Feasibility of Ultrasound-Guided Percutaneous Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation and its Effect on the Recovery of Spontaneous Heartbeat in Patients with ECPR.

Objective: The measurement of the right and left axillary arteries and aortic arch and their vessels by multi-row spiral CT angiography provides the basis for clinical catheter selection and depth for axillary artery placement. This study reported the clinical experience of 7 patients who successfully underwent ultrasound-guided percutaneous axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Methods: Patients who had CT angiography of the thoracic aorta at our institution between January 2020 and March 2022 were assessed for eligibility and included. The diameters of the cephalic trunk (D1), right common carotid artery (D2), right axillary artery (D3), left common carotid artery (D4), left axillary artery opening (D5), right axillary artery cannulation length (L1), and left axillary artery cannulation length (L2) were measured. The tangential angles α, ß, and γ of the cephalic trunk, left common carotid artery and left subclavian and aorta was measured using an automatic angle-forming tool. The decision to use a 15F cannula for ultrasound-guided percutaneous axillary artery cannulation in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) aims to achieve optimal vascular access. This cannula size strikes a balance, providing sufficient blood flow rates for ECMO support while minimizing the risk of complications associated with larger cannulas. Precise measurements of arterial dimensions, including the cephalic trunk, common carotid arteries, and axillary arteries, play a crucial role in guiding catheter selection and determining the depth of axillary artery placement. These measurements allow for tailored approaches based on individual patient characteristics, enhancing the safety and efficacy of the intervention. Additionally, measuring tangential angles (α, ß, and γ) provides insights into arterial alignment, optimizing the cannula trajectory for efficient blood flow. The use of an automatic angle-forming tool enhances measurement precision, contributing to procedural accuracy, minimizing complications, and ensuring the success of ultrasound-guided percutaneous axillary artery cannulation. In summary, the choice of a 15F cannula and precise measurements are essential components of the methodology, emphasizing safety, efficacy, and personalized approaches in VA-ECMO. From March to June 2022, 7 patients (6 males and 1 female) in our intensive care medicine department underwent successful ultrasound-guided percutaneous axillary artery cannulation for VA-ECMO with 15F cannula, including 3 cases with extracorporeal cardiopulmonary resuscitation (ECPR) and 4 cases with circulatory collapse. Results: 292 patients met the study criteria, 215 males and 77 females, with a mean age of 67.2±14.2 years. The measurements showed that D1 was (13.1±2.0) mm, D2 was (8.8±2.5) mm, D3 was (6.1±1.2) mm, D4 was (8.3±3.5) mm, D5 was (6.1±1.1) mm, L1 was (114.1±17.8) mm, and L2 was (128.4±20.2) mm. The tangential angles α of the cephalic trunk left common carotid artery and left subclavian artery to the aorta were (43.8°±17.1°), ß was (50.7°±14.8°), and γ was (62.4°±19.1°). Males had significantly wider D3 and D5, longer L1 and L2, and smaller gamma angles than females (P < .05). Three ECPR cases showed no recovery of the spontaneous heartbeat with femoral artery cannulation for VA-ECMO but recovered spontaneous heartbeat after axillary artery cannulation for VA-ECMO was adopted. The measurements in this study have important implications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) procedures. They provide crucial information about arterial dimensions, including the cephalic trunk, common carotid arteries, and axillary arteries. This information guides clinicians in selecting catheters and determining the ideal depth for percutaneous axillary artery cannulation during ECMO interventions. Notable gender differences in arterial dimensions highlight the need for personalized approaches in ECMO procedures. Customizing catheter choices and cannulation depth based on individual patient characteristics, informed by these measurements, improves the safety and effectiveness of the intervention. The measured tangential angles (α, ß, and γ) offer insights into arterial alignment, crucial for optimizing cannula trajectory and ensuring proper alignment for efficient blood flow. The use of an automatic angle-forming tool enhances measurement precision, contributing to procedural accuracy and minimizing the risk of complications during ECMO procedures. In summary, these measurements directly enhance the precision and safety of VA-ECMO procedures, underscoring the importance of personalized approaches based on individual anatomical variations and improving overall intervention success and outcomes. Conclusion: Ultrasound-guided percutaneous axillary artery cannulation for VA-ECMO with a 15F cannula is clinically feasible. Axillary artery cannulation for VA-ECMO contributes to the restoration of spontaneous heartbeat in ECPR patients more than femoral artery cannulation, and the possible mechanism is a better improvement of coronary blood flow. However, the study has limitations, including a modest sample size and a single-center, retrospective design, impacting its generalizability. To validate and extend these findings, further research with larger and diverse cohorts, including prospective investigations, is necessary to ensure their applicability across various clinical settings and patient demographics in VA-ECMO.

[Analysis of risk factors for prognosis of patients with acute paraquat intoxication].

OBJECTIVE: To explore the risk factors influencing the prognosis by analyzing clinical data of patients with acute paraquat intoxication, and to assess the prognostic values of acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, and Acute Kidney Injury Network (AKIN) stage. METHODS: The clinical data of patients with acute paraquat intoxication admitted into the First People's Hospital of Xianyang City during October 2005 to May 2015 were retrospectively analyzed. The patients were divided into death group and survival group according to 28-day outcome after poisoning. The gender, age, body weight index, toxin dose, time elapsed from poisoning to gastric lavage, time elapsed from poisoning to hemoperfusion (HP), times of HP treatment, white blood cell count (WBC), alanine aminotransferase (ALT), aspartate transaminase (AST), total bilirubin (TBil), serum creatinine (SCr), blood urea nitrogen (BUN), creatine kinase (CK) were determined at admission. Arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), arterial lactate (Lac), and APACHE II score, SOFA score and AKIN stage were recorded and compared between two groups. The receiver operating characteristic (ROC) curve was plotted for APACHE II score, SOFA score and AKIN stage to analyze the prognostic value for patients with acute paraquat intoxication. RESULTS: There were 118 cases in total, with 64 survivors and 54 deaths in 28 days, and the fatality rate was 45.76%. Compared with survival group, the toxic dose (mL: 66.29 ± 27.40 vs. 29.16 ± 19.40), time elapsed from poisoning to gastric lavage (minutes: 60.37 26.68 vs. 41.17 ± 14.82), WBC count ( X 109/L: 16.86 ± 2.77 vs. 10.25 ± 2.60), ALT (U/L: 53.94 ± 10.85 vs. 36.40 ± 9.21), SCr (µmol/L: 159.69 ± 42.85 vs. 81.73 ± 34.40) at admission as well as Lac (mmol/L: 3.06 ± 1.33 vs. 1.71 ± 0.88), APACHE II score (6.46 ± 2.38 vs. 3.31 ± 1.51), SOFA score (3.31 ± 1.06 vs. 2.21 ± 0.76) 48 hours after admission were significantly higher in the death group (all P < 0.01). PaO2 and PaCO2 48 hours after admission were significantly lower in death group than those in the survival group [PaO2 (mmHg, 1 mmHg = 0.133 kPa): 64.07 ± 13.04 vs. 75.40 ± 13.27, PaCO2 (mmHg): 26.20 ± 8.89 vs. 31.25 ± 6.29, both P < 0.01]. There were 18, 15, 11 and 10 patients in AKIN 0, 1, 2, 3 stage 48 hours after admission respectively in death group, and 38, 15, 7, 4 in survival group. The difference between two groups was statistically significant (P < 0.01). There were no statistically significant differences in gender, age, body mass index, time elapsed from poisoning to HP, levels of HP, and AST, TBil, BUN and CK at admission between the two groups. At 48 hours after admission, the area under the ROC curve (AUC) of APACHE II score predicting the prognosis of patients with acute paraquat poisoning was 0.875 [95% confidence interval (95%CI) = 0.814-0.935, P = 0.000]. When the cut-off point of APACHE II score was 4, the sensitivity and specificity were 79.6% and 79.7%, and the best Youden index was 0.593. The AUC of SOFA score was 0.776 (95% CI = 0.692-0.859, P = 0.000). When the cut-off point of FOFA score was 3, the sensitivity was 72.2%, the specificity 67.2%, and the best Youden index 0.394. The AKIN stage of ROC curve had an area of 0.656 (95% CI = 0.556-0.755, P = 0.004). When the cut-off point of AKIN stage was 1, the sensitivity was 66.7%, the specificity was 59.4%, and the best Youden index was 0.261. CONCLUSIONS: Amount of the poison, time elapsed from poisoning to gastric lavage, and WBC, ALT, SCr at admission as well as PaO2, PaCO2 and Lac 48 hours after admission are the risk factors for prediction of the prognosis of acute paraquat intoxication. APACHE II score, SOFA score and AKIN stage can be used to assess the prognosis of acute paraquat poisoning, and APACHE II score is better than SOFA score and AKIN stage.

[Successful management of massive gastrointestinal bleeding using recombinant factor VIIa in an elderly patient with respiratory and renal failure].

Recombinant activated factor VII (rFVIIa) is a novel therapeutic agent for life-threatening massive gastrointestinal bleeding. We report a case of massive gastrointestinal bleeding in a 78-year-old female patient with respiratory and renal failure. After failure of management of the bleeding with routine pharmacotherapy, we gave the patient rFVIIa injection at the dose of 20 µg/kg and the bleeding was rapidly controlled. Adverse side effects of the drug were not observed in this patient.

[Effects of peroxisome proliferators-activated receptor-gamma on the function of the vital organs in rats with pancreatitis].

OBJECTIVE: To observe the effects of peroxisome proliferators-activated receptor-gamma (PPARgamma) on the function of the vital organs in rats with pancreatitis. METHODS: Acute pancreatitis (AP) was induced in 30 male SD rats by ductal injection of 4% sodium taurocholate at 1.0 ml/kg. The rats received subsequent intravenously injection of 0.3 mg/kg of PPARgamma ligand (rosiglitazone, n=10), PPARgamma antagonist (GW9662, n=10) followed 10 min later by rosiglitazone administration at 0.3 mg/kg, or left untreated (AP model group, n=10). Another 10 male SD rats receiving no particular treatment served as the control group. The rats were sacrificed 6 h after the operation, and blood samples were collected for measurement of the biochemical indices of the vital organs. The histological changes of the pancreas and portal vein blood endotoxin content were examined. RESULTS: The rats in AP group and GW9662 group showed significantly higher level of the biochemical indices for the vital organs, pathological scores of the pancreas and portal vein blood endotoxin content were significantly higher in the control group and roglitazone-treated groups (P<0.05). CONCLUSION: PPARgamma ligand roglitazone can significantly ameliorate multiple organ injuries and effectively protect the functions of the organs in rats with experimental pancreatitis.