Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome: a pooled individual patient data analysis : Mechanical ventilation during ECMO.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients. METHODS: In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality. RESULTS: Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure - PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO2/FiO2, higher arterial pH and lower PaCO2 levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03-1.10)]. CONCLUSION: In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality.

[Extracorporeal membrane oxygenation for treatment of acute respiratory failure in adults].

Extracorporeal membrane oxygenation (ECMO) can support gas exchange independently of mechanical ventilation in patients with severe acute respiratory failure. Veno-venous ECMO is a temporary technique for providing life support by pulmonary dysfunction. ECMO should be considered for patients with respiratory failure when they cannot survive with conventional therapy. ECMO may be used either as a rescue therapy or to prevent ventilator-associated lung injury. Exact criteria for ECMO are not available. Transportation while using ECMO is safe when a team from the management centre provides it.

Change in hemostatic intervention after implementation of thromboelastometry.

OBJECTIVE: To monitor the use of blood products and hemostatic intervention after implementation of thromboelastometry. DESIGN: Observational prospective study using a historic control. SETTING: Single-center university hospital. PARTICIPANTS: Patients undergoing cardiac surgery during 2008 (n = 811) were compared with similar patients in 2009 (n = 865). INTERVENTIONS: Thromboelastometry was implemented in December 2008. Changes in transfusion of blood products and changes in use of recombinant factor VIIa and fibrinogen were studied. MEASUREMENTS AND MAIN RESULTS: Use of blood products was not decreased significantly after implementation of thromboelastometry. However, in patients receiving blood products, the units of red blood cells were decreased significantly (p = 0.04). Regarding hemostatic reagents, the use of recombinant factor VIIa was decreased significantly (p = 0.04), and the use of fibrinogen increased significantly (p < 0.001). Most blood products (>70%) were given to a minority of patients (∼10%) in 2008 and 2009. In 2009, thromboelastometry was performed in 146 patients (17%), and the use of blood products (p < 0.0001), recombinant factor VIIa (p < 0.001), and fibrinogen (p < 0.001) was significantly higher compared with patients in whom thromboelastometry was not performed. CONCLUSIONS: After implementation of thromboelastometry, the use of recombinant factor VIIa was decreased significantly, whereas the use of blood products was not decreased significantly in patients undergoing cardiac surgery.

Failure of combination oral oseltamivir and inhaled zanamivir antiviral treatment in ventilator- and ECMO-treated critically ill patients with pandemic influenza A (H1N1)v.

OBJECTIVE: The objective of this study was to describe the clinical course of severe and complicated pandemic (H1N1)v infection treated with oral oseltamivir and inhaled zanamivir in a series of intensive care patients. METHODS: We investigated a case series of patients with respiratory failure and a positive (H1N1)v real-time reverse transcriptase polymerase chain reaction (rRT-PCR). Treatment consisted of oseltamivir tablets 75 mg × 4 daily in a nasogastric tube plus zanamivir intravenous (i.v.) solution 25 mg × 4 daily as inhalation. Ventilator inspiratory plateau airway pressure in the ventilator was kept below 30 cmH2O, PaO2 above 8 kPa and pH above 7.30. If this could not be achieved, inhalational nitric oxide (NO) was added or extracorporeal membrane oxygenation (ECMO) was initiated. RESULTS: Twenty-one patients were admitted, with a median age of 50 y (range 6-69 y). Five patients (23.8%) died in the intensive care unit (ICU) and 1 patient died 2 weeks after ICU discharge. Nine patients received ECMO treatment, of whom 3 died during ECMO (33.3%; 3/9) and 1 at 2 weeks after. The mortality in patients not receiving ECMO treatment was 16.6% (2/12). Sixteen patients (76%) were influenza PCR-positive on day 7 after the start of antiviral treatment. Irreversible presumed lung fibrosis complicated with pneumothorax was common. A high Murray score at admission was significantly associated with a fatal outcome. CONCLUSIONS: The mortality in these patients was high despite combined antiviral treatment with oseltamivir and zanamivir. Patients shed virus for a long time despite intensive therapy. Optimal management of patients with bilateral pneumonia and respiratory failure caused by (H1N1)v still needs to be determined.

Transfusion requirements in 811 patients during and after cardiac surgery: a prospective observational study.

OBJECTIVE: To identify patients at risk for intra- and postoperative blood product transfusion in a mixed adult cardiac surgical patient population. DESIGN: A prospective, observational study. SETTING: A single-center university hospital. PARTICIPANTS: Patients (n = 811) undergoing cardiac surgery from January 1, 2008, to November 30, 2008. INTERVENTIONS: The outcome in terms of transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and/or pooled platelets within the first 24 hours after surgery was studied. Pre- and perioperative risk factors for bleeding and transfusion of blood products were studied. MEASUREMENTS AND MAIN RESULTS: The majority of RBCs and FFP (>70%) were given to a minority of patients (<12%). The type of surgical procedure, previous cardiac surgery, and emergency operations were all significantly associated with the transfusion of RBCs, FFP, and platelets. Antithrombotic therapy was not significantly associated with the transfusion requirement in the mixed group of cardiac patients. However, in the low-risk procedures such as coronary artery bypass graft surgery, ongoing antithrombotic therapy at the time of the operation significantly increased the risk of transfusion in this otherwise low-risk category of surgery. CONCLUSIONS: The identification of high-risk patients is necessary to optimize the perioperative management of bleeding complications. Because of the high variability in transfusion requirements, a specifically tailored patient intervention based on the individual's risk profile appears more likely to improve patient outcome compared with general interventions given to the entire patient group.

[Catheter-based aortic valve substitution. Initial experiences with stent valve implantation]. / Kateterbaseret aortaklapsubstitution. Initiale erfaringer med implantation af stentklap.

INTRODUCTION: Recent years have seen the introduction of catheter-based aortic valve substitution with stent valves to treat aortic valve stenosis in patients who were deemed inoperable via conventional open heart surgery. We here report our initial experience. MATERIAL AND METHODS: Register-based study with prospective registration of prespecified parameters. A total of 26 patients were treated with an aortic stent valve, 12 via transfemoral (TFA-AVI) and 14 via transapical (TAP-AVI) access. In the TFA-AVI group, 75% were women and the average age was 85 4.5 years; in the TAP-AVI group, 71% were women and the average age was 79 8.4 years. RESULTS: In the TFA-AVI group, successful stent valve implantation was performed in 9/12 (75%) and TAP-AVI in 13/14 (93%) patients. Mortality after 30 days was 25% in the TFA-AVI and 7% in the TAP-AVI group. The aortic valve area increased from 0.6 0.13 cm(2) to 1.6 0.39 (2) in the TFA-AVI group and from 0.7 0.2 (2) to 1.6 0.37 (2) in the TAP-AVI group. 91% of patients showed clinical improvement after treatment. CONCLUSION: Transcatheter aortic valve implantation of conventional unresectable patients requires close cooperation between different specialities. The treatment seems to be a realistic alternative to medical treatment for inoperable patients and may even be used in operable high-risk patients.

Transapical transcatheter treatment of a stenosed aortic valve bioprosthesis using the Edwards SAPIEN Transcatheter Heart Valve.

Transcatheter transapical or transfemoral aortic valve replacement has emerged as an alternative therapy of severe, symptomatic valvular aortic stenosis in surgically nonamenable patients. We report a transapical treatment of a severely stenosed 21-mm aortic Mitroflow valve bioprosthesis (Sorin Group, Vancouver, British Columbia, Canada) in an 82-year-old woman using a 23-mm Edwards SAPIEN Transcatheter Heart Valve (Edwards Lifesciences, Irvine, CA).

Central venous oxygen saturation cannot replace mixed venous saturation in patients undergoing cardiac surgery.

OBJECTIVE: It has been argued that venous oxygen saturation from a central venous catheter (ScvO(2)) could be an inexpensive alternative to mixed venous oxygen saturation (SvO(2)). The aim was to evaluate whether ScvO(2) measurements could replace SvO(2) readings after cardiac surgery and to analyze factors influencing any differences found. DESIGN: A prospective observational study. SETTING: A university hospital. PARTICIPANTS: Twenty patients scheduled for elective cardiac surgery. INTERVENTIONS: Patients were followed postoperatively with corresponding ScvO(2)/SvO(2) measurements. MEASUREMENTS AND MAIN RESULTS: The overall bias between ScvO(2) and SvO(2) was 1.9. In coronary artery bypass graft (CABG) patients, the bias was 0.6 compared with 6.4 in procedures involving aortic valve replacement. In situations with peripheral saturation (SAT) <92%, the bias was 10.7 compared with 0.8 when SAT was >or=99%. In 25.5% of measurements, the ScvO(2) was more than 10% different from SvO(2), and in only 50% the difference was less than 5%. CONCLUSIONS: The ScvO(2) and SvO(2) measurements are not interchangeable, and, especially in patients undergoing aortic valve surgery, this lack of agreement is crucial. However, the present data indicate that ScvO(2) may be used in CABG patients, although it is not completely accurate in terms of absolute venous saturations. A low SAT, low hemoglobin, or low cardiac index increased the venous gap.