International survey on the management of mechanical ventilation during ECMO in adults with severe respiratory failure.

BACKGROUND: No consensus exists on the optimal settings of mechanical ventilation during veno-venous extracorporeal membrane oxygenation (ECMO). Our aim was to describe how mechanical ventilation and related interventions are managed by adult ECMO centres. METHODS: A cross-sectional, multi-centre, international survey of 173 adult respiratory ECMO centres. The survey was generated through an iterative process and assessed for clarity, content and face validity. RESULTS: One hundred thirty-three centres responded (76.8%). Pressure control was the most commonly used mechanical ventilation mode (64.4%). Although the median PEEP was 10 cmH2O, 22.6% set PEEP <10 cmH2O and 15.5% used 15-20 cmH2O. In 63% of centres PEEP was fixed and not titrated. Recruitment maneuvres, were never used in 34.1% of centres, or used daily in 13.2%. Centres reported using either a "lung rest" (45.7%), or an "open lung" strategy (44.2%). Only 24.8% used chest CT to guide mechanical ventilation. Adjunctive treatments were never or occasionally used. Only 10% of centres extubated patients on ECMO, mainly in more experienced centres. 71.3% of centres performed tracheostomy on ECMO, with large variability in timing (most frequent on days 6-10). Only 27.1% of ECMO centres had a protocol for mechanical ventilation on ECMO. CONCLUSION: We found large variability in ventilatory practices during ECMO. The clinicians' training background and the centres' experience had no influence on the approach to ventilation. This survey shows that well conducted studies are necessary to determine the best practice of mechanical ventilation during ECMO and its impact on patient outcome.

Diversity in sexual health: problems and dilemmas.

The increase in migrant populations in western Europe has led to specific problems and dilemmas in the area of sexual and reproductive health and service provision. In general, these problems and dilemmas can be divided into four categories: (1) epidemiology of diseases and risk factors; (2) psychosocial and cultural aspects; (3) communication; and (4) moral and ethical dilemmas. Regarding epidemiology, there is an increased prevalence in migrant groups of unwanted pregnancy and abortion, HIV/STDs, and sexual violence. Effective contraceptive use is hampered by knowledge deficits, uncertain living conditions, ambivalence regarding the use of contraceptives, and problems accessing (information on) contraception. Psychosocial and cultural aspects relate to the norms and attitudes individuals and groups have regarding the family, social relationships, sexuality, and gender. These norms and attitudes have an impact on the sexual and reproductive choices people make and the possibilities and restrictions they feel in this respect. Problems in communication concern not only language but also communication styles, the way patients present their problems, and the expectations they have from the service provider. Communication problems inevitably lead to a lower quality of care. Moral and ethical dilemmas arise where cultures collide, for example regarding sexuality education and virginity problems. Two examples of practical situations in which migrant patients ask for help with sexual or reproductive health problems will be described.

The efficacy of heparinization in prolonging patency of arterial and central venous catheters in children: a randomized double-blind trial.

This study evaluates the efficacy of heparinization in prolonging patency of arterial and central venous catheters in children. A randomized double-blind trial in a tertiary 10-bed pediatric intensive care unit was used to evaluate 300 children (age older than 4 weeks, younger than 18 years). Trial medication consisted of either NaCl 0.9% infusion or NaCl 0.9% infusion to which 1 IU of heparin per milliliter was added. The number of nonpatent arterial and central venous catheters and the duration of stay of patent arterial and central venous catheters were measured. There was a significant risk increase for nonpatency in the nonheparinized arterial catheters (relative risk [RR]: 3.54; 95% confidence interval [CI]: 1.01-12.42). No significant risk increase for nonpatency could be demonstrated for the nonheparinized central venous catheters (RR: 7.63; 95% CI: 0.40-145). The median duration of stay of the patent arterial and central venous catheters was similar for both treatment groups. These results indicate that the use of normal saline in arterial catheters is associated with an increased frequency of catheter nonpatency as compared with heparinized saline.