Search Results (125)

Background/Objectives: Low-dose corticosteroids have gained popularity in the treatment of acute respiratory distress syndrome (ARDS); however, the efficacy of high-dose corticosteroids as pulse steroid therapy remains controversial. This study aimed to evaluate the efficacy of pulse steroid therapy in patients with severe ARDS requiring venovenous (V-V) extracorporeal membrane oxygenation (ECMO), where enhanced anti-inflammatory effects may be beneficial. Methods: Using data from the J-CARVE registry, which included patients with severe ARDS managed with V-V ECMO across 24 Japanese hospitals between January 2012 and December 2022, we identified 373 patients treated with corticosteroids. The patients were divided into two groups: pulse steroid therapy and non-pulse steroid therapy. Propensity score matching was performed, and all-cause hospital mortality and ECMO-free days within 28 days were compared between groups. Pulse steroid therapy was defined as methylprednisolone at a dose of 1000 mg/day. Results: After matching, 48 patients were included in each group. The all-cause hospital mortality rates were 41.7% (20/48) in the pulse steroid group and 47.9% (23/48) in the non-pulse steroid group, with no significant difference (odds ratio, 1.28; 95% confidence interval: 0.53–3.12, p = 0.68). The median ECMO-free days were 9.5 (interquartile range [IQR]: 0–17.3) in the pulse steroid group and 3 (IQR: 0–17) in the non-pulse steroid group, showing no significant difference (p = 0.69). Conclusions: Pulse steroid therapy did not improve all-cause hospital mortality or ECMO-free days in patients with severe ARDS who required V-V ECMO. Full article

Background and Objectives: Severe sepsis complicated by refractory shock is associated with high mortality. Adding continuous hemofiltration to venovenous extracorporeal membrane oxygenation (ECMO) may accelerate clearance of inflammatory mediators and improve haemodynamic stability, but evidence remains limited. We analysed 44 consecutive septic-shock patients treated with combined ECMO-hemofiltration (ECMO group) and compared them with 92 septic-shock patients managed without ECMO or renal replacement therapy (non-ECMO group). Methods: This retrospective single-centre study reviewed adults admitted between January 2018 and March 2025. Demographic, haemodynamic, laboratory and outcome data were extracted from electronic records. Primary outcome was 28-day mortality; secondary outcomes included intensive-care-unit (ICU) length-of-stay, vasopressor-free days, and change in Sequential Organ Failure Assessment (SOFA) score at 72 h. Results: Baseline age (49.2 ± 15.3 vs. 52.6 ± 16.1 years; p = 0.28) and APACHE II (27.8 ± 5.7 vs. 26.9 ± 6.0; p = 0.41) were comparable. At 24 h, mean arterial pressure rose from 52.3 ± 7.4 mmHg to 67.8 ± 9.1 mmHg in the ECMO group (mean change [∆] + 15.5 mmHg, p < 0.001). Controls exhibited a modest 4.9 mmHg rise that did not reach statistical significance (p = 0.07). Inflammatory markers decreased more sharply with ECMO (IL-6 ∆ −778 pg mL⁻¹ vs. −248 pg mL⁻¹, p < 0.001). SOFA fell by 3.6 ± 2.2 points with ECMO versus 1.6 ± 2.4 in controls (p = 0.01). Twenty-eight-day mortality did not differ (40.9% vs. 48.9%, p = 0.43), but ICU stay was longer with ECMO (median 12.5 vs. 9.3 days, p = 0.002). ΔIL-6 correlated with ΔSOFA (ρ = 0.46, p = 0.004). Conclusions: ECMO-assisted hemofiltration improved early haemodynamics and organ-failure scores and accelerated cytokine clearance, although crude mortality remained unchanged. Larger prospective trials are warranted to clarify survival benefit and optimal patient selection. Full article

Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) supports critically ill patients with respiratory failure. However, ECMO may induce systemic inflammation, hemolysis, and hemodilution, potentially resulting in endothelial activation and damage. Therefore, this study explored the longitudinal changes in circulating markers of inflammation, hemolysis, and endothelial activation and damage in patients with COVID-19 on VV-ECMO. Methods Plasma was obtained before, within 48 h as well as on day 4, week 1, and week 2 of ECMO support and after decannulation. Circulating markers were measured using Luminex, ELISA, and spectrophotometry. Human pulmonary endothelial cells were exposed to patient plasma, and in vitro endothelial permeability was assessed using electric cell-substrate impedance sensing. Results From April 2020 to January 2022, plasma was collected from 14 patients (71.4% male; age 54 (45–61) years). IL-6 levels decreased (1.238 vs. 0.614 ng/mL, p = 0.039) while ICAM-1 increased (667 vs. 884 ng/mL, p = 0.003) over time when compared to pre-ECMO. Angiopoietin-1 decreased after ECMO initiation (7.57 vs. 3.58 ng/mL, p = 0.030), whereas angiopoietin-2 increased (5.20 vs. 10.19 ng/mL, p = 0.017), particularly in non-survivors of ECMO. Cell-free hemoglobin decreased directly after VV-ECMO initiation but remained stable thereafter (55.29 vs. 9.19 mg/dL, p = 0.017). Moreover, the plasma obtained at several time points during the ECMO run induced in vitro pulmonary endothelial hyperpermeability. Conclusions This exploratory study shows that patients on VV-ECMO support due to COVID-ARDS exhibit progressive endothelial activation and damage but not inflammation and hemolysis. Larger prospective studies are necessary to elucidate pathophysiological pathways leading to endothelial activation and damage, thereby reducing organ failure in these critically ill patients. Full article

Background and Objectives: Coronavirus disease 2019 (COVID-19) triggers a dysregulated host response that may culminate in refractory hypoxaemic shock. Whether veno-venous ECMO modifies the inflammatory cascade more effectively in COVID-19 than in other septic states, and how it compares with conventional ventilatory support for COVID-19, remains uncertain. We compared three groups: COVID-19 patients supported with ECMO (COVID-ECMO, n = 25), non-COVID-19 septic shock patients on ECMO (SEPSIS-ECMO, n = 19) and critically ill COVID-19 patients managed without ECMO (COVID-CONV, n = 74). Methods: This retrospective study (January 2018–January 2025) extracted demographic, laboratory and clinical data at baseline, 48 h and 72 h. The primary end-point was the 72 h change in SOFA score (ΔSOFA). The secondary end-points included the evolution of interleukin-6 (IL-6), C-reactive protein (CRP), D-dimer and ferritin; haemodynamic variables; and 28 day mortality. A post hoc inverse-probability-of-treatment weighting (IPTW) sensitivity analysis adjusted for between-group severity imbalances. Results: Baseline APACHE II differed significantly (29.5 ± 5.8 COVID-ECMO, 27.4 ± 6.1 SEPSIS-ECMO, 18.2 ± 4.9 COVID-CONV; p < 0.001). At 48 h, IL-6 fell by 51.8% in COVID-ECMO (−1 116 ± 473 pg mL⁻¹) versus 32.4% in SEPSIS-ECMO and 18.7% in COVID-CONV (p < 0.001). The ΔSOFA values at 72 h were −4.6 ± 2.2, −3.1 ± 2.5 and −1.4 ± 1.9, respectively (p < 0.001). ECMO groups achieved larger mean arterial pressure rises (+16.8 and +14.2 mmHg) and greater norepinephrine reduction than COVID-CONV. The twenty-eight-day mortality was 36.0% (COVID-ECMO), 42.1% (SEPSIS-ECMO) and 39.2% (COVID-CONV) (p = 0.88). Across all patients, IL-6 clearance correlated with ΔSOFA (ρ = 0.48, p < 0.001) and with vasopressor-free days (ρ = 0.37, p = 0.002). Conclusions: ECMO, regardless of aetiology, accelerates inflammatory-marker decline and organ failure recovery compared with conventional COVID-19 management, but survival advantage remains elusive. COVID-19 appears to display a steeper cytokine-response curve to ECMO than bacterial sepsis, suggesting phenotype-specific benefits that merit confirmation in prospective trials. Full article

Background/Objectives: Extracorporeal membrane oxygenation (ECMO) is increasingly used in critically ill patients, but may significantly alter the pharmacokinetics (PK) of antifungals. Data on plasma concentrations of Isavuconazole (IsaPlasm) in ECMO patients are limited. Our objective is to evaluate Isavuconazole exposure and variability in critically ill COVID-19 patients receiving ECMO. Methods: We conducted a pharmacokinetic analysis of Isavuconazole in critically ill patients receiving Veno-Venous ECMO for respiratory support. Plasma concentrations were measured using therapeutic drug monitoring (TDM) at multiple time points, including sampling before and after the membrane oxygenator. PK parameters—Area Under Curve (AUC_0–24), Minimum Plasma Concentration (Cmin), Elimination Half-Life (T_1/2), volume of distribution (Vd), and clearance (CL)—were estimated and compared with published data in non-ECMO populations. Results: Five patients were included. The median AUC_0–24 was 227.3 µg·h/mL (IQR 182.4–311.35), higher than reported in non-ECMO patients. The median Vd was 761 L (727–832), suggesting extensive peripheral distribution and potential drug sequestration in the ECMO circuit. CL was increased (1.6 L/h, IQR 1.5–3.4). Two patients with recently replaced ECMO circuits exhibited significant drug loss across the membrane. Obesity and hypoalbuminemia were identified as factors associated with altered drug exposure. Conclusions: Isavuconazole pharmacokinetics show marked variability in critically ill ECMO patients. Increased AUC and Vd, along with reduced clearance, highlight the need for individualized dosing. Full article

We investigated echocardiographic and hemodynamic effects of intraaortic balloon pump (IABP) in 26 patients with cardiogenic shock on veno-arterial membrane oxygenation (VA ECMO). Our study demonstrated an 8.1% increase in left ventricular velocity time integral (p = 0.023) without reduction in left ventricular diameters and 4.7% decrease in right ventricular end diastolic base diameter (p = 0.05) when using IABP 1:1 mode compared to no augmentation. This was associated with a 3.2% decrease in heart rate (p < 0.001) and a 3.0% increase in mixed venous oxygen saturation (p = 0.057). Since the magnitude of the documented favorable changes is rather small, the clinical relevance of concomitant IABP in patients with cardiogenic shock on VA ECMO remains questionable. Full article

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan–Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53–1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51–1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12–11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded ‘late’ fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality. Full article

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) can support patients with severe cardiopulmonary failure, but it poses risks such as hemolysis, leading to complications. Plasma-free hemoglobin (PFH) is a hemolysis biomarker, with elevated levels linked to mortality. This study evaluates PFH and ECMO survival in COVID-19, non-COVID-19 pulmonary, and cardiac patients, focusing on late PFH spikes. Materials and Methods: We retrospectively analyzed 122 ECMO patients treated at our tertiary hospital (January 2020–December 2021). Patients were categorized by indication: post-COVID-19, non-COVID-19 pulmonary, or cardiac. We classified patients as Expired (died during ECMO or ≤30 days post-ECMO) or Survived (>30 days post-ECMO). Data included demographics, ECMO duration, and PFH values at 24 h and during the last 3 and 5 ECMO days. Groups were compared using two-tailed t-tests, with p < 0.05 indicating significance. Results: COVID-19 patients survived after significantly longer ECMO duration than non-COVID-19 pulmonary and cardiac patients. Expired COVID-19 patients had higher PFH values during the last 3 and 5 days of ECMO compared to survivors. Cardiac patients had the highest overall PFH levels regardless of mortality. No significant differences in PFH trends were observed between non-COVID-19 pulmonary and cardiac patients. Conclusions: Late PFH spikes correlated with mortality in COVID-19 patients, suggesting the utility of measuring late PFH spikes in ECMO management. Additionally, COVID-19 pulmonary patients survived when undergoing ECMO significantly longer than both groups, while VA ECMO was more prone to hemolysis. However, technical cannulation differences and frequent use of an Impella pump in cardiac patients may increase blood stress and PFH values. Full article

Introduction: Desirable outcome after venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome (ARDS) is frequently defined by survival. However, quality of life (QoL) and mental health status may take precedence over mere survival, from a patient-centered perspective. We aimed to evaluate QoL and mental health status in survivors after V-V ECMO for coronavirus disease 2019 (COVID-19)-related ARDS, hypothesizing a similar QoL comparable to the general population. Methods: All patients supported with venovenous ECMO for COVID-19-related ARDS between 01/2020 and 03/2022 in our center were included. Survivors were invited to participate in a follow-up interview assessing QoL, anxiety, and depression one year after hospital discharge. Primary endpoint was the quality of life, measured by the SF-36 questionnaire, with results compared to data from the DEGS1 study (German normative population). Results: During the study period, 97 patients received venovenous ECMO for COVID-19 ARDS at our ICU. Overall, 43/97 (44.3%) survived, and 21/97 (21.6%) completed the SF-36 questionnaire. The median follow-up duration was 1.7 years. Patients who completed the SF-36 were significantly younger than those who did not (48.7 vs. 55.6 years, p = 0.012); other patient characteristics and ECMO parameters were similar between those with and without questionnaire. Anxiety, depression, and post-traumatic stress disorder were detected in 33%, 14%, and 29% of patients, respectively. Compared to the German normative population, ECMO survivors had significantly lower QoL (mean 77.2 vs. 61.0, p < 0.001). Conclusions: QoL and mental health status after venovenous ECMO for ARDS was significantly lower compared to the normative population. These findings highlight the importance of further research and comprehensive follow-up care for ECMO survivors. Full article

Background and Objectives: Pediatric ECMO is a valid support mechanism for refractory cardiac and/or respiratory failure. Magnetic levitation technology applied to the centrifugal pump has reduced the hemolysis caused by this procedure, which can be particularly dangerous, especially in neonates and small children. ECMOLife, a new magnetic levitation centrifugal pump, has been introduced for these patients. Materials and Methods: Four patients were supported with the ECMOLife System in a newborn setting, with veno-venous application in two cases and veno-arterial in the other two. All parameters related to pump functioning, anticoagulation, hemolysis, and inflammation were recorded for the duration of the support. Results: All patients survived the procedure, in three cases achieving recovery, while one veno-arterial ECMO was switched to VAD, and then the patient underwent heart transplantation. All recorded parameters were compatible with clinical conditions. In particular, free haemoglobin was close to 0 g/L in all recorded samples. The possibility of monitoring pump functioning parameters, venous and arterial O2 saturation, and venous and arterial pressures creates an opportunity to check the adequacy of mechanical support for the clinical condition of the patient. Conclusions: This is the first reported experiment in a newborn setting with ECMOLife mechanical support. At present, ECMOLife represents the only system with a newborn and pediatric pump, allowing for the continuous monitoring of perfusion and hemodynamic parameters, with a large number of facilities for transportation available. Full article

Veno-venous extracorporeal membrane oxygenation (vvECMO) is a life-saving intervention for severe respiratory failure unresponsive to conventional therapies. However, managing refractory hypoxemia in morbidly obese patients poses significant challenges due to the unique physiological characteristics of this population, including hyperdynamic circulation, elevated cardiac output, and increased oxygen consumption. These factors can limit the effectiveness of vvECMO by diluting arterial oxygen content and complicating oxygen delivery. Refractory hypoxemia in obese patients supported by vvECMO often stems from an imbalance between ECMO blood flow and cardiac output. Hyperdynamic circulation exacerbates the recirculation of oxygenated blood and impairs the efficiency of oxygen transfer. To address these challenges, a stepwise, individualized approach is essential. Strategies to reduce oxygen consumption include deep sedation, neuromuscular blockade, and temperature control. Cardiac output modulation can be achieved through beta-blockers and cautious therapeutic hypothermia. Optimizing oxygen delivery involves improving residual lung function; high positive end-expiratory pressure ventilation guided by esophageal pressure monitoring; prone positioning; and adjustments to the ECMO circuit, such as using dual oxygenators, larger membranes, or additional drainage cannulas. This review highlights the interplay of physiological adaptations and technical innovations required to overcome the challenges of managing refractory hypoxemia in obese patients during vvECMO. By addressing the complexities of high cardiac output and obesity, clinicians can enhance the effectiveness of vvECMO and improve outcomes for this high-risk population. Full article

Background and Objectives: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) was described in December 2019 for the first time, and it was responsible for a global pandemic. An alarming number of patients with coronavirus disease 2019 (COVID-19) also developed acute kidney injury (AKI), especially those who required extracorporeal membrane oxygenation (ECMO) therapy for acute respiratory distress syndrome (ARDS). The aim of our retrospective observational study was to assess the prognostic significance of AKI in these patients. This study observed, in COVID-19 patients admitted to an intensive care unit (ICU), AKI stages and the need for renal replacement therapy (RRT), assessing the risk factors and outcomes. Moreover, we evaluated the mortality rate of patients treated by ECMO. Materials and Methods: Between November 2020 and December 2022, among 396 patients admitted to our intensive care unit (ICU) diagnosed with SARS-CoV-2 infection, we selected patients with severe ARDS requiring veno-venous (vv) ECMO support and AKI. Results: The 30-day mortality after ECMO positioning was 85.7%. A Cox regression revealed a significant advantage for RRT with a high cut-off (HCO) hemofilter both for ICU mortality (HR 0.17 [95% CI: 0.031–0.935], p = 0.035) and 15 day-mortality after the start of vv-ECMO (HR 0.13 [95%CI: 0.024–0.741], p= 0.021), whereas the early onset of vasoplegic shock after ECMO implantation indicated a higher risk of death (HR 11.55 [95% CI: 1.117–119.567], p = 0.04) during the ICU stay. Conclusions: COVID-19 induces a high risk of AKI and RRT. In our cohort, hypertension, pre-existing renal disease, and mechanical ventilation represented independent risk factors for AKI. Patients requiring ECMO support had a high mortality rate. The early implementation of RRT reduced the risk of death during the ICU stay. Full article

Background: Treatment with veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a frequently considered rescue therapy in patients with severe acute respiratory distress syndrome (ARDS). Hemolysis is a common complication in patients treated with ECMO. Currently, it is unclear whether increased ECMO blood flow (Q̇_EC) contributes to mortality and might be associated with increased hemolysis. Methods: A total of 441 patients with ARDS and VV ECMO, treated in a tertiary ARDS center, were included. The Q̇_EC value for a significant increase in ICU mortality was determined by binary recursive partitioning. Linear regression analysis was performed to analyze a correlation between mean Q̇_EC and mean plasma concentrations of cell-free hemoglobin (CFH). Results: A Q̇_EC of 4 L/min divided the cohort into two groups with significantly different ICU mortality (Q̇_EC ≤ 4 L/min: 39.3% (n = 300) versus Q̇_EC > 4 L/min: 71.6% (n = 141), p < 0.001). Patients with Q̇_EC > 4 L/min had a higher 28-day mortality. Furthermore, a higher mean Q̇_EC was associated with increased CFH and decreased haptoglobin plasma concentrations. Conclusion: In patients with ARDS and VV ECMO, a mean Q̇_EC > 4 L/min is associated with increased mortality, increased CFH and decreased haptoglobin plasma concentrations. Whether increased hemolysis determines the poorer outcome associated with higher Q̇_EC should be the subject of future research. Full article

Background: A fever is an important sign that affects patient outcomes with various etiologies in the post-decannulation period of extracorporeal membrane oxygenation (ECMO); however, the cause is not fully understood. This study aimed to investigate the characteristics and clinical implications of fevers after ECMO decannulation in critically ill patients. Methods: We conducted a retrospective, single-center study of adult patients who were successfully weaned off venoarterial (VA) or venovenous (VV) ECMO. Decannulation fever was defined as fever that occurred within 72 h of ECMO decannulation. The peak and duration of fever were followed for 2 weeks after decannulation, and the relationship with infection was assessed. Results: A total of 47 patients were included (22 [46.8%] on VA ECMO and 25 [53.2%] on VV ECMO). There were 35 (74.5%) patients who had decannulation fever, including 16 (34%) with active infections. Active infection during the study period was not related to the ECMO setting or duration; rather, infectious fever lasted longer than non-infectious fever (4 [interquartile range; IQR: 1–7] vs. 11 [IQR: 2–7] days, p = 0.023), and the C-reactive protein level was higher on post-decannulation day 7 (p = 0.006). Active infection was associated with increased mortality (odds ratio [OR] 6.067, 95% confidence interval [CI] 1.1289–32.644, p = 0.036), whereas decannulation fever was not (OR 0.156, 95% CI 0.025–0.977, p = 0.047). Conclusions: Fever is an important indicator of ECMO decannulation. However, the different timing and duration of fevers during the post-decannulation period of ECMO may have various clinical implications. Full article

Noncardiogenic pulmonary edema after cardiac surgery is a rare but severe complication. The etiology remains poorly understood; however, the issue may arise from multiple sources. Possible causes include a significant inflammatory response or an autoimmune process. Pulmonary edema resulting from noncardiac etiologies can necessitate extracorporeal membrane oxygenation (ECMO) because most of the cases present a substantial volume of fluid expelled from the lungs and the medical team must manage the inability to achieve effective ventilation. A 64-year-old patient with known heart disease was admitted to our clinic with acute pulmonary edema. His medical history included Barlow’s disease, severe mitral regurgitation (IIP2), moderate–severe tricuspid regurgitation, and moderate pulmonary hypertension. The patient had a coronary angiography performed in a prior hospitalization before the surgical intervention which indicated the absence of coronary lesions. Preoperative screening (nasal, pharyngeal exudate, inguinal pouch culture, and urine culture) was negative, with no active dental infections. The patient was stabilized, and 14 days post-admission, mitral and tricuspid valve repair was performed via a thoracoscopic approach. After being admitted to intensive care post-surgery, the patient quickly developed pulmonary edema, producing a large volume (4.5 L) of yellow secretions through the intubation tube followed by hemodynamic instability necessitating high doses of medications to support circulation but no cardiorespiratory arrest. Due to his worsening condition, the patient was urgently taken back to the operating room, where veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated to support oxygenation and stabilize the patient. Full article