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Objective To explore the clinical value of transthoracic echocardiography(TTE)and related clinical indexesin the evaluation of percutaneous coronary intervention(PCI)supported by arteriovenous extracor-poreal membrane oxygenation(VA-ECMO)in the treatment of patients with acute myocardial ischemia complicated by refractory cardiogenic shock.Methods The clinical data of 70 patients with acute myocardial ischemia complicated by refractory cardiogenic shock treated with VA-ECMO in the First Hospital of Lanzhou University from January 2022 to April 2023 were analyzed retrospectively.According to the success of VA-ECMO withdrawal,the patients were divided into success group(54 cases)and failure group(16 cases).The general data,Intraoperative condi-tion,hemodynamic and biochemical indexes of the two groups were compared,and the independent risk factors affecting the clinical outcome were analyzed.Results The time of ECMO assistance in the success group was significantly shorter than that in the failure group(P<0.05).There was no significant difference inother general information between the two groups(all P>0.05).There was no significant difference in preoperative TIMI grade,number of diseased vascular branches,use of IVUS,ECG results and SYNTAX score between the two groups(all P>0.05).Compared with those before treatment,arterial oxygen saturation(SaO2),left ventricular stroke volume(LVSV),left ventricular ejection fraction(LVEF),mitral annulus systolic velocity(Sa),aortic orifice forward flow spectrum(AV),velocity-time integral(VTI)and tricuspid annulus systolic displacement(TAPSE)increased significantly after ECMO plus PCI treatment(all P<0.05).Left ventricular end systolic volume(LVESV)decreased significantly(P<0.05).Compared with those in the failure group,the heart rate(HR),shock index(SI),blood lactic acid(Lac),C-reactive protein(CRP),aspartate aminotransferase(AST)and total bilirubin(TBIL)were lower in the success group(all P<0.05).There was no significant difference in ECMO flow and SaO2 between the two groups(P>0.05).Univariate logistic regression analysis showed that ECMO-supporting time,HR,Lac,CRP,AST and TBIL were the influencing factors of weaning failure in patients with acute myocardial ischemia complicated with refractory cardiogenic shock.Conclusion VA-ECMO combined with PCI can significantly improve cardiac function in patients with acute myocardial ischemia complicated by refractory cardiogenic shock.Echocardiographic parameters(LVESV,LVSV,LVEF,Sa,AV,VTI,TAPSE)and clinical indexes(HR,Lac,CRP,AST,TBIL)have certain clinical value for theprognosis.
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The clinical research in the field of extracorporeal life support (ECLS) in 2023 has focused on the efficacy of veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with infarct-related cardiogenic shock. Additionally, the research also explored the efficacy of prone positioning during veno-venous ECMO, transfusion strategies, and the impact of obesity on outcomes. Awake veno-venous ECMO has shown novel therapeutic potential, but its optimal practice methods and management strategies remain to be determined. In in-hospital cardiac arrest patients, extracorporeal cardiopulmonary resuscitation has demonstrated higher survival rates and better neurological recovery compared to conventional cardiopulmonary resuscitation. The effectiveness of extracorporeal carbon dioxide removal varies among patients with different types of respiratory failure. Future research should focus on optimizing the application strategies and process management of ECLS technologies, investigating personalized therapy, and studying how to improve long-term rehabilitation and quality of life for survivors.
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Objective:To investigate the prognostic value of the ratio of veno-arterial carbon dioxide partial pressure difference to arterio-venous oxygen content difference (Pv-aCO 2/Ca-vO 2) in children with primary peritonitis-related septic shock. Methods:A retrospective study was conducted. Sixty-three children with primary peritonitis-related septic shock admitted to department of intensive care unit of the Children's Hospital Affiliated to Xi'an Jiaotong University from December 2016 to December 2021 were enrolled. The 28-day all-cause mortality was the primary endpoint event. The children were divided into survival group and death group according to the prognosis. The baseline data, blood gas analysis, blood routine, coagulation, inflammatory status, critical score and other related clinical data of the two groups were statistics. The factors affecting the prognosis were analyzed by binary Logistic regression, and the predictability of risk factors were tested by the receiver operator characteristic curve (ROC curve). The risk factors were stratified according to the cut-off, Kaplan-Meier survival curve analysis compared the prognostic differences between the groups.Results:A total of 63 children were enrolled, including 30 males and 33 females, the average age (5.6±4.0) years old, 16 cases died in 28 days, with mortality was 25.4%. There were no significant differences in gender, age, body weight and pathogen distribution between the two groups. The proportion of mechanical ventilation, surgical intervention, vasoactive drug application, and procalcitonin, C-reactive protein, activated partial thromboplastin time, serum lactate (Lac), Pv-aCO 2/Ca-vO 2, pediatric sequential organ failure assessment, pediatric risk of mortality Ⅲ in the death group were higher than those in the survival group. Platelet count, fibrinogen, mean arterial pressure were lower than those in the survival group, and the differences were statistically significant. Binary Logistic regression analysis showed that Lac and Pv-aCO 2/Ca-vO 2 were independent risk factors affecting the prognosis of children [odds ratio ( OR) and 95% confidence interval (95% CI) were 2.01 (1.15-3.21), 2.37 (1.41-3.22), respectively, both P < 0.01]. ROC curve analysis showed that the area under curve (AUC) of Lac, Pv-aCO 2/Ca-vO 2 and their combination were 0.745, 0.876 and 0.923, the sensitivity were 75%, 85% and 88%, and the specificity were 71%, 87% and 91%, respectively. Risk factors were stratified according to cut-off, and Kaplan-Meier survival curve analysis showed that the 28-day cumulative probability of survival of Lac ≥ 4 mmol/L group was lower than that in Lac < 4 mmol/L group [64.29% (18/28) vs. 82.86% (29/35), P < 0.05]. Pv-aCO 2/Ca-vO 2 ≥ 1.6 group 28-day cumulative probability of survival was less than Pv-aCO 2/Ca-vO 2 < 1.6 group [62.07% (18/29) vs. 85.29% (29/34), P < 0.01]. After a hierarchical combination of the two sets of indicator variables, the 28-day cumulative probability of survival of Pv-aCO 2/Ca-vO 2 ≥ 1.6 and Lac ≥ 4 mmol/L group significantly lower than that of the other three groups (Log-rank test, χ2 = 7.910, P = 0.017). Conclusion:Pv-aCO 2/Ca-vO 2 combined with Lac has a good predictive value for the prognosis of children with peritonitis-related septic shock.
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Objective·To assess the effect of veno-arterial extracorporeal membrane oxygenation(VA-ECMO)treatment on the mortality rate of patients suffering from cardiogenic shock and cardiac arrest in hospital.Methods·A total of 19 patients with cardiogenic shock or cardiac arrest who were treated with VA-ECMO treatment in Suzhou Kowloon Hospital,Shanghai Jiao Tong University School of Medicine from September 2017 to March 2022 were included in the retrospective study.Patients were divided into extracorporeal cardiopulmonary resuscitation(ECPR)group(n=9)and VA-ECMO for cardiogenic shock(E-CS)group(n=10)according to whether cardiac arrest had occurred.The general demographic data,clinical data,Sequential Organ Failure Assessment(SOFA)scores,postoperative complications and prognostic indicators of the two groups of patients were collected.Univariate and multivariate Cox proportional hazard regression analyses were used to evaluate the correlation between each covariate and hospital mortality.Results·Among the included patients,there were 15 males(78.9％),with an average age of 46.5(34.5,61.6)years.The incidence of postoperative complications was as follows:bleeding(47.4％),AKI(36.8％),infection(31.6％),limb ischemia(15.8％)and cerebrovascular accident(5.3％).The duration of VA-ECMO was 4.0(2.0,6.8)days,and the intensive care duration was 11.5(5.8,26.2)days;the ECMO withdrawal success rate was 63.2％,and the hospital mortality was 63.2％.The results of univariate Cox proportional hazard regression analysis showed that AKI(prior to VA-ECMO initiation),postoperative complications of infection and limb ischemia were correlated with the hospital mortality of patients(all P＜0.05).The results of multivariate Cox proportional hazard regression analysis showed that AKI(prior to VA-ECMO initiation),postoperative complications of infection and limb ischemia were also independent risk factors for the hospital mortality of patients(all P＜0.05).Conclusion·For patients with cardiogenic shock and cardiac arrest treated with VA-ECMO,AKI(prior to VA-ECMO initiation),postoperative infection and limb ischemia are independently associated with higher hospital mortality.
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Objective:To determine the predictive role of combined assessment of vasoactive-inotropic score(VIS) and lactate for the prognosis of patients with postcardiotomy cardiogenic shock(PCS) requiring venoarterial extracorporeal membrane oxygenation(VA-ECMO).Methods:222 adults with PCS requiring VA-ECMO were retrospectively analyzed and divided into four groups according to the cut-off values of VIS and lactate(Lac) at 24 h after ECMO initiation: group 1(59 cases): VIS≤14.5, Lac≤2.45 mmol/L; group 2(17 cases): VIS>14.5, Lac≤2.45 mmol/L; group 3(90 cases): VIS≤14.5, Lac>2.45 mmol/L; group 4(56 cases): VIS>14.5, Lac>2.45 mmol/L. The incidence of in-hospital mortality and other clinical outcomes were analyzed. The associations of VIS and lactate and in-hospital mortality were analyzed using Cox proportional hazards analysis.Results:The in-hospital mortality was 18.6%, 58.8%, 63.3% and 71.4% in the four groups( P<0.001), while the rate of successful weaning off ECMO was 88.1%, 88.2%, 58.9% and 33.9% respectively( P<0.001). The group 1 significantly differed from other three groups with regards to in-hospital mortality and ECMO weaning rate( P<0.05). The groups 1 also showed significantly improved cumulative 60-day survival compared with other three groups( log- rank test, P<0.05). Cox proportional hazards analysis showed age( HR=1.03, 95% CI: 1.01-1.05, P=0.001), female( HR=1.87, 95% CI: 1.27-2.76, P=0.002), VIS at 24 h after ECMO initiation( HR=1.02, 95% CI: 1.00-1.05, P=0.020), and lactate at 24h after ECMO initiation( HR=1.12, 95% CI: 1.08-1.16, P<0.001) were independently predictive of in-hospital mortality. Conclusion:Patients with VIS≤14.5 and Lac≤2.45 within 24 h after ECMO initiation had better in-hospital and 60-day outcomes, suggesting that combined assessment of VIS and lactate may be instructive for determining the prognosis of PCS patients requiring VA-ECMO support.
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Introduction:Veno-arterial extracorporeal membrane oxygenation (ECMO) is well-recognized treatment modality for patients with refractory cardiogenic shock. Uncomplicated cannulation is a prerequisite and basis for achieving a successful outcome in ECMO. Vascular access is obtained either by surgical cut-down. Common vascular access complications are bleeding and limb ischemia. Objective: To evaluate cannulation technique, the incidence of vascular complications, and their impact on the outcome. Methods: A retrospective data analysis conducted on 95 patients receiving ECMO from 2013 to 2020 was done. The patients were divided into two groups: no vascular access complications (non-VAC group) and vascular access complications (VAC group). The groups were compared related to the hospital and ICU stays and blood transfusion. Results: The patients in both groups were demographically and clinically comparable. The Non-VAC group had 75 patients, whereas the VAC group had a total of 20 patients. The main complication observed in the VAC group was bleeding from the cannulation site which required more blood transfusion than the non-VAC group (6.8 ± 1.02 vs 4.2 ± 1.26). Limb ischemia was another complication seen in the VAC group (4.2%, n = 4). Two patients had delayed bleeding after decannulation. The overall average length of stay in the hospital was statistically similar in both the groups (22 days in the VAC group vs 18 days in the non-VAC group), but the average ICU stay was more in the VAC group compared to the non-VAC group (18 days vs 12.06 days). Conclusion: Bleeding and limb ischemia are the important vascular access site complications, which increase blood transfusion requirements, ICU stay, and overall hospital stay.
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Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal circulation technique that provides circulatory and oxygenation support, and it is currently used in the treatment of cardiogenic shock (CS), pulmonary embolism, cardiac arrest (CA), and other diseases. However, this technology is still associated with high complications and mortality. The use of predictive scores for risk stratification before VA-ECMO will be helpful to screen the optimal benefiting population, make optimal clinical decisions, and allocate medical resources reasonably. At present, there are few reports about predictive scores for VA-ECMO. This article systematically reviewed the predictive performance of various scoring tools [the survival after venoarterial ECMO (SAVE) score, prediction of cardiogenic shock outcome for acute myocardial infarction (AMI) patients salvaged by VA-ECMO (ENCOURAGE) score, model for end-stage liver disease (MELD-Ⅺ) score, post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) score, the predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting (REMEMBER) score, predictors of mortality with VA-ECMO for acute massive pulmonary embolism, extracorporeal cardiopulmonary resuscitation (ECPR) score, the hypothermia outcome prediction after extracorporeal life support (HOPE) score] for patients receiving VA-ECMO to provide reference for clinical treatment.
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OBJECTIVES@#Extracorporeal membrane oxygenation (ECMO) is an extracorporeal life support strategy for the treatment of critically ill children with reversible heart and lung failure, increasingly being used in patients with low cardiac output after cardiac surgery. However, the mortality of patients is closely related to the complications of ECMO, especially bleeding, thrombosis, and infection, ECMO-related nosocomial infection has become a challenge to the success of ECMO. This study aims to analyze the incidence and risk factors for venoarterial-ECMO (VA-ECMO)-related nosocomial infections in children after cardiac surgery.@*METHODS@#We retrospectively collected the data of patients who underwent VA-ECMO treatment after pediatric cardiac surgery in the Second Xiangya Hospital of Central South University from July 2015 to March 2021, and divided them into an infected group and a non-infected group. The clinical characteristics of the 2 groups of patients, VA-ECMO-related nosocomial infection factors, pathogenic microorganisms, and patient mortality were compared. Logistic regression was used to analyze the risk factors for nosocomial infection related to VA-ECMO after cardiac surgery.@*RESULTS@#Of the 38 pediatric patients, 18 patients (47.37%) had VA-ECMO related nosocomial infection, served as the infected group, including 7 patients with blood infections and 11 respiratory tract infections. Gram-negative pathogens (16 strains, 88.9%) were the main bacteria, such as Acinetobacter baumannii (6 strains), Klebsiella pneumoniae (3 strains), and Stenotrophomonas maltophilia (3 strains). Compared with the non-infected group (n=20), the infection group had longer time of cardiopulmonary bypass, time of myocardial block, and time of VA-ECMO assistance (All P<0.05). Multivariate logistic regression analysis showed that time of cardiopulmonary bypass (OR=1.012, 95% CI 1.002 to 1.022; P=0.021) was an independent risk factor for ECMO-related nosocomial infection. The number of surviving discharges in the infected group was less than that in the non-infected group (1 vs 11, P<0.05).@*CONCLUSIONS@#Cardiopulmonary bypass time is an independent risk factor for VA-ECMO-related nosocomial infection in children after cardiac surgery. Shortening the duration of extracorporeal circulation may reduce the incidence of VA-EMCO-related nosocomial infections in children after cardic surgery. The occurrence of VA-ECMO-related nosocomial infections affects the number of patient's discharge alive.
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Enfant , Humains , Procédures de chirurgie cardiaque/effets indésirables , Infection croisée/étiologie , Oxygénation extracorporelle sur oxygénateur à membrane/effets indésirables , Études rétrospectives , Facteurs de risqueRÉSUMÉ
Objective:To examine the long-term survival outcomes and identify mortality risk factors for coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation(VA-ECMO) for postcardiotomy cardiogenic shock.Methods:Data from 121 consecutive venoarterial extracorporeal membrane oxygenation-treated coronary artery bypass grafting(CABG) patients at Beijing Anzhen Hospital between June 2012 and December 2016 were analyzed. There were 84 males and 24 females. The median age was 62(55, 67) years, and the median body mass index was 25(23, 27)kg/m 2. Thirty-seven patients(34%) had left main artery disease, and 56 patients(52%) underwent off-pump CABG. According to the 3 year survival outcome after ECMO, patients were divided into survival group(35 cases) and non-survival group(73 cases). The differences of clinical indicators between the two groups were compared and analyzed. Multivariable Cox regression modeling was used to identify factors independently associated with 36 month mortality. Results:Sixty-five patients(60%) could be weaned from VA-ECMO, 49 patients(45%) survived to hospital discharge, and 35 patients(32%) survived to 3 years. The median( IQR) time on VA-ECMO support was 4(3, 5) days. The median( IQR) length of ICU stay and hospital stay duration were 8(5, 12) and 20(13, 29) days, respectively. Older age( HR=1.06, 95% CI: 1.03-1.10, P<0.001), left main coronary artery disease( HR=1.62, 95% CI: 1.00-2.60, P=0.048), and vasoactive inotropic score( HR=1.09, 95% CI: 1.03-1.17, P=0.007)were independent risk factors associated with 3-year mortality. The area under the receiver operating characteristic curve for the model, which was constructed with age≥60years, left main coronary artery disease, and vasoactive inotropic score>60, was 0.88(95% CI: 0.80-0.95). Conclusion:Long-term survival of patients who survive to discharge appears favorable. Older age, left main coronary artery disease, and vasoactive inotropic score were associated with 3-year mortality in coronary artery bypass grafting patients who received VA-ECMO.
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Resumen La cardiomiopatía de Takotsubo es una entidad caracterizada por disfunción ventricular aguda y transitoria, la cual está generalmente relacionada a un evento desencadenante (estrés emocional o físico) y que, por lo general, se presenta con disfunción sistólica regional del ventrículo izquierdo, aunque hasta en un 30% puede ser biventricular. Según su severidad, en algunos casos puede condicionar choque cardiogénico refractario a manejo con inotrópicos y vasopresores, por lo que para estos casos deben considerarse los dispositivos de asistencia circulatoria. Presentamos el caso de una paciente joven a quien se realizó cambio valvular pulmonar con prótesis biológica, la cual siete semanas posteriores a la cirugía acudió al servicio de urgencias con derrame pericárdico y fisiología de tamponade secundario a síndrome pospericardiotomía. Por tal motivo se le practicó ventana pericárdica, sin embargo durante el transquirúrgico presentó cardiomiopatía de Takotsubo biventricular que le condicionó choque cardiogénico con insuficiencia mitral y tricúspidea severas y refractariedad a tratamiento médico, así como a balón intraaórtico de contrapulsación (BIAC), por lo cual requirió soporte circulatorio con ECMO venoarterial durante 5 días.
Abstract Takotsubo cardiomyopathy is an entity characterized by acute and transient ventricular dysfunction, which is usually related to a triggering event (emotional or physical stress), and usually presents with regional systolic dysfunction of the left ventricle, however up to 30% may be biventricular. Depending on its severity in some cases the disease can condition refractory cardiogenic shock to management with inotropics and vasopressors, so for these cases circulatory assistance devices should be considered. We present the case of a young patient who had pulmonary valve change with biological prosthesis, which seven weeks after surgery went to the emergency department with pericardial effusion and tamponade physiology secondary to postpericardiotomy syndrome. For this reason pericardial window was practiced, however during the procedure she presented biventricular Takotsubo cardiomyopathy which conditioned cardiogenic shock with severe mitral and tricuspid regurgitation, and refractivity to medical treatment as well as intraaortic balloon pump, requiring circulatory support with venoarterial ECMO for 5 days.
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Humains , Femelle , Adulte , Oxygénation extracorporelle sur oxygénateur à membrane , Syndrome de tako-tsubo/thérapieRÉSUMÉ
@#Although extracorporeal membrane oxygenation (ECMO) has been in existence since the 1970s as a means of supporting respiratory or cardiac function, early application of this technology was plagued by high complication rates. Peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) causes higher left ventricular end-diastolic pressure, pulmonary edema, left ventricular distention, ventricular arrhythmia, low coronary perfusion, myocardial ischemia, substantial thrombus formation within left ventricule cavity and even multiple organ dysfunction. Mechanical left ventricular decompression is required to treat these related complications. In this article, we reviewed the problems associated with left ventricular decompression supported by peripheral V-A ECMO in patients with cardiogenic shock.
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Objective:To analyze the early volume characteristics of patients with severe cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the relationship between their early volume and the prognosis.Methods:This study reviewed patients of Emergency Medical University , treated with VA-ECMO and screened the patients with severe cardiogenic shock and VA-ECMO running more than 72 h for further study. The basic condition of the patients was recorded, and the fluid balance in the first 72 h was analyzed. The patients were grouped according to their fluid balance in the first 72 h. The gender, age, survival rate, continuous renal replacement therapy (CRRT) rate, intra-aortic balloon pump (IABP) rate, and invasive mechanical ventilation rate were compared between the two groups, and the relative risk to the prognosis was calculated. The prognosis was compared between the two groups. Results:Totally 77 patients with severe cardiogenic shock were enrolled. Forty-one cases survived, with an overall survival rate of 53.2%. The volume balance at 48-72 h and the total volume balance at the first 72 h were different between the survival and dead groups. Compared with the positive balance group, patients in the negative balance group were less likely to receive CRRT or invasive mechanical ventilation during the first 72 h. Patients in the negative balance group during the first 72 h had a better survival rate, and their relative risk of survival was 1.81 (95% confidence interval: 1.101, 2.985). However, there was no significant difference in survival rate according to every 24 h fluid balance.Conclusions:Patients with severe cardiogenic shock treated with VA-ECMO who had negative total volume balance during the first 72 h are more likely to survive and less likely to require CRRT or invasive mechanical ventilation.
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Objective:To summarize the clinical characteristics and influencing factors on clinical outcome of patients receiving extracorporeal cardiopulmonary resuscitation (ECPR).Methods:A total of 78 patients receiving ECPR admitted to the Department of Emergency Medicine of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People’s Hospital) from March 2015 to December 2020 were retrospectively enrolled. Patients were divided into the survival group and death group according to clinical outcome. Their baseline data, CPR associated parameters, and pre-ECPR laboratory tests were compared between the two groups.Results:Of the 78 included patients, 51 patients were male and 27 female. Twenty-three patients finally survived, including 10 males and 13 females. There were no significant differences in age, body mass index and underlying diseases (hypertension, diabetes and coronary heart disease) between the two groups (all P > 0.05). The proportion of male patients in the survival group was lower than that in the death group ( P=0.017). Meanwhile Survival After Veno-Arterial ECMO (SAVE) score was significantly higher in the survival group than that in the death group[ (-1.57±4.15) vs. (-9.36±5.36), P<0.001]. The proportion of by-stander CPR in the survival group was higher than that in the death group ( P=0.014). The pre-ECPR serum AST, ALT, and Cr levels in the survival group were significantly lower than those in the death group (all P<0.05). Logistic regression analysis showed that by-stander CPR ( OR=0.114, 95% CI: 0.015~0.867, P=0.036) and SAVE score ( OR=0.625, 95% CI: 0.479~0.815, P=0.001) were independent risk factors predicting ICU death in patients receiving ECPR. Conclusions:ECPR is an efficient tool to improve clinical outcomes of patients with cardiac arrest. By-stander CPR and SAVE score are independent risk factors predicting ICU death in patients receiving ECPR.
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Objective:To investigate the predictive value of echocardiography hemodynamic parameters on 30-day survival rate after veno-arterial extracorporeal membrane oxygenation in refractory cardiogenic shock.Methods:A total of 44 patients with refractory cardiogenic shock who passed VA-ECMO weaning trial were retrospectively analyzed from September 2014 to February 2021. According to their 30-day survival outcomes after VA-ECMO removal, these patients were divided into the survival group (32 cases) and the death group (12 cases). Baseline data and the change rate of echocardiographic parameters between the first day of VA-ECMO and the day on VA-ECMO removal were compared, and the ultrasonic indicators affecting the survival of VA-ECMO within 30 days after withdrawal were determined.Results:The change rate of left ventricular ejection fraction(ΔLVEF%), the change rate of velocity time integral of the left ventricular outflow tract(ΔLVOT-VTI%), the change rate of ΔSa% and the change rate of right ventricular fractional area change(ΔRVFAC%) were improved significantly in the survival group ( P<0.05). The correlation coefficients between ΔLVEF% and ΔLVOT-VTI%, ΔLVEF% and ΔSa%, ΔLVEF % and ΔRVFAC% were 0.885, 0.861, 0.675, respectively( P<0.001); The correlation coefficient between ΔLVOT-VTI% and ΔSa was 0.918( P<0.001). ROC curve showed that the cut off values of ΔLVEF%, ΔLVOT-VTI%, ΔSa% and ΔRVFAC% to predict 30-day survival rate were 23.6%, 20.1%, 22.8% and 23.2% respectively, the sensitivity was 89.5%, 93%, 89.5% and 74.6% respectively, specificity was 66.7%, 66.7%, 66.8% and 75% respectively, the area under ROC curve (AUC) was 0.841, 0.867, 0.841 and 0.768, respectively. Conclusions:ΔLVEF%, ΔLVOT-VTI%, ΔSa% and ΔRVFAC% are predictive indicators of VA-ECMO withdrawl in patients with refractory cardiac shock. ΔLVOT-VTI% is the most valuable indicator of predicting 30-day survival rate after VA-ECMO withdrawl. Patients who meet two or more VA-ECMO echocardiographic indicators are more likely to succeed in VA-ECMO withdrawl. The improvement of right ventricular systolic function is a prerequisite for survival after 30 days of VA-ECMO withdrawal, while LVEF is an important criterion for survival after 30 days of VA-ECMO withdrawal.
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The utilization of temporary circulatory support in the form of extracorporeal membrane oxygenation (ECMO) has increased and its indications are expanding. Anesthesiologists may be involved in the care of these patients during the initiation of and weaning off from ECMO, surgical procedures with an ECMO in situ, and transfer of patients on ECMO between the operating theater and intensive care unit. This article addresses the anesthetic considerations and management for explant of veno-arterial ECMO in adults.
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Objective To investigate the efficacy of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in the treatment of refractory septic shock in children.Methods From January 2016 to December 2018,the clinical data of children with refractory septic shock (RSS) treated by VA-ECMO in Department of Critical Medicine Affiliated Children's Hospital of Shanghai Jiao Tong University were retrospectively analyzed.The patients with refractory septic shock (RSS) treated by VA-ECMO were compared with those with non-refractory septic shock (NRSS).Results There were 8 cases in the RSS-ECMO group and 6 cases in the NRSS-ECMO group.The sex,age,PRISM score,complication showed no significant difference in the two groups.The median time of ECMO in the RSS-ECMO group was 182 (141,216) h,and 5 patients were survived and were discharged from the hospital.The blood lactic acid and vasoactive drug index in the RSS-ECMO group was significantly higher than that in the NRSS-ECMO group (P＜0.05 or P＜0.01).The time of vasoactive drugs use and the ratio of combined continuous renal replacement therapy (CRRT) in the RSS-ECMO group were higher than those in the NRSS-ECMO group,but there was no significant difference (P ＞ 0.05).Atter ECMO establishment,the mean invasive arterial pressure increased significantly at 6 h,and lactic acid decreased significantly at 12 h after ECMO support.SCVO2 returned to normal at 24-h ECMO therapy.Conclusions The success rate of VA-ECMO treatment in children with refractory septic shock complicated with MODS is similar to that of children with non-refractory septic shock.The relationship between ECMO and hemodynamic indexes in sepsis should be further explored.
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Objective To observe the feasibility of early enteral nutrition (EEN) in adult patients during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and its related clinical results. Methods Thirty-four patients admitted to the Intensive Care Unit (ICU) of Ningbo Medical Center Li Huili Hospital from January 2012 to December 2017 to receive VA-ECMO treatment were selected as the study objects. All patients received EEN after exclusion of contraindications; the target calories were calculated by using 104.65 kJ·kg-1·d-1(25 kcal·kg-1·d-1) and according to 1.2 g·kg-1·d-1, the target protein requirements were calculated. Within one week of EN energetic treatment, if the feeding amount reached 80% or over of the above calculated targets, the EN administration was fulfilling the standard, thus the patients were divided into a standard group and a non-standard group, After ICU admission, the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, multiple organ dysfunction syndrome (MODS) score, the time from the beginning of ECMO to the start of EN, time reaching feeding standard, VA-ECMO persistent days, ICU days of stay, total hospitalization days, hospital mortality, and reasons for feeding interruptions were recorded, and the effects of EEN on prognosis of patients during VA-ECMO were analyzed in the two groups. Results The APACHE Ⅱ score and MODS score of the non-standard group were higher than those of the standard group on admission of ICU (APACHE Ⅱscore: 25.50±5.62 vs. 19.91±8.53, MODS score: 11.08±3.26 vs. 6.73±2.05, both P < 0.05), and the hospital mortality was lower in the standard group than that in non-standard group [40.9% (9/22) vs. 83.3% (10/12), P < 0.05]. The comparisons of differences in time from the beginning of ECMO to the start of EN, time of reaching feeding standard, VA-ECMO treatment days, ICU days of stay, hospitalization days between the two groups were of no statistical significance (all P > 0.05). The most common reason for interruption of feeding was high gastric residual volume (GRV). Conclusion Whether a critically ill patient receiving VA-ECMO can reach the target feeding amount in a week or not is related to the degree of disease severity; it is difficult for a seriously ill patient to reach the target amount of feeding, that may affect their prognosis.
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We hereby report a child with transposition of great arteries and regressed ventricle who underwent arterial switch operation (ASO) with the aid of cardiopulmonary bypass and “integrated” extracorporeal membrane oxygenation (ECMO) circuit. The significance of lactate clearance as a guide to initiate and terminate veno-arterial ECMO in a post ASO child with regressed left ventricle is discussed.
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Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.
Sujet(s)
Humains , Dépression , Hémodynamique , Hypovolémie , Lactates , Logique , Examen physique , Physiologie , Sepsie , Choc , Choc septiqueRÉSUMÉ
Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.