[Health-related quality of life. Long-term survival in patients with ARDS following extracorporeal membrane oxygenation (ECMO)]. / Gesundheitsbezogene Lebensqualität. Langzeitüberlebende, erwachsene Patienten mit ARDS nach extrakorporaler Membranoxygenation (ECMO).

UNLABELLED: Treatment of severe acute respiratory distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO) can be lifesaving but requires maximal use of intensive care resources over prolonged periods of time, resulting in high costs. Little is known about the health-related quality of life (HRQL) in long-term survivors. This case-controlled retrospective study was designed to assess the health-related quality of life in long-term survivors of ARDS and ECMO-therapy. METHODS: 14 long-term survivors of ARDS (APACHE II score = 24, Lung Injury Score = 3.25, median values) treated using ECMO between 1992 and 1995 (median time interval between data collection and discharge from the ICU 16 months) and 14 ARDS-patients conventionally treated during the same period (group I) were identified and completed the SF-36 Health Status Questionnaire (Medical Outcome Trust, Boston, USA). 14 healthy subjects (group II) were drawn at random from a large data base generated to provide normal values for the SF-36 in a German population. All three groups were comparable with respect to sex and age. RESULTS: Long-term survivors of ECMO-therapy reported significant reductions in physical functioning when compared with patients treated by mechanical ventilation alone (group I, -12.5%, p < 0.05) and with healthy controls (group II, -50%, p < 0.05) and showed a higher incidence of chronic physical pain (+5% and +24%, respectively, p < 0.05). There were no differences with regard to the mental health dimensions of the SF-36 (e.g. vitality, mental health index or social functioning) between ECMO-patients and all controls. Nine patients (64.3%) from the ECMO group versus all patients treated conventionally (group I) had full-time employment (p = 0.46, Chi2 test). CONCLUSIONS: The majority of long-term survivors of ECMO-treatment show good physical and social functioning, including a high rate of employment. The more aggressive approach of ECMO-therapy and a possibly more severe underlying disease process may explain impairments in health-related quality of life outcomes after ECMO-treatment. Despite these limitations, long-term survivors of ECMO-therapy are able to reach a highly satisfactory health-related quality of life.

Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome.

OBJECTIVES: Despite considerable progress in intensive care management of the acute respiratory distress syndrome (ARDS), little is known about health-related quality of life in long-term survivors. In addition, intensive care treatment can be extremely stressful, and many survivors of ARDS report adverse experiences such as respiratory distress, anxiety, or pain during intensive care unit (ICU) treatment. This study was performed to assess health-related quality of life in survivors of ARDS and to test the hypothesis that adverse experiences during ICU treatment result in posttraumatic stress disorder (PTSD) and negative effects on health-related quality of life. DESIGN: Retrospective, cohort, case-controlled analyses. SETTING: A 12-bed multidisciplinary ICU of a tertiary care university hospital, capable of providing extracorporeal life support for adults with severe ARDS. PATIENTS: We studied 80 patients who were admitted to our hospital from 1985 to 1995 and who survived an episode of ARDS. ARDS was defined according to the criteria of the American-European Consensus Conference on ARDS. INTERVENTIONS: Health-related quality of life was measured using the Health Status Questionnaire of the self-administered Medical Outcomes Study Short Form Survey that consists of 36 questions (SF-36) and the German version of the Post Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10), a self-report scale for the diagnosis of posttraumatic stress disorder based on the Diagnostic and Statistical Manual (Third Edition) criteria (American Psychiatric Association). The number of adverse experiences (anxiety, respiratory distress, pain, and nightmares) during intensive care was evaluated by means of a structured questionnaire. For each patient with ARDS, three age- and gender-comparable controls were randomly selected from databases providing normal values for the SF-36 and PTSS-10 scores in populations at risk for posttraumatic stress disorder. MEASUREMENTS AND MAIN RESULTS: Survivors of ARDS showed statistically significant impairments in all eight health dimensions of the SF-36 when compared with normal controls (median reduction 21.3%, p < .006) with maximal impairments in physical function (median reduction 28.9%, p = .000) and a 38% higher frequency of chronic pain (p = .0001). Three of 34 patients reporting none, or one, adverse experience had evidence of posttraumatic stress disorder vs. 19 of 46 patients remembering multiple traumatic episodes (p = .007). Patients reporting multiple adverse experiences described the lowest health-related quality of life, with maximal impairments in psychosocial functioning (p < .005) and only small limitations in physical function. CONCLUSIONS: Long-term survivors of ARDS describe a good overall health-related quality of life. Major impairments in mental health domains of health-related quality of life are associated with the development of posttraumatic stress disorder and are a possible result of traumatic experiences during ICU therapy.

[Venovenous extracorporeal membrane oxygenation (ECMO) with a heparin-lock bypass system. An effective addition in the treatment of acute respiratory failure (ARDS)]. / Veno-venöse extrakorporale Membranoxygenierung (ECMO) mit heparinbeschichtetem Bypass-System. Eine effektive Erweiterung bei der Behandlung des akuten Lungenversagens (ARDS).

Mortality of severe acute respiratory distress syndrome (ARDS) in Germany is about 60%. Respiratory therapy can make the lung injury worse by high positive airway pressures, high tidal volumes and high inspiratory oxygen concentrations. Extracorporeal membrane oxygenation (ECMO) was employed to reduce aggressive mechanical ventilation, but it has not been proved to be superior to conventional ventilation. However, encouraged by recently developed improvements in the technique and concept of ECMO, we introduced this therapy into our program for the treatment of ARDS. PATIENTS AND METHODS. All patients with severe ARDS (lung injury score > 2.5) admitted to our multidisciplinary intensive care unit from March 1992 to March 1995 were evaluated prospectively. After admission, the patients first underwent a conventional therapeutic approach, including pressure-controlled inverse-ratio ventilation, permissive hypercapnia, changes in body position (in particular, the prone position), negative fluid balance, anti-biotics, and low-dose hydrocortisone infusion. ECMO via a covalently heparin-coated, venovenous bypass-system with a vortex pump and two membrane lungs was performed if ARDS did not improve after 24-96 h of conventional therapy and if two of three of the slow-entry criteria for ECMO were fulfilled: (1) PaO2/FiO2 < 150 mmHg at PEEP > 5 mbar; (2) semistatic compliance < 30 ml/mbar; (3) right-left shunt > 30%. Only in cases of life-threatening hypoxemia (PaO2 < 50 mmHg at FiO2 1.0 and PEEP > 5 mbar for > 2 h (fast-entry criteria) was ECMO instituted immediately. RESULTS. Sixty patients fulfilled the entry criteria for our study. Thirty-nine patients were treated with a conventional protocol, 37 after improvement of ARDS and 2 who had not improved but in whom there were contraindications to the use of ECMO. ECMO was performed in 10 patients who had not improved, but who fulfilled the slow-entry criteria and in 11 primarily hypoxemic patients who fulfilled the fast-entry criteria. The survival rate was 30/39 (77%) for the conventional therapy group, 6/10 (60%) for the slow-entry group, and 11/11 (100%) for the fast-entry group. The onset of ECMO allowed a significant decrease in peak and mean airway pressures, tidal volume, ventilatory rate, minute volume and inspiratory oxygen concentration. Sufficient gas exchange was provided, and pulmonary artery pressures significantly decreased on bypass. The most frequent complications on bypass were pneumothorax (15/21 patients) and bleeding (7/21 patients). CONCLUSION. In comparison with the historical results at our own institution, the present study demonstrates an improvement in the survival rate from 56% to 78% since ECMO has become available. We conclude that venovenous ECMO with a heparin-bonded bypass circuit is an effective additional option for the treatment of patients with severe ARDS.

Thermodilution cardiac output may be incorrect in patients on venovenous extracorporeal lung assist.

Cardiac output measurement is part of routine monitoring in critically ill patients. In patients on extracorporeal lung assist, thermodilution cardiac output measurement may lead to erroneous results caused by indicator loss into the extracorporeal circuit. Seven patients on venovenous extracorporeal lung assist were studied using different extracorporeal blood flows. We compared conventional thermodilution cardiac output determinations with dye dilution cardiac output measurement, with dye injection into the pulmonary artery. The latter method is not affected by the extracorporeal circuit. The conventional thermodilution method overestimated cardiac output up to a maximum of 300%, providing results up to 10 L/min higher than true cardiac output. The mean difference between thermodilution and true cardiac output as determined by dye dilution with pulmonary artery indicator injection was 3.0 +/- 2.41 L/min. There was no correlation between thermodilution cardiac output values and true cardiac output (r = 0.06). We conclude that conventional thermodilution is not a suitable method for cardiac output measurement in patients on extracorporeal lung assist, especially if high extracorporeal blood flows are applied.

Long-term evaluation of a continuous intra-arterial blood gas monitoring system in patients with severe respiratory failure.

OBJECTIVE: The purpose of this study was to evaluate the reliability and accuracy of a new continuous intra-arterial blood gas monitoring system (IABG; PB3300, Puritan Bennett) over a prolonged period of time (> 7 days). DESIGN: Prospective criterion standard study. SETTING: Anesthesiological intensive care unit in a university hospital. PATIENTS: 11 sensors were tested in 10 mechanically ventilated patients with severe respiratory failure. INTERVENTIONS: PO2, PCO2, and pH measured using IABG were compared to values obtained from 2 conventional blood gas analyzers. The quality of blood pressure tracings was assessed using a scoring system consisting of 5 grades. RESULTS: The median study period was 205h/sensor (range: 169-506h). 320 blood samples were obtained. The ranges of measured parameters were: PO2 = 46-433 mmHg, PCO2 = 25-79 mmHg, pH = 7.25-7.55. The mean (SD) differences for the whole study period were: -4.3 (11.9) mmHg for PO2, for the clinically important range (PO2 < 150 mmHg) -1.9 (5.4) mmHg, -2.8 (4.5) mmHg for PCO2, and -0.03 (0.04) for the pH value. The MD (SD) in relation to the sensor lifetime were for days 1-3: -1.1 (5.1) mmHg for PO2, -0.4 (3.9) mmHg for PCO2, and -0.01 (0.03) for the pH value; for days 4-6: -1.5 (6.0) mmHg for PO2, -3.3 (4.0) mmHg for PCO2, and -0.03 (0.03) for the pH value; for days 7-9: -2.5 (4.7) mmHg for PO2, -5.1 (4.6) mmHg for PCO2, and -0.04 (0.04) for the pH value; for days > 9: -4.9 (4.4) mmHg for PO2, -5.3 (4.1) mmHg for PCO2, and -0.05 (0.03) for the pH value. CONCLUSIONS: The IABG reliably measured blood gases and pH values with acceptable clinical performance based on the overall results. There was, however, a decline in the agreement of the sensors and conventional values with increasing sensor lifetime. The mean differences (bias) and the standard deviation of differences (precision) of PO2, PCO2 and the pH values were acceptable for clinical purposes up to day 6. The arterial blood pressure tracings and blood withdrawal were not adversely affected. No side effects due to the sensors occurred. In summary, a prolonged sensor use for a period of up to 6 days appears to be reasonable. This system offers on-line information on oxygenation, ventilation, and acid-base status and allows immediate detection of acute and potentially life-threatening events.

MR imaging of pediatric cardiac tumors previously diagnosed by echocardiography.

Ten children, ranging in age from 3 weeks to 11 years, with a history of primary cardiac tumors were studied by two-dimensional echocardiography and by ECG triggered magnetic resonance (MR) imaging (six of them had rhabdomyomas). Eighteen of 31 tumors with intracavitary extension diagnosed by echocardiography were detected by MR. In addition, three intracavitary tumors were found by MR but not by echocardiography. Only 2 of 15 intramural tumors detected by echocardiography were identified by MR. Magnetic resonance imaging is inferior to echocardiography in the detection of intramural rhabdomyomas, but superior in delineation of the intra- and extracardiac extension of nonrhabdomyomal tumors.