Custo-Efetividade da Oxigenação por Membrana Extracorpórea Venoarterial no Choque Cardiogênico Refratário: Um Estudo na Perspectiva Brasileira / Cost-Utility of Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock: A Brazilian Perspective Study

Resumo Fundamento O choque cardiogênico (CC) refratário está associado com altas taxas de mortalidade, e o uso de oxigenação por membrana extracorpórea venoarterial (VA-ECMO, do inglês venoarterial extracorporeal membrane oxygenation) como uma opção terapêutica tem gerado discussões. Nesse sentido, sua custo-efetividade, principalmente em países de baixa e média renda como o Brasil, continua incerto.Objetivos: Conduzir uma análise de custo-efetividade na perspectiva do Sistema Único de Saúde (SUS) para avaliar a custo-efetividade de VA-ECMO combinado com o tratamento padrão em comparação ao tratamento padrão isolado em pacientes adultos com CC refratário. Métodos Acompanhamos uma coorte de pacientes com CC refratário tratados com VA-ECMO em centros de assistência terciária do sul brasileiro. Coletamos dados de desfechos e custos hospitalares. Realizamos uma revisão sistemática para complementar nossos dados e usamos o modelo de Markov para estimar a razão de custo-efetividade incremental (RCEI) por ano de vida ajustado pela qualidade (QALY) e por ano de vida ganho. Resultados Na análise do caso-base, a VA-ECMO gerou uma RCEI de Int$ 37 491 por QALY. Análises de sensibilidade identificaram o custo de internação, o risco relativo de sobrevida, e a sobrevida do grupo submetido à VA-ECMO como principais variáveis influenciando os resultados. A análise de sensibilidade probabilística mostrou um benefício do uso de VA-ECMO, com uma probabilidade de 78% de custo-efetividade no limiar recomendado de disposição a pagar. Conclusões Nosso estudo sugere que, dentro do SUS, VA-ECMO pode ser uma terapia custo-efetiva para o CC refratário. Contudo, a escassez de dados sobre a eficácia e de ensaios clínicos recentes que abordem seus benefícios em subgrupos específicos de pacientes destaca a necessidade de mais pesquisas. Ensaios clínicos rigorosos, incluindo perfis diversos de pacientes, são essenciais para confirmar a custo-efetividade com uso de VA-ECMO e assegurar acesso igualitário a intervenções médicas avançadas dentro dos sistemas de saúde, especialmente em países com desigualdades socioeconômicas como o Brasil.

Abstract Background Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. Methods We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. Results In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Conclusions Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

O Índice de Imuno Inflamação Sistêmica Prevê Mortalidade Hospitalar em Pacientes Submetidos à Cirurgia Cardíaca com Circulação Extracorpórea / The Systemic Immune-Inflammation Index Predicts In-Hospital Mortality in Patients Who Underwent On-Pump Cardiac Surgery

Resumo Fundamento: O índice de imuno-inflamação sistêmica (SII), um novo índice inflamatório calculado usando contagens de plaquetas, neutrófilos e linfócitos, demonstrou ser um fator de risco independente para a identificação de doença arterial coronariana de alto risco em pacientes submetidos a intervenção coronária percutânea e cardiovascular e cirurgia com circulação extracorpórea (CEC). A relação entre as taxas de mortalidade relacionadas ao SII e à CEC permanece obscura. Objetivo: Esta pesquisa foi desenhada para investigar o uso do SII para prever mortalidade hospitalar em pacientes submetidos à cirurgia cardíaca com CEC. Métodos: Quatrocentos e oitenta pacientes submetidos a procedimento cardíaco envolvendo CEC durante 3 anos foram coletados do banco de dados do hospital. Foram comparados os dados demográficos, comorbidades, perfis hematológicos e bioquímico e dados operatórios dos grupos. Análises múltiplas de regressão logística foram feitas para determinar preditores independentes de mortalidade. Os fatores prognósticos foram avaliados por análise multivariada e os valores preditivos de SII, relação neutrófilo-linfócito (NLR) e razão plaqueta-linfócito (PLR) para mortalidade foram comparados. Um valor de p <0,05 foi considerado significativo. Resultados: Dos 480 pacientes, 78 desenvolveram mortalidade hospitalar após cirurgia cardíaca. O SII foi um preditor independente de mortalidade hospitalar (odds ratio: 1,003, intervalo de confiança de 95%: 1,001-1,005, p<0,001). O valor de corte do SII foi >811,93 com sensibilidade de 65% e especificidade de 65% (área sob a curva: 0,690). Os valores preditivos de SII, PLR e NLR foram próximos entre si. Conclusão: Altos escores pré-operatórios do SII podem ser usados para determinação precoce de tratamentos apropriados, o que pode melhorar os resultados cirúrgicos de cirurgia cardíaca no futuro.

Abstract Background: Systemic immune-inflammation index (SII), a new inflammatory index calculated using platelet, neutrophil, and lymphocyte counts, has been demonstrated to be an independent risk factor for the identification of high-risk coronary artery disease in patients undergoing percutaneous coronary intervention and cardiovascular surgery with cardiopulmonary bypass (CPB). The relationship between SII and CPB-related mortality rates remains unclear. Objective: This research was designed to investigate the use of SII to predict in-hospital mortality in patients undergoing cardiac surgery with CPB. Methods: Four hundred eighty patients who underwent a cardiac procedure involving CPB over 3 years, were obtained from the hospital's database. The demographic data, comorbidities, hematological and biochemical profiles, and operative data of the groups were compared. Multiple logistic regression analyses were done to determine independent predictors of mortality. Prognostic factors were assessed by multivariate analysis, and the predictive values of SII, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) for mortality were compared. A p-value <0.05 was considered significant. Results: Of 480 patients, 78 developed in-hospital mortality after cardiac surgery. SII was an independent predictor of in-hospital mortality (Odds ratio: 1.003, 95% confidence interval: 1.001-1.005, p<0.001). The cut-off value of the SII was >811.93 with 65% sensitivity and 65% specificity (area under the curve: 0.690). The predictive values of SII, PLR, and NLR were close to each other. Conclusion: High preoperative SII scores can be used for early determination of appropriate treatments, which may improve surgical outcomes of cardiac surgery in the future.

Atuação do enfermeiro perfusionista na cirurgia cardíaca / Role of the perfusion nurse in cardiac surgery / La actuación del enfermero perfusionista en la cirugía cardíaca

Objetivo: Analisar a atuação do enfermeiro perfusionista na cirurgia cardíaca. Método: Estudo exploratório com abordagem qualitativa, desenvolvida em ambiente virtual no período de 1 a 30 de junho de 2022. Amostra intencional, não probabilística, constituída de 14 enfermeiros perfusionistas. Os dados foram analisados por meio da análise de conteúdo de Bardin. Resultados: Emergiram duas categorias temáticas: Atuação do enfermeiro perfusionista na circulação extracorpórea e A relevância da interação do enfermeiro com os membros da equipe durante a cirurgia cardíaca com circulação extracorpórea. Os relatos identificaram que o enfermeiro perfusionista realiza inúmeras atribuições que vão desde o histórico de enfermagem, até o preparo e a escolha de materiais, circuitos, dispositivos e maquinários para a condução da circulação extracorpórea. Destaca-se a interação desse profissional com os demais membros da equipe no tocante à comunicação a fim de minimizar riscos e obter resultado cirúrgico positivo para o paciente. Conclusão: A atividade do enfermeiro perfusionista é complexa e necessita de um rigoroso preparo teórico-prático, especializações reconhecidas pelos órgãos competentes, bem como frequentes atualizações mesmo já sendo um profissional experiente. (AU)

Objective: To analyze the role of the perfusionist nurse in cardiac surgery. Method: Exploratory study with a qualitative approach, conducted in a virtual environment from June 1st to June 30th, 2022. The sample consisted of 14 perfusionist nurses, selected intentionally and non-probabilistically. Data were analyzed through Bardin's content analysis. Results: Two thematic categories emerged: the role of the perfusionist nurse in extracorporeal circulation and the relevance of the nurse's interaction with team members during cardiac surgery with extracorporeal circulation. The reports identi-fied that the perfusionist nurse performs numerous tasks ranging from nursing history to the preparation and selection of materials, circuits, devices, and machinery for extracorporeal circulation. The interaction of this professional with other team members regarding communication stands out, aiming to minimize risks and achieve positive surgical outcomes for the patient. Conclusion: The activity of the perfusionist nurse is complex and requires rigo-rous theoretical-practical preparation, recognized specializations by competent bodies, as well as frequent updates even for experienced professionals

Objetivo: Analizar el papel del enfermero de perfusión en la cirugía cardíaca. Método: Estudio exploratorio con enfoque cualitativo, desarrol-lado en ambiente virtual durante el período del 1 al 30 de junio de 2022. Muestra intencional, no probabilística, compuesta por 14 enfermeros de perfu-sión. Los datos fueron analizados mediante el análisis de contenido de Bardin. Resultados: Surgieron dos categorías temáticas: El papel del enfermero perfusionista en circulación extracorporea y la relevancia de la interacción del enfermero con los miembros del equipo durante la cirugía cardíaca con circulación extracorporea. Los informes identificaron que el enfermero perfusionista desempeña numerosas atribuciones que van desde el historial de enfermería hasta la preparación y elección de materiales, circuitos, dispositivos y maquinaria para la conducción de la circulación extracorporea. Se des-taca la interacción de este profesional con los demás miembros del equipo en lo que respecta a la comunicación para minimizar riesgos y obtener resulta-dos quirúrgicos positivos para el paciente. Conclusión: La actividad del enfermero de perfusión es compleja y requiere una preparación teórico-práctica rigurosa, especializaciones reconocidas por los órganos competentes, así como actualizaciones frecuentes incluso siendo un profesional experimentado

Interpretation of"Extracorporeal Life Support Organization(ELSO):guidelines for neonatal respiratory failure" / 解放军医学杂志

According to the extracorporeal life support(ECLS)registry report,the use of extracorporeal membrane oxygenation(ECMO)in neonates with severe respiratory failure reached its peak in 1992.With the emergence of new respiratory support methods such as nitric oxide,pulmonary surfactant,and high-frequency ventilation,the number of neonates with ECMO for respiratory support decreased gradually,maintaining at about 1000 cases per year.However,it also means that the neonates who need ECMO support will be in a more severe condition,which requires higher requirements for clinicians.In order to further standardize the technique of neonatal extracorporeal life support,the Extracorporeal Life Support Organization(ELSO)published the guidelines for neonatal respiratory failure in 2020.The guidelines provide suggestions on the technology,patient management and complications during ECMO.This article mainly interprets the patient selection,support mode,technical considerations,management and complications during ECMO.

Clinical evaluation of extracorporeal cardiopulmonary resuscitation in adult sudden cardiac death / 中华急诊医学杂志

Objective:To summarize the experience and effect of extracorporeal cardiopulmonary resuscitation (ECPR) on the treatment of sudden cardiac death (SCD).Methods:The data of 120 adults with SCD-ECPR in emergency department of the first affiliated hospital of Nanjing Medical University from April 2015 to April 2023 were retrospectively analyzed. The patients were grouped by Survival/death at 90 days, OHCA/IHCA (out-of-hospital/in-hospital cardiac arrest), with/without acute myocardial infarction (AMI) and divided according to 60 min of the time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time). Age, sex, Charlson comorbidity index, IHCA/OHCA, initial rhythm, no-flow time, CA-Pump On time, ECMO evacuation success rate, 90-day survival rate, ECMO treatment time were analyzed.Results:①Total of 114 adult patients with SCD-ECPR were enrolled, and 45 (39.5%) patients survived at 90 days, of whom 40 (88.9%) patients had good neurological outcomes.②Age and no-flow time were significantly lower in the 90-day survival group than that in death group, and the proportion of IHCA and shockable initial rhythm was higher. ③The no flow time in IHCA group was significantly lower than that in OHCA group, and the 90-day survival rate was higher. ④OHCA and regional interhospital transport prolonged CA-Pump On time and reduced the 90-day survival rate. ⑤The AMI group was older with a higher Charlson comorbidity index, and the 90-day survival rate was significantly lower than that in non-AMI group.Conclusions:ECPR improves the prognosis of patients with SCD, there are high benefits in patients with long healthy life expectancy, IHCA, shockable initial rhythm, and short no flow time. The smooth life-saving chain of SCD-ECPR improves survival rate, by screening high benefit candidates in patients with OHCA, delayed initiation of ECPR or requiring interhospital transport, despite CA-Pump On time > 60 min, there is still survival potential.

Analysis of early acute gastrointestinal injury and its influencing factors in patients with extracorporeal membrane oxygenation / 中华急诊医学杂志

Objective:To investigate the acute gastrointestinal injury (AGI) in patients with extracorporeal membrane oxygenation (ECMO) at the early stage of operation and its influencing factors.Methods:A total of 70 patients with ECMO who were hospitalized in the Emergency Care Unit of Guangxi Zhuang Autonomous Region People's Hospital from September 2020 to December 2021 were retrospectively analyzed, and a total of 70 patients with ECMO who were hospitalized in the emergency care unit of Guangxi Zhuang Autonomous Region People's Hospital from September 2020 to December 2021 were retrospectively analyzed. According to the 2012 guidelines of the European Society of Intensive Care Medicine on the classification of acute gastrointestinal injury in critically ill patients, the patients were divided into AGI group and non-AGI group. The incidence of acute gastrointestinal injury in the early stage was statistically analyzed, and the results of blood gas analysis during ECMO loading and ECMO parameters, hemodynamic indexes and biochemical indexes after ECMO transfer were statistically analyzed. To explore the influencing factors and independent risk factors of AGI in the early stage. In addition, 70 patients were divided into successful group and non-successful group according to whether they were successfully withdrawn. The occurrence of acute gastrointestinal injury between the two groups was compared, and the effect of acute gastrointestinal injury on ECMO patients was analyzed.Results:Among the 70 ECMO patients, the incidence of early AGI was 71.43% (50 cases), and the components of AGI Ⅰ, Ⅱ, Ⅲ and Ⅳ were 18.57% (13 cases), 41.43% (29 cases), 11.43% (8 cases) and 0% (0 cases), respectively. ① Univariate analysis showed that systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), vasoactive drug index (VIS), pH, lactic acid and BMI were significantly different between AGI group and non-AGI group when ECMO was used ( P < 0.05). Logistic binary regression analysis showed that BMI was an independent risk factor for early AGI in ECMO patients (ROC area 0.657, 95% confidence interval 0.522-0.791 ( P < 0.05), and Yoden index 0.15). (3) The AGI composition ratio of the unsuccessful group was higher than that of the unsuccessful group ( P < 0.05). Conclusions:Patients with ECMO have a high incidence of AGI in the early stage, mainly occurring in grade I and Ⅱ. Systolic blood pressure, diastolic blood pressure, MAP, VIS, pH, lactic acid and BMI when ECMO is put on are influential factors for the early development of AGI in ECMO patients, among which BMI is an independent risk factor for the early development of AGI in ECMO patients. The occurrence of AGI reduces the probability of successful withdrawal in ECMO patients.

Risk factors for poor prognosis in patients with extracorporeal cardiopulmonary resuscitation / 中华急诊医学杂志

Objective:To analyze the clinical characteristics of patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR), and to explore the risk factors leading to poor prognosis.Methods:The clinical data of 95 patients with ECPR admitted to the First Affiliated Hospital of Zhengzhou University from January 2020 to May 2023 were retrospectively analyzed. According to the survival status at the time of discharge, the patients were divided into the survival group and death group. The difference of clinical data between the two groups was compared to explore the risk factors related to death and poor prognosis. Risk factors associated with death were identified by Binary Logistic regression analysis. Results:A total of 95 patients with ECPR were included in this study, 62 (65.3%) died and 33 (34.7%) survived at discharge. Patients in the death group had longer low blood flow time [40 (30, 52.5) min vs. 30 (24.5, 40) min ] and total cardiac arrest time[40 (30, 52.5) min vs. 30(24.5, 40) min], shorter total hospital stay [3 (2, 7.25) d vs. 19 (13.5, 31) d] and extracorporeal membrane oxygenation (ECMO) assisted time [26.5 (17, 50) h vs. 62 (44, 80.5) h], and more IHCA patients (56.5% vs. 33.3%) and less had spontaneous rhythm recovery before ECMO (37.1% vs. 84.8%). Initial lactate value [(14.008 ± 5.188) mmol/L vs.(11.23 ± 4.718) mmol/L], APACHEⅡ score [(30.10 ± 7.45) vs. (25.88 ± 7.68)] and SOFA score [12 (10.75, 16) vs. 10 (9.5, 13)] were higher ( P< 0.05). Conclusions:No spontaneous rhythm recovery before ECMO, high initial lactic acid and high SOFA score are independent risk factors for poor prognosis in ECPR patients.

The major adverse kidney events in acute myocardial infarction with extracorporeal cardiopulmonary resuscitation / 中华急诊医学杂志

Objective:To investigate the major adverse kidney events (MAKE) in acute myocardial infarction (AMI) with extracorporeal cardiopulmonary resuscitation (ECPR).Methods:The data of 75 patients with AMI-ECPR in Emergency Medicine Department of the First Affiliated Hospital of Nanjing Medical University from April 2015 to April 2023 were retrospectively analyzed. The patients were grouped by survival/death at 90 days, with/without renal replacement therapy (RRT), and whether to initiate RRT because of acute kidney injury (AKI). age, sex, Charlson comorbidity index, OHCA/IHCA (out-of-hospital/in-hospital cardiac arrest), initial rhythm, Gensini score, ECPR initial blood gas pH and lactate value, no-flow time, time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time), ECMO and RRT treatment time, 90-day survival rate were analyzed. Moreover, the renal function of the survivors was followed up.Results:① Total of 68 AMI-ECPR patients were enrolled, 22 (32.4%) patients survived at 90 days, 54 (79.4%) combined with RRT, and 48 (70.6%) MAKE within 90 days. ②Compared with the death group, the 90-day survival group had a higher proportion of initial shockable heart rhythm, a lower Gensini score, a higher ECPR initial blood gas pH and a lower lactic acid value. ③The severity of coronary artery disease, ECPR initial acidosis and hyperlactacemia in the RRT group was significantly higher than that in the non-RRT group, and all the non-RRT group patients survived. ④ There was no difference between the AKI-RRT group and the non-AKI-RRT group. Of 21 patients with stage 1 AKI initiating RRT, 5 survived, one of them still needs RRT for 90 days, and 7 patients with stage 2 to 3 AKI initiating RRT died.Conclusions:The 90-day MAKE rate in AMI-ECPR patients was as high as 70.6%, and the 90-day renal insufficiency rate in AMI-ECPR survivors with AKI was as high as 20.0%. Active initiation of RRT to avoid AKI or early initiation of RRT may improve the prognosis of AMI-ECPR patients.

Independent risk factors for renal function non-recovery at 28 days after ECMO initiation among patients receiving ECMO complicated with acute kidney injury / 中华急诊医学杂志

Objective:To investigate the recovery of renal function and its influencing factors in patients receiving extracorporeal membrane oxygenation (ECMO) support and complicated with acute kidney injury(AKI).Methods:This was a retrospective observational study. The clinical data of patients with ECMO support and AKI admitted to the Emergency intensive care unit of the People's Hospital of Guangxi Zhuang Autonomous Region from October 2019 to December 2021 were collected. The patients were divided into renal function recovery group and renal function non-recovery group according to the recovery of renal function after 28 days of ECMO. With renal function non-recovery at 28 days as the end point of the study, and the variables with significant differences in baseline were selected for stepwise backward regression to determine the independent risk factors. The receiver operator characteristic (ROC) curve was drawn, and the area under the curve (AUC) was used to evaluate the diagnostic value of independent risk factors.Results:A total of 40 patients were enrolled, of which 28 patients (70%) had recovery of renal function, and 12 patients (30%) did not have recovery of renal function. Stepwise backward multivariate logistic regression analysis showed that lactate level at ECMO initiation was an independent risk factor for non-recovery of renal function ( OR = 1.380, 95% CI: 1.096-1.738, P = 0.006). The ROC curve showed that the AUC and 95% CI were 0.863 (0.751-0.975), the sensitivity was 100%, and the specificity was 75%. Conclusion:Lactate level at ECMO initiation was an independent risk factor for non-recovery of renal function on 28 days after ECMO initiation among patients undergoing ECMO support complicated with AKI. Lactate has a high predictive value for the non-recovery of renal function.

Preparation process for initiating extracorporeal cardiopulmonary resuscitation in hospital: best evidence summary / 中国实用护理杂志

Objective:To retrieve, evaluate and integrate the evidence related to the preparation process for initiating extracorporeal cardiopulmonary resuscitation in hospital, so as to provide reference for clinical implementation of extracorporeal cardiopulmonary resuscitation.Methods:According to the evidence-based nursing method and the 6S evidence model, guidelines, clinical decisions, expert consensus, systematic review and other literatures related to the preparation process for initiating extracorporeal cardiopulmonary resuscitation in hospital were searched from National Guideline Clearinghouse, Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence, and other websites, UpToDate, The Cochrane Library, PubMed, Embase, CNKI, Wanfang and other databases. The retrieval date limit was from the establishment of the database to May 20, 2023. Researchers assessed the quality of the included articles, and extracted and summarized the evidence that met the quality standards.Results:A total of 11 articles were included, including 2 guidelines, 6 expert consensuses, 1 systematic review and 2 quasi-experimental studies. A total of 18 pieces of evidences were summarized from 6 aspects, including medical conditions, team building, materials management, operation mechanism, pre-initiating treatment and initiating judgment.Conclusions:This study summarizes the evidence of preparation process for initiating extracorporeal cardiopulmonary resuscitation in hospital, which can provide reference for promoting the implementation of extracorporeal cardiopulmonary resuscitation. Future studies still need to focus on team building, personnel training and assessment, and optimisation of the management system, so as to improve the efficiency and readiness of treatment.

Summary of the evidence for the prevention of lower limb ischemic complications associated with venous-arterial extracorporeal membrane oxygenation patients / 中国实用护理杂志

Objective:To retrieve, evaluate and integrate the relevant evidence of prevention of lower limb ischemic complications in venous-arterial extracorporeal membrane oxygenation (VA-ECMO) patients, and provide reference for the development of scientific and complete prevention and management of lower limb ischemic complications.Methods:According to the evidence-based methodology, clinical decisions, guidelines, expert consensus, evidence summary, systematic review, randomized controlled trials and experimental studies related to lower limb ischemia complications in VA-ECMO patients were searched from CNKI, Wanfang, PubMed, Cochrane Library and other domestic and foreign databases as well as relevant professional websites. The literature search period was from the establishment of the database to August 2023. Two researchers independently evaluated the literature quality, and then extracted and summarized the evidence according to the theme.Results:A total of 27 004 articles were obtained in the preliminary search, and 11 articles were finally included after screening, including 1 guide, 2 expert consensus, 2 systematic reviews and 6 original studies. Through literature reading, evidence extraction and classification, and expert group meetings, a total of 24 best evidences were concluded in four dimensions, including team training and management, VA-ECMO pre-computer evaluation, VA-ECMO catheter selection, and the monitoring and management of lower limb ischemia.Conclusions:This study summarized the best evidence for the prevention of lower limb ischemia complications associated with VA-ECMO patients, and can provide reference for healthcare providers in clinical practice. In order to ensure the safety of VA-ECMO treatment and reduce the incidence of related complications, healthcare professionals should carefully select and apply evidence according to the clinical context and patients′ wishes.

Prognostic factors of patients undergoing percutaneous coronary intervention supported by extracorporeal membrane oxygenation / 实用医学杂志

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.

Visual analysis of extracorporeal shock wave therapy for pain / 中国组织工程研究

BACKGROUND:Extracorporeal shock wave therapy,as its potential benefits for various musculoskeletal diseases,has received widespread attention.Increasingly studies have demonstrated that it has excellent effects such as pain relief and functional recovery.However,bibliometric analysis in the domain of extracorporeal shock wave therapy for pain is relatively lacking. OBJECTIVE:To visually analyze the studies related to extracorporeal shock wave therapy for pain and to sort out the knowledge structure and explore its research status as well as hot trends in this field at home and abroad. METHODS:The publications related to extracorporeal shock wave therapy for pain from 2002 to 2022 in Web of Science Core Collection database and CNKI database were searched.Visual analysis using Citespace software was performed to produce the diagrams and interpret their meanings. RESULTS AND CONCLUSION:A total of 2 101 studies were included.The number of documents issued showed a fluctuating upward trend and the United States and China had certain advantages in the number of documents issued.The issuing institutions are mainly universities and hospitals and the issuing authors mostly belonged to independent teams.The exchange between issuing institutions and authors needed to be strengthened and the degree of cross-institutional and cross-regional cooperation was low.Keyword visual analysis indicated that extracorporeal shock wave therapy has been widely used in musculoskeletal diseases and further studies should focus on multidisciplinary in-depth study and observation of the clinical efficacy of combined therapy.The studies on the topic of extracorporeal shock wave therapy treating pain mainly focus on musculoskeletal diseases,including plantar fasciitis,scapulohumeral periarthritis,and tennis elbow.In recent years,combined treatment with ultrasound-guided injection therapy,traditional Chinese treatment techniques and expansion of new fields become research trends and hotspots of concern.

5 patients with severe ARDS complicated with hypercapnia received in vitro carbon dioxide removal therapy / 中华护理杂志

To summarize the nursing experience of 5 patients with severe ARDS complicated with hypercapnia who underwent extracorporeal carbon dioxide removal(ECCO2R).Key points of nursing care included:establishing a rapid emergency response nursing team for ECCO2R;PETCO2 real-time monitoring to grasp the timing of the machine;ensuring continuity of treatment and improving the removal efficiency;respiratory-related monitoring;prevention of complications of blood coagulation and hypothermia;and weaning from extracorporeal carbon dioxide removal.After careful treatment and care,all the 5 patients were successfully removed from ECCO2R treatment.

Evidence summary of early mobilization in awake patients on extracorporeal membrane oxygenation / 中华护理杂志

Objective To retrieve,evaluate and summarize the best evidence of early mobilization in awake patients on extracorporeal membrane oxygenation,and to provide a reference for clinical practice.Methods UpToDate,BMJ Best Practice,Registered Nurses'Association of Ontario,National Guideline Clearinghouse,National Institute for Health and Care Excellence,Yimaitong,Joanna Briggs Institute Library,Cochrane Library,CINAHL,PubMed,SinoMed,CNKI,Wanfang Database,Vip Database and Extracorporeal Life Support Organization Website were researched to collect the literature,including clinical guidelines,expert consensuses,evidence summaries,systematic reviews,and well-designed original studies.The time limit for retrieval was until June 2023.The quality of literature and the level of evidence were evaluated by the evaluation criteria and evidence grading system of J BI Evidence-Based Health Care Center.Results 14 pieces of the literature were included,including 2 clinical guidelines,4 expert consensuses,5 systematic reviews,2 cohort studies and 1 case series.Totally 33 pieces of evidence were summarized,covering 7 aspects:adaptation conditions for the implementation of awake ECMO,team composition,comprehensive assessment,pre-mobilization preparation,mobilization content,prevention and control of adverse events,and effect evaluation.Conclusion The study summarizes the best evidence of early mobilization in awake patients on extracorporeal membrane oxygenation.It is suggested that medical institutions establish a professional team for the early mobilization of awake ECMO patients,apply the best evidence to standardize the early mobilization process,and formulate an individualized mobilization program.

Predictive value of esophageal deviation index for clinical outcomes of patients with left-sided congenital diaphragmatic hernia / 中华围产医学杂志

Objective:To evaluate the predictive value of postnatal esophageal deviation index for clinical outcomes of fetuses with left-sided congenital diaphragmatic hernia (L-CDH).Methods:This retrospective study analyzed the clinical data of 103 neonates with prenatally diagnosed L-CDH who were admitted to Guangzhou Women and Children's Medical Center from January 2016 to February 2023. These patients were divided into the survival group ( n=82) and the death group ( n=21) according to the outcomes, and the extracorporeal membrane oxygenation (ECMO) group ( n=25) and the non-ECMO group ( n=78) according to whether ECMO support was required. Thoracoabdominal X-ray screening was performed on all neonates within 24 h after admission and the esophageal deviation index and cardiac deviation index were calculated. Independent sample t-test or Fisher's exact probability test were used to analyze the differences in general condition and postnatal imaging features between different groups. Receiver operating characteristic (ROC) curve was used to evaluate the value of postnatal imaging features in predicting the prognosis of L-CDH. Results:The esophageal deviation index and the cardiac deviation index of neonates in the survival group were lower than those in the death group [(10.5±5.3)% vs. (18.0±4.5)%, t=－5.47; (37.7±7.1)% vs. (42.8±8.2)%, t=－2.62; both P<0.05], while that were both higher in the ECMO group compared with the non-ECMO group [(18.0±4.3)% vs. (10.1±5.2)%, t=6.34; (42.4±7.9)% vs. (37.6±7.1)%, t=2.63; both P<0.05]. ROC curve showed that the area under the curve (AUC) for predicting the need for ECMO support was 0.879 (95% CI: 0.805-0.953) for esophageal deviation index and 0.712 (95% CI: 0.570-0.854) for cardiac deviation index, with the optimal cut-off values of 11.7% and 41.7%, respectively. The AUC for predicting the survival rate in patients with L-CDH by esophageal deviation index and cardiac deviation index were 0.854 (95% CI: 0.761-0.947) and 0.735 (95% CI: 0.582-0.887), respectively, with the corresponding optimal cut-off values of 15.8% and 41.7%. Conclusion:Postnatal esophageal deviation index is of value in predicting the need for ECMO support and survival rate in patients with L-CDH.

Establishment and validation of a predictive model for the efficacy of repeated extracorporeal shock wave lithotripsy in patients with upper urinary calculi / 现代泌尿外科杂志

【Objective】 To analyze the independent influencing factors of repeated extracorporeal shock wave lithotripsy (ESWL) in the treatment of upper urinary calculi (UUC), based on which a nomogram model was established to predict the efficacy. 【Methods】 Clinical and imaging data of 203 patients receiving repeated ESWL during Jan.2020 and Dec.2022 were collected, including 117 cases in the successful group and 86 cases in the unsuccessful group.The patients’ age and sex, stone volume (SV), surface area (SA), skin-to-site distance (SSD), maximum CT value, mean stone density (MSD), and stone heterogeneity index (SHI) were compared between the two groups.The independent predictors were analyzed with logistic regression and the meaningful variables (P<0.05) were used to establish a nomogram.The efficacy of the model was evaluated using receiver operating characteristic (ROC) curve and decreasing curve analysis (DCA).Internal validation was also performed. 【Results】 Stepwise regression showed that SV, SSD, MSD and SHI were independent influencing factors (P<0.05).The area under the ROC curve (AUC), optimal threshold, sensitivity and specificity were 0.793 (95%CI: 0.674-0.911), 0.619, 77.1% and 74.0%, respectively.The DCA curve was above two extreme curves.Hosmer-Lemeshow test and calibration curve showed that the nomogram had a good fitting degree (χ2=5.526, P=0.489), and the correction C-index was 0.746. 【Conclusion】 SV, SSD, MSD and SHI are independent predictors of the efficacy of repeated ESWL in the treatment of UUC.The nomogram established based on the above indicators has good predictive efficiency and clinical applicability.

Extracorporeal membrane oxygenation for post-aortic surgery: A retrospective study in a single center / 中国胸心血管外科临床杂志

@#Objective To describe the outcomes of extracorporeal membrane oxygenation (ECMO) for patients after aortic surgery and to summarize the experience. Methods The clinical data of patients who received ECMO support after aortic surgery in Fuwai Hospital from 2009 to 2020 were retrospectively analyzed. The patients who received an aortic dissection surgery were allocated into a dissection group, and the other patients were allocated into a non-dissection group. The in-hospital and follow-up survival rates were compared between the two groups, and the causes of death were analyzed. Results A total of 22 patients were enrolled, including 17 patients in the dissection group [13 males and 4 females, with a median age of 54 (46, 61) years] and 5 patients in the non-dissection group [3 males and 2 females, with a median age of 51 (41, 65) years]. There was no statistical difference in the age and gender between the two groups (P>0.05). The in-hospital survival rate (11.8% vs. 100.0%, P=0.001) and follow-up survival rate (11.8% vs. 80.0%, P=0.009) of the patients in the dissection group were significantly lower than those in the non-dissection group. The causes of death in the dissection group included massive bleeding and disseminated intravascular coagulation (3 patients), ventricular thrombosis (1 patient), irreversible brain injury (2 patients), visceral malperfusion syndrome (4 patients) and irreversible heart failure (5 patients). Conclusion ECMO after aortic dissection surgery is associated with high mortality, which is related to the pathological features of aortic dissection and severely disrupted coagulation system after the surgery. For these patients, strict indication selection and optimal management strategy are important.

Minimally invasive therapeutic modalities for pediatric urolithiasis: A single center experience from the Philippines

Introduction@#There is a limited data on the incidence of pediatric urolithiasis in the Philippines as well as studies on how it is managed. With the advent of endourology, there is already an evident shift from open stone surgery to minimally invasive surgery as first line in the treatment of pediatric urolithiasis. A tertiary referral center in the country caters to most pediatric urolithiasis cases in the country and offers the different minimally invasive modalities outlined in the latest guidelines. This study aimed to review the different minimally invasive therapeutic modalities for pediatric urolithiasis and its outcomes in the past ten years in a tertiary referral center in the Philippines.@*Methods@#This retrospective study was conducted through charts review of all pediatric patients (0-18 years) who underwent stone surgery from January 2012 to December 2022. Demographic and clinical data, stone characteristics, types of stone surgery, and outcomes were obtained.@*Results@#A total of 87 pediatric patients (54 boys, 33 girls) with 105 urolithiases were analyzed. The patients had a mean age of 13 years, with an interquartile range (IQR) spanning from 6 to 18 years. Among them, 62.07% were male, while 37.93% were female. The most prevalent symptom reported was flank pain, affecting 41.38% of the patients, followed by urinary tract infections (UTI) (11.49%) and gross hematuria (8.05%). For the management, 82.86% of the patients underwent minimally invasive stone procedures with extracorporeal shockwave lithotripsy (ESWL) as the most common procedure (44.76%) and ureterolithiases as the most common stone (43.81%). On the other hand, 17.14% of the subjects underwent open stone surgery done mostly on cystolithiases and large ureterolithiases (38.89% each). All patients recovered and were discharged post operatively.@*Conclusion@#The institution practices minimally invasive approaches in the majority of pediatric patients with urolithiasis. Open stone surgery is reserved for patient with large complex stones and those with anatomic abnormalities.

Lung transplantation after paraquat poisoning in an adolescent: one case report and literature review / 器官移植

Objective To summarize the effect of the timing of lung transplantation and related treatment measures on clinical prognosis of patients with paraquat poisoning. Methods Clinical data of a patient with paraquat poisoning undergoing bilateral lung transplantation were retrospectively analyzed. Clinical manifestations, auxiliary examination, diagnosis and treatment of this patient were summarized and analyzed. Results A 17-year-old adolescent was admitted to hospital due to nausea, vomiting, cough and systemic fatigue after oral intake of 20-30 mL of 25% paraquat. After symptomatic support treatment, the oxygen saturation was not improved, and pulmonary fibrosis continued to progress. Therefore, sequential bilateral lung transplantation was performed under extracorporeal membrane oxygenation (ECMO). After postoperative rehabilitation and active prevention and treatment for postoperative complications, the patient was discharged at postoperative 50 d. Conclusions The timing of lung transplantation after paraquat poisoning may be selected when the liver and kidney function start to recover. Active and targeted prevention of potential pathogen infection in perioperative period and early rehabilitation training contribute to improving clinical prognosis of lung transplant recipients.