Haemofiltration in newborns treated with extracorporeal membrane oxygenation: a case-comparison study

Introduction  

Extracorporeal membrane oxygenation is a supportive cardiopulmonary bypass technique for patients with acute reversible cardiovascular or respiratory failure. Favourable effects of haemofiltration during cardiopulmonary bypass instigated the use of this technique in infants on extracorporeal membrane oxygenation. The current study aimed at comparing clinical outcomes of newborns on extracorporeal membrane oxygenation with and without continuous haemofiltration.     

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.     

1例前纵隔淋巴瘤并发严重气道梗阻患儿的护理

总结1例前纵隔淋巴瘤并发严重气道梗阻患儿的抢救和护理体会。包括严密的观察和监测患儿病情,心肺复苏下迅速有效应用体外膜肺氧合进行救治;在体外膜肺运行期间密切观察患儿生命体征,动态评估气道梗阻症状,加强气道管理和监测。经过精心的治疗和护理,体外膜肺机运行70.5 h后成功撤离,患儿于入科第7天病情恢复平稳,转至血液科继续进行专科治疗。     

Complications of extracorporeal membrane oxygenation in neonates

In cases of severe respiratory failure, cardiopulmonary bypass has been used as support until cardiac and pulmonary recovery occurs. We report the Wilford Hall USAF Medical Center experience with extracorporeal membrane oxygenation (ECMO) and its associated complications. From July 1985 to March 1989, 57 neonates were placed on membrane oxygenators. The overall survival was 79%. Technical complications encountered included catheter-related problems, mechanical complications of the pump apparatus, and hemorrhage. Hemorrhagic complications were the most frequent and devastating complications encountered. Intracranial hemorrhage accounted for six deaths associated with bypass. Extracorporeal membrane oxygenation is successful in significantly improving survival of neonates whose predicted mortality approaches 100% with conventional treatment. The rate of infant mortality using the membrane oxygenator is not affected by technical complications related to catheter position, mechanical problems with the circuit, or hemorrhage, excluding intracranial hemorrhage. The major cause of death of infants receiving extracorporeal membrane oxygenation is the underlying disease process leading to cardiopulmonary failure.     

Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation

Use of extracorporeal membrane oxygenation to support patients with critical cardiorespiratory illness is increasing. Systemic anticoagulation is an essential element in the care of extracorporeal membrane oxygenation patients. While unfractionated heparin is the most commonly used agent, unfractionated heparin is associated with several unique complications that can be catastrophic in critically ill patients, including heparin-induced thrombocytopenia and acquired antithrombin deficiency. These complications can result in thrombotic events and subtherapeutic anticoagulation. Direct thrombin inhibitors (DTIs) are emerging as alternative anticoagulants in patients supported by extracorporeal membrane oxygenation. Increasing evidence supports DTIs use as safe and effective in extracorporeal membrane oxygenation patients with and without heparin-induced thrombocytopenia. This review outlines the pharmacology, dosing strategies and available protocols, monitoring parameters, and special use considerations for all available DTIs in extracorporeal membrane oxygenation patients. The advantages and disadvantages of DTIs in extracorporeal membrane oxygenation relative to unfractionated heparin will be described.     

Evaluation of furosemide regimens in neonates treated with extracorporeal membrane oxygenation

Introduction  

Loop diuretics are the most frequently used diuretics in patients treated with extracorporeal membrane oxygenation (ECMO). In patients after cardiopulmonary bypass (CPB) surgery, the use of continuous furosemide infusion is increasingly documented. Because ECMO and CPB are 'comparable' procedures, continuous furosemide infusion is used in newborns on ECMO. We report on the use of continuous intravenous furosemide in neonates treated with ECMO.     

First experiences with a new miniaturised life support system for mobile percutaneous cardiopulmonary bypass

AIM: As a result of healthcare changes, interhospital transfer has become common in the care even of patients with severely deteriorated cardiopulmonary function. This study describes experience with the use of a specially downsized, lightweight extracorporeal circulation system (Emergency-MECC) which enables percutaneous cardiopulmonary bypass support in resistant cases of severe cardiac and cardiopulmonary failure. METHODS: Between March 2006 and June 2007, the Emergency-MECC system, consisting of a centrifugal pump and a membrane oxygenator, was used to facilitate interhospital transfer of five adults. The technique included percutaneous cannulation, femoro-femoral venoarterial (n=4) and femoro-jugular venovenous (n=1) life support by extracorporeal membrane oxygenation. RESULTS: Bedside cannulation was uneventful and the extracorporeal circulation support achieved adequate systemic blood flow and oxygen delivery in all cases. Vasopressor support could be immediately reduced and hypoxaemia was treated effectively. During interhospital transfer (air ambulance in three and ground ambulance in two cases), no technical complication occurred. Hospital survival rate was 80%. CONCLUSIONS: The Emergency-MECC system is safe, rapid and highly effective in restoring blood flow and oxygen delivery. Interhospital transfer on cardiopulmonary bypass was made possible without extended technical or personnel support.     

RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest

There is a growing interest in using point-of-care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno-arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.     

Idioventricular rhythm induced by therapeutic hypothermia

We report the case of a 11-year-old girl with fulminant myocarditis and cardiogenic shock who received cardiopulmonary resuscitation and extracorporeal membrane oxygenation support. During the induction of hypothermia, her rhythm degenerated into idioventricular rhythm with extremely prolonged QRS duration. The hypothermia-induced bradycardia caused a drop of mixed venous oxygenation saturation and which was resolved by re-warming to normothermia. This finding suggested that hypothermia may compromise cardiac performance and physicians should be cautious about its application in patients with fulminant myocarditis.     

行体外膜肺氧合治疗并发症的观察及护理

目的探讨行体外膜肺氧合（ECMO）治疗并发症的观察及护理要点。方法对8例因心肺功能不全而在术中或术后建立ECMO的患者，对治疗过程中出现的并发症进行分析和总结。结果8例患者使用ECMO时间为4～81h，4例患者能顺利脱离ECMO,4例不能脱机，其中2例因心跳停止不能恢复，1例出血不止，1例因怀疑肺栓塞而放弃。结论出血仍是ECMO最主要的并发症，使用肝素涂层的膜肺和管道并合理应用肝素，是减少出血的方法之一。     

Extracorporeal membrane oxygenation rescue for critically ill children with cardiopulmonary failure北大核心CSCD

Objective To summarize the therapeutic effects of extracorporeal membrane oxygenation (ECMO) on critically ill children with severe cardiopulmonary failure. Methods The pediatric patients supported with ECMO admitted to pediatric intensive care unit (PICU) from December 2015 to August 2017 were enrolled in this study. The data of demographics of patients, diagnosis, indication for ECMO, the procedure of ECMO support, complications, and survival status were analyzed. Results A total of 17 pediatric patients including 9 male and 8 female with severe cardiopulmonary failure treated with ECMO were studied. The median of age was 24 (2, 117) months, and the median of body weight was 12 (5, 33) kg. The indications for initiation of ECMO were cardiovascular failure with poor response to conventional therapy and severe acute respiratory distress syndrome (ARDS) without any beneficial effect obtained from mechanical ventilation. The percutaneous cannulation was done under ultrasound guidance by a team of trained intensivists through right cervical vein and internal carotid artery resulting in veno-Arterial extracorporeal membrane oxygenation support. The mean duration of ECMO support was 212. 5 h with median 188. 5 (3-924) h. All patients were treated with mechanical ventilation for prevention from pulmonary atelectasis. Of 17 patients, 10 were coupled with continuous renal replacement therapy (CRRT) to keep fluid balance. As a result, 11 children (64. 7%) were successfully weaned from ECMO defined as survival for 24 h after ECMO, and 10 children (58. 8%) were alive to discharge from hospital. One of 2 cardiac arrest cases treated with extracorporeal cardiopulmonary resuscitation (ECPR) was alive. During ECMO support, there were 41 adverse events happened including pressure ulcers (64.7%), thrombocytopenia (52. 9%), bleeding (35. 3%) . Conclusions The survival rate at discharge was 58. 8% in pediatric patients with severe cardiopulinonaiy failure with poor response to conventional therapy. Our data suggest that ECMO support is an important rescue technique for pediatric critical illness.     

The use of immobilized heparin in perfusion systems with membrane oxygenation during heart surgery

The analysis of 65 cases of cardiopulmonary bypass surgery using systems distinct in the type of the oxygenator used (contact, membrane) and the degree of thromboresistance of blood-contacting surfaces has demonstrated that the use of heparin-covered membrane blood oxygenators and systems allows of a considerable reduction in blood trauma during perfusion and a 5-6-fold decrease of heparin doses employed for extracorporeal membrane blood oxygenation.     

急诊体外膜肺氧合辅助下重症心肌梗死的介入治疗

目的 探讨体外膜肺氧合辅助下对急性重症心肌梗死(AMI)患者中的行急诊经皮冠状动脉介入治疗(PCI)的疗效. 方法 回顾分析2003年1月至2007年12月期间中山大学附属中山医院住院的25例诊断急性心肌梗死合并心脏骤停、严重心律失常或心功能衰竭的患者,在体外膜肺氧合(ECMO)支持下行急诊PCI治疗的临床疗效观察. 结果 25例患者均在ECMO支持下血流动力学稳定,并成功行PCI,梗死相关动脉全部开通,20例患者血流达到TIMI 3级,5例患者发生慢血流或无复流(血流TIMI 0～2级).急诊介入手术中无一例死亡,介入治疗术后住院期内死亡7例,住院期间总的死亡率为28%(7/25). 结论 ECMO支持下,能促进重症AMI患者血流动力学恢复稳定,为重症患者进行PCI提供了必备的前提条件;为冠状动脉血运重建赢得了时间,从而提高了重症AMI患者的存活率.     

Duration of resuscitation prior to rescue extracorporeal membrane oxygenation impacts outcome in children with heart disease

Purpose  

Survival outcomes in children with heart disease after use of either non-emergent extracorporeal membrane oxygenation (ECMO) or cardiopulmonary resuscitation (CPR) onto ECMO (ECPR) are comparable. Concerns remain regarding the impact of CPR duration on survival and neurological outcome.     

经颅多普勒超声在体外膜肺氧合患者脑血流动力学监测及预后评估中的应用

  目的  探讨经颅多普勒超声在体外膜肺氧合患者脑血流动力学监测及预后评估中的应用价值。  方法  回顾性分析2015年5月20日~2020年1月3日在本院87例进行体外膜肺氧合治疗患者的临床资料,比较患者治疗前后脑血流动力学指标[收缩峰值血流速度(Vs)、舒张期峰值流速(Vd)、平均血流速度(Vm)、搏动指数(PI)]和心功能指标[左心射血分数(LVEF)、左心室流出道血流速度时间积分(VTI)、平均动脉压(MAP)]。随访1年,统计患者的预后状态。依据其不同的预后状态分为预后良好组(n= 56)和预后不良组(n=31),比较两组性别、年龄、疾病分类、肾功能不全、肝功能异常、多器官衰竭、体外膜肺氧合流量、正性肌力药物评分(IS)、Vs、Vd、Vm、PI、LVEF、MAP水平。  结果  治疗前与治疗后Vs、Vd、Vm、PI值差异无统计学意义(P>0.05);体外膜肺氧合患者治疗后LVEF、MAP、VTI升高(P < 0.05);单因素分析结果显示,两组肾功能不全、多器官功能衰竭率及Vs、Vd、Vm、PI、LVEF、VTI、MAP值的差异有统计学意义(P < 0.05),两组性别、年龄、疾病分类、体外膜肺氧合流量及IS评分的差异无统计学意义(P>0.05);Logistics回归分析结果显示,肾功能不全、Vs、Vd、Vm、PI、MAP是影响体外膜肺氧合患者预后不良的独立危险因素(P < 0.05)。  结论  脑血流动力学指标(Vs、Vd、Vm、PI)与体外膜肺氧合患者预后有密切联系,临床需加强联合各指标检测,尽早评估体外膜肺氧合患者预后状态。      

体外膜肺氧合技术的临床应用及护理进展

综述体外膜肺氧合(ECMO)技术近年来的临床应用以及在护理过程中的监护要点和并发症护理,提出通过有效的监护是预防并减少并发症的发生以提高ECMO辅助效果的有力保障.     

体外膜肺氧合技术在重症呼吸衰竭病人护理中的应用进展

从体外膜肺氧合(ECMO)治疗的基本原理及其发展、ECMO技术应用于重症呼吸衰竭的适应证、ECMO技术应用于重症呼吸衰竭病人的护理(包括循环和生命体征的监测、气道及呼吸机管理、预防感染、氧合器护理等)方面综述了体外膜肺氧合技术在重症呼吸衰竭病人护理中的应用进展.     

Bivalirudin and post-cardiotomy ECMO: a word of caution

ABSTRACT: Bivalirudin has been proposed as the sole anticoagulant in patients under extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass. Owing to the pharmacodynamic properties of bivalirudin, areas of blood stagnation should be carefully avoided in order to limit the risk of thrombosis. The ECMO circuit has no reservoir and is usually devoid of blood stagnation areas. Conversely, under some circumstances, intracardiac blood stagnation areas may exist. In this case, there is a potential risk for the spontaneous formation of an intracardiac thrombus. We suggest that, under bivalirudin anticoagulation, a minimal degree of intracardiac blood flow with left heart valve movement is allowed.     

Infantile pulmonary alveolar proteinosis with interstitial pneumonia: bilateral simultaneous lung lavage utilizing extracorporeal membrane oxygenation and steroid therapy.

An infant with refractory pulmonary alveolar proteinosis (PAP) associated with severe interstitial pneumonia is described. Although she was treated by bilateral simultaneous lung lavage utilizing extracorporeal membrane oxygenation and steroid therapy, she died of progressive respiratory failure 28 days after admission. Histologic examination of lung autopsy specimen showed only partial alveolar spaces to be filled with a dense PAS positive granular eosinophilic material and showed severe interstitial pneumonia with marked fibrosis of alveolar walls and interstitium. The lung lavage seemed to be effective for PAP because the effluent fluid sufficiently became clear and the PAS positive material was detected only in partial alveoli. The full venoarterial cardiopulmonary bypass with extracorporeal membrane oxygenation seemed to be very useful to support bilateral lung lavage for small infants. The refractory symptoms and failure of treatment were resulted from the association of severe interstitial pneumonia. In neonates or infants with PAP and severe interstitial pneumonia with poor response for steroid therapy, the lung transplantation should be considered.