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The occurrence of airway obstruction due to severe stenosis from lung cancer poses a significant risk of asphyxia. Although the placement of a metallic stent may relieve the obstruction, the procedure is associated with a high risk of asphyxia. To mitigate this risk, extracorporeal membrane pulmonary oxygenation (ECMO) has been proposed to temporarily substitute for cardiopulmonary function during the procedure. However, the use of systemic anticoagulation with heparin during ECMO may increase the likelihood of bleeding during surgery. This case report describes a successful treatment of a patient with malignant central airway obstruction through low-dose heparin veno-venous ECMO. This approach resulted in reduced intraoperative bleeding and invasive operation time, allowing for prompt postoperative withdrawal and recovery.
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BACKGROUND: Bedside measurements of critical closure pressure (Pcc) and mean systemic circulation filling pressure (Pmsf) were utilized to evaluate the response to esmolol in septic shock patients, in relation to the vascular waterfall phenomenon and body oxygen supply and demand. METHODS: This prospective observational self-controlled study included patients with septic shock, newly admitted to the intensive care unit, between August 2019 and January 2021. Pcc and Pmsf, along with the heart rate and other hemodynamic indicators were observed and compared before and 1 h after esmolol IV infusion. RESULTS: After 24 h of initial hemodynamic optimization, 56 patients were finally enrolled. After start of esmolol infusion, patients had a significant decrease in cardiac index (CI) (4.0 vs. 3.3 L/min/m2, P < 0.001), a significant increase in stroke index (SI) (34.1 vs. 36.6 mL/m2, P < 0.01), and a significant decrease in heart rate (HR) (116.8 vs. 90.6 beats/min, P < 0.001). After 1 h of treatment with esmolol, patients had a significant increase in Pcc (31.4 vs. 36.7 mmHg, P < 0.01). The difference between Pcc and Pmsf before and after treatment was statistically different (4.0 vs. 10.0 mmHg, P < 0.01). After heart rate control with esmolol, the patients had a significant increase in the body circulation vascular resistance indices (RIs) (15.14 vs. 18.25 mmHg/min/m2/L, P < 0.001). There was an increase in ScvO2 in patients after treatment with esmolol, but the difference was not statistically significant (68.4% vs. 69.8%, P > 0.05), while Pcv-aCO2 was significantly lower (6.3 vs. 4.9 mmHg, P < 0.001) and patients had a significant decrease in blood lactate levels (4.0 vs. 3.6 mmol/L, P < 0.05). CONCLUSION: Patients with septic shock whose heart rate is greater than 95 beats/min after hemodynamic optimization were treated with esmolol, which could effectively control heart rate and reduce CI, as well as improve Pcc and increase the difference between Pcc and Pmsf (known as "vascular waterfall" phenomenon), without affecting MAP, CVP, Pmsf and arteriovenous vascular resistance, and improve the balance of oxygen supply and demand in the body.
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OBJECTIVE: To explore the effect of goal-directed therapy bundle based on pulse-indicated continuous cardiac output (PiCCO) parameters to the prevention and treatment of acute kidney injury (AKI) in patients after cardiopulmonary bypass cardiac operation. METHODS: A prospective observational study was conducted. The adult patients with selective cardiopulmonary bypass cardiac operation admitted to the Third People's Hospital of Chengdu from December 2015 to January 2018 were enrolled. All patients were divided into two groups based on informed consent for PiCCO monitor at the time of admission to the intensive care unit (ICU): regular monitoring and treatment group (group A) and goal-directed therapy group based on PiCCO parameters (group B). In group A, the restrictive capacity management strategy was implemented to maintain the mean arterial pressure (MAP) > 65 mmHg (1 mmHg = 0.133 kPa) and the central venous pressure (CVP) between 8 mmHg and 10 mmHg. In group B, volume and hemodynamic status were optimized depending on PiCCO parameters to a goal of cardiac index (CI) > 41.68 mL×s-1×m-2, global end diastolic volume index (GEDVI) > 700 mL/m2 or intrathoracic blood volume index (ITBVI) > 850 mL/m2, extravascular lung water index (EVLWI) < 10 mL/kg, and MAP > 65 mmHg. Then the changes in hemodynamics and different prognosis of the patients in two groups were observed. Risk factors affecting the AKI were analyzed by Logistic regression. RESULTS: 171 cases were included, with 68 in group A and 103 in group B. There were no significant differences in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), operation ways, operation time, cardiopulmonary bypass time, intraoperative dominant liquid equilibrium quantity, the use of intra-aortic balloon counterpulsation (IABP) during operation, and serum creatinine (SCr) level at the time of admission to ICU between the two groups. There were no significant differences in CVP within 24 hours after admission to ICU between the two groups. MAP in group B was significantly higher than that in group A at 8 hours and 16 hours after ICU admission (mmHg: 68.9±6.3 vs. 66.7±5.1, 69.0±4.9 vs. 67.0±5.3, both P < 0.05). Sequential organ failure assessment (SOFA) score in group B was significantly lower than that in group A at 24 hours after ICU admission (5.7±2.2 vs. 6.9±2.8, P < 0.05). Dominant liquid equilibrium quantity in group B was significant higher than that in group A at 24 hours after ICU admission (mL/kg: 7.1±6.2 vs. -0.1±8.2, P < 0.01), but there was no significant difference of that between groups at 48 hours and 72 hours after ICU admission. Compared with group A, incidence of combination with AKI during 72 hours after ICU admission was significantly decreased in group B [48.5% vs. 69.1%; odds ratio (OR) = 0.422, 95% confidence interval (95%CI) = 0.222-0.802, P < 0.05], and incidence of moderate to severe AKI was also significantly decreased in group B (19.4% vs. 35.3%; OR = 0.442, 95%CI = 0.220-0.887, P < 0.05). There was no significant difference in usage of continuous renal replacement therapy (CRRT) after ICU admission between both groups (group A was 4.4%, group B was 4.9%, P > 0.05). It was shown by correlation analysis that only MAP and CI at 8 hours after ICU admission were significantly negatively correlated with AKI (MAP and AKI: r = -0.697, P = 0.000; CI and AKI: r = -0.664, P = 0.000). It was shown by Logistic regressive analysis that the MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI at 72 hours after ICU admission (MAP: OR = 0.736, 95%CI = 0.636-0.851, P = 0.000; CI: OR = 0.006, 95%CI = 0.001-0.063, P = 0.000). There were no significant differences in the duration of mechanical ventilation, the length of ICU stay, the post-operation complications (except AKI), 7-day and 28-day mortality between the two groups. CONCLUSIONS: Goal-directed therapy bundle based on PiCCO parameters reduced the incidence of AKI in patients after cardiopulmonary bypass cardiac operation and improved the severity of systemic disease. However, it did not reduce the duration of mechanical ventilation, length of ICU stay, the incidence of complications (except AKI), short-term mortality. The MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI in patients after cardiopulmonary bypass cardiac operation.
Subject(s)
Acute Kidney Injury/prevention & control , Cardiac Output/physiology , Cardiopulmonary Bypass , Acute Kidney Injury/epidemiology , Adult , Goals , Humans , Incidence , Intensive Care Units , Prospective Studies , Treatment OutcomeABSTRACT
OBJECTIVE: To explore the clinic values of early goal directed treatment (EGDT) with the target of mixed venous oxygen saturation (SvO2) and difference of mixed venous-arterial partial pressure of carbon dioxide (Pv-aCO2) in monitoring of oxygen metabolism and treatment for patients post open-heart operation. METHODS: A prospective study was conducted. The adult patients admitted to Third People's Hospital of Chengdu from December 2011 to March 2014 with SvO2<0.65 and blood lactic acid>2 mmol/L when admitted in intensive care unit (ICU) were selected on whom elective open-heart operation and pulmonary artery catheter examination were done. All patients received EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg (1 mmHg=0.133 kPa) and were divided into three groups by the values of SvO2and Pv-aCO2at 6-hour after ICU admission: A group with SvO2≥0.65 and Pv-aCO2<6 mmHg, B group with SvO2≥0.65 and Pv-aCO2≥6 mmHg, and C group with SvO2<0.65. Then the changes and prognosis of the patients in different groups were observed. RESULTS: 103 cases were included, 44 in A group, 31 in B group and 28 in C group. The acute physiology and chronic health evaluation II (APACHEII) score in group A were significantly lower than that in group B or C at 6, 24, 48 and 72 hours (T6, T24, T48, T72) of ICU admission (T6: 11.4 ± 5.8 vs. 13.9 ± 5.4, 13.7 ± 6.4; T24: 8.8 ± 3.7 vs. 10.8 ± 4.8, 11.8 ± 5.4; T48: 8.7 ± 4.1 vs. 9.6 ± 4.2, 10.2 ± 5.1; T72: 7.5 ± 3.4 vs. 8.6 ± 2.9, 9.2 ± 4.2, all P<0.05), and the sequential organ failure assessment (SOFA) showed the same tendency (T6: 6.5 ± 4.3 vs. 8.0 ± 3.8, 9.1 ± 4.5; T24: 6.6 ±3.6 vs. 8.6 ± 3.9, 8.5 ± 3.3; T48: 5.2 ± 3.4 vs. 7.0 ± 3.6, 7.6 ± 5.1; T72: 4.6 ± 2.4 vs. 5.8 ± 2.5, 6.8 ± 3.5, all P<0.05). The values of blood lactic acid (mmol/L) in group A and B were significant lower than that in group C at T6, T24, T48 and T72 (T6: 1.60 ± 0.95, 2.20 ± 1.02 vs. 2.55 ± 1.39; T24: 2.26 ± 1.26, 2.70 ± 1.36 vs. 3.34 ± 2.36; T48: 2.01 ± 1.15, 2.17 ± 1.51 vs. 2.42 ± 1.63; T72: 1.62±1.14, 1.64±0.75 vs. 2.11±1.29, all P<0.05). The time of machine ventilation (days) in group A or B was significantly shorter than that in group C (2.8 ± 2.0, 3.6 ± 2.3 vs. 5.0 ± 3.1, both P<0.05). ICU day (days) in group A was significant shorter than that in group C (4.6 ± 2.5 vs. 6.5 ± 3.7, P<0.05). The 7-day mortalities after operation in three groups were significantly different. Compared with group A (2.3%), the odds ratio (OR) in group B (22.6%) was 12.5 (P<0.05), group C (25.0%) 14.3 (P<0.05). The morbidity and 28-day mortality in three groups were not significantly different. Pv-aCO2negatively correlated with cardiac index (CI, r=-0.685, P=0.000), but not correlated with blood lactic acid (r=0.187, P=0.080). CONCLUSIONS: EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg improved the general condition and tissue hypoxia, shortened the time of machine ventilation and duration of hospitalization in ICU, and decrease the 7-day mortality.
