Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study.

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. METHODS: A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. RESULTS: A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). CONCLUSIONS: Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial.

BACKGROUND: Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy. METHODS/DESIGN: Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. PARTICIPANTS: 100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months. INTERVENTION: The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU. DISCUSSION: The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04186468 . Submitted 2 December 2019.

The impact of venovenous extracorporeal membrane oxygenation on cytokine levels in patients with severe acute respiratory distress syndrome: a prospective, observational study.

OBJECTIVE: The immunoinflammatory response is central to the pathogenesis of acute respiratory distress syndrome (ARDS). However, little is known how this is affected by venovenous (VV) extracorporeal membrane oxygenation (ECMO). Our objective was to investigate the factors that influence the inflammatory response of patients with ARDS undergoing VV ECMO, and to analyse the impact of this response on hospital mortality. DESIGN AND SETTING: A prospective observational study of all consecutive patients with severe ARDS who had VV ECMO at a tertiary German ECMO centre from 2009 to 2015. Patients without complete datasets were excluded. Cytokines (interleukin [IL]6, IL8 and tissue necrosis factor [TNF]α) and inflammatory markers (white cell count and C-reactive protein) were assessed before ECMO initiation and on Days 1, 5 and 10, before explantation and at explantation. RESULTS: A total of 262 adult patients undergoing VV ECMO were analysed. Their median Sequential Organ Failure Assessment score was 12, PaO2/FiO2 ratio was 64 mmHg, and overall in-hospital mortality was 34%. Cytokine levels fell quickly within 24 hours and fell further over the first 5 days. Extra-pulmonary ARDS was associated with higher IL6 and IL8 levels compared with pulmonary ARDS. Mechanical ventilation with positive end-expiratory pressure ≥ 15 cmH2O before ECMO was associated with higher IL6, IL8 and TNFα levels. Driving pressures ≥ 19 cmH2O before ECMO were associated with higher IL8 levels. Non-survivors had higher IL6 and IL8 levels for the duration of ECMO. CONCLUSION: Cytokine levels, on average, fall rapidly after initiation of VV ECMO, which may be related to the reduction of invasiveness of mechanical ventilation. Higher cytokine levels are associated with extrapulmonary causes of ARDS, more aggressive mechanical ventilation before VV ECMO, and mortality.

Acquired von Willebrand syndrome in respiratory extracorporeal life support: a systematic review of the literature.

BACKGROUND AND OBJECTIVE: Venovenous extracorporeal membrane oxygenation (VV ECMO) and extracorporeal CO2 removal (ECCO2R) are increasingly used in the management of severe respiratory failure. With bleeding complications being one of the major risks of these techniques, our aim in this systematic review was to assess the available literature on acquired von Willebrand syndrome (AvWS) and extracorporeal support. AvWS has previously been associated with bleeding and shear stress. DESIGN AND DATA SOURCES: A systematic review, using Medline via PubMed, was performed to identify eligible studies up to January 2017. RESULTS AND CONCLUSION: The prevalence of AvWF among patients on VV ECMO or ECCO2R is high, but only a limited number of studies are reported in the literature. AvWS testing should be performed, including vWF multimer analysis, vWF activity and vWF antigen concentration. The extent to which vWF contributes to bleeding during ECMO, or how much changes in ECMO management can influence high molecular weight vWF multimer levels, cannot be answered from the currently available evidence and there remains a need for future studies.

Management strategies in venovenous extracorporeal membrane oxygenation: a retrospective comparison from five European centres.

OBJECTIVE: To investigate contemporary clinical practice in the management of venovenous (VV) extracorporeal membrane oxygenation (ECMO) in critically ill patients with bacterial pneumonia. METHODS: In this multicentre retrospective study, 48 patients with severe respiratory failure due to bacterial pneumonia receiving VV ECMO therapy in five experienced European ECMO centres were included. Ventilator and ECMO settings were analysed. RESULTS: Ventilator settings showed great variability between participating centres, particularly relating to positive end-expiratory pressure, peak inspiratory pressure and driving pressure. Different strategies in cannulation, ECMO setting and weaning procedures were also observed. CONCLUSION: There is great diversity in management modalities for ventilator and ECMO settings for patients with bacterial pneumonia. Our study emphasises the lack of clinical consensus in VV ECMO management.

Extraesophageal symptoms of gastroesophageal reflux disease during pregnancy.

AIM: Typical symptoms of gastroesophageal reflux disease (GERD) are known to be frequent in pregnancy. The aim of this study was to gain a first estimation of the occurrence of extraesophageal symptoms in this context. METHODS: A prospective longitudinal study was performed on 166 pregnant women and in a control group of 285 women. The diagnosis of GERD was based on the Montreal classification using the reflux disease questionnaire (RDQ). Extraesophageal symptoms were recorded with a self-administered questionnaire. Typical GERD symptoms and extraesophageal GERD symptoms were recorded in each trimester of pregnancy. RESULTS: The prevalence of GERD during pregnancy was 16.9% in the first, 25.3% in the second and 51.2% in the third trimester. The prevalence of GERD in the control group was 6.3%. Asthma was reported by 3.5% of controls and by 6% of pregnant women during pregnancy. Chest pain occurred in 6% of the controls and in 1.8%, 2.4% and 2.4% during the trimesters of pregnancy, chronic cough was reported by 1.1% of controls and 1.2% of pregnant women. With the diagnosis of GERD the odds ratios and 95% confidence intervals for asthma, chronic cough and chest pain in the third trimester of pregnancy were as follows: 1.56 (0.58-4.22) for asthma, 0.91 (0.08-10.28) for chronic cough and 2.04 (0.49-8.46) for chest pain. CONCLUSION: GERD is very frequent during pregnancy with progressive incidence during the course of pregnancy. Extraesophageal symptoms of GERD have an unexpected low prevalence during pregnancy.

[Intralobar pulmonary sequestration with aspergillosis in an asymptomatic 39-year-old man]. / Intralobulärer Lungensequester mit Aspergillose bei einem beschwerdefreien 39-jährigen Mann.

HISTORY AND CLINICAL FINDINGS: During a screening examination a pulmonary mass in the left lower lobe was detected in a 39-year-old man. The patient was asymptomatic and had hitherto been healthy. CT pulmonary angiography revealed an intralobar pulmonary sequestration with an afferent arterial branch from the thoracic aorta. DIAGNOSIS, TREATMENT AND COURSE: Thoracotomy with resection of the sequestration was performed. On the first postoperative day hemiparesis of the left side occurred because of an infarction of the arteria cerebri media. After aspiration of the thrombus and intraarterial thrombolysis the patient recovered completely. Histology of the sequestration showed invasive growth of aspergillus and severe inflammation, caused by invasive mycosis. Subsequently the patient received voriconazol for four weeks. CONCLUSION: Diagnosis of pulmonary sequestration in adults is rare. In asymptomatic patients there is still controversy about the treatment. Surgery, arterial embolisation and a "watch and wait" strategy can be taken into account. Because of the risk of infection an operative approach should be favoured.

[Bronchopulmonary manifestations of gastroesophageal reflux disease]. / Bronchopulmonale Manifestationen der gastroösophagealen Refluxerkrankung.

Gastroesophageal reflux disease (GERD) is a common disease in the western world. Usually it occurs with typical symptoms like heartburn and regurgitation, but almost every third GERD-patient presents with extraesophageal symptoms and diseases in which a causal relation with GERD is discussed. The extraesophageal symptoms possibly associated with GERD are chronic cough, bronchial asthma, sleep disturbances including obstructive sleep apnea, hoarseness, dental erosions, non-cardiac chest pain and idiopathic pulmonary fibrosis. This article gives an overview of the reflux-associated diseases of the airways as well as the proposed pathomechanisms and therapeutic options.

The elucidation of peptic esophagitis: from Hamperl to heartburn.

Although the esophagus was initially considered as the "humble" organ, it has in recent times evoked both substantial interest and considerable controversy as esophagitis becomes a global pandemic and the debate over the causes of esophagitis and the management of Barrett's has escalated. The esophagus has always defied easy understanding and the origins of its name and its symptomatology continue to confound those who address them. Esophagitis is increasing relentlessly on a global scale and the challenge of defining its symptomatology remains today as great a problem as when initially identified by Herwig Hamperl and Asher Winkelstein. Their identification of the entity they called "peptic esophagitis" in 1934, while initially for the most part overlooked, has today become one of the centers of gastroenterological focus. Although the initial symptomatology of esophagitis was limited to heartburn, it has more recently become apparent that a diverse group of symptoms is produced by the inflammation associated with intermittent reflux of gastric acid. Of interest is the nature of the original observations that led to the identification of the physiopathology of esophagitis and the elucidation of the relationship between symptomatology, acid reflux and inflammation. Although Asher Winkelstein of New York has long been considered the first to define the relationship of acid peptic reflux, esophageal ulceration and reflux symptomatology, it is of note to consider the seminal role of Herwig Hamperl, an Austrian pathologist in the elucidation of acid peptic esophagitis. Indeed, a careful consideration of the relative contributions of these two pioneers suggests that both deserve credit for identifying a disease process that, although initially for the most part ignored by clinicians, has now become one of the most fundamental problems faced by both gastroenterologists and pathologists.

[Handling of the gastroesophageal reflux disease (GERD) during pregnancy--a review]. / Management der gastroösophagealen Refluxkrankheit (GERD) in der Schwangerschaft.

Gastroesophageal reflux disease (GERD) is common during pregnancy. The pathogenesis is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. The most common symptom of GERD is heartburn. Nevertheless, serious reflux complications during pregnancy are rare. In contrast to non-pregnant patients, GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line on-demand drug therapy. If symptoms persist, any of the histamine-2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. Usually, heartburn during pregnancy resolves soon after delivery but little is known about the late sequelae or, respectively, an influence on subsequent pregnancies. Accordingly a prospective study (longitudinal cohort analysis) is currently underway.