Journal of Clinical Medicine

Research

Jump to: Review

11 pages, 1779 KiB

Open AccessArticle

Injection Site Matters: A Comparative Analysis of Transpulmonary Thermodilution via Simultaneous Femoral and Jugular Indicator Injections under Veno-Venous Extracorporeal Membrane Oxygenation Therapy

by Sabrina Kopp, Johannes Windschmitt, Lena Schnauder, Thomas Münzel, Karsten Keller, Susanne Karbach, Lukas Hobohm, Philipp Lurz, Ingo Sagoschen and Johannes Wild

J. Clin. Med. 2024, 13(8), 2334; https://doi.org/10.3390/jcm13082334 - 17 Apr 2024

Viewed by 561

Abstract

Background: The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) in acute lung failure has witnessed a notable increase. The PiCCO system is frequently used for advanced hemodynamic monitoring in this cohort. Our study aimed to investigate whether the choice of indicator injection site [...] Read more.

Background: The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) in acute lung failure has witnessed a notable increase. The PiCCO system is frequently used for advanced hemodynamic monitoring in this cohort. Our study aimed to investigate whether the choice of indicator injection site (jugular vs. femoral) in patients undergoing vv-ECMO therapy affects transpulmonary thermodilution (TPTD) measurements using the PiCCO^® device (Pulsion Medical Systems SE, Munich, Germany). Methods: In a retrospective single-center analysis, we compared thermodilution-derived hemodynamic parameters after simultaneous jugular and femoral injections in 28 measurements obtained in two patients with respiratory failure who were undergoing vv-ECMO therapy. Results: Elevated values of the extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end-diastolic volume index (GEDVI) were observed following femoral indicator injection compared to jugular indicator injection (EVLWI: 29.3 ± 10.9 mL/kg vs. 18.3 ± 6.71 mL/kg, p = 0.0003; ITBVI: 2163 ± 631 mL/m² vs. 806 ± 125 mL/m², p < 0.0001; GEDVI: 1731 ± 505 mL/m² vs. 687 ± 141 mL/m², p < 0.0001). The discrepancy between femoral and jugular measurements exhibited a linear correlation with extracorporeal blood flow (ECBF). Conclusions: In a PiCCO®-derived hemodynamic assessment of patients on vv-ECMO, the femoral indicator injection, as opposed to the jugular injection, resulted in an overestimation of all index parameters. This discrepancy can be attributed to mean transit time (MTt) and downslope time-dependent (DSt) variations in GEDVI and cardiac function index and is correlated with ECBF. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Figure 1

8 pages, 772 KiB

Open AccessCommunication

Predictive Value of Serial Model of End-Stage Liver Disease Score Determination in Patients with Postcardiotomy Extracorporeal Membrane Oxygenation

by Oliver Sommerfeld, Caroline Neumann, Marcel-Dominic Pfeifer, Gloria Faerber, Hristo Kirov, Christian von Loeffelholz, Torsten Doenst and Christoph Sponholz

J. Clin. Med. 2024, 13(7), 1856; https://doi.org/10.3390/jcm13071856 - 23 Mar 2024

Viewed by 450

Abstract

(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these [...] Read more.

(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these circumstances, calculating a model of end-stage liver disease (MELD) score was shown to determine organ dysfunction and predicting mortality. (2) Methods: We evaluated whether serial MELD score determination increases mortality prediction in patients with postcardiotomy ECMO support. (3) Results: Statistically, a cutoff of a 2.5 MELD score increase within 48 h of ECMO initiation revealed an AUC of 0.722. Further, we found a significant association between hospital mortality and 48 h MELD increase (HR: 2.5, 95% CI: 1.33–4.75, p = 0.005) after adjustment for possible confounders. (4) Conclusions: Therefore, serial MELD score determinations on alternate days may be superior to single measurements in this special patient cohort. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Figure 1

10 pages, 851 KiB

Open AccessArticle

Bleeding Complications in COVID-19 Critically Ill ARDS Patients Receiving VV-ECMO Therapy

by Armin Niklas Flinspach, Dorothée Bobyk, Kai Zacharowski, Vanessa Neef and Florian Jürgen Raimann

J. Clin. Med. 2023, 12(19), 6415; https://doi.org/10.3390/jcm12196415 - 9 Oct 2023

Cited by 1 | Viewed by 961

Abstract

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is rapidly expanding worldwide, yet this therapy has a serious risk of bleeding. Whether coagulation-activating viral infections such as COVID-19 may have an impact on the risk of bleeding is largely unknown. This study conducted a monocentric [...] Read more.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is rapidly expanding worldwide, yet this therapy has a serious risk of bleeding. Whether coagulation-activating viral infections such as COVID-19 may have an impact on the risk of bleeding is largely unknown. This study conducted a monocentric investigation of severely affected COVID-19 patients receiving VV-ECMO therapy with regard to the occurrence and possible influences of minor and major bleeding and transfusion requirements. Among the 114 included study patients, we were able to assess more than 74,000 h of VV-ECMO therapy. In these, 103 major bleeding events and 2283 minor bleeding events were detected. In total, 1396 red blood concentrates (RBCs) were administered. A statistically significant correlation with the applied anticoagulation or demographic data of the patients was not observed. Contrary to the frequently observed thromboembolic complications among COVID-19 patients, patients with VV-ECMO therapy, even under low-dose anticoagulation, show a distinct bleeding profile, especially of minor bleeding, with a substantial need for blood transfusions. COVID-19 patients show a tendency to have frequent bleeding and require repeated RBC transfusions during VV-ECMO. This fact might not be solely explained by the mechanical alteration of ECMO or anticoagulation. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Figure 1

10 pages, 3696 KiB

Open AccessArticle

Prognostic Impact of Serial Imaging in Severe Acute Respiratory Distress Syndrome on the Extracorporeal Membrane Oxygenation

by Martin Balik, Michal Maly, Michal Huptych, Masego Candy Mokotedi and Lukas Lambert

J. Clin. Med. 2023, 12(19), 6367; https://doi.org/10.3390/jcm12196367 - 5 Oct 2023

Cited by 1 | Viewed by 850

Abstract

Background: The impact of serial imaging on the outcome of ICU patients has not been studied specifically in patients with high illness severity. Methods: The authors sought a relationship between the numbers of antero-posterior supine chest X-rays (CXR), computed tomography (CT) examinations, and [...] Read more.

Background: The impact of serial imaging on the outcome of ICU patients has not been studied specifically in patients with high illness severity. Methods: The authors sought a relationship between the numbers of antero-posterior supine chest X-rays (CXR), computed tomography (CT) examinations, and outcome in a cohort of 292 patients with severe COVID-19 ARDS collected over 24 months in a high-volume ECMO center with established ultrasound and echocardiographic diagnostics. Of the patients, 172 (59%) were obese or morbidly obese, and 119 (41%) were treated with ECMO. Results: The median number of CXRs was eight per 14 days of the length of stay in the ICU. The CXR rate was not related to ICU survival (p = 0.37). Patients required CT scanning in 26.5% of cases, with no relationship to the outcome except for the better ICU survival of the ECMO patients without a need for a CT scan (p = 0.01). The odds ratio for survival associated with ordering a CT scan in an ECMO patient was 0.48, p = 0.01. The calculated savings for not routinely requesting a whole-body CT scan in every patient were 98.685 EUR/24 months. Conclusions: Serial imaging does not impact the survival rates of patients with severe ARDS. Extracorporeal membrane oxygenation patients who did not need CT scanning had significantly better ICU outcomes. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Graphical abstract

Review

Jump to: Research

13 pages, 1877 KiB

Open AccessReview

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients—A Literature Review

by Hubert Hymczak, Aleksandra Gołąb, Sylweriusz Kosiński, Paweł Podsiadło, Dorota Sobczyk, Rafał Drwiła, Bogusław Kapelak, Tomasz Darocha and Dariusz Plicner

J. Clin. Med. 2023, 12(21), 6730; https://doi.org/10.3390/jcm12216730 - 25 Oct 2023

Viewed by 1333

Abstract

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest [...] Read more.

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Figure 1

18 pages, 2825 KiB

Open AccessReview

Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review

by Lars Mikael Broman, Olga Dubrovskaja and Martin Balik

J. Clin. Med. 2023, 12(20), 6661; https://doi.org/10.3390/jcm12206661 - 20 Oct 2023

Viewed by 3137

Abstract

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO [...] Read more.

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70–90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo–arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m⁻²) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m⁻²) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Figure 1

10 pages, 1304 KiB

Open AccessReview

Growing Evidence for LV Unloading in VA ECMO

by Jan Soltes, Daniel Rob, Petra Kavalkova, Jan Bruthans and Jan Belohlavek

J. Clin. Med. 2023, 12(18), 6069; https://doi.org/10.3390/jcm12186069 - 20 Sep 2023

Viewed by 1949

Abstract

Impressively increasing availability of mechanical circulatory/cardiac support systems (MCSs) worldwide, together with the deepening of the knowledge of critical care medical practitioners, has inevitably led to the discussion about further improvements of intensive care associated to MCS. An appealing topic of the left [...] Read more.

Impressively increasing availability of mechanical circulatory/cardiac support systems (MCSs) worldwide, together with the deepening of the knowledge of critical care medical practitioners, has inevitably led to the discussion about further improvements of intensive care associated to MCS. An appealing topic of the left ventricle (LV) overload related to VA ECMO support endangering myocardial recovery is being widely discussed within the scientific community. Unloading of LV leads to the reduction in LV end-diastolic pressure, reduction in pressure in the left atrium, and decrease in the LV thrombus formation risk. Consequently, better conditions for myocardial recovery, with comfortable filling pressures and a better oxygen delivery/demand ratio, are achieved. The combination of VA ECMO and Impella device, also called ECPELLA, seems to be a promising strategy that may bring the improvement of CS mortality rates. The series of presented trials and meta-analyses clearly showed the potential benefits of this strategy. However, the ongoing research has brought a series of new questions, such as whether Impella itself is the only appropriate unloading modality, or any other approach to unload LV would be beneficial in the same way. Benefits and potential risks of LV unloading and its timing are being discussed in this current review. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures

Scheme 1

12 pages, 682 KiB

Open AccessReview

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure

by Filip Burša, Michal Frelich, Peter Sklienka, Ondřej Jor and Jan Máca

J. Clin. Med. 2023, 12(16), 5196; https://doi.org/10.3390/jcm12165196 - 9 Aug 2023

Viewed by 1181

Abstract

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal [...] Read more.

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid–base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

► Show Figures