Challenges in the Extracorporeal Membrane Oxygenation Era

A special issue of Membranes (ISSN 2077-0375). This special issue belongs to the section "Membrane Applications".

Deadline for manuscript submissions: closed (20 May 2021) | Viewed by 83061

Special Issue Editors

IRCCS-ISMETT - School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Interests: ECMO; liver transplantation; vitamin D; metabolism
IRCCS-ISMETT - School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Interests: ECMO; V-A ECMO; Ex-vivo lung perfusion; cardiac surgery; transplantation
School of Medicine and Surgery, University of Milano-Bicocca, via Cadore 48, 20900 Monza, Italy
Interests: ARDS; CRRT; ECMO
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

In the last decade, the use of extracorporeal membrane oxygenation (ECMO) in cases of cardiac and/or lung failure has increased significantly. Thanks to technological improvement, as well as the more efficient biocompatibility of materials and recent improvements in clinical management, ECMO has now become a pivotal tool to support critically ill patients worldwide. In fact, its use has expanded to bridge-to-lung and cardiac transplantation, as well as to ventricular assist devices, and it is being used on a number of new patients year by year, its potential contraindications trailing behind the successful expansion of its applications. Despite this, however, several aspects of ECMO setup, management, and characteristics are still obscure, and knowledge in this topic needs continuous updating. In this light, “ECMO-logy” is becoming a distinct discipline with a vast and peculiar background.

This Special Issue on the “Challenges in the new Extracorporeal Membrane Oxygenation Era” of the journal Membranes seeks contributions that explore the current borders of ECMO applications and what is needed or what is missing to set up and manage proper ECMO support. Topics include the definition of new patient selection, updates in survival during ECMO, as well as updates in strategies to monitor coagulation, hemodynamics, and gas exchanges. Basic sciences and contributions in the diffusion of ECMO support and preclinical studies on in vivo basic sciences are welcome to define the most updated picture of modern ECMO and its future perspectives.

Authors are invited to submit their latest results; both original papers and reviews are welcome. 

Dr. Gennaro Martucci
Dr. Antonio Arcadipane
Dr. Marco Giani
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Membranes is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • ECMO transportation
  • Gas exchanges
  • Infections
  • Education in ECMO
  • Patient selection

Published Papers (26 papers)

Order results
Result details
Select all
Export citation of selected articles as:

Editorial

Jump to: Research, Review, Other

4 pages, 205 KiB  
Editorial
Challenges in the Extracorporeal Membrane Oxygenation Era
by Marco Giani, Antonio Arcadipane and Gennaro Martucci
Membranes 2021, 11(11), 829; https://doi.org/10.3390/membranes11110829 - 27 Oct 2021
Cited by 1 | Viewed by 1493
Abstract
In the last decade, the use of extracorporeal membrane oxygenation (ECMO) has significantly increased [...] Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)

Research

Jump to: Editorial, Review, Other

10 pages, 600 KiB  
Article
Effects of Steroids and Tocilizumab on the Immune Response Profile of Patients with COVID-19-Associated ARDS Requiring or Not Veno-Venous Extracorporeal Membrane Oxygenation
by Vito Fanelli, Giorgia Montrucchio, Gabriele Sales, Umberto Simonetti, Chiara Bonetto, Francesca Rumbolo, Giulio Mengozzi, Rosario Urbino, Costanza Pizzi, Lorenzo Richiardi, Paola Cappello and Luca Brazzi
Membranes 2021, 11(8), 603; https://doi.org/10.3390/membranes11080603 - 09 Aug 2021
Cited by 5 | Viewed by 2433
Abstract
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a life-saving rescue therapy in patients with Acute Respiratory Distress Syndrome (ARDS). ECMO has been associated with development of lymphocytopenia that is also common in COVID-19. Hyperinflammation may complicate SARS-CoV-2 pneumonia, prompting therapy with steroids and immunomodulatory [...] Read more.
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a life-saving rescue therapy in patients with Acute Respiratory Distress Syndrome (ARDS). ECMO has been associated with development of lymphocytopenia that is also common in COVID-19. Hyperinflammation may complicate SARS-CoV-2 pneumonia, prompting therapy with steroids and immunomodulatory drugs. We aimed to evaluate the association of therapies such as steroids and Tocilizumab with trajectories of the total leukocytes, lymphocyte subpopulation count, and inflammatory and fibrinolysis markers in COVID-19-related ARDS, requiring or not VV-ECMO support. The association of the trajectories of the leukocytes, lymphocyte subpopulation count, and inflammatory and fibrinolysis markers with treatment with steroids (Steroids), Tocilizumab (Tocilizumab), both drugs (Steroids + Tocilizumab), and absence of treatment (No Treatment) were analyzed using mixed effects regression models, where ECMO was considered as a potential effect modifier. One hundred and thirty-nine leukocyte and eighty-one lymphocyte subpopulation counts were obtained from thirty-one patients who required (VV-ECMO, N = 13) or not (no VV-ECMO, N = 18) extracorporeal support. In both groups, treatment with Steroids + Tocilizumab was independently associated with a significant reduction of 46% and 67% in total lymphocytes, 22% and 60% in CD3+, and 61% and 91% in CD19+ (B lymphocytes) compared to those obtained without treatment, respectively. In the no VV-ECMO group, Tocilizumab was associated with a 79% increase in total lymphocytes and with a reduction in procalcitonin compared to no treatment. CD45+, CD3+CD4+ (Th cell), CD3+CD8+, CD4+/CD8+, the NK cell subpopulation, neutrophils, monocytes, and basophils were significantly reduced by Steroids + Tocilizumab without an effect modification by VV-ECMO support. In critically ill COVID-19 patients with ARDS, concomitant therapies with steroids and Tocilizumab, beside mitigating the inflammation and fibrinolysis, could reduce the total leukocyte, lymphocyte, and subpopulation count. Moreover, the effect of Tocilizumab in increasing the total lymphocytes and reducing procalcitonin might be blunted by VV-ECMO. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

15 pages, 5060 KiB  
Article
Circulating miRNAs as Promising Biomarkers to Evaluate ECMO Treatment Responses in ARDS Patients
by Gennaro Martucci, Antonio Arcadipane, Fabio Tuzzolino, Giovanna Occhipinti, Giovanna Panarello, Claudia Carcione, Alessandro Bertani, Pier Giulio Conaldi and Vitale Miceli
Membranes 2021, 11(8), 551; https://doi.org/10.3390/membranes11080551 - 22 Jul 2021
Cited by 1 | Viewed by 1880
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) has increased in the last decade. However, mortality remains high, and the complexity of ECMO requires individualized treatment. There are some biomarkers to monitor progression and predict clinical outcomes of [...] Read more.
The use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) has increased in the last decade. However, mortality remains high, and the complexity of ECMO requires individualized treatment. There are some biomarkers to monitor progression and predict clinical outcomes of ARDS. This project aims to advance the management of ARDS patients treated with ECMO by exploring miRNA expression in whole blood. The analysis was conducted on two groups with different length of ECMO: Group A (longer runs) and group B (shorter runs). We analyzed miRNAs before ECMO cannulation, and at 7 and 14 days of ECMO support. Our results showed that in the group B patients, 11 deregulated miRNAs were identified, and showed an opposite trend of expression compared to the group A patients. In silico analysis revealed that these 11 miRNAs were related to processes involved in the pathogenesis and evolution of ARDS. This scenario could represent homeostatic mechanisms by which, in ECMO responsive patients, pathways activated during ARDS progression are switched-off. Circulating miRNAs could represent promising biomarkers to monitor the evolution of ARDS under ECMO support. Further studies may shed light on this topic to improve a personalized approach in such a complex setting of patients. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

14 pages, 1674 KiB  
Article
Sharing Mechanical Ventilator: In Vitro Evaluation of Circuit Cross-Flows and Patient Interactions
by Sebastiano Maria Colombo, Michele Battistin, Eleonora Carlesso, Luigi Vivona, Fabio Carfagna, Carlo Valsecchi, Gaetano Florio, Luca Carenzo, Tommaso Tonetti, Vito Marco Ranieri, Maurizio Cecconi, Antonio Pesenti, Giacomo Grasselli and Alberto Zanella
Membranes 2021, 11(7), 547; https://doi.org/10.3390/membranes11070547 - 20 Jul 2021
Cited by 2 | Viewed by 2783
Abstract
During the COVID-19 pandemic, a shortage of mechanical ventilators was reported and ventilator sharing between patients was proposed as an ultimate solution. Two lung simulators were ventilated by one anesthesia machine connected through two respiratory circuits and T-pieces. Five different combinations of compliances [...] Read more.
During the COVID-19 pandemic, a shortage of mechanical ventilators was reported and ventilator sharing between patients was proposed as an ultimate solution. Two lung simulators were ventilated by one anesthesia machine connected through two respiratory circuits and T-pieces. Five different combinations of compliances (30–50 mL × cmH2O−1) and resistances (5–20 cmH2O × L−1 × s−1) were tested. The ventilation setting was: pressure-controlled ventilation, positive end-expiratory pressure 15 cmH2O, inspiratory pressure 10 cmH2O, respiratory rate 20 bpm. Pressures and flows from all the circuit sections have been recorded and analyzed. Simulated patients with equal compliance and resistance received similar ventilation. Compliance reduction from 50 to 30 mL × cmH2O−1 decreased the tidal volume (VT) by 32% (418 ± 49 vs. 285 ± 17 mL). The resistance increase from 5 to 20 cmH2O × L−1 × s−1 decreased VT by 22% (425 ± 69 vs. 331 ± 51 mL). The maximal alveolar pressure was lower at higher compliance and resistance values and decreased linearly with the time constant (r² = 0.80, p < 0.001). The minimum alveolar pressure ranged from 15.5 ± 0.04 to 16.57 ± 0.04 cmH2O. Cross-flows between the simulated patients have been recorded in all the tested combinations, during both the inspiratory and expiratory phases. The simultaneous ventilation of two patients with one ventilator may be unable to match individual patient’s needs and has a high risk of cross-interference. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

15 pages, 4887 KiB  
Article
Advanced Thermochromic Ink System for Medical Blood Simulation
by Mohammad Noorizadeh, Abdullah Alsalemi, Yahya Alhomsi, Aya Nabil Khalaf Mohamed Sayed, Faycal Bensaali, Nader Meskin and Ali Ait Hssain
Membranes 2021, 11(7), 520; https://doi.org/10.3390/membranes11070520 - 11 Jul 2021
Cited by 4 | Viewed by 2766
Abstract
Simulators for extracorporeal membrane oxygenation (ECMO) have problems of bulky devices and low-fidelity methodologies. Hence, ongoing efforts for optimizing modern solutions focus on minimizing expenses and blending training with the intensive care unit. This is particularly evident following the coronavirus pandemic, where economic [...] Read more.
Simulators for extracorporeal membrane oxygenation (ECMO) have problems of bulky devices and low-fidelity methodologies. Hence, ongoing efforts for optimizing modern solutions focus on minimizing expenses and blending training with the intensive care unit. This is particularly evident following the coronavirus pandemic, where economic resources have been extensively cut. In this paper, as a part of an ECMO simulator for training management, an advance thermochromic ink system for medical blood simulation is presented. The system was developed and enhanced as a prototype with successful and reversible transitions between dark and bright red blood color to simulate blood oxygenation and deoxygenation in ECMO training sessions. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

7 pages, 244 KiB  
Article
Apneic Tracheostomy in COVID-19 Patients on Veno-Venous Extracorporeal Membrane Oxygenation
by Matteo Rossetti, Chiara Vitiello, Valeria Campitelli, Raffaele Cuffaro, Claudia Bianco, Gennaro Martucci, Giovanna Panarello, Federico Pappalardo and Antonio Arcadipane
Membranes 2021, 11(7), 502; https://doi.org/10.3390/membranes11070502 - 30 Jun 2021
Cited by 6 | Viewed by 2032
Abstract
COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory [...] Read more.
COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory failure calling for an extracorporeal approach (veno-venous ECMO). In this scenario, most of these patients need an early tracheostomy procedure to be carried out, which creates the risk of distribution of aerosol particles, possibly leading to personnel infection. The use of apneic tracheostomy has been proposed for COVID-19 patients, but in case of ECMO it may produce lung derecruitment, severe hypoxemia, and sudden worsening of respiratory mechanics. We developed an apneic tracheostomy technique and applied it in over 32 patients supported by veno-venous ECMO. We present data showing the safety and feasibility of this technique in terms of patient care and personnel protection. Gas exchange and pH did not show statistically significant changes after the tracheostomy, nor did respiratory mechanics data or the need for inspiratory pressure and FiO2. The use of apneic tracheostomy was a safe option for patient care during ECMO and reduced the possibility of virus spreading. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
18 pages, 10487 KiB  
Article
Alkaline Liquid Ventilation of the Membrane Lung for Extracorporeal Carbon Dioxide Removal (ECCO2R): In Vitro Study
by Luigi Vivona, Michele Battistin, Eleonora Carlesso, Thomas Langer, Carlo Valsecchi, Sebastiano Maria Colombo, Serena Todaro, Stefano Gatti, Gaetano Florio, Antonio Pesenti, Giacomo Grasselli and Alberto Zanella
Membranes 2021, 11(7), 464; https://doi.org/10.3390/membranes11070464 - 22 Jun 2021
Cited by 1 | Viewed by 2052
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is a promising strategy to manage acute respiratory failure. We hypothesized that ECCO2R could be enhanced by ventilating the membrane lung with a sodium hydroxide (NaOH) solution with high CO2 absorbing capacity. A [...] Read more.
Extracorporeal carbon dioxide removal (ECCO2R) is a promising strategy to manage acute respiratory failure. We hypothesized that ECCO2R could be enhanced by ventilating the membrane lung with a sodium hydroxide (NaOH) solution with high CO2 absorbing capacity. A computed mathematical model was implemented to assess NaOH–CO2 interactions. Subsequently, we compared NaOH infusion, named “alkaline liquid ventilation”, to conventional oxygen sweeping flows. We built an extracorporeal circuit with two polypropylene membrane lungs, one to remove CO2 and the other to maintain a constant PCO2 (60 ± 2 mmHg). The circuit was primed with swine blood. Blood flow was 500 mL × min−1. After testing the safety and feasibility of increasing concentrations of aqueous NaOH (up to 100 mmol × L−1), the CO2 removal capacity of sweeping oxygen was compared to that of 100 mmol × L−1 NaOH. We performed six experiments to randomly test four sweep flows (100, 250, 500, 1000 mL × min−1) for each fluid plus 10 L × min−1 oxygen. Alkaline liquid ventilation proved to be feasible and safe. No damages or hemolysis were detected. NaOH showed higher CO2 removal capacity compared to oxygen for flows up to 1 L × min−1. However, the highest CO2 extraction power exerted by NaOH was comparable to that of 10 L × min−1 oxygen. Further studies with dedicated devices are required to exploit potential clinical applications of alkaline liquid ventilation. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

13 pages, 1257 KiB  
Article
Transition from Simple V-V to V-A and Hybrid ECMO Configurations in COVID-19 ARDS
by Piotr Suwalski, Jakub Staromłyński, Jakub Brączkowski, Maciej Bartczak, Silvia Mariani, Dominik Drobiński, Konstanty Szułdrzyński, Radosław Smoczyński, Marzena Franczyk, Wojciech Sarnowski, Agnieszka Gajewska, Anna Witkowska, Waldemar Wierzba, Artur Zaczyński, Zbigniew Król, Ewa Olek, Michał Pasierski, Justine Mafalda Ravaux, Maria Elena de Piero, Roberto Lorusso and Mariusz Kowalewskiadd Show full author list remove Hide full author list
Membranes 2021, 11(6), 434; https://doi.org/10.3390/membranes11060434 - 09 Jun 2021
Cited by 15 | Viewed by 5445
Abstract
In SARS-CoV-2 patients with severe acute respiratory distress syndrome (ARDS), Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) was shown to provide valuable treatment with reasonable survival in large multi-centre investigations. However, in some patients, conversion to modified ECMO support forms may be needed. In [...] Read more.
In SARS-CoV-2 patients with severe acute respiratory distress syndrome (ARDS), Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) was shown to provide valuable treatment with reasonable survival in large multi-centre investigations. However, in some patients, conversion to modified ECMO support forms may be needed. In this single-centre retrospective registry, all consecutive patients receiving V-V ECMO between 1 March 2020 to 1 May 2021 were included and analysed. The patient cohort was divided into two groups: those who remained on V-V ECMO and those who required conversion to other modalities. Seventy-eight patients were included, with fourteen cases (18%) requiring conversions to veno-arterial (V-A) or hybrid ECMO. The reasons for the ECMO mode configuration change were inadequate drainage (35.7%), inadequate perfusion (14.3%), myocardial infarction (7.1%), hypovolemic shock (14.3%), cardiogenic shock (14.3%) and septic shock (7.1%). In multivariable analysis, the use of dobutamine (p = 0.007) and a shorter ICU duration (p = 0.047) predicted the conversion. The 30-day mortality was higher in converted patients (log-rank p = 0.029). Overall, only 19 patients (24.4%) survived to discharge or lung transplantation. Adverse events were more common after conversion and included renal, cardiovascular and ECMO-circuit complications. Conversion itself was not associated with mortality in the multivariable analysis. In conclusion, as many as 18% of patients undergoing V-V ECMO for COVID-19 ARDS may require conversion to advanced ECMO support. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

21 pages, 7512 KiB  
Article
A Modular Approach for a Patient Unit for Extracorporeal Membrane Oxygenation Simulator
by Yahya Alhomsi, Abdullah Alsalemi, Mohammad Noorizadeh, Faycal Bensaali, Nader Meskin and Ali Ait Hssain
Membranes 2021, 11(6), 424; https://doi.org/10.3390/membranes11060424 - 31 May 2021
Cited by 7 | Viewed by 3016
Abstract
Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At [...] Read more.
Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At Hamad Medical Corporation (HMC) in Qatar, there is a critical need of expert ECMO staff. Thus, a modular ECMO simulator is being developed to enhance the training process in a cost-effective manner. This ECMO simulator gives the instructor the ability to control the simulation modules and run common simulation scenarios through a tablet application. The core modules of the simulation system are placed in the patient unit. The unit is designed modularly such that more modules can be added throughout the simulation sessions to increase the realism of the simulation sessions. The new approach is to enclose the patient unit in a trolley, which is custom-designed and made to include all the components in a modular fashion. Each module is enclosed in a separate box and then mounted to the main blood simulation loop box using screws, quick connect/disconnect liquid fittings, and electrical plugs. This method allows fast upgrade and maintenance for each module separately as well as upgrading modules easily without modifying the trolley’s design. The prototype patient unit has been developed for portability, maintenance, and extensibility. After implementation and testing, the prototype has proven to successfully simulate the main visual and audio cues of the real emergency scenarios, while keeping costs to a minimum. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

11 pages, 6420 KiB  
Article
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Propensity Score Matching
by Li-Chung Chiu, Li-Pang Chuang, Shaw-Woei Leu, Yu-Jr Lin, Chee-Jen Chang, Hsin-Hsien Li, Feng-Chun Tsai, Chih-Hao Chang, Chen-Yiu Hung, Shih-Wei Lin, Han-Chung Hu, Chung-Chi Huang, Huang-Pin Wu and Kuo-Chin Kao
Membranes 2021, 11(6), 393; https://doi.org/10.3390/membranes11060393 - 26 May 2021
Cited by 5 | Viewed by 2640
Abstract
The high mortality rate of patients with severe acute respiratory distress syndrome (ARDS) warrants aggressive clinical intervention. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for life-threatening hypoxemia. Randomized controlled trials of ECMO for severe ARDS comprise a number of ethical and methodological [...] Read more.
The high mortality rate of patients with severe acute respiratory distress syndrome (ARDS) warrants aggressive clinical intervention. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for life-threatening hypoxemia. Randomized controlled trials of ECMO for severe ARDS comprise a number of ethical and methodological issues. Therefore, indications and optimal timing for implementation of ECMO, and predictive risk factors for outcomes have not been adequately investigated. We performed propensity score matching to match ECMO-supported and non-ECMO-supported patients at 48 h after ARDS onset for comparisons based on clinical outcomes and hospital mortality. A total of 280 severe ARDS patients were included, and propensity score matching of 87 matched pairs revealed that the 90-d hospital mortality rate was 56.3% in the ECMO group and 74.7% in the non-ECMO group (p = 0.028). Subgroup analysis revealed that greater severity of ARDS, higher airway pressure, or a higher Sequential Organ Failure Assessment score tended to benefit from ECMO treatment in terms of survival. Multivariate logistic regression revealed that hospital mortality was significantly lower among patients who received ECMO than among those who did not. Our findings suggested that early initiation of ECMO (within 48 h) may increase the likelihood of survival for patients with severe ARDS. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

7 pages, 3995 KiB  
Communication
ECMO Support and Operator Safety in the Context of COVID-19 Outbreak: A Regional Center Experience
by Giorgia Montrucchio, Gabriele Sales, Rosario Urbino, Umberto Simonetti, Chiara Bonetto, Erik Cura Stura, Erika Simonato, Giovanni Fuoco, Vito Fanelli and Luca Brazzi
Membranes 2021, 11(5), 334; https://doi.org/10.3390/membranes11050334 - 30 Apr 2021
Cited by 8 | Viewed by 2702
Abstract
Since the beginning of the COVID-19 emergency, the referral Intensive Care Unit for the Extracorporeal Membrane Oxygenation (ECMO) support of Piedmont Region (Italy), in cooperation with infectious disease specialists, perfusionists and cardiac surgeons, developed a protocol to guarantee operator safety during invasive procedures, [...] Read more.
Since the beginning of the COVID-19 emergency, the referral Intensive Care Unit for the Extracorporeal Membrane Oxygenation (ECMO) support of Piedmont Region (Italy), in cooperation with infectious disease specialists, perfusionists and cardiac surgeons, developed a protocol to guarantee operator safety during invasive procedures, among which the ECMO positioning or inter-hospital transport. The use of powered air-purifying respirators, filtering facepiece particles (FFP) 2–3 masks, protective suits, disposable sterile surgical gowns, and two pairs of sterile gloves as a part of a protocol seemed effective and feasible for trained healthcare workers and allow all the complex activities connected with the positioning of the ECMO support to be completed effectively. The simulation training on donning and doffing procedures and the presence of a dedicated team member to verify the compliance with the safety procedure effectively reassured operators and likely reduced the risk of self-contamination. From 1 March to 31 December 2020, we used the procedure in 35 severe acute respiratory distress syndrome (ARDS) patients and one acute respiratory failure caused by neoplastic total tracheal obstruction, all positive to COVID-19, to be connected to veno-venous ECMO in peripheral hospitals and centralized for ECMO management. This preliminary experience seems to confirm that the use of ECMO during COVID-19 outbreaks is feasible and the risks associated with its positioning and management are sustainable for the health-care workers and safe for patients. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

12 pages, 1693 KiB  
Article
Extracorporeal Membrane Oxygenation-Induced Hemolysis: An In Vitro Study to Appraise Causative Factors
by Chris Hoi Houng Chan, Katrina K. Ki, Meili Zhang, Cooper Asnicar, Hwa Jin Cho, Carmen Ainola, Mahe Bouquet, Silver Heinsar, Jo Philipp Pauls, Gianluigi Li Bassi, Jacky Suen and John F. Fraser
Membranes 2021, 11(5), 313; https://doi.org/10.3390/membranes11050313 - 25 Apr 2021
Cited by 12 | Viewed by 5527
Abstract
In vitro hemolysis testing is commonly used to determine hemocompatibility of ExtraCorporeal Membrane Oxygenation (ECMO). However, poor reproducibility remains a challenging problem, due to several unidentified influencing factors. The present study investigated potential factors, such as flow rates, the use of anticoagulants, and [...] Read more.
In vitro hemolysis testing is commonly used to determine hemocompatibility of ExtraCorporeal Membrane Oxygenation (ECMO). However, poor reproducibility remains a challenging problem, due to several unidentified influencing factors. The present study investigated potential factors, such as flow rates, the use of anticoagulants, and gender of blood donors, which could play a role in hemolysis. Fresh human whole blood was anticoagulated with either citrate (n = 6) or heparin (n = 12; 6 female and 6 male blood donors). Blood was then circulated for 360 min at 4 L/min or 1.5 L/min. Regardless of flow rate conditions, hemolysis remained unchanged over time in citrated blood, but significantly increased after 240 min circulation in heparinized blood (p ≤ 0.01). The ratio of the normalized index of hemolysis (NIH) of heparinized blood to citrated blood was 11.7-fold higher at 4 L/min and 16.5–fold higher at 1.5 L/min. The difference in hemolysis between 1.5 L/min and 4 L/min concurred with findings of previous literature. In addition, the ratio of NIH of male heparinized blood to female was 1.7-fold higher at 4 L/min and 2.2-fold higher at 1.5 L/min. Our preliminary results suggested that the choice of anticoagulant and blood donor gender could be critical factors in hemolysis studies, and should be taken into account to improve testing reliability during ECMO. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Graphical abstract

18 pages, 3146 KiB  
Article
A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management
by Aakash Shah, Sagar Dave, Samuel Galvagno, Kristen George, Ashley R. Menne, Daniel J. Haase, Brian McCormick, Raymond Rector, Siamak Dahi, Ronson J. Madathil, Kristopher B. Deatrick, Mehrdad Ghoreishi, James S. Gammie, David J. Kaczorowski, Thomas M. Scalea, Jay Menaker, Daniel Herr, Ali Tabatabai and Eric Krause
Membranes 2021, 11(5), 306; https://doi.org/10.3390/membranes11050306 - 21 Apr 2021
Cited by 4 | Viewed by 3948
Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on [...] Read more.
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

13 pages, 2331 KiB  
Article
A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part I: System Planning and Care Teams
by Sagar Dave, Aakash Shah, Samuel Galvagno, Kristen George, Ashley R. Menne, Daniel J. Haase, Brian McCormick, Raymond Rector, Siamak Dahi, Ronson J. Madathil, Kristopher B. Deatrick, Mehrdad Ghoreishi, James S. Gammie, David J. Kaczorowski, Thomas M. Scalea, Jay Menaker, Daniel Herr, Eric Krause and Ali Tabatabai
Membranes 2021, 11(4), 258; https://doi.org/10.3390/membranes11040258 - 02 Apr 2021
Cited by 4 | Viewed by 2543
Abstract
Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective [...] Read more.
Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

12 pages, 814 KiB  
Article
ECMO Retrieval over the Mediterranean Sea: Extending Hospital Arms
by Brianna A. Hildreth, Giovanna Panarello, Gennaro Martucci, Fabio Tuzzolino, Alberto Piacentini, Giovanna Occhipinti, Andrea Giunta, Fabio Genco, Giuseppe M. Raffa, Michele Pilato, Guido Capitanio and Antonio Arcadipane
Membranes 2021, 11(3), 210; https://doi.org/10.3390/membranes11030210 - 17 Mar 2021
Cited by 5 | Viewed by 2789
Abstract
The retrieval and transport of patients from peripheral hospitals to high volume extracorporeal membrane oxygenation (ECMO) centers aims to reduce complications and improve survival. In Sicily (Italy), our institute houses a mobile ECMO team that serves a population of around 10 million people [...] Read more.
The retrieval and transport of patients from peripheral hospitals to high volume extracorporeal membrane oxygenation (ECMO) centers aims to reduce complications and improve survival. In Sicily (Italy), our institute houses a mobile ECMO team that serves a population of around 10 million people for a vast area in southern Italy and Malta. This observational, descriptive study includes all patients that required veno–venous (V-V) ECMO and transport by a mobile team between October 2009 and May 2020. Linear and multiple logistic regressions were applied to explore the risk factors for mortality in the ICU. Kaplan–Meier estimates were generated to predict the survival in patients transported by helicopter or ambulance, and the two cohorts were compared according to their baseline characteristics. Of 122 patients transported, 89 (73%) survived to ICU discharge (50 (41%) patients were transported by ambulance, and 72 (59%) were transported by helicopter). Independent predictive factors associated with mortality in a stepwise multiple regression model were prone positioning, acute kidney injury, and the number of days spent on mechanical ventilation (MV). Kaplan–Meier estimates for survival favored the helicopter cohort (79%) rather than the ambulance cohort (64%). Patients transported by helicopter had better pre-ECMO profiles, with shorter hospital and ICU stays, a shorter duration of MV use, and higher RESP scores, which indicate better survival probabilities. ECMO transport can be carried out safely over long distances; in rural areas with underdeveloped roads, transportation via helicopter or ambulance can extend the arm of the hospital to remote areas. Early ECMO initiation can be crucial in improving survival outcomes, and when transportation is the limiting factor to starting ECMO support, it should be attempted at the earliest logistical stage possible. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

12 pages, 2757 KiB  
Article
Effects of Ultralow-Tidal-Volume Ventilation under Veno-Venous Extracorporeal Membrane Oxygenation in a Porcine Model with Ventilator-Induced Lung Injury
by Sung Yoon Lim, Young-Jae Cho, Dong Jung Kim, Jun Sung Kim, Sanghoon Jheon, Jin Haeng Chung and Jae Ho Lee
Membranes 2020, 10(12), 379; https://doi.org/10.3390/membranes10120379 - 28 Nov 2020
Cited by 2 | Viewed by 1854
Abstract
Low-tidal-volume ventilation decreases mortality in acute respiratory distress syndrome (ARDS) patients. This study investigated the effects of ultralow tidal ventilation under veno-venous extracorporeal membrane oxygenator (ECMO) support in pigs with ARDS. Eight pigs were intubated and inoculated with methicillin-resistant Staphylococcus aureus through bronchoscopy. [...] Read more.
Low-tidal-volume ventilation decreases mortality in acute respiratory distress syndrome (ARDS) patients. This study investigated the effects of ultralow tidal ventilation under veno-venous extracorporeal membrane oxygenator (ECMO) support in pigs with ARDS. Eight pigs were intubated and inoculated with methicillin-resistant Staphylococcus aureus through bronchoscopy. Ultralow tidal ventilation (3 mL/kg) under extracorporeal membrane oxygenator (ECMO) support was applied to one group and high tidal ventilation (15 mL/kg) was applied to another group to maintain comparable oxygenation for 12 h without ECMO support. Each group had similar arterial blood gas values and hemodynamic variables at baseline and during the experiment. The high-tidal-volume ventilation group showed a gradual decline in arterial oxygen levels, and repeated ANOVA showed significant differences in oxygenation change over time in the ultralow tidal ventilation group. Inflammatory cytokine levels in the bronchoalveolar lavage fluid and lung ultrasound scores were similar between two groups. Histologic analysis showed that both groups developed pneumonia after 12 h; however, the ultralow tidal ventilation group had a lower lung injury score assessed by the pathologist. We developed the first ultralow-tidal-volume ventilation porcine model under veno-venous ECMO support. The ultralow-tidal-volume ventilation strategy can mitigate mechanical ventilator-associated lung injury. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

Review

Jump to: Editorial, Research, Other

15 pages, 755 KiB  
Review
New Trends, Advantages and Disadvantages in Anticoagulation and Coating Methods Used in Extracorporeal Life Support Devices
by Anne Willers, Jutta Arens, Silvia Mariani, Helena Pels, Jos G. Maessen, Tilman M. Hackeng, Roberto Lorusso and Justyna Swol
Membranes 2021, 11(8), 617; https://doi.org/10.3390/membranes11080617 - 12 Aug 2021
Cited by 30 | Viewed by 5623
Abstract
The use of extracorporeal life support (ECLS) devices has significantly increased in the last decades. Despite medical and technological advancements, a main challenge in the ECLS field remains the complex interaction between the human body, blood, and artificial materials. Indeed, blood exposure to [...] Read more.
The use of extracorporeal life support (ECLS) devices has significantly increased in the last decades. Despite medical and technological advancements, a main challenge in the ECLS field remains the complex interaction between the human body, blood, and artificial materials. Indeed, blood exposure to artificial surfaces generates an unbalanced activation of the coagulation cascade, leading to hemorrhagic and thrombotic events. Over time, several anticoagulation and coatings methods have been introduced to address this problem. This narrative review summarizes trends, advantages, and disadvantages of anticoagulation and coating methods used in the ECLS field. Evidence was collected through a PubMed search and reference scanning. A group of experts was convened to openly discuss the retrieved references. Clinical practice in ECLS is still based on the large use of unfractionated heparin and, as an alternative in case of contraindications, nafamostat mesilate, bivalirudin, and argatroban. Other anticoagulation methods are under investigation, but none is about to enter the clinical routine. From an engineering point of view, material modifications have focused on commercially available biomimetic and biopassive surfaces and on the development of endothelialized surfaces. Biocompatible and bio-hybrid materials not requiring combined systemic anticoagulation should be the future goal, but intense efforts are still required to fulfill this purpose. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

31 pages, 1663 KiB  
Review
Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature
by Lars-Olav Harnisch and Onnen Moerer
Membranes 2021, 11(8), 584; https://doi.org/10.3390/membranes11080584 - 30 Jul 2021
Cited by 17 | Viewed by 6034
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, [...] Read more.
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute—refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative—advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ −2 points, PRESET score ≥ 6 points, and “do not attempt resuscitation” order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

11 pages, 1310 KiB  
Review
Extra-Corporeal Membrane Oxygenation Cadaver Donors: What about Tissues Used as Allografts?
by Gregorio Marchiori, Matteo Berni, Giorgio Cassiolas, Leonardo Vivarelli, Nicola Francesco Lopomo, Milena Fini, Dante Dallari and Marco Govoni
Membranes 2021, 11(7), 545; https://doi.org/10.3390/membranes11070545 - 19 Jul 2021
Cited by 5 | Viewed by 2161
Abstract
Several studies demonstrated the efficacy of post-mortem extracorporeal membrane oxygenation (ECMO) on donors in preserving organ function addressing organ transplantation. Nevertheless, no common and shared evidence was reached about the possibility of using ECMO donors in tissue harvesting. Therefore, this work aimed first [...] Read more.
Several studies demonstrated the efficacy of post-mortem extracorporeal membrane oxygenation (ECMO) on donors in preserving organ function addressing organ transplantation. Nevertheless, no common and shared evidence was reached about the possibility of using ECMO donors in tissue harvesting. Therefore, this work aimed first to review the current scientific literature about ECMO donors, and then to focus on the use of ECMO tissues as allografts, mainly addressing musculoskeletal tissues, which are of the most interest for reconstruction. A search was conducted on the current scientific literature, focusing on the keywords “ECMO” and “Donor”. Several online databases were used, including PubMed, Scopus, and Web of Science. From the preliminary search, 478 articles were obtained, out of which 173 specifically reported the use of ECMO for donation and transplantation purposes. Literature reported extensive analyses of ECMO organs—overall from the abdomen—both in pre- and post-transplantation studies. On the other hand, ECMO tissues were explanted only in a very limited number of cases; moreover, no information was referred about their status and use. A revision of the current scientific literature highlighted the lack of information concerning ECMO tissues and the necessity to perform preclinical, ex vivo studies to compare allografts from ECMO donors, with respect to standard donors, and, thus, to verify whether they can be harvested and implanted safely and with efficacy. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

11 pages, 245 KiB  
Review
Extracorporeal Support Prognostication—Time to Move the Goal Posts?
by Neel Shah and Ahmed S. Said
Membranes 2021, 11(7), 537; https://doi.org/10.3390/membranes11070537 - 15 Jul 2021
Cited by 8 | Viewed by 2487
Abstract
Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to [...] Read more.
Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to mostly registry-based data and with mortality as the main outcome of interest. There continues to be a gap in clinically applicable decision support tools to aid in the timing of ECMO cannulation to improve patients’ long-term outcomes. We present a brief review of the commonly available adult and pediatric ECMO prognostication tools, their limitations, and future directions. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
7 pages, 590 KiB  
Review
The Evolution of the Use of Extracorporeal Membrane Oxygenation in Respiratory Failure
by Danielle Feldhaus, Daniel Brodie, Philippe Lemaitre, Joshua Sonett and Cara Agerstrand
Membranes 2021, 11(7), 491; https://doi.org/10.3390/membranes11070491 - 30 Jun 2021
Cited by 6 | Viewed by 4067
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support patients with acute respiratory failure, most commonly, and severe forms of acute respiratory distress syndrome (ARDS). The marked increase in the global use of ECMO followed the publication of a large [...] Read more.
Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support patients with acute respiratory failure, most commonly, and severe forms of acute respiratory distress syndrome (ARDS). The marked increase in the global use of ECMO followed the publication of a large randomized trial in 2009 and the experience garnered during the 2009 influenza A (H1N1) pandemic, and has been further supported by the release of a large, randomized clinical trial in 2018, confirming a benefit from using ECMO in patients with severe ARDS. Despite a rapid expansion of ECMO-related publications, optimal management of patients receiving ECMO, in terms of patient selection, ventilator management, anticoagulation, and transfusion strategies, is evolving. Most recently, ECMO is being utilized for an expanding variety of conditions, including for cases of severe pulmonary or cardiac failure from coronavirus disease 2019 (COVID-19). This review evaluates modern evidence for ECMO for respiratory failure and the current challenges in the field. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

9 pages, 990 KiB  
Review
Extracorporeal Membrane Oxygenation Use in Thoracic Surgery
by Pavel Suk, Vladimír Šrámek and Ivan Čundrle, Jr.
Membranes 2021, 11(6), 416; https://doi.org/10.3390/membranes11060416 - 31 May 2021
Cited by 8 | Viewed by 3123
Abstract
This narrative review is focused on the application of extracorporeal membrane oxygenation (ECMO) in thoracic surgery, exclusive of lung transplantation. Although the use of ECMO in this indication is still rare, it allows surgery to be performed in patients where conventional ventilation is [...] Read more.
This narrative review is focused on the application of extracorporeal membrane oxygenation (ECMO) in thoracic surgery, exclusive of lung transplantation. Although the use of ECMO in this indication is still rare, it allows surgery to be performed in patients where conventional ventilation is not feasible—especially in single lung patients, sleeve lobectomy or pneumonectomy and tracheal or carinal reconstructions. Comparisons with other techniques, various ECMO configurations, the management of anticoagulation, anesthesia, hypoxemia during surgery and the use of ECMO in case of postoperative respiratory failure are reviewed and supported by two cases of perioperative ECMO use, and an overview of published case series. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

19 pages, 4454 KiB  
Review
A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation
by Thomas Hughes, David Zhang, Priya Nair and Hergen Buscher
Membranes 2021, 11(4), 251; https://doi.org/10.3390/membranes11040251 - 30 Mar 2021
Cited by 13 | Viewed by 2270
Abstract
Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage [...] Read more.
Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

11 pages, 572 KiB  
Review
Modalities of Left Ventricle Decompression during VA-ECMO Therapy
by Juan Pablo Ricarte Bratti, Yiorgos Alexandros Cavayas, Pierre Emmanuel Noly, Karim Serri and Yoan Lamarche
Membranes 2021, 11(3), 209; https://doi.org/10.3390/membranes11030209 - 16 Mar 2021
Cited by 14 | Viewed by 3488
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left [...] Read more.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to sustain circulatory and respiratory support in patients with severe cardiogenic shock or refractory cardiac arrest. Although VA-ECMO allows adequate perfusion of end-organs, it may have detrimental effects on myocardial recovery. Hemodynamic consequences on the left ventricle, such as the increase of afterload, end-diastolic pressure and volume, can lead to left ventricular (LV) distention, increase of myocardial oxygen consumption and delayed LV function recovery. LV distention occurs in almost 50% of patients supported with VA-ECMO and is associated with an increase in morbidity and mortality. Thus, recognizing, preventing and treating LV distention is key in the management of these patients. In this review, we aim to discuss the pathophysiology of LV distention and to describe the strategies to unload the LV in patients supported with VA-ECMO. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

18 pages, 354 KiB  
Review
Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions
by Marco Giani, Simone Redaelli, Antonio Siragusa, Benedetta Fumagalli, Roberto Rona and Giuseppe Foti
Membranes 2021, 11(3), 172; https://doi.org/10.3390/membranes11030172 - 28 Feb 2021
Cited by 9 | Viewed by 2526
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients [...] Read more.
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)

Other

7 pages, 935 KiB  
Case Report
COVID-19-Related Acute Respiratory Distress Syndrome in a Pregnant Woman Supported on ECMO: The Juxtaposition of Bleeding in a Hypercoagulable State
by Mohsen Khalil, Abid Butt, Eiad Kseibi, Eyad Althenayan, Manal Alhazza and Hend Sallam
Membranes 2021, 11(7), 544; https://doi.org/10.3390/membranes11070544 - 17 Jul 2021
Cited by 6 | Viewed by 2716
Abstract
A 40-year-old pregnant woman at 28 weeks of gestation was diagnosed with severe acute respiratory failure syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). She had severe hypoxemia despite the use of mechanical ventilation and muscle relaxant infusion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) [...] Read more.
A 40-year-old pregnant woman at 28 weeks of gestation was diagnosed with severe acute respiratory failure syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). She had severe hypoxemia despite the use of mechanical ventilation and muscle relaxant infusion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was used, and she had a cesarian section while on ECMO support. She developed disseminated intravascular coagulation (DIC) with overt bleeding. This was managed by a multidisciplinary team (MDT) and a change of the ECMO circuit resulted in a dramatic improvement of her coagulation profile. Both the mother and the baby were discharged and went home in good condition. Full article
(This article belongs to the Special Issue Challenges in the Extracorporeal Membrane Oxygenation Era)
Show Figures

Figure 1

Back to TopTop