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Background@#Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing, the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear. Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS.@*Methods@#We conducted a multi-center, retrospective, cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018. Patients with severe ARDS who received VV-ECMO support were included. The detailed demographic data and physiologic data were used to match ARDS patients without ECMO. The primary endpoint was the 28-day mortality.@*Results@#Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study. The acute physiology and chronic health evaluation II score was 23.1 ± 6.3 in the ECMO group and 24.8 ± 8.5 in the control group (P = 0.1195). The sequential organ failure assessment score was 12.8 ± 3.4 in the ECMO group and 13.7 ± 3.5 in the control group (P = 0.0848). The 28-day mortality of patients with ECMO support was 39.4%, and that of the control group was 55.6%. The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (P = 0.0097). Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]: 1.006; 95% confidence interval [CI]: 1.001–1.013; P = 0.030) and duration of mechanical ventilation before ECMO (HR: 3.299; 95% CI: 1.264–8.609; P = 0.034).@*Conclusions@#This study showed that ECMO improved the survival of patients with severe ARDS. The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.
ABSTRACT
BACKGROUND@#Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing, the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear. Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS.@*METHODS@#We conducted a multi-center, retrospective, cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018. Patients with severe ARDS who received VV-ECMO support were included. The detailed demographic data and physiologic data were used to match ARDS patients without ECMO. The primary endpoint was the 28-day mortality.@*RESULTS@#Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study. The acute physiology and chronic health evaluation II score was 23.1 ± 6.3 in the ECMO group and 24.8 ± 8.5 in the control group (P = 0.1195). The sequential organ failure assessment score was 12.8 ± 3.4 in the ECMO group and 13.7 ± 3.5 in the control group (P = 0.0848). The 28-day mortality of patients with ECMO support was 39.4%, and that of the control group was 55.6%. The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (P = 0.0097). Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]: 1.006; 95% confidence interval [CI]: 1.001-1.013; P = 0.030) and duration of mechanical ventilation before ECMO (HR: 3.299; 95% CI: 1.264-8.609; P = 0.034).@*CONCLUSIONS@#This study showed that ECMO improved the survival of patients with severe ARDS. The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.
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<p><b>BACKGROUND</b>Early goal-directed therapy (EGDT) has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients.</p><p><b>METHODS</b>A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients' characteristics were compared before treatment (T0), immediately after EGDT (T1), and 24 h after EGDT (T2). This study is registered at ClinicalTrials.org, NCT02060773.</p><p><b>RESULTS</b>Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients; therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate (ICG-PDR) and 15-min retention rate (R15) at T0 (11.9 ± 5.0%/min and 20.0 ± 13.2%), T1 (11.4 ± 5.1%/min and 23.6 ± 14.9%), and T2 (11.0 ± 4.5%/min and 23.7 ± 15.3%) (all P > 0.05). Both of the alterations of ICG-PDR and R15 showed no differences at T0, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected (P > 0.05).</p><p><b>CONCLUSION</b>There were no hepatic perfusion improvements after EGDT in the early phase of patients with septic shock.</p><p><b>TRIAL REGISTRATION</b>Clinicaltrials.gov NCT02060773 (https://clinicaltrials.gov/ct2/show/NCT02060773).</p>
Subject(s)
Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Cardiac Output , Physiology , Disease Management , Fluid Therapy , Hemodynamics , Physiology , Intensive Care Units , Prospective Studies , Shock, Septic , TherapeuticsABSTRACT
<p><b>BACKGROUND</b>Hypotension due to the induction of sedation with dexmedetomidine infusion may be harmful in critically ill patients. Changes in pulse pressure induced by the passive leg raising test (PLR-ΔPP) as marker of fluid responsiveness, assessed prior to sedation, may predict hemodynamic changes. The present study was to investigate the power of the PLR test in critically ill patients in predicting hypotension induced by the induction of dexmedetomidine sedation.</p><p><b>METHODS</b>Fluid responsiveness was estimated by a passive leg raising (PLR) test before dexmedetomidine sedation. Patients were assigned to either the "Nonresponders" or "Responders" group according to their hemodynamic responses to the PLR test ("Nonresponders", PLR-ΔPP < 10.3%; "Responders", PLR-ΔPP ≥ 10.3%). Sedation was performed with a dexmedetomidine infusion (0.5 µg/kg over a 10-minute loading period, then 0.2 - 0.7 µg×kg(-1)×h(-1)) and titrated to maintain the target Richmond agitation sedation scale (RASS) score in the range of -2 to -1 and the bispectral index value in the range of 60 to 75. Radial artery pulse pressure, heart rate (HR), and central venous pressure (CVP) were measured at each phase of the study procedure. Hemodynamic fluctuations during the use of dexmedetomidine sedation were recorded and compared between the two groups.</p><p><b>RESULTS</b>Fifty patients had a median (25% - 75% interquartile range) of 71 (61 - 78) years old were studied. At baseline, 39 of the 50 patients were "Nonresponders" and 11 were "Responders". Following dexmedetomidine sedation, patients classified as "Responders" had a significantly greater systolic blood pressure decrease during the induction of dexmedetomidine sedation than the "Nonresponders" ((-26.3 ± 6.8)% vs. -11.8 ± 8.5)%, P < 0.001). In addition, the "Responders" group required significantly more fluid boluses (8 vs. 3; P < 0.001) and vasopressors (2 vs. 0; P < 0.05) than the "Nonresponders" group to restore blood pressure. Finally, PLR-ΔPP was positively correlated with changes in systolic blood pressure (PLR-ΔSBP) (r(2) = 0.576; P < 0.001) and significantly correlated with dexmedetomidine infusion-induced changes in SBP (r(2) = 0.202; P < 0.05). AUC for PLR-ΔPP was 0.84 (95%CI 0.71 - 0.93). PLR-ΔPP predicted hypotension with a sensitivity of 73% and a specificity of 92%.</p><p><b>CONCLUSIONS</b>The fluid responsiveness assessment pre-sedation was found to predict blood pressure fluctuation during the induction of dexmedetomidine sedation. The PLR test conducted prior to sedation may be a useful tool to identify patients with a high risk of hemodynamic events and may be used to indicate the need for prophylactic treatment.</p>
Subject(s)
Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Blood Pressure , Conscious Sedation , Critical Illness , Dexmedetomidine , Pharmacology , Hypotension , Leg , Prospective Studies , Single-Blind MethodABSTRACT
<p><b>BACKGROUND</b>Intra-abdominal hypertension (IAH) is common in acute respiratory distress syndrome (ARDS) patients and when resulting in decrease of chest wall compliance will weaken the effect of positive end expiratory pressure (PEEP). We investigated the effect of PEEP titrated by transpulmonary pressure (Ptp) on oxygenation and respiratory mechanics in ARDS patients with IAH compared with PEEP titrated by ARDSnet protocol.</p><p><b>METHODS</b>ARDS patients admitted to the intensive care unit (ICU) of the Zhongda Hospital were enrolled. Patients were ventilated with volume control mode with tidal volume of 6 ml/kg under two different PEEP levels titrated by Ptp method and ARDSnet protocol. Respiratory mechanics, gas exchange and haemodynamics were measured after 30 minutes of ventilation in each round. IAH was defined as intra-abdominal pressure of 12 mmHg or more.</p><p><b>RESULTS</b>Seven ARDS patients with IAH and 8 ARDS patients without IAH were enrolled. PEEP titrated by Ptp were significant higher than PEEP titrated by ARDSnet protocol in both ARDS patients with IAH ((17.3 ± 2.6) cmH2O vs. (6.3 ± 1.6) cmH2O and without IAH ((9.5 ± 2.1) cmH2O vs. (7.8 ± 1.9) cmH2O). Arterial pressure of O2/fraction of inspired oxygen (PaO2/FiO2) was much higher under PEEP titrated by Ptp when compared with PEEP titrated by ARDSnet protocol in ARDS patients with IAH ((27.2 ± 4.0) cmHg vs. (20.9 ± 5.0) cmHg. But no significant difference of PaO2/FiO2 between the two methods was found in ARDS patients without IAH. In ARDS patients with IAH, static compliance of lung and respiratory system were higher under PEEP titrated by Ptp than by ARDSnet protocol. In ARDS patients with IAH, central venous pressure (CVP) was higher during PEEP titrated by Ptp than by ARDSnet protocol.</p><p><b>CONCLUSION</b>Positive end expiratory pressure titrated by transpulmonary pressure was higher than PEEP titrated by ARDSnet protocol and improved oxygenation and respiratory mechanics in ARDS patients with IAH.</p>
Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Intra-Abdominal Hypertension , Therapeutics , Positive-Pressure Respiration , Methods , Respiratory Distress Syndrome , Therapeutics , Respiratory Mechanics , PhysiologyABSTRACT
<p><b>OBJECTIVE</b>To detect the changes of central venous-to-arterial carbon dioxide difference (P(cv-a)CO(2)) during early goal-directed therapy (EGDT) in patients with septic shock and evaluate its' value in predicting adequate resuscitation and prognosis.</p><p><b>METHODS</b>From April 2009 to October 2010, 26 septic shock patients were enrolled in the study. EGDT was performed in all the patients immediately after enrollment. According to the whether they achieved early goal with in the 6 hour or not, patients were separated to EGDT achievement and un-achievement groups. At the onset and after the 6 hours EGDT, mean arterial pressure (MAP), cardiac index (CI), central venous oxygen saturation (ScvO(2)), oxygen delivery (DO(2)), oxygen consumption (VO(2)), oxygen extraction ratio (O(2) ext), lactate, P(cv-a)CO(2) were recorded. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and 28 day mortality were compared between 2 groups.</p><p><b>RESULTS</b>There were no significant difference of age and sex between the 15 patients who achieved early goals and 11 patients who did not. EGDT un-achievement patients had higher APACHE II score (21 ± 5) and 28 day mortality (9/11) when compared with EGDT achievement patients (t = 2.985, χ(2) = 4.547, P < 0.05). In EGDT un-achievement group, MAP, CI, DO(2), VO(2), O(2)ext, ScvO(2), Lac, P(cv-a)CO(2) were comparable between the onset and 6 hours after EGDT. However, in EGDT achievement group, MAP ((90 ± 9) mmHg (1 mmHg = 0.133 kPa)), CI ((4.0 ± 1.8) L×min(-1)×m(-2)), DO(2) ((596 ± 274) ml×min(-1)×m(-2)), ScvO(2) (76.9% ± 4.1%) increased, and P(cv-a)CO(2) ((4.2 ± 2.7) mmHg) decreased significantly after 6 hours of EGDT (t values were -3.393, -2.985, -2.103 and -3.195 respectively, all P < 0.05). The changes of P(cv-a)CO(2) between the onset and 6 hours after EGDT, demonstrated high value for predictability of outcome, according to the area under the ROC curve (AUC) was 0.839 (P = 0.004). As a predictor for death, increasing of P(cv-a)CO(2) after 6 hours of EGDT has a sensibility of 100% and specificity of 60%.</p><p><b>CONCLUSIONS</b>Increasing of P(cv-a)CO(2) after EGDT purports inadequate tissue perfusion in patients with septic shock. Changes of P(cv-a)CO(2) during EGDT demonstrated a useful tool to evaluate adequate resuscitation and prognosis.</p>
Subject(s)
Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Blood Gas Analysis , Carbon Dioxide , Blood , Prognosis , Resuscitation , Shock, Septic , Blood , TherapeuticsABSTRACT
<p><b>OBJECTIVE</b>To evaluate the effect of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients.</p><p><b>METHODS</b>Randomized controlled trials (RCTs) that studied the effect of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients were searched from Pubmed, Embase, The Cochrane Library, CBM during January 1990 to June 2010. The quality of the RCTs was evaluated. Meta-analysis of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients were conducted using the methods recommended by the Cochrane Collaboration. Definition of early tracheotomy was the patients performed tracheotomy during 10 days after admission to hospital or ICU, mechanical ventilation or intubation. Late tracheotomy was defined tracheotomy performed beyond 10 days of admission to hospital or ICU, mechanical ventilation or intubation; or those mechanically ventilated through intubation all the time.</p><p><b>RESULTS</b>Eight hundred and twenty eight patients, 411 in early tracheotomy group and 417 in late tracheotomy group, from 6 RCTs were included in the analysis of data. The meta-analysis showed that early tracheotomy could reduce mortality of patients (RR: 0.81, 95%CI: 0.66 - 0.99, P = 0.04); but it didn't significantly alter the incidence of pneumonia (RR:0.89, 95%CI: 0.68 - 1.17, P = 0.41), mechanical ventilation days (mean difference: -2.19, 95%CI: -9.86 - 5.49, P = 0.58) and length of ICU stay (mean difference: -5.65, 95%CI: -17.11 - 5.81, P = 0.33).</p><p><b>CONCLUSIONS</b>In critically ill adult patients who require prolonged mechanical ventilation, early tracheotomy performed at an earlier stage reduces the mortality, but doesn't reduce the incidence of pneumonia and shorten the mechanical ventilation days and ICU length of stay. But more high quality RCTs are required to confirm it.</p>
Subject(s)
Humans , Prognosis , Randomized Controlled Trials as Topic , Respiration, Artificial , Time Factors , TracheotomyABSTRACT
<p><b>BACKGROUND</b>It is still controversial as to the implementation of higher positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). This study was conducted to compare the lower and higher PEEP in patients with ARDS ventilated with low tidal volume, to investigate the relationship between the recruited lung volume by higher PEEP and relevant independent variables and to provide a bedside estimate of the percentage of potentially recruitable lung by higher PEEP.</p><p><b>METHODS</b>Twenty-four patients with ARDS were studied. A lung recruiting maneuver was performed, then each patient was ventilated with PEEP of 8 cmH(2)O for 4 hours and subsequently with PEEP of 16 cmH(2)O for 4 hours. At the end of each PEEP level period, gas exchange, hemodynamic data, lung mechanics, stress index "b" of the dynamic pressure-time curve, intrinsic PEEP and recruited volume by PEEP were measured.</p><p><b>RESULTS</b>Fourteen patients were recruiters whose alveolar recruited volumes induced by PEEP 16 cmH(2)O were (425 +/- 65) ml and 10 patients were non-recruiters. Compared with the PEEP 8 cmH(2)O period, after the application of the PEEP 16 cmH(2)O, the PaO(2)/FiO(2) ratio and static lung compliance both remained unchanged in non-recruiters, whereas they increased significantly in recruiters. Changes in PaO(2)/FiO(2) and static lung compliance after PEEP increase were independently associated with the alveolar recruitment. Analyzing the relationship between recruiting maneuver (RM)-induced change in end-expiratory lung volume and the alveolar recruitment induced by PEEP, we found a notable correlation.</p><p><b>CONCLUSIONS</b>The results of this study indicated that the potential for alveolar recruitment might vary among the ARDS population and the higher PEEP levels should be limited to recruiters. Improving in PaO(2)/FiO(2), static lung compliance after PEEP increase and the shape of the pressure-time curve could be helpful for PEEP application.</p>