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Original Article
Pediatrics
Outcomes of extracorporeal membrane oxygenation support in pediatric hemato-oncology patients
Hong Yul An, Hyoung Jin Kang, June Dong Park
Acute Crit Care. 2024;39(1):108-116.   Published online January 24, 2024
DOI: https://doi.org/10.4266/acc.2023.01088
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AbstractAbstract PDFSupplementary Material
Background
In this study, we reviewed the outcomes of pediatric patients with malignancies who underwent hematopoietic stem cell transplantation (HSCT) and extracorporeal membrane oxygenation (ECMO). Methods: We retrospectively analyzed the records of pediatric hemato-oncology patients treated with chemotherapy or HSCT and who received ECMO in the pediatric intensive care unit (PICU) at Seoul National University Children’s Hospital from January 2012 to December 2020. Results: Over a 9-year period, 21 patients (14 males and 7 females) received ECMO at a single pediatric institute; 10 patients (48%) received veno-arterial (VA) ECMO for septic shock (n=5), acute respiratory distress syndrome (ARDS) (n=3), stress-induced myopathy (n=1), or hepatopulmonary syndrome (n=1); and 11 patients (52%) received veno-venous (VV) ECMO for ARDS due to pneumocystis pneumonia (n=1), air leak (n=3), influenza (n=1), pulmonary hemorrhage (n=1), or unknown etiology (n=5). All patients received chemotherapy; 9 received anthracycline drugs and 14 (67%) underwent HSCT. Thirteen patients (62%) were diagnosed with malignancies and 8 (38%) were diagnosed with non-malignant disease. Among the 21 patients, 6 (29%) survived ECMO in the PICU and 5 (24%) survived to hospital discharge. Among patients treated for septic shock, 3 of 5 patients (60%) who underwent ECMO and 5 of 10 patients (50%) who underwent VA ECMO survived. However, all the patients who underwent VA ECMO or VV ECMO for ARDS died. Conclusions: ECMO is a feasible treatment option for respiratory or heart failure in pediatric patients receiving chemotherapy or undergoing HSCT.
Review Article
CPR/Resuscitation
Plasma biomarkers for brain injury in extracorporeal membrane oxygenation
Shrey Kapoor, Anna Kolchinski, Aaron M. Gusdon, Lavienraj Premraj, Sung-Min Cho
Acute Crit Care. 2023;38(4):389-398.   Published online November 29, 2023
DOI: https://doi.org/10.4266/acc.2023.01368
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AbstractAbstract PDF
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.
Original Articles
Pulmonary
Outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation and continuous renal replacement therapy in the United States
Carlos R Franco Palacios, Rudiona Hoxhaj, Catlyn Thigpen, Jeffrey Jacob, Atul Bhatnagar, Asif Saberi
Acute Crit Care. 2023;38(3):308-314.   Published online August 30, 2023
DOI: https://doi.org/10.4266/acc.2023.00115
  • 1,653 View
  • 58 Download
  • 1 Web of Science
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AbstractAbstract PDF
Background
Coronavirus disease 2019 (COVID-19) infection is associated with significant morbidity and mortality. Some patients develop severe acute respiratory distress syndrome and kidney failure requiring the combination of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT).
Methods
Retrospective cohort study of 127 consecutive patients requiring combined ECMO and CRRT support in intensive care units at an ECMO center in Marietta, GA, United States.
Results
Sixty and 67 patients with and without COVID-19, respectively, required ECMO-CRRT support. After adjusting for confounding variables, patients with COVID-19 had increased mortality at 30 days (hazard ratio [HR], 5.19; 95% confidence interval [CI], 2.51–10.7; P<0.001) and 90 days (HR, 6.23; 95% CI, 2.60–14.9; P<0.001).
Conclusions
In this retrospective study, patients with COVID-19 who required ECMO-CRRT had increased mortality when compared to patients without COVID-19.

Citations

Citations to this article as recorded by  
  • Factors associated with post-hospitalization dialysis dependence in ECMO patients who required continuous renal replacement therapy
    Carlos Rodrigo Franco Palacios, Rudiona Hoxhaj, Catlyn Thigpen, Jeffrey Jacob
    Renal Failure.2024;[Epub]     CrossRef
Cardiology
Risk factors for cannula-associated arterial thrombosis following extracorporeal membrane oxygenation support: a retrospective study
Ngan Hoang Kim Trieu, Xuan Thi Phan, Linh Thanh Tran, Huy Minh Pham, Dai Quang Huynh, Tuan Manh Nguyen, Anh Tuan Mai, Quan Quoc Minh Du, Bach Xuan Nguyen, Thao Thi Ngoc Pham
Acute Crit Care. 2023;38(3):315-324.   Published online August 23, 2023
DOI: https://doi.org/10.4266/acc.2023.00500
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  • 1 Web of Science
  • 1 Crossref
AbstractAbstract PDF
Background
Hemostatic dysfunction during extracorporeal membrane oxygenation (ECMO) due to blood-circuit interaction and the consequences of shear stress imposed by flow rates lead to rapid coagulation cascade and thrombus formation in the ECMO system and blood vessels. We aimed to identify the incidence and risk factors for cannula-associated arterial thrombosis (CaAT) post-decannulation.
Methods
A retrospective study of patients undergoing arterial cannula removal following ECMO was performed. We evaluated the incidence of CaAT and compared the characteristics, ECMO machine parameters, cannula sizes, number of blood products transfused during ECMO, and daily hemostasis parameters in patients with and without CaAT. Multivariate analysis identified the risk factors for CaAT.
Results
Forty-seven patients requiring venoarterial ECMO (VA-ECMO) or hybrid methods were recruited for thrombosis screening. The median Sequential Organ Failure Assessment score was 11 (interquartile range, 8–13). CaAT occurred in 29 patients (61.7%), with thrombosis in the superficial femoral artery accounting for 51.7% of cases. The rate of limb ischemia complications in the CaAT group was 17.2%. Multivariate analysis determined that the ECMO flow rate–body surface area (BSA) ratio (100 ml/min/m2) was an independent factor for CaAT, with an odds ratio of 0.79 (95% confidence interval, 0.66–0.95; P=0.014).
Conclusions
We found that the incidence of CaAT was 61.7% following successful decannulation from VA-ECMO or hybrid modes, and the ECMO flow rate–BSA ratio was an independent risk factor for CaAT. We suggest screening for arterial thrombosis following VA-ECMO, and further research is needed to determine the risks and benefits of such screening.

Citations

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  • Has the role of veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock following acute myocardial infarction been fully determined? A case report
    Kha Minh Nguyen, Hai Phuong Nguyen Tran, Vi Tuong Dang, Sy Van Hoang, Josip Andelo Borovac, Dmitry Duplyakov, Chiara De Biase, Pok-Tin Tang
    European Heart Journal - Case Reports.2024;[Epub]     CrossRef
CPR/Resuscitation
Prognostic significance of respiratory quotient in patients undergoing extracorporeal cardiopulmonary resuscitation in Korea
Yun Im Lee, Ryoung-Eun Ko, Soo Jin Na, Jeong-Am Ryu, Yang Hyun Cho, Jeong Hoon Yang, Chi Ryang Chung, Gee Young Suh
Acute Crit Care. 2023;38(2):190-199.   Published online May 25, 2023
DOI: https://doi.org/10.4266/acc.2022.01438
  • 1,732 View
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  • 3 Web of Science
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AbstractAbstract PDF
Background
Respiratory quotient (RQ) may be used as a tissue hypoxia marker in various clinical settings but its prognostic significance in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) is not known. Methods: Medical records of adult patients admitted to the intensive care units after ECPR in whom RQ could be calculated from May 2004 to April 2020 were retrospectively reviewed. Patients were divided into good neurologic outcome and poor neurologic outcome groups. Prognostic significance of RQ was compared to other clinical characteristics and markers of tissue hypoxia. Results: During the study period, 155 patients were eligible for analysis. Of them, 90 (58.1%) had a poor neurologic outcome. The group with poor neurologic outcome had a higher incidence of out-of-hospital cardiac arrest (25.6% vs. 9.2%, P=0.010) and longer cardiopulmonary resuscitation to pump-on time (33.0 vs. 25.2 minutes, P=0.001) than the group with good neurologic outcome. For tissue hypoxia markers, the group with poor neurologic outcome had higher RQ (2.2 vs. 1.7, P=0.021) and lactate levels (8.2 vs. 5.4 mmol/L, P=0.004) than the group with good neurologic outcome. On multivariable analysis, age, cardiopulmonary resuscitation to pump-on time, and lactate levels above 7.1 mmol/L were significant predictors for a poor neurologic outcome but not RQ. Conclusions: In patients who received ECPR, RQ was not independently associated with poor neurologic outcome.

Citations

Citations to this article as recorded by  
  • Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study
    Amir Vahedian-Azimi, Ibrahim Fawzy Hassan, Farshid Rahimi-Bashar, Hussam Elmelliti, Anzila Akbar, Ahmed Labib Shehata, Abdulsalam Saif Ibrahim, Ali Ait Hssain
    Intensive and Critical Care Nursing.2024; 83: 103674.     CrossRef
  • What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study
    Amir Vahedian-Azimi, Ibrahim Fawzy Hassan, Farshid Rahimi-Bashar, Hussam Elmelliti, Anzila Akbar, Ahmed Labib Shehata, Abdulsalam Saif Ibrahim, Ali Ait Hssain
    International Journal of Emergency Medicine.2024;[Epub]     CrossRef
  • Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest and in-hospital cardiac arrest with return of spontaneous circulation: be careful when comparing apples to oranges
    Hwa Jin Cho, In Seok Jeong, Jan Bělohlávek
    Acute and Critical Care.2023; 38(2): 242.     CrossRef
Review Article
Basic science and research
Extracorporeal circulation models in small animals: beyond the limits of preclinical research
Mukhammad Kayumov, Reverien Habimana, Dowan Kim, Francis O Obiweluozor, In Seok Jeong, Hwa Jin Cho
Acute Crit Care. 2023;38(1):1-7.   Published online February 28, 2023
DOI: https://doi.org/10.4266/acc.2023.00381
  • 2,393 View
  • 200 Download
  • 2 Web of Science
  • 3 Crossref
AbstractAbstract PDF
Extracorporeal membrane oxygenation (ECMO) use has remarkably increased in recent years. Although ECMO has become essential for patients with refractory cardiac and respiratory failure, extracorporeal circulation (ECC) is associated with significant complications. Small-animal models of ECC have been developed and widely used to better understand ECC-induced pathophysiology. This review article summarizes the development of small-animal ECC models, including the animal species, circuit configuration, priming, perioperative procedures, cannulation, and future perspectives of small-animal ECMO models.

Citations

Citations to this article as recorded by  
  • Venoarterial Extracorporeal Membrane Oxygenation Implementation in Septic Shock Rat Model
    Tianlong Wang, Mingru Zhang, Wenhao Dong, Jing Wang, Han Zhang, Yuefu Wang, Bingyang Ji
    ASAIO Journal.2024;[Epub]     CrossRef
  • Multiorgan recovery in a cadaver body using mild hypothermic ECMO treatment in a murine model
    Nodir Madrahimov, Vitalii Mutsenko, Ruslan Natanov, Dejan Radaković, André Klapproth, Mohamed Hassan, Mathias Rosenfeldt, Florian Kleefeldt, Ivan Aleksic, Süleyman Ergün, Christoph Otto, Rainer G. Leyh, Constanze Bening
    Intensive Care Medicine Experimental.2023;[Epub]     CrossRef
  • Post-Mortem Extracorporeal Membrane Oxygenation Perfusion Rat Model: A Feasibility Study
    Matthias Manfred Deininger, Carl-Friedrich Benner, Lasse Johannes Strudthoff, Steffen Leonhardt, Christian Simon Bruells, Gernot Marx, Christian Bleilevens, Thomas Breuer
    Animals.2023; 13(22): 3532.     CrossRef
Original Articles
Pediatrics
Characteristics and timing of mortality in children dying in pediatric intensive care: a 5-year experience
Edin Botan, Emrah Gün, Emine Kübra Şden, Cansu Yöndem, Anar Gurbanov, Burak Balaban, Fevzi Kahveci, Hasan Özen, Hacer Uçmak, Ali Genco Gençay, Tanil Kendirli
Acute Crit Care. 2022;37(4):644-653.   Published online November 11, 2022
DOI: https://doi.org/10.4266/acc.2022.00395
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  • 2 Web of Science
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AbstractAbstract PDF
Background
Pediatric intensive care units (PICUs), where children with critical illnesses are treated, require considerable manpower and technological infrastructure in order to keep children alive and free from sequelae. Methods: In this retrospective comparative cohort study, hospital records of patients aged 1 month to 18 years who died in the study PICU between January 2015 and December 2019 were reviewed. Results: A total of 2,781 critically ill children were admitted to the PICU. The mean±standard deviation age of 254 nonsurvivors was 64.34±69.48 months. The mean PICU length of stay was 17 days (range, 1–205 days), with 40 children dying early (<1 day of PICU admission). The majority of nonsurvivors (83.9%) had comorbid illnesses. Children with early mortality were more likely to have neurological findings (62.5%), hypotension (82.5%), oliguria (47.5%), acidosis (92.5%), coagulopathy (30.0%), and cardiac arrest (45.0%) and less likely to have terminal illnesses (52.5%) and chronic illnesses (75.6%). Children who died early had a higher mean age (81.8 months) and Pediatric Risk of Mortality (PRISM) III score (37). In children who died early, the first three signs during ICU admission were hypoglycemia in 68.5%, neurological symptoms in 43.5%, and acidosis in 78.3%. Sixty-seven patients needed continuous renal replacement therapy, 51 required extracorporeal membrane oxygenation support, and 10 underwent extracorporeal cardiopulmonary resuscitation. Conclusions: We found that rates of neurological findings, hypotension, oliguria, acidosis, coagulation disorder, and cardiac arrest and PRISM III scores were higher in children who died early compared to those who died later.

Citations

Citations to this article as recorded by  
  • Descriptive and Clinical Characteristics of Nonsurvivors in a Tertiary Pediatric Intensive Care Unit in Turkey: 6 Years of Experience
    Zeynep Karakaya, Merve Boyraz, Seyma Koksal Atis, Servet Yuce, Muhterem Duyu
    Journal of Pediatric Intensive Care.2023;[Epub]     CrossRef
  • Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit
    Huan Liang, Kyle A. Carey, Priti Jani, Emily R. Gilbert, Majid Afshar, L. Nelson Sanchez-Pinto, Matthew M. Churpek, Anoop Mayampurath
    Frontiers in Pediatrics.2023;[Epub]     CrossRef
Pulmonary
The role of nafamostat mesilate as a regional anticoagulant during extracorporeal membrane oxygenation
Jae Ha Lee, Jin Han Park, Ji Hoon Jang, Se Hun Kim, Sung Yong Hong, Woon Heo, Dong-Hwan Lee, Hye Sook Choi, Ki Hoon Kim, Hang-Jea Jang
Acute Crit Care. 2022;37(2):177-184.   Published online April 20, 2022
DOI: https://doi.org/10.4266/acc.2021.01312
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  • 6 Web of Science
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AbstractAbstract PDF
Background
Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment. Methods: We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation. Results: The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group. Conclusions: NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.

Citations

Citations to this article as recorded by  
  • Management of cardiopulmonary bypass in patients with ischemic and hemorrhagic strokes in surgery for active infective endocarditis
    Takahiro Yamazato, Hiroshi Munakata, Yutaka Okita
    Indian Journal of Thoracic and Cardiovascular Surgery.2024; 40(S1): 61.     CrossRef
  • Approach to Decompensated Right Heart Failure in the Acute Setting
    Catherine V. Levitt, Caitlin A. Williams, Jalil Ahari, Ali Pourmand
    Journal of Clinical Medicine.2024; 13(3): 869.     CrossRef
  • Critical Care Management of Severe Asthma Exacerbations
    Shameek Gayen, Stephen Dachert, Bilal Lashari, Matthew Gordon, Parag Desai, Gerard Criner, Juan Cardet, Kartik Shenoy
    Journal of Clinical Medicine.2024; 13(3): 859.     CrossRef
  • Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock
    Jan-Sören Padberg, Jannik Feld, Leonie Padberg, Jeanette Köppe, Lena Makowski, Joachim Gerß, Patrik Dröge, Thomas Ruhnke, Christian Günster, Stefan Andreas Lange, Holger Reinecke
    Journal of Clinical Medicine.2024; 13(4): 1167.     CrossRef
  • Extra-Corporeal Membrane Oxygenation in Pregnancy
    Tatsiana Romenskaya, Yaroslava Longhitano, Aman Mahajan, Gabriele Savioli, Antonio Voza, Manfredi Tesauro, Christian Zanza
    Journal of Clinical Medicine.2024; 13(6): 1634.     CrossRef
  • Anticoagulants in adult extracorporeal membrane oxygenation: alternatives to standardized anticoagulation with unfractionated heparin
    Shu Tang, Liqing Xu, Hui Li, Zhanshen Wu, Qiang Wen
    European Journal of Clinical Pharmacology.2023; 79(12): 1583.     CrossRef
Pulmonary
Association of pulmonary arterial pressure with volume status in patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation
Tae Hwa Hong, Hyoung Soo Kim, Sunghoon Park
Acute Crit Care. 2022;37(2):159-167.   Published online March 11, 2022
DOI: https://doi.org/10.4266/acc.2021.00927
  • 4,396 View
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AbstractAbstract PDFSupplementary Material
Background
Data on pulmonary hemodynamic parameters in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) are scarce.
Methods
The associations between pulmonary artery catheter parameters for the first 7 days of ECMO, fluid balance, and hospital mortality were investigated in adult patients (aged ≥19 years) who received venovenous ECMO for refractory ARDS between 2015 and 2017.
Results
Twenty patients were finally included in the analysis (median age, 56.0 years; interquartile range, 45.5–68.0 years; female, n=10). A total of 140 values were collected for each parameter (i.e., 7 days×20 patients). Net fluid balance was weakly but significantly correlated with systolic and diastolic pulmonary arterial pressures (PAPs; r=0.233 and P=0.011; r=0.376 and P<0.001, respectively). Among the mechanical ventilation parameters, above positive end-expiratory pressure was correlated with systolic PAP (r=0.191 and P=0.025), and static compliance was negatively correlated with diastolic PAP (r=−0.169 and P=0.048). Non-survivors had significantly higher systolic PAPs than in survivors. However, in multivariate analysis, there was no significant association between mean systolic PAP and hospital mortality (odds ratio, 1.500; 95% confidence interval, 0.937–2.404; P=0.091).
Conclusions
Systolic PAP was weakly but significantly correlated with net fluid balance during the early ECMO period in patients with refractory ARDS receiving ECMO.
Review Article
Pulmonary
Awakening in extracorporeal membrane oxygenation as a bridge to lung transplantation
Su Hwan Lee
Acute Crit Care. 2022;37(1):26-34.   Published online February 22, 2022
DOI: https://doi.org/10.4266/acc.2022.00031
  • 4,641 View
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AbstractAbstract PDF
Although the rate of lung transplantation (LTx), the last treatment option for end-stage lung disease, is increasing, some patients waiting for LTx need a bridging strategy for LTx due to the limited number of available donor lungs. For a long time, mechanical ventilation has been employed as a bridge to LTx because the outcome of using extracorporeal membrane oxygenation (ECMO) as a bridging strategy has been poor. However, the outcome after mechanical ventilation as a bridge to LTx was poor compared with that in patients without bridges. With advances in technology and the accumulation of experience, the outcome of ECMO as a bridge to LTx has improved, and the rate of ECMO use as a bridging strategy has increased over time. However, whether the use of ECMO as a bridge to LTx can achieve survival rates similar to those of non-bridged LTx patients remains controversial. In 2010, one center introduced awake ECMO strategy for LTx bridging, and its use as a bridge to LTx has been showing favorable outcomes to date. Awake ECMO has several advantages, such as maintenance of physical activity, spontaneous breathing, avoidance of endotracheal intubation, and reduced use of sedatives and analgesics, but it may cause serious problems. Nonetheless, several studies have shown that awake ECMO performed by a multidisciplinary team is safe. In cases where ECMO or mechanical ventilation is required due to unavoidable exacerbation in patients awaiting LTx, the application of awake ECMO performed by an appropriately trained ECMO multi-disciplinary team can be useful.

Citations

Citations to this article as recorded by  
  • Extracorporeal membrane oxygenation as a bridge to lung transplantation: Practice patterns and patient outcomes
    Hannah J. Rando, Jonathon P. Fanning, Sung-Min Cho, Bo S. Kim, Glenn Whitman, Errol L. Bush, Steven P. Keller
    The Journal of Heart and Lung Transplantation.2024; 43(1): 77.     CrossRef
  • Anesthetic considerations for perioperative ECMO in lung transplantation
    Julien Fessler, Jaromir Vajter, Archer Kilbourne Martin
    Best Practice & Research Clinical Anaesthesiology.2024;[Epub]     CrossRef
  • Long-Term Follow-Up of Patients Needing Extracorporeal Membrane Oxygenation Following a Critical Course of COVID-19
    Samuel Genzor, Pavol Pobeha, Martin Šimek, Petr Jakubec, Jan Mizera, Martin Vykopal, Milan Sova, Jakub Vaněk, Jan Praško
    Life.2023; 13(4): 1054.     CrossRef
  • Dangers in using beta-blockers in patients with venovenous extracorporeal membrane oxygenation
    Diego Rodríguez Álvarez, Elena Pérez-Costa, Juan José Menéndez Suso
    Acute and Critical Care.2022; 37(4): 683.     CrossRef
Case Reports
Basic science and research
COVID-19–related acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation and programmed multi-level ventilation: a case report
Filip Depta, Anton Turčan, Pavol Török, Petra Kapraľová, Michael A. Gentile
Acute Crit Care. 2022;37(3):470-473.   Published online January 21, 2022
DOI: https://doi.org/10.4266/acc.2021.01109
  • 3,808 View
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AbstractAbstract PDF
We report a patient with severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) treated with veno-venous extracorporeal membrane oxygenation (VV ECMO) and programmed multi-level ventilation (PMLV). VV ECMO as a treatment modality for severe ARDS has been described multiple times as a rescue therapy for refractory hypoxemia. It is well known that conventional ventilation can cause ventilator-induced lung injury. Protective ventilation during VV ECMO seems to be beneficial, translating to using low tidal volumes, prone positioning with general concept of open lung approach. However, mechanical ventilation is still required as ECMO per se is usually not sufficient to maintain adequate gas exchange due to hyperdynamic state of the patient and limitation of blood flow via VV ECMO. This report describes ventilation strategy using PMLV during “resting” period of the lung. In short, PMLV is a strategy for ventilating non-homogenous lungs that incorporates expiratory time constants and multiple levels of positive end-expiratory pressure. Using this approach, most affected acute lung injury/ARDS areas can be recruited, while preventing overdistension in healthy areas. To our knowledge, case report using such ventilation strategy for lung resting period has not been previously published.

Citations

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  • Treatment of acute respiratory failure: extracorporeal membrane oxygenation
    Jin-Young Kim, Sang-Bum Hong
    Journal of the Korean Medical Association.2022; 65(3): 157.     CrossRef
Pharmacology
Successful treatment of propofol-related infusion syndrome in critically ill patient receiving low-dose propofol infusion: a case report
Nahyeon Park, Tae Sun Ha
Acute Crit Care. 2023;38(1):144-148.   Published online November 26, 2021
DOI: https://doi.org/10.4266/acc.2021.00829
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AbstractAbstract PDF
Propofol is widely used to sedate agitated patients in intensive care units. However, it can cause a rare but fatal complication, propofol-related infusion syndrome (PRIS). The pathophysiology of PRIS is not clear, and there is no definitive diagnosis and treatment. We report a successfully treated case of PRIS in a critically ill patient receiving low-dose propofol infusion. A 59-year-old male patient complaining of sudden chest pain repeatedly collapsed in an ambulance and the emergency room, and veno-arterial extracorporeal membrane oxygenation was delivered. He was diagnosed with a total occluded left anterior descending coronary artery in coronary angiography. On day 20, he showed arrhythmia, increased creatinine kinase (CK), and increased CK-MB and troponin I, accompanied by unstable hemodynamic status despite high-dose vasopressors. He was administered propofol for 20 days at an average dose of 1.3 mg/kg/hr owing to issues with agitation and ventilator synchrony. We strongly suspected PRIS and immediately discontinued propofol infusion, and he was successfully treated with aggressive supportive care. PRIS can occur in patients administered propofol for a prolonged period at low doses. Thus, clinicians should use propofol with caution for PRIS and change to alternative sedatives for long-term sedation.

Citations

Citations to this article as recorded by  
  • Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome
    Jananthan Paramsothy, Sai Dheeraj Gutlapalli, Vijay Durga Pradeep Ganipineni, Isabelle Mulango, Ikpechukwu J Okorie, Divine Besong Arrey Agbor, Crystal Delp, Hanim Apple, Borislav Kheyson, Jay Nfonoyim, Nidal Isber, Mallikarjuna Yalamanchili
    Cureus.2023;[Epub]     CrossRef
Review Articles
Pulmonary
Critical care management of pulmonary arterial hypertension in pregnancy: the pre-, peri- and post-partum stages
Vorakamol Phoophiboon, Monvasi Pachinburavan, Nicha Ruamsap, Natthawan Sanguanwong, Nattapong Jaimchariyatam
Acute Crit Care. 2021;36(4):286-293.   Published online November 26, 2021
DOI: https://doi.org/10.4266/acc.2021.00458
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AbstractAbstract PDF
The mortality rate of pulmonary hypertension in pregnancy is 25%–56%. Pulmonary arterial hypertension is the highest incidence among this group, especially in young women. Despite clear recommendation of pregnancy avoidance, certain groups of patients are initially diagnosed during the gestational age step into the third trimester. While the presence of right ventricular failure in early gestation is usually trivial, it can be more severe in the late trimester. Current evidence shows no consensus in the management and serious precautions for each stage of the pre-, peri- and post-partum periods of this specific group. Pulmonary hypertension-targeted drugs, mode of delivery, type of anesthesia, and some avoidances should be planned among a multidisciplinary team to enhance maternal and fetal survival opportunities. Sudden circulatory collapse from cardiac decompensation during the peri- and post-partum phases is detrimental, and mechanical support such as extracorporeal membrane oxygenation should be considered for mitigating hemodynamics and extending cardiac recovery time. Our review aims to explain the pathophysiology of pulmonary arterial hypertension and summarize the current evidence for critical management and precautions in each stage of pregnancy.

Citations

Citations to this article as recorded by  
  • Maternal Outcomes Among Pregnant Women With Congenital Heart Disease–Associated Pulmonary Hypertension
    Qian Zhang, Fang Zhu, Guocheng Shi, Chen Hu, Weituo Zhang, Puzhen Huang, Chunfeng Zhu, Hong Gu, Dong Yang, Qiangqiang Li, Yonghua Niu, Hao Chen, Ruixiang Ma, Ziyi Pan, Huixian Miao, Xin Zhang, Genxia Li, Yabing Tang, Guyuan Qiao, Yichen Yan, Zhongqun Zhu,
    Circulation.2023; 147(7): 549.     CrossRef
  • Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension
    Karolina Barańska-Pawełczak, Celina Wojciechowska, Wojciech Jacheć
    International Journal of Environmental Research and Public Health.2023; 20(5): 4625.     CrossRef
  • Pregnancy in Severe Pulmonary Hypertension: A Case Report and Literature Analysis
    一人 王
    Advances in Clinical Medicine.2023; 13(10): 16433.     CrossRef
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CPR/Resuscitation
Role of extracorporeal cardiopulmonary resuscitation in adults
Hongsun Kim, Yang Hyun Cho
Acute Crit Care. 2020;35(1):1-9.   Published online February 29, 2020
DOI: https://doi.org/10.4266/acc.2020.00080
  • 9,811 View
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  • 21 Web of Science
  • 23 Crossref
AbstractAbstract PDF
Extracorporeal cardiopulmonary resuscitation (ECPR) has been performed with increasing frequency worldwide to improve the low survival rate of conventional cardiopulmonary resuscitation (CCPR). Several studies have shown that among patients who experience in-hospital cardiac arrest, better survival outcomes and neurological outcomes can be expected after ECPR than after CCPR. However, studies have not clearly shown a short-term survival benefit of ECPR for patients who experience out-of-hospital cardiac arrest. Favorable outcomes are associated with a shorter low-flow time, an initial shockable rhythm, lower serum lactate levels, higher blood pH, and a lower Sequential Organ Failure Assessment score. Indications for ECPR include young age, witnessed arrest with bystander cardiopulmonary resuscitation, an initial shockable rhythm, correctable causes such as a cardiac etiology, and no return of spontaneous circulation within 10–20 minutes of CCPR. ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system, and it has the risk of several life-threatening complications. Therefore, physicians should carefully select patients for ECPR who can gain the most benefit, instead of applying ECPR indiscriminately.

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Original Article
Thoracic Surgery
How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation?
Sua Kim, Jin Seok Kim, Jae Seung Shin, Hong Ju Shin
Acute Crit Care. 2019;34(4):263-268.   Published online November 29, 2019
DOI: https://doi.org/10.4266/acc.2019.00577
  • 6,386 View
  • 141 Download
  • 8 Web of Science
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AbstractAbstract PDF
Background
Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients.
Methods
Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO.
Results
The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred.
Conclusions
An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.

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ACC : Acute and Critical Care