate model. There, creatinine clearance (p < 0.01, b = −26.3, 95% confidence interval (CI) −41.8–−10.8), fluid balance (p = 0.002, b = 0.92, 95% CI 0.33–1.51), and CRP (p = 0.004, b = 127.6, 95% CI 41.6–213.7) were associated with Ang-II concentration. Furthermore, patients with KRT (median: 15,219 pg/mL, IQR: 10,548–20,270) had significantly (p < 0.01) higher Ang-II concentrations than those with vv-ECMO support (median: 6412 pg/mL, IQR: 5246–10,257) or those without extracorporeal therapy (median: 7156 pg/mL, IQR: 4409–12,741). Conclusion: Increased CRP, positive fluid balance, and impaired kidney function were associated with higher Ang-II concentrations in critically ill patients in the early stage of sepsis in this post hoc analysis. In particular, patients with KRT had very high Ang-II concentrations, whereas the use of vv-ECMO was not related to higher Ang-II concentrations. The significance for clinical practice should be clarified by a prospective study with standardized measurements. Full article

Background: Gastrointestinal dysfunction is a common complication of medical nutrition therapy in critically ill patients. Whether prone positioning leads to a deterioration in gastrointestinal function has not been fully clarified. Thus, we aimed to analyze the influence of prone positioning on the tolerance of medical nutrition therapy. Methods: We conducted a retrospective analysis of 102 SARS-CoV-2 infected patients with venovenous extracorporeal membrane oxygenation support (VV ECMO). Gastric residual volume (GRV) was used to assess the tolerance of enteral nutrition. Results: Nutritional data were collected for 2344 days. Undernutrition was observed in 40.8%, with a significantly higher incidence on days in prone position (48.4% versus 38.6%, p < 0.001). On days in supine position, significantly more calories were administered enterally than on days in prone position (p < 0.001). The mean GRV/24 h was 111.1 mL on days in supine position and 187.3 mL on days in prone position (p < 0.001). Prone positioning was associated with higher rates of GRV of ≥500 mL/24 h independent of age, disease severity at ECMO start, ECMO runtime and ICU length of stay (adjusted hazard ratio: 4.06; 95%CI: 3.0–5.5; p < 0.001). Conclusions: Prone position was associated with lower tolerance of enteral nutrition, as indicated by an increased GRV. As a result, reduced enteral nutritional support was administered. Full article

Blood clot formation inside the membrane oxygenator (MO) remains a risk in extracorporeal membrane oxygenation (ECMO). It is associated with thromboembolic complications and normally detectable only at an advanced stage. Established clinical monitoring techniques lack predictive capabilities, emphasizing the need for refinement in MO monitoring towards an early warning system. In this study, an MO was modified by integrating four sensor fibers in the middle of the hollow fiber mat bundle, allowing for bioimpedance measurement within the MO. The modified MO was perfused with human blood in an in vitro test circuit until fulminant clot formation. The optical analysis of clot residues on the extracted hollow fibers showed a clot deposition area of 51.88% ± 14.25%. This was detectable via an increased bioimpedance signal with a significant increase 5 min in advance to fulminant clot formation inside the MO, which was monitored by the clinical gold standard (pressure difference across the MO (dp-MO)). This study demonstrates the feasibility of detecting clot growth early and effectively by measuring bioimpedance within an MO using integrated sensor fibers. Thus, bioimpedance may even outperform the clinical gold standard of dp-MO as a monitoring method by providing earlier clot detection. Full article

Purpose of review: Congenital diaphragmatic hernia (CDH) remains a significant challenge, particularly in severe cases with persistent pulmonary hypertension (PPHN) and hypoplastic lungs and heart. For patients unresponsive to conventional therapies, ECMO is required. While the surgical repair is relatively simple, determining the optimal timing for surgery in patients requiring ECMO is particularly challenging. This review explores the dilemma of surgical timing and proposes a two-staged approach: a reduction in herniated organs and the creation of a silo to relieve abdominal pressure before initiating ECMO, with defect closure following ECMO decannulation. Recent Findings: Studies support pre-, on-, and post-ECMO repair, each with its own risks and benefits. Pre-ECMO repair may enhance ECMO efficacy by relieving organ compression but poses risks due to instability. Post-ECMO repair is safer but may result in losing the chance to repair. On-ECMO repair has significant hemorrhage risks, but early repair with careful anticoagulation management is currently recommended. Recently, the author reported a successful case using a two-staged approach—reducing herniated organs and creating a silo before ECMO, followed by defect closure after ECMO decannulation—which suggests a potential alternative strategy for managing severe CDH. Summary: A two-staged approach may offer a solution for severe CDH patients requiring ECMO. Full article

Extracorporeal membrane oxygenation (ECMO) provides critical support for patients with severe cardiopulmonary dysfunction. Unfractionated heparin (UFH) is used for anticoagulation to maintain circuit patency and avoid thrombotic complications, but it increases the risk of bleeding. Extracellular vesicles (EVs), nano-sized subcellular spheres with potential pro-coagulant properties, are released during cellular stress and may serve as potential targets for monitoring anticoagulation, particularly in thromboinflammation. We investigated the impact of UFH dose during ECMO therapy at the coagulation–inflammation interface level, focusing on complement activation and changes in circulating large EV (lEV) subsets. In a post hoc analysis of a multicenter randomized controlled trial comparing two anticoagulation management algorithms, we examined lEV levels and complement activation in 23 veno-venous-ECMO patients stratified by UFH dose. Blood samples were collected at different time points and grouped into three phases of ECMO therapy: initiation (day 1), mid (days 3–4), and late (days 6–7). Immunoassays detected complement activation, and flow cytometry analyzed lEV populations with an emphasis on mitochondria-carrying subsets. Patients receiving <15 IU/kg/h UFH exhibited higher levels of the complement activation product C5a and soluble terminal complement complex (sC5b-9). Lower UFH doses were linked to increased endothelial-derived lEVs, while higher doses were associated with elevated RBC-derived and mitochondria-positive lEVs. Our findings suggest the potential theranostic relevance of EV detection at the coagulation–inflammation interface. Further research is needed to standardize EV detection methods and validate these findings in larger ECMO patient cohorts. Full article

Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO. Full article

Background: This study examines the results of autopsy examinations specifically aimed at documenting complications arising from the implantation phase and treatment with veno–arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with refractory cardiac arrest. ECMO and VA-ECMO in particular are life-saving interventions that, in the case of cardiac arrest, can temporarily replace cardiac pump function. VA-ECMO is, however, a very invasive procedure and is associated with early mechanical, haemorrhagic, and thrombotic events, infections, and late multi-organ dysfunction. Aim: This research aims to evaluate autoptic and histologic findings in patients on VA-ECMO support, providing clinical and forensic evaluation elements with respect to the procedure and clinical settings. Materials and Methods: The study analysed 10 cases, considering variables such as the duration of cardiac arrest, understood as the time between the cardiac arrest event and reperfusion with VA-ECMO, the duration of VA-ECMO support, and any complications detected by clinicians during treatment. Results: The results highlighted the presence of numerous ischemic and haemorrhagic events affecting various organs. Among them, the intestines were particularly vulnerable, even after a short ECMO duration. Conclusions: ECMO was found to accelerate post-mortem decomposition, affecting post-mortem interval estimations, and cardiac damage from reperfusion, underlining the need to meticulously select indications for treatment with VA-ECMO and perform constant clinical evaluations during the treatment itself. Full article

Background: The World Health Organization recommends extracorporeal membrane oxygenation (ECMO) as a therapeutic option for the most critical cases of severe coronavirus disease 2019 (COVID-19). However, data on universally agreed-upon risk factors that contribute to ECMO weaning failure and mortality in COVID-19 patients undergoing ECMO are limited. This lack of consensus leads to significant uncertainties in developing effective management strategies for these patients. We aimed to identify the factors associated with early outcomes after ECMO support in patients with COVID-19-induced acute respiratory distress syndrome, specifically the success rate of ECMO weaning and in-hospital mortality. Methods: We reviewed 25 patients with COVID-19 who received ECMO support at a single institution between January 2020 and July 2022. This retrospective data collection and review included clinical characteristics, adjunctive treatments, complications, and early patient outcomes. Results: A total of 72% of the patients were successfully weaned off ECMO, and 68% were discharged alive. Significant associations were observed between ECMO weaning success and in-hospital survival, particularly younger age and a history of rehabilitation therapy. Furthermore, the absence of a history of immunosuppressive therapy contributed significantly to successful ECMO weaning. Conclusions: Younger age and the implementation of rehabilitation therapy are associated with improved outcomes in patients with COVID-19 receiving ECMO support. Full article

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with circulatory and/or pulmonary failure; however, the rate of complications remains high. ECMO induces systemic inflammation, which may activate and damage the endothelium, thereby causing edema and organ dysfunction. Advancing our understanding in this area is crucial for improving patient outcomes during ECMO. The goal of this review is to summarize the current evidence of the effects of ECMO on endothelial activation and damage in both animals and patients. PubMed and Embase databases were systematically searched for both clinical and animal studies including ECMO support. The outcome parameters were markers of endothelial activation and damage or (in)direct measurements of endothelial permeability, fluid leakage and edema. In total, 26 studies (patient n = 16, animal n = 10) fulfilled all eligibility criteria, and used VA-ECMO (n = 13) or VV-ECMO (n = 6), or remained undefined (n = 7). The most frequently studied endothelial activation markers were adhesion molecules (ICAM-1) and selectins (E- and P-selectin). The levels of endothelial activation markers were comparable to or higher than in healthy controls. Compared to pre-ECMO or non-ECMO, the majority of studies showed stable or decreased levels. Angiopoietin-2, von Willebrand Factor and extracellular vesicles were the most widely studied circulating markers of endothelial damage. More than half of the included studies showed increased levels when compared to normal ranges, and pre-ECMO or non-ECMO values. In healthy animals, ECMO itself leads to vascular leakage and edema. The effect of ECMO support in critically ill animals showed contradicting results. ECMO support (further) induces endothelial damage, but endothelial activation does not, in the critically ill. Further research is necessary to conclude on the effect of the underlying comorbidity and type of ECMO support applied on endothelial dysfunction. Full article

Extracorporeal Carbon Dioxide Removal (ECCO₂R) systems support patients with severe respiratory failure. Concurrent ambulation and physical therapy improve patient outcomes, but these procedures are limited by the complexity and size of the extracorporeal systems and rapid changes in patient metabolism and the acid–base balance. Here, we present the first prototype of a wearable ECCO₂R system capable of adjusting to a patient’s changing metabolic needs. Exhaust gas CO₂ (EGCO₂) partial pressure is used as an analog for blood CO₂ partial pressure (pCO₂). Twin blowers modulate sweep gas through the AL to achieve a desired target EGCO₂. The integrated system was tested in vitro for 24 h with water, under varying simulated metabolic conditions and target EGCO₂ values, and in a single test with whole blood. When challenged with changing inlet water pCO₂ levels in in vitro tests, the system adjusted the sweep gas to achieve target EGCO₂ within 1 min. Control runs with a fixed sweep gas (without negative feedback) demonstrated higher EGCO₂ levels when challenged with higher water flow rates. A single in vitro test with whole ovine blood confirmed functionality in blood. This is the first step toward wearable ECCO₂R systems that automatically respond to changing metabolism. Such devices would facilitate physical therapy and grant greater autonomy to patients. Full article

ANCA-associated vasculitides (AAVs) are rare diseases with a prevalence of less than 200 cases per million persons and an incidence of less than 25 cases per million person-years. Their presenting features can vary from prodromal and nonspecific symptoms to dramatic organ-specific symptoms such as respiratory failure due to diffuse alveolar hemorrhage (DAH) and acute kidney injury (AKI). The latter two are hallmark features of pulmonary-renal syndrome, a potentially fatal condition that necessitates early recognition and treatment in intensive care units (ICUs) and rapid induction of immunosuppressive therapy. Background and case summaries: We described three patients with newly diagnosed AAV during the treatment of critical illness. All patients had DAH and two had AKI. The initial disease severity was extremely high in patients with myeloperoxidase (MPO)-AAV, reaching Sequential Organ Failure Assessment (SOFA) scores of 15 and 14 with predicted mortality ≥ 95.2%. Both patients needed mechanical ventilation, one additional venovenous extracorporeal membrane oxygenation (VV-ECMO), and renal replacement therapy. The patient with proteinase 3 (PR3)-AAV had a less severe disease, SOFA 3, requiring only modest oxygen supplementation and exhibiting only hematuria with normal renal function parameters. Immunosuppressive therapy was initiated during the ICU stay. The patient with the most severe clinical presentation died during the ICU stay because of sepsis, and the other two patients were discharged home. Conclusions: Patients with AAV presenting with pulmonary-renal syndrome necessitate various degrees of organ support. Nevertheless, these patients can be successfully treated in the early, critical stages of the disease and achieve remission. Full article

Background: Neonatal hypoxic respiratory failure (HRF) secondary to PPHN (persistent pulmonary hypertension of the newborn) is an uncommon but life-threatening complication. Despite advances in therapeutic interventions, there are neonates who may require ECMO (extracorporeal membrane oxygenation), which improves survival. In establishing the capability of ECMO in transport in New South Wales, significant variation in referral thresholds and management of PPHN in referring hospitals has been noted. Aim: To review cases referred to the Newborn and paediatric Emergency Transport Service (NETS) for consideration of ECMO due to HRF in neonates. The aetiology of HRF, the number of retrievals and their short-term outcomes were reported. Methods: A retrospective audit of referrals to NETS (January 2019 to December 2022) of infants aged <28 days with HRF for ECMO. Patient demographics, management, advice at the time of call and the outcome are described. Results: The mean weight was 3511 g, mean gestation was 37.1 weeks and 69% of the patients were male. The main diagnoses were MAS/PPHN (50%), and there was variation in inotropes and ventilation strategies at the time of the referral. Six (25%) of the fifteen babies who were transported by NETS to paediatric intensive care were placed on ECMO at the referring hospital. A further six babies were stabilised at the referral centre following NETS co-ordinated specialist advice and did not require retrieval or ECMO. All the babies who received ECMO and survived had normal early development (<6 months) with normal head US or MRI imaging. Conclusions: Optimising ventilation and inotrope management can eliminate the need for ECMO prior to or following retrieval. Early referral for the consideration of ECMO and a collaborative discussion can assist in optimising conventional therapy, thus eliminating the need for ECMO. Neonates requiring ECMO for HRF have good survival rates with good short-term neurological outcomes. Full article