Fig 1 - uploaded by Kiyohiro Oshima
Content may be subject to copyright.
Source publication
In this study, we analyzed the respiratory status and the prognosis of patients, including adults with acute respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV ECMO) to maintain respiratory status. We then evaluated the differences between patients who could be removed from VV ECMO and those who could not.
From January...
Context in source publication
Context 1
... and standard 3/8-inch tubing. The blood-contact surfaces of these components were heparin-coated. ECMO was established with venous drainage (19.5 Fr or 21 Fr) from the femoral vein (the tip of the tube was placed in the right atrium), and arterialized blood was returned to another side of the femoral vein using a 15 Fr or 16.5 Fr arterial cannula (Fig. 1). In recent practice, we have used a Capiox SP Pump Controller Sp-101 and a Capiox circuit (Terumo Co., Tokyo, Japan). ECMO flow was initially maintained in the range of 1.0 to 2.0 L/min/m 2 , and the activated clotting time was maintained at 150-250 seconds with the administration of nafamostat mesylate, a potent antiplatelet agent, ...
Similar publications
Hantavirus cardiopulmonary syndrome has a high mortality rate, and early connection to extracorporeal membrane oxygenation has been suggested to improve outcomes. We report the case of a patient with demonstrated Hantavirus cardiopulmonary syndrome and refractory shock who fulfilled the criteria for extracorporeal membrane oxygenation and responded...
Objectives:
To assess in-hospital neurologic (CNS) complications in adult patients undergoing veno-venous extracorporeal membrane oxygenation for respiratory failure.
Design:
Retrospective analysis of the Extracorporeal Life Support Organization's data registry.
Setting:
Data reported to Extracorporeal Life Support Organization from 350 intern...
Extracorporeal membrane oxygen (ECMO) has been used for many years in patients with life-threatening hypoxaemia and/or hypercarbia. While early trials demonstrated that it was associated with poor outcomes and extensive haemorrhage, the technique has evolved. It now encompasses new technologies and understanding that the lung protective mechanical...
Vancomycin during continuous venovenous hemofiltration (CVVH) is either administered by intermittent infusion (II) or continuous infusion (CI). In this patient population, the best method to rapidly achieve target serum concentrations of 15 mcg/ml to 25 mcg/ml remains to be elucidated. We hypothesized that CI would achieve a target serum level of 1...
Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized for cardiopulmonary failure. We aimed to qualify and quantify the predictors of morbidity and mortality in infants requiring VA-ECMO.
Methods: Data was collected from 170 centers participating in the extracorporeal life support organization (ELSO) registry. Relation...
Citations
... The fibrinogen level of the nonsurvivor group at any time point was much lower than that of the survivor group. Our data confirmed the previous finding that high fibrinogen concentration following ECMO initiation has a protective effect and positive predictive value of treatment success, which may be attributable to its indication of effective immune response and relative scarcity of bleeding disorders [26]. ...
Background
No definitive conclusions have been drawn from the available data about the utilization of extracorporeal membrane oxygenation (ECMO) to treat severe acute respiratory distress syndrome (ARDS). The aim of this study was to review our center’s experience with ECMO and determine predictors of outcome from our Chinese center.
Material/Methods
We retrospectively analyzed a total of 23 consecutive candidates who fulfilled the study entry criteria between January 2009 and December 2015. Detailed clinical data, ECMO flow, and respiratory parameters before and after the introduction of ECMO were compared among in-hospital survivors and nonsurvivors; factors associated with mortality were investigated.
Results
Hemodynamics and oxygenation parameters were significantly improved after ECMO initiation. Thirteen patients survived to hospital discharge. Univariate correlation analysis demonstrated that APACHE II score (r=−0.463, p=0.03), acute kidney injury (r=−0.574, p=0.005), membrane oxygenator replacement (r=−0.516, p=0.014) and total length of hospital stay (r=0.526, p=0.012) were significantly correlated with survival to hospital discharge, and that the evolution of the levels of urea nitrogen, platelet, and fibrinogen may help to determine patient prognosis. Sixteen patients referred for ECMO from an outside hospital were successfully transported to our institution by ambulance, including seven transported under ECMO support. The survival rate of the ECMO-transport group was comparable to the conventional transport or the non-transport group (both p=1.000).
Conclusions
ECMO is an effective alternative option for severe ARDS. APACHE II score on admission, onset of acute kidney injury, and membrane oxygenator replacement, and the evolution of levels of urea nitrogen, platelet, and fibrinogen during hospitalization may help to determine the in-hospital patient prognosis. By establishing a well-trained mobile ECMO team, a long-distance, inter-hospital transport can be administered safely.
... [1][2][3][4][5] Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used as salvage therapy in this situation. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Extracorporeal membrane oxygenation is an extracorporeal gas exchange device (see Figure 1) that includes cannulas, a blood pump, a membrane oxygenator, a heat exchanger, monitors, and alarms. 24 Numerous technical innovations have improved performance, reliability, and biocompatibility of the extracorporeal circuit: Centrifugal pumps offer a lower resistance to blood and smaller priming volumes, hollow fiber membrane oxygenator, higher effective gas exchange properties of membrane, and circuit coated with heparin or other polymers intended to minimize blood surface interaction. ...
... Positive results have been achieved in many case series of patients with severe ARDS of various causes treated with VV-ECMO (severe influenza A [H1N1], posttraumatic respiratory distress syndrome, bacterial pneumonia, and so on). [16][17][18][19][20][21][22][23] This explains the current resurgence of interest in ECMO for severe respiratory distress. 2 Despite these technical improvements, achieving satisfactory oxygenation remains tricky. ...
Purpose:
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapeutic option in the management of the most severe forms of acute respiratory distress syndrome. Oxygenation during VV-ECMO depends on many parameters, and its management is complex. The management of ECMO is still not completely codified. The aim of this study was to rationalize the management of hypoxemia during VV-ECMO.
Methods:
To build a comprehensive flow diagram for management of hypoxemia during VV-ECMO, we considered (1) relationship between O2 arterial saturation and its determinants; (2) analysis of physiopathology of oxygenation under VV-ECMO; and (3) main guidelines and recommendations recapitulated in troubleshooting charts.
Results:
We propose a stepwise approach that could guide specific intervention to improve oxygenation during VV-ECMO. The first step is to obtain adequate pump flow, the main determinant of oxygenation, by eliminating a mechanical problem or inadequate venous drainage. Second, if hypoxemia persists, algorithm considers multiple reasons for inadequate oxygenation, namely: (1) excessive recirculation, (2) excessive cardiac output (decrease of ratio pump flow/cardiac output), (3) decrease in SvO2 (oxygen saturation in mixed venous blood), (4) malfunction of oxygenator, and (5) deterioration of residual lung function. Finally, for each modification of oxygenation parameters, specific measures are proposed to restore an adequate oxygenation by extracorporeal membrane oxygenation.
Conclusion:
If hypoxemia occurs during VV-ECMO, collecting oxygenation parameters and a clear step-by-step algorithm could guide specific intervention to improve oxygenation. This flow diagram is in accordance with current recommendations recapitulated in guidelines or troubleshooting chart but more accurate and complete. Although rational and appealing, it remains to be tested together with a number of still unsolved issues.
... In addition to technological progress, there has been improvement related to the clinical application of extracorporeal support devices in individual patients, including early introduction and strategies for changing from devices as clinically indicated. [27,28] ...
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.
Background:
Extracorporeal membrane oxygenation (ECMO) is widely used for cardiopulmonary assistance during lung transplantation (LTx). However, the optimal timing for ECMO removal remains controversial. This study aimed to evaluate the risk factors and early prognosis of delayed withdrawal ECMO after LTx.
Methods:
267 patients who underwent LTx supported by ECMO were included in this study. Based on whether or not ECMO was completely stopped in the operating room, patients were divided into early ECMO withdrawal group (group E, 107 cases) and delayed withdrawal group (group D, 160 cases). Peri-operative data of the donors and recipients, including the suspected risk factors for delayed removal of ECMO, post-operative complications, and hospital survival rate, were retrospectively analyzed.
Results:
Preoperative New York Heart Association (NYHA) cardiac function for recipient and mechanical ventilation time for donor were independent risk factors for delayed weaning of ECMO in veno-arterial ECMO (V-A-ECMO) patients. Compared with group E, the odds of post-operative pulmonary infection, primary graft dysfunction, renal dysfunction, blood transfusion volume and mechanical ventilation time were significantly higher in group D (all P < 0.05). Delayed withdrawal ECMO was decisive factor for early post-operative death, as the risk of early post-operative death in the group D was 1.99 (95% confidence interval: 1.13-3.54) times as that in the group E.
Conclusions:
During the period of LTx, NYHA grade III/IV for recipient and mechanical ventilation time ≥ 5 days for donor are suggestive of delayed V-A-ECMO removal, and clinicians should minimize the post-operative bypass time of ECMO when conditions permit.
Mechanical ventilation remains the cornerstone of respiratory support for patients with acute respiratory failure. However, high pressure and volume associated with tidal ventilation are known to aggravate lung injury in this setting [1]. Furthermore, profound gas-exchange abnormalities threatening patients’ lives can occur in the most severe forms of the disease despite recourse to conventional salvage therapies [2, 3]. Extracorporeal gas exchange devices, i. e., venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), were developed more than 40 years ago [4, 5] to rescue these dying patients. Whereas venovenous ECMO provides complete extracorporeal blood oxygenation and decarboxylation using high blood flows (4–6 l/min) and large (20–30 Fr) cannulas [6–9], efficient extracorporeal CO2 removal (with minimal blood oxygenation) can be achieved with ECCO2R devices using limited extracorporeal blood flow (0.4–1 l/min) and thin double lumen venous catheters (14–18 Fr) [10, 11], because CO2 clearance is more effective than oxygenation due to the greater solubility and more rapid diffusion of CO2 [12]. Extracorporeal gas exchange devices also permit ‘ultraprotective’ mechanical ventilation with further reduction of volume and pressure, which may ultimately enhance lung protection and improve clinical outcomes for patients with acute respiratory distress syndrome (ARDS). However, results of trials evaluating extracorporeal gas exchange for respiratory failure performed in the 1970s, 80s and 90s were often disappointing [13, 14]. In recent years, major technological advances have occurred and the latest generation extracorporeal gas exchange devices, with polymethylpentene hollow-fiber membrane lungs and Mendler-designed centrifugal pumps offer lower resistance to blood flow, have smaller priming volumes, higher effective gas exchange properties and are coated with more biocompatible materials.
In the United States, Pneumocystis jirovecii (PCP) is a leading cause of morbidity and mortality in hospitalized patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and can result in severe hypoxemia despite maximal conventional ventilator support. We present 2 adult patients with HIV/AIDS and PCP who were managed with extracorporeal membrane oxygenation (ECMO) because of refractory hypoxemia. After prolonged hospitalization, the first patient developed multiorgan failure, and the decision was made to withdraw life support. The second patient required ECMO for 7 days and survived. We also review 2 previously published cases in which ECMO was used in adult HIV patients with severe hypoxemia from PCP. In the patients that survived, ECMO was initiated earlier in the course of hospitalization compared with those that died (mean 3.5 vs. 15 d). Furthermore, the patient that survived required a much shorter duration of ECMO support (mean 5.5 vs. 41.5 d). The use of ECMO early in the course of hospitalization can be considered in patients with HIV/AIDS and refractory hypoxemia due to PCP.
Following cardiac surgery, patients can develop acute respiratory failure. We present the case of a 66-year-old male successfully treated with extracorporeal venovenous membrane oxygenation (vvECMO) for acute respiratory failure postsurgery and review the literature on vvECMO in this specific setting.
