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1.
J Matern Fetal Neonatal Med ; 37(1): 2355293, 2024 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38873894

RESUMO

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) use in peripartum patients is rare, and there is a gap in the literature on the outcomes and guidance on using ECMO in peripartum patients. This study describes ECMO strategies our institution uses for peripartum patients and reports outcomes of ECMO use in peripartum patients with respiratory and/or cardiac failure. METHODS: A case series of all peripartum patients, defined as pregnant or up to 6 weeks after delivery of an infant >20 weeks gestation, from 2018 to 2023 from a single center requiring ECMO support. Patients were included if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. Patient demographics, operative details, ECMO data, and adverse outcomes for maternal, fetus, and neonates were all collected. RESULTS: Eighteen patients met the inclusion criteria. The cohort had a mean maternal age of 30.7 years old and was racially diverse. A majority of this cohort tested positive for COVID-19 (n = 10, 55%). ECMO was a bridge to recovery for all patients, of whom 14 (78%) were discharged out of the hospital alive. No patients received transplantation or a durable mechanical device. The most common complications were infection (25%) and postpartum hemorrhage (22%). CONCLUSIONS: ECMO use in peripartum patients in a single tertiary center was associated with a high survival rate. Furthermore, a strong multidisciplinary team, careful reevaluation of clinical trajectory, and consideration of complications and risks associated with using ECMO in peripartum patients are possible frameworks to use when challenged with critically ill peripartum patients.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Período Periparto , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Gravidez , Adulto , COVID-19/terapia , COVID-19/complicações , Estudos Retrospectivos , Recém-Nascido , SARS-CoV-2 , Insuficiência Respiratória/terapia , Insuficiência Cardíaca/terapia , Adulto Jovem
2.
Crit Care Med ; 52(6): 869-877, 2024 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-38752812

RESUMO

OBJECTIVES: To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. DESIGN: Retrospective observational cohort study. SETTING: Adult patients in the Extracorporeal Life Support Organization registry. PATIENTS: Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. CONCLUSIONS: Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support.


Assuntos
Oxigenação por Membrana Extracorpórea , Sistema de Registros , Síndrome do Desconforto Respiratório , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/mortalidade , Masculino , Estudos Retrospectivos , Feminino , Pessoa de Meia-Idade , Adulto , Fatores de Tempo , Prevalência , Idoso
3.
Crit Care ; 28(1): 158, 2024 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-38730424

RESUMO

BACKGROUND: An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult. METHODS: We searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model. RESULTS: Among the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14-38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74-0.96, P = 0.01) and 0.80 (95% CI 0.71-0.90, P < 0.001), respectively. CONCLUSION: Results showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.


Assuntos
Infecção Hospitalar , Oxigenação por Membrana Extracorpórea , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/métodos , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/mortalidade , Incidência , Fatores de Risco , Adulto
4.
Crit Care ; 28(1): 160, 2024 05 13.
Artigo em Inglês | MEDLINE | ID: mdl-38741176

RESUMO

BACKGROUND: Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR) followed by veno-arterial extracorporeal membrane oxygenation (ECMO) decannulation, versus those who experienced cardiac arrest without receiving ECPR. This study aims to explore organ donation practices and outcomes post-ECPR to enhance our understanding of the donation potential after cardiac arrest. METHODS: We conducted a nationwide retrospective cohort study using data from the Japan Organ Transplant Network database, covering all deceased organ donors between July 17, 2010, and August 31, 2022. We included donors who experienced at least one episode of cardiac arrest. During the study period, patients undergoing ECMO treatment were not eligible for a legal diagnosis of brain death. We compared the timeframes associated with each donor's management and the long-term graft outcomes of recipients between ECPR and non-ECPR groups. RESULTS: Among 370 brain death donors with an episode of cardiac arrest, 26 (7.0%) received ECPR and 344 (93.0%) did not; the majority were due to out-of-hospital cardiac arrests. The median duration of veno-arterial ECMO support after ECPR was 3 days. Patients in the ECPR group had significantly longer intervals from admission to organ procurement compared to those not receiving ECPR (13 vs. 9 days, P = 0.005). Lung graft survival rates were significantly lower in the ECPR group (log-rank test P = 0.009), with no significant differences in other organ graft survival rates. Of 160 circulatory death donors with an episode of cardiac arrest, 27 (16.9%) received ECPR and 133 (83.1%) did not. Time intervals from admission to organ procurement following circulatory death and graft survival showed no significant differences between ECPR and non-ECPR groups. The number of organs donated was similar between the ECPR and non-ECPR groups, regardless of brain or circulatory death. CONCLUSIONS: This nationwide study reveals that lung graft survival was lower in recipients from ECPR-treated donors, highlighting the need for targeted research and protocol adjustments in post-ECPR organ donation.


Assuntos
Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Obtenção de Tecidos e Órgãos , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/tendências , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/tendências , Adulto , Japão/epidemiologia , Estudos de Coortes , Doadores de Tecidos/estatística & dados numéricos , Parada Cardíaca/terapia , Parada Cardíaca/mortalidade , Idoso , Morte Encefálica
5.
BMJ Open Qual ; 13(2)2024 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-38782489

RESUMO

INTRODUCTION: In healthcare teams, psychological safety is associated with improved performance, communication, collaboration and patient safety. Extracorporeal membrane oxygenation (ECMO) retrieval teams are multidisciplinary teams that initiate ECMO therapy for patients with severe acute respiratory failure in referring hospitals and transfer patients to regional specialised centres for ongoing care. The present study aimed to explore an ECMO team's experience of psychological safety and generate recommendations to strengthen psychological safety. METHODS: The study was conducted in the Royal Brompton Hospital (RBH), part of Guy's and St Thomas' NHS Foundation Trust in London. RBH is one of six centres commissioned to provide ECMO therapy in the UK. 10 participants were recruited: 2 consultants, 5 nurses and 3 perfusionists. Semistructured interviews were used to explore the team members' views on teamwork, their perceived ability to discuss concerns within the team and the interaction between speaking up, teamwork and hierarchy. A Reflexive Thematic Analysis approach was used to explore the interview data. RESULTS: The analysis of the interview dataset identified structural and team factors shaping psychological safety in the specific context of the ECMO team. The high-risk environment in which the team operates, the clearly defined process and functions and the structured opportunities that provide legitimate moments to reflect together influence how psychological safety is experienced. Furthermore, speaking up is shaped by the familiarity among team members, the interdependent work, which requires boundary spanning across different roles, and leadership behaviour. A hierarchy of expertise is privileged over traditional institutional ranking. CONCLUSION: This study surfaced the structural and team factors that influence speaking up in the specific context of an ECMO retrieval team. Such information is used to suggest interventions to improve and strengthen psychological safety.


Assuntos
Oxigenação por Membrana Extracorpórea , Equipe de Assistência ao Paciente , Segurança do Paciente , Pesquisa Qualitativa , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/normas , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Equipe de Assistência ao Paciente/normas , Equipe de Assistência ao Paciente/estatística & dados numéricos , Segurança do Paciente/normas , Segurança do Paciente/estatística & dados numéricos , Londres , Entrevistas como Assunto/métodos , Melhoria de Qualidade , Feminino , Masculino , Segurança Psicológica
7.
J Surg Res ; 298: 94-100, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38593603

RESUMO

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy. METHODS: Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders. RESULTS: A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330). CONCLUSIONS: ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences.


Assuntos
Síndromes Compartimentais , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea , Fasciotomia , Humanos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Masculino , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/epidemiologia , Síndromes Compartimentais/terapia , Síndromes Compartimentais/mortalidade , Síndromes Compartimentais/cirurgia , Feminino , Pessoa de Meia-Idade , Bases de Dados Factuais/estatística & dados numéricos , Fasciotomia/estatística & dados numéricos , Adulto , Idoso , Amputação Cirúrgica/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , Extremidade Inferior/irrigação sanguínea , Extremidade Superior , Tempo de Internação/estatística & dados numéricos , Resultado do Tratamento
8.
Intensive Crit Care Nurs ; 83: 103674, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38461711

RESUMO

OBJECTIVES: This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest. METHODS: This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed. SETTING: Hamad General Hospital, Qatar. MAIN OUTCOME MEASURES: Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale. RESULTS: Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group. CONCLUSION: This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings. IMPLICATIONS FOR CLINICAL PRACTICE: The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Parada Cardíaca/terapia , Parada Cardíaca/mortalidade , Parada Cardíaca/complicações , Adulto , Catar , Idoso , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Reanimação Cardiopulmonar/normas , Doenças do Sistema Nervoso/etiologia , Doenças do Sistema Nervoso/complicações
9.
Anesthesiology ; 141(1): 116-130, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38526387

RESUMO

BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS: Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.


Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Disparidades em Assistência à Saúde , Medicaid , Medicare , Humanos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , COVID-19/terapia , Masculino , Feminino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Idoso , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Adulto , Mortalidade Hospitalar , Alta do Paciente/estatística & dados numéricos , Resultado do Tratamento
10.
ASAIO J ; 70(6): 479-484, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38237607

RESUMO

As the availability of extracorporeal membrane oxygenation (ECMO) expands, so has the need for interfacility transfer to ECMO centers. However, the impact of these transfers is unknown. We hypothesized that interfacility transfers would be associated with increased complications and mortality. This retrospective cohort study includes adult patients treated with venovenous (VV) ECMO at all four adult ECMO centers comprising our statewide registry. Complications, mortality, ECMO duration, length of stay, and disposition were compared based on cannulation at an ECMO center versus outside hospital and transferred by air versus ground after adjusting for baseline covariates/parameters. The study included 420 adult patients, 36% of whom were cannulated at an outside institution before transfer. Of these, 63% were transported by ground and the remainder by air. Risk adjusted logistic regression revealed similar odds of mortality between those cannulated at ECMO centers versus referring hospital and then transported (odds ratio [OR] = 0.77, confidence interval [CI] = 0.49-1.22). This study supports the practice of interfacility ECMO transfer.


Assuntos
Oxigenação por Membrana Extracorpórea , Transferência de Pacientes , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Estudos Retrospectivos , Masculino , Pessoa de Meia-Idade , Feminino , Transferência de Pacientes/estatística & dados numéricos , Transferência de Pacientes/métodos , Adulto , Idoso , Resultado do Tratamento , Tempo de Internação/estatística & dados numéricos
11.
Asian Cardiovasc Thorac Ann ; 31(4): 321-331, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37036252

RESUMO

BACKGROUND: A few prognostic scoring systems have been developed for predicting mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), albeit with variations in performance. This study aimed to assess and compare various mortality prediction models in a cohort of patients receiving VA-ECMO following cardiogenic shock or arrest. METHODS: We retrospectively analyzed 77 patients with cardiogenic shock who were placed on VA-ECMO support between March 2014 and August 2021. The APACHE II, SAPS II, SAVE, Modified SAVE, ENCOURAGE, and ECMO-ACCEPTS scores were calculated for each patient to predict the in-hospital mortality. RESULTS: Fifty-six (72.7%) patients died. All prediction model scores, except the ECMO-ACCEPTS, differed significantly between non-survivors and survivors as follows: ENCOURAGE, 23 versus 16 (p < 0.001); SAVE, -6 versus -3 (p = 0.008); Modified SAVE, -5 versus 0 (p = 0.005); APACHE II, 32 versus 22 (p = 0.009); and SAPS II, 67 versus 49 (p = 0.002). The ENCOURAGE score demonstrated the best discriminatory ability with an area under the receiver-operating characteristic curve of 0.81 (95% confidence interval: 0.7-0.81). All prognostic scoring systems possessed limited calibration ability. However, the SAPS II, SAVE, and ENCOURAGE scores had lower Akaike and Bayesian information criteria values, which were consistent with the results of the Hosmer-Lemeshow C statistic test, indicating better performance than the other scores. CONCLUSIONS: The ENCOURAGE score can help predict in-hospital mortality in all subsets of VA-ECMO patients, even though it was originally designed to predict intensive care unit mortality in the post-acute myocardial infarction setting.


Assuntos
Oxigenação por Membrana Extracorpórea , Mortalidade Hospitalar , Choque Cardiogênico , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Choque Cardiogênico/mortalidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Estudos Retrospectivos , Prognóstico
12.
Clin Obstet Gynecol ; 66(1): 151-162, 2023 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-36044634

RESUMO

In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.


Assuntos
Oxigenação por Membrana Extracorpórea , Feminino , Humanos , Gravidez , COVID-19/epidemiologia , COVID-19/terapia , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Pandemias , Respiração Artificial , Falha de Tratamento , Síndrome do Desconforto Respiratório/terapia
13.
J Heart Lung Transplant ; 42(4): 503-511, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-36435686

RESUMO

BACKGROUND: Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence. METHODS: We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO2 and PaCO2 with ABI. RESULTS: Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89). CONCLUSIONS: Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.


Assuntos
Lesões Encefálicas , Dióxido de Carbono , Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Hiperóxia , Oxigênio , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Lesões Encefálicas/sangue , Lesões Encefálicas/epidemiologia , Lesões Encefálicas/etiologia , Dióxido de Carbono/sangue , Reanimação Cardiopulmonar/efeitos adversos , Reanimação Cardiopulmonar/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Hiperóxia/sangue , Hiperóxia/epidemiologia , Hiperóxia/etiologia , Hemorragias Intracranianas/sangue , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/etiologia , AVC Isquêmico/sangue , AVC Isquêmico/epidemiologia , AVC Isquêmico/etiologia , Oxigênio/sangue , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
15.
Crit Care Med ; 50(2): 224-234, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-35100195

RESUMO

OBJECTIVES: In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. DESIGN: Mixed method approach combining multicenter retrospective study and survey. SETTING: Sixteen ICUs worldwide. PATIENTS: Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. CONCLUSIONS: Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.


Assuntos
Transfusão de Eritrócitos/normas , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Adulto , Austrália , Bélgica , Estudos de Coortes , Croácia , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Itália , Masculino , Pessoa de Meia-Idade , Países Baixos , Estudos Retrospectivos , Suécia , Resultado do Tratamento
16.
J Cardiovasc Pharmacol Ther ; 27: 10742484211069005, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35006031

RESUMO

BACKGROUND: Little data is published describing the use of medications prescribed for pulmonary arterial hypertension (PAH) in patients receiving extracorporeal membrane oxygenation (ECMO). Even though many patients with PAH may require ECMO as a bridge to transplant or recovery, little is reported regarding the use of PAH medications in this setting. METHODS: This retrospective case series summarizes the clinical experience of 8 patients with PAH receiving ECMO and reviews medication management in the setting of ECMO. RESULTS: Eight PAH patients, 5 of whom were female, ranging in age from 21 to 61 years old, were initiated on ECMO. Veno-arterial (VA) ECMO was used in 4 patients, veno-venous (VV) ECMO and hybrid ECMO configurations in 2 patients respectively. Common indications for ECMO included cardiogenic shock, bridge to transplant, and cardiac arrest. All patients were on intravenous (IV) prostacyclin therapy at baseline. Refractory hypotension was noted in 7 patients of whom 5 patients required downtitration or discontinuation of baseline PAH therapies. Three patients had continuous inhaled epoprostenol added during their time on ECMO. In patients who were decannulated from ECMO, PAH therapies were typically resumed or titrated back to baseline dosages. One patient required no adjustment in PAH therapy while on ECMO. Two patients were not able to be decannulated from ECMO. CONCLUSION: The treatment of critically ill PAH patients is challenging given a variety of factors that could affect PAH drug concentrations. In particular, PAH patients on prostacyclin analogues placed on VA ECMO appear to have pronounced systemic vasodilation requiring vasopressors which is alleviated by temporarily reducing the intravenous prostacyclin dose. Patients should be closely monitored for potential need for rapid titrations in prostacyclin therapy to maintain hemodynamic stability.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Hipertensão Arterial Pulmonar/terapia , Adulto , Antagonistas dos Receptores de Endotelina/uso terapêutico , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Inibidores da Fosfodiesterase 5/uso terapêutico , Estudos Retrospectivos , Adulto Jovem
17.
JAMA ; 327(3): 227-236, 2022 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-35040887

RESUMO

Importance: Platelets represent a potential therapeutic target for improved clinical outcomes in patients with COVID-19. Objective: To evaluate the benefits and risks of adding a P2Y12 inhibitor to anticoagulant therapy among non-critically ill patients hospitalized for COVID-19. Design, Setting, and Participants: An open-label, bayesian, adaptive randomized clinical trial including 562 non-critically ill patients hospitalized for COVID-19 was conducted between February 2021 and June 2021 at 60 hospitals in Brazil, Italy, Spain, and the US. The date of final 90-day follow-up was September 15, 2021. Interventions: Patients were randomized to a therapeutic dose of heparin plus a P2Y12 inhibitor (n = 293) or a therapeutic dose of heparin only (usual care) (n = 269) in a 1:1 ratio for 14 days or until hospital discharge, whichever was sooner. Ticagrelor was the preferred P2Y12 inhibitor. Main Outcomes and Measures: The composite primary outcome was organ support-free days evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and, for those who survived to hospital discharge, the number of days free of respiratory or cardiovascular organ support up to day 21 of the index hospitalization (range, -1 to 21 days; higher scores indicate less organ support and better outcomes). The primary safety outcome was major bleeding by 28 days as defined by the International Society on Thrombosis and Hemostasis. Results: Enrollment of non-critically ill patients was discontinued when the prespecified criterion for futility was met. All 562 patients who were randomized (mean age, 52.7 [SD, 13.5] years; 41.5% women) completed the trial and 87% received a therapeutic dose of heparin by the end of study day 1. In the P2Y12 inhibitor group, ticagrelor was used in 63% of patients and clopidogrel in 37%. The median number of organ support-free days was 21 days (IQR, 20-21 days) among patients in the P2Y12 inhibitor group and was 21 days (IQR, 21-21 days) in the usual care group (adjusted odds ratio, 0.83 [95% credible interval, 0.55-1.25]; posterior probability of futility [defined as an odds ratio <1.2], 96%). Major bleeding occurred in 6 patients (2.0%) in the P2Y12 inhibitor group and in 2 patients (0.7%) in the usual care group (adjusted odds ratio, 3.31 [95% CI, 0.64-17.2]; P = .15). Conclusions and Relevance: Among non-critically ill patients hospitalized for COVID-19, the use of a P2Y12 inhibitor in addition to a therapeutic dose of heparin, compared with a therapeutic dose of heparin only, did not result in an increased odds of improvement in organ support-free days within 21 days during hospitalization. Trial Registration: ClinicalTrials.gov Identifier: NCT04505774.


Assuntos
Anticoagulantes/administração & dosagem , Tratamento Farmacológico da COVID-19 , Heparina/administração & dosagem , Pacientes Internados , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , COVID-19/sangue , COVID-19/mortalidade , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Comorbidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Mortalidade Hospitalar , Humanos , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Oxigenoterapia/estatística & dados numéricos , Ativação Plaquetária/efeitos dos fármacos , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Receptores Purinérgicos P2Y12 , Respiração Artificial/estatística & dados numéricos , Trombose/epidemiologia , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
18.
BMJ ; 376: e068407, 2022 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-34996756

RESUMO

OBJECTIVE: To assess the effect of statin treatment versus placebo on clinical outcomes in patients with covid-19 admitted to the intensive care unit (ICU). DESIGN: INSPIRATION/INSPIRATION-S was a multicenter, randomized controlled trial with a 2×2 factorial design. Results for the anticoagulation randomization have been reported previously. Results for the double blind randomization to atorvastatin versus placebo are reported here. SETTING: 11 hospitals in Iran. PARTICIPANTS: Adults aged ≥18 years with covid-19 admitted to the ICU. INTERVENTION: Atorvastatin 20 mg orally once daily versus placebo, to be continued for 30 days from randomization irrespective of hospital discharge status. MAIN OUTCOME MEASURES: The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or all cause mortality within 30 days from randomization. Prespecified safety outcomes included increase in liver enzyme levels more than three times the upper limit of normal and clinically diagnosed myopathy. A clinical events committee blinded to treatment assignment adjudicated the efficacy and safety outcomes. RESULTS: Of 605 patients randomized between 29 July 2020 and 4 April 2021 for statin randomization in the INSPIRATION-S trial, 343 were co-randomized to intermediate dose versus standard dose prophylactic anticoagulation with heparin based regimens, whereas 262 were randomized after completion of the anticoagulation study. 587 of the 605 participants were included in the primary analysis of INSPIRATION-S, reported here: 290 were assigned to atorvastatin and 297 to placebo (median age 57 years (interquartile range 45-68 years); 256 (44%) women). The primary outcome occurred in 95 (33%) patients assigned to atorvastatin and 108 (36%) assigned to placebo (odds ratio 0.84, 95% confidence interval 0.58 to 1.21). Death occurred in 90 (31%) patients in the atorvastatin group and 103 (35%) in the placebo group (odds ratio 0.84, 95% confidence interval 0.58 to 1.22). Rates for venous thromboembolism were 2% (n=6) in the atorvastatin group and 3% (n=9) in the placebo group (odds ratio 0.71, 95% confidence interval 0.24 to 2.06). Myopathy was not clinically diagnosed in either group. Liver enzyme levels were increased in five (2%) patients assigned to atorvastatin and six (2%) assigned to placebo (odds ratio 0.85, 95% confidence interval 0.25 to 2.81). CONCLUSIONS: In adults with covid-19 admitted to the ICU, atorvastatin was not associated with a significant reduction in the composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or all cause mortality compared with placebo. Treatment was, however, found to be safe. As the overall event rates were lower than expected, a clinically important treatment effect cannot be excluded. TRIAL REGISTRATION: ClinicalTrials.gov NCT04486508.


Assuntos
Anticoagulantes/uso terapêutico , Atorvastatina/uso terapêutico , COVID-19/complicações , Cuidados Críticos/métodos , Tromboembolia Venosa/epidemiologia , Adolescente , Adulto , Idoso , COVID-19/mortalidade , Cuidados Críticos/estatística & dados numéricos , Método Duplo-Cego , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Heparina/uso terapêutico , Humanos , Unidades de Terapia Intensiva , Irã (Geográfico)/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , SARS-CoV-2 , Resultado do Tratamento , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/virologia , Adulto Jovem
19.
Sci Rep ; 12(1): 1265, 2022 01 24.
Artigo em Inglês | MEDLINE | ID: mdl-35075252

RESUMO

To identify predictors of neonatal ECMO circuit health, a retrospective analysis of circuit functional pressure and flow parameters as well as infant clotting values were collected 48 h prior to and 24 h post circuit change. Circuit impairment was defined as need for partial or total circuit change. Statistical analysis used multivariate statistics and non-parametric Mann-Whitney U-test with possible non-normality of measurements. A total of 9764 ECMO circuit and clotting values in 21 circuits were analyzed. Circuit delta-P mean, and maximum values increased from 8.62 to 48.59 mmHg (p < 0.011) and 16.00 to 53.00 mmHg (p < 0.0128) respectively prior to need for circuit change. Maximum and mean Pump Flow Revolutions per minute (RPM) increased by 75% (p < 0.0043) and 81% (p < 0.0057), respectively. Mean plasma free hemoglobin (pfHb) increased from 26.45 to 76.00 mg/dl, (p < 0.0209). Sweep, venous pressure, and clotting parameters were unaffected. ECMO circuit delta-P, RPM, and pfHb were early predictors of circuit impairment.


Assuntos
Oxigenação por Membrana Extracorpórea/instrumentação , Testes de Coagulação Sanguínea , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Masculino , Contagem de Plaquetas , Estudos Retrospectivos
20.
Am J Surg ; 223(2): 388-394, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-33894980

RESUMO

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.


Assuntos
COVID-19/complicações , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Influenza Humana/complicações , Síndrome do Desconforto Respiratório/mortalidade , Adulto , COVID-19/mortalidade , COVID-19/terapia , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Mortalidade Hospitalar , Humanos , Influenza Humana/mortalidade , Influenza Humana/terapia , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
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