Echocardiography Before Extracorporeal Membrane Oxygenation in Refractory Respiratory Failure: SARS-CoV-2 Infection Versus Other Etiologies.

OBJECTIVES: The study authors hypothesized that in patients with SARS-CoV-2, COVID-19-related refractory respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support echocardiographic findings (just before ECMO implantation) would be different from those observed in patients with refractory respiratory failure from different etiologies. DESIGN: A single-center observational study. SETTING: At an intensive care unit (ICU). PARTICIPANTS: A total of 61 consecutive patients with refractory COVID-19-related respiratory failure (COVID-19 series) and 74 patients with refractory acute respiratory disease syndrome from other etiologies (no COVID-19 series), all needing ECMO support. INTERVENTIONS: Echocardiogram pre-ECMO. MEASUREMENTS AND MAIN RESULTS: Right ventricle dilatation and dysfunction were defined in the presence of the RV end-diastolic area and/or left ventricle end-diastolic area (LVEDA >0.6 and tricuspid annular plane systolic excursion [TAPSE] <15 mm. Patients in the COVID-19 series showed a higher body mass index (p < 0.001) and a lower Sequential Organ Failure Assessment score (p = 0.002). In-ICU mortality rates were comparable between the 2 subgroups. Echocardiograms performed in all patients before ECMO implantation revealed an incidence of RV dilatation that was higher in patients in the COVID-19 series (p < 0.001), and they also showed higher values of systolic pulmonary artery pressure (sPAP) (p < 0.001) and lower TAPSE and/or sPAP (p < 0.001). The multivariate logistic regression analysis showed that COVID-19-related respiratory failure was not associated with early mortality. The presence of RV dilatation and the uncoupling of RV function and pulmonary circulation were associated independently with COVID-19 respiratory failure. CONCLUSIONS: The presence of RV dilatation and an altered coupling between RVe function and pulmonary vasculature (as indicated by TAPSE and/or sPAP) are associated strictly with COVID-19-related refractory respiratory failure needing ECMO support.

Persistent Right Ventricle Dilatation in SARS-CoV-2-Related Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation Support.

OBJECTIVES: Venovenous extracorporeal membrane oxygenation (ECMO) support may be considered in experienced centers for patients with acute respiratory distress syndrome (ARDS) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection refractory to conventional treatment. In ECMO patients, echocardiography has emerged as a clinical tool for implantation and clinical management; but to date, little data are available on COVID-related ARDS patients requiring ECMO. The authors assessed the incidence of right ventricular dilatation and dysfunction (RvDys) in patients with COVID-related ARDS requiring ECMO. DESIGN: Single-center investigation. SETTING: Intensive care unit (ICU). PARTICIPANTS: A total of 35 patients with COVID-related ARDS requiring ECMO, consecutively admitted to the ICU (March 1, 2020, to February 28, 2021). INTERVENTIONS: Serial echocardiographic examinations. RvDys was defined as RV end-diastolic area/LV end-diastolic area >0.6 and tricuspid annular plane excursion <15 mm. MEASUREMENTS AND MAIN RESULTS: The incidence of RvDys was 15/35 (42%). RvDys patients underwent ECMO support after a longer period of mechanical ventilation (p = 0.006) and exhibited a higher mortality rate (p = 0.024) than those without RvDys. In nonsurvivors, RvDys was observed in all patients (n = nine) who died with unfavorable progression of COVID-related ARDS. In survivors, weaned from ECMO, a significant reduction in systolic pulmonary arterial pressures was detectable. CONCLUSIONS: According to the authors' data, in COVID-related ARDS requiring ECMO support, RvDys is common, associated with increased ICU mortality. Overall, the data underscored the clinical role of echocardiography in COVID-related ARDS supported by venovenous ECMO, because serial echocardiographic assessments (especially focused on RV changes) are able to reflect pulmonary COVID disease severity.

Right Ventricular Hypertrophy in Refractory Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation Support.

OBJECTIVE: In severe acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO), right ventricular (RV failure) and dilation have been investigated with the use of echocardiography, whereas RV hypertrophy has not been addressed in the literature. The present study assessed the incidence of RV hypertrophy using echocardiography before ECMO treatment and at intensive care unit (ICU) discharge in severe ARDS patients. DESIGN: Observational, retrospective, single-center study. SETTING: A single ECMO center. PARTICIPANTS: The study comprised 46 consecutive patients with severe ARDS. INTERVENTION: Echocardiographic evaluation and ECMO support. MEASUREMENTS AND MAIN RESULTS: A dual-lumen cannula was implanted in most patients (38/46 [82.6%]). Before the start of ECMO, RV hypertrophy was present in 28 patients (60.8%) with no significant differences in baseline characteristics between the 2 subgroups. The ICU mortality rate was 30.4% (14/46), with no difference between patients with RV hypertrophy and those without. At ICU discharge, all patients showed RV hypertrophy. CONCLUSIONS: In severe ARDS treated with ECMO support, RV hypertrophy is a common finding and patients with normal RV wall thickness developed RV hypertrophy after ECMO support. The latter finding may suggest that during ECMO support, the right ventricle still may be subjected to increased afterload. However, additional research should be performed to elucidate the spectrum of mechanism(s) involved in the genesis of RV hypertrophy.

Activities of an ECMO Center for Severe Respiratory Failure: ECMO Retrieval and Beyond, A 4-Year Experience.

OBJECTIVE: Beyond retrieval and management of patients with severe acute respiratory distress syndrome, an extracorporeal membrane oxygenation (ECMO) center also encompasses several other actions, such as on-call consultations, advice, and counseling, to the physicians at the peripheral centers, but few data are available on this topic. Therefore, the authors describe the composite activities of retrieval and counseling of an ECMO center since 2014. DESIGN: The referral calls addressed to the authors' ECMO center for patients with respiratory failure were prospectively recorded in a dedicated database. Referral call frequency, patient data, and results of the calls were analyzed. SETTING: The 12-bed intensive care unit of Careggi Hospital in Florence, the ECMO referral center for Tuscany, and the center of Italy, with a mobile ECMO team. PARTICIPANTS: Patients from intensive care units of peripheral hospitals for whom a referral call was addressed to the authors' ECMO center. INTERVENTIONS: Many possible responses were given after a referral call, varying from ECMO team deployment to advice or to refusal. MEASUREMENTS AND MAIN RESULTS: From January 1, 2014, to December 31, 2017, 231 calls were received at the authors' ECMO center, of which 220 calls were for acute respiratory failure cases. Throughout the study period the overall number of calls did not vary, but the percentage of ECMO retrievals decreased, whereas the percentage of ARF patients from peripheral hospital admitted to our ECMO center on conventional ventilation increased. Fifty-five patients were treated by the mobile ECMO team and were transferred on ECMO; 59 were admitted on ventilatory support. In flu periods the overall calls were more frequent than in the no-flu periods (171 v 82 calls), and more ECMO retrieval missions were deployed. CONCLUSIONS: During the study period, a decreased number of patients retrieved on ECMO was observed, whereas patients transferred on ventilation increased, with an overall unchanged number of referred patients.

Bedside diagnostic laparoscopy for critically ill patients in the Intensive Care Unit: Retrospective study and review of literature.

BACKGROUND: Bedside diagnostic laparoscopy could be helpful in extremely critically ill patients. The aim of this retrospective study is to evaluate the safety and diagnostic accuracy of bedside diagnostic laparoscopy in the identification of intra-abdominal pathology in critically ill patients and to compare its accuracy and outcomes with the ones of laparotomy. PATIENTS AND METHODS: A retrospective review was conducted on the medical records of patients admitted to the Intensive Care Unit (ICU) of Careggi University Hospital and submitted to bedside diagnostic laparoscopy between January 2006 and May 2017. This group of patients was compared with a group of patients that were admitted to the ICU and submitted directly to explorative laparotomy for suspected intra-abdominal pathologies. RESULTS: One hundred and twenty-nine patients (M/F = 81/48, mean age = 71.64 years) underwent bedside diagnostic laparoscopy in ICU. 154 patients instead were submitted directly to explorative laparotomy in operatory room (mean age 75.70 years, M/F = 94/60). Among the 129 patients submitted to bedside laparoscopy, 53.49% were positive for intra-abdominal pathologies whereas 46.51% were negative, while among the 154 patients submitted directly to laparotomy, 76.62% were positive for intra-abdominal pathologies whereas 23.38% were negative. In 55.03% of all patients submitted to bedside laparoscopy, a non-therapeutic laparotomy was avoided, while the 33.76% of patients submitted directly to laparotomy had a non-therapeutic laparotomy that could be avoidable. CONCLUSIONS: Our results pinpoint the advantages of performing bedside diagnostic laparoscopy in the ICU setting, which can be considered an option every time there is the suspicion of an intra-abdominal pathology.

The 8-Year Experience of the Florence Referral ECMO Center and Retrieval Team for Acute Respiratory Failure.

OBJECTIVE: Many extracorporeal membrane oxygenation (ECMO) centers for respiratory failure and ECMO mobile teams were instituted during the H1N1 pandemic. Data on transportation are scarce and heterogeneous. The authors therefore described the experience of their referral ECMO center for severe respiratory failure from 2009 to 2016 and gave a comprehensive report of transfers performed by their mobile ECMO team. DESIGN: Observational retrospective study. SETTING: An intensive care unit (ECMO referral center) in a teaching hospital. PARTICIPANTS: One hundred and sixty consecutive patients with acute respiratory distress syndrome refractory to conventional treatment requiring veno-venous (VV)-ECMO. INTERVENTION: VV-ECMO implantation. MEASUREMENTS AND MAIN RESULTS: In this series, the transferred patients on ECMO averaged 57%, with annual percentages ranging from 28% to 90% over the years. No adverse event was observed during transportation. A progressive increase in simplified acute physiology score (SAPS) values and in the use of norepinephrine were detectable (p = 0.048 and p = 0.037, respectively) as well as in neuromuscular blockers use (p = 0.004). Dual-lumen cannule were more frequently used in recent years (p < 0.001). The overall mortality rate was 40% (64/160), with no differences over the years or between transferred and local patients. Body mass index and pre-ECMO neuromuscular blockers and SAPS were independent predictors for early mortality (when adjusted for age). CONCLUSIONS: The workload of the authors' referral center and mobile team did not change, documenting that severe respiratory failure requiring VV-ECMO support is still a clinical need. No difference in mortality rate was detectable during this period or between transferred and local patients who were managed by the same team.

Bilirubin in the early course of venovenous extracorporeal membrane oxygenation support for refractory ARDS.

Bilirubin is known as a marker of hepatic dysfunction and is incorporated in scoring algorithms to assess prognosis in critically ill patients. No data are so far available on the prognostic role of hepatic dysfunction in patients with severe ARDS on venovenous extracorporeal membrane oxygenation (VV-ECMO) support. In 112 consecutive patients with severe ARDS treated with VV-ECMO, we aimed at assessing whether increased bilirubin during the first 72 h could affect early death. Increased serum bilirubin (≥1.2 mg/dl) was detectable in 29 patients (25.9%) who were older (p = 0.031), exhibited a higher SOFA score (p = 0.006), were more frequently given pre-ECMO muscular blockers (p = 0.001) and supported with ECMO for a longer period (p = 0.024), when compared to patients with normal bilirubin. No difference in in-ICU mortality rate was observed between the two subgroups. In survivors, bilirubin showed a progressive and significant decrease (p = 0.032) during the first 72 h of ECMO support, while it increased in dead patients (p = 0.007).The mortality rate was higher in patients with increased bilirubin at 24, 48 and 72 h after ECMO start in respect to that of patients with normal values. Pre-ECMO increased bilirubin values (≥1.2 mg/dl), being detectable in about one-fourth of the entire population, is not associated with increased in-ICU mortality, while the persistence of increased bilirubin values after 24 h of ECMO start and within the first 3 days identified a subgroup of patients at higher risk of death.

Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support.

BACKGROUND: Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients. METHODS: We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS. RESULTS: The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024). CONCLUSIONS: In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).

Right ventricular dysfunction and Pre Implantation Vasopressors in Refractory ARDS Supported by VV-ECMO.

BACKGROUND: Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients. METHODS: We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation. RESULTS: In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups. CONCLUSIONS: In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support.

Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation.

The aims of the present investigation, performed in 118 consecutive patients with refractory ARDS treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), were as follows: (a) to assess ICU mortality in overweight, obese and morbid obese patients in respect to normal weight; (b) to evaluate echocardiographic findings according to BMI subgroups. Echocardiography was performed before VV-ECMO implantation. Forty-five patients (38.1%) showed normal BMI, 37 patients (31.4%) were overweight and the remaining were obese (21.2%), or morbid obese (9.3%). Morbid obese showed the lowest ICU mortality rate (p = 0.003). No differences were detectable among BMI subgroups in echocardiographic findings apart from the fact that obese patients showed the lowest incidence of LV dysfunction (p = 0.015). At stepwise regression analysis the following variables were independent predictor of ICU mortality (when adjusted for age): RV dilatation (OR 4.361, 95 % CI 1.809-10.512, p < 0.001), BMI (OR 0.884, 95% CI 0.821-0.951, p < 0.001). In other terms, the presence of RV dilatation is an independent predictor of ICU mortality. In refractory ARDS treated with VV-ECMO, BMI > 30 kg/m2 is common (accounting for one-third of the entire population) but it is not associated with a worse outcome, so that it cannot be considered per se a contraindication to ECMO implantation. The incidence of RV dilatation and failure, which are known to negatively affect prognosis in ARDS patients, were comparable among BMI subgroups.

Clinical significance of echocardiography in patients supported by venous-venous extracorporeal membrane oxygenation.

Although there are extensive published data regarding venous-arterial (VA) ECMO, particularly in the pediatric population, there is a paucity of data (mainly including case reports and observational studies) delineating the role of echocardiography in the management of adult patients supported by venous-venous (VV) ECMO. The present review is aimed at specifically addressing the rationale for echocardiography use in patients supported by VV-ECMO and at summarizing the available evidence on this topic. Based on the available evidence and on the experience of our group, practical considerations on the use of echocardiography in adult patients on VV-ECMO support are reported. To date, echocardiography is mainly used for selecting the type of ECMO (VA vs VV), monitoring cannulation and the early detection of complications, but it is underused in patients supported by VV-ECMO. Nevertheless, in these patients, this methodology can provide useful information in monitoring cardiac function, cannula positioning, pericardial fluid (for early detection of tamponade) during ECMO support, and therefore it can contribute to the integrated assessment and management of these complex patients. There is a clinical need to elaborate shared protocols for echocardiography use during VV ECMO support, particularly at this time when advanced echocardiography is gaining interest among intensivists.

Active Donor Management Goals in Serial Donors After Brain Death.

OBJECTIVES: Management of potential organ donors is crucial in the donation process, considering that hemodynamic instability is quite common. MATERIALS AND METHODS: In the this single-center retrospective observational study, we analyzed 87 utilized brain death donors consecutively admitted to our intensive care unit from January 1, 2019, to December 31, 2022. We assessed the achievement of donor management goals during the observation period, and we also evaluated whether the achieve-ment of donor goals differed between younger and older donors (arbitrary age cutoff of 65 years). RESULTS: In our series, mean age of donors was 67 ± 18 y, and organ-per-donor ratio was 2.3. The number of donor goals significantly increased during the 6-hour observation period (P < .001) and all donor goals were achieved in most donors (84/87) at the end of the observation period with no changes in the use and dose of vasoactive drugs. With respect to age, the number of donor goals was significantly higher in older donors at first evaluation, but goals significantly increased in both age subgroups of donors at the end of the 6-hour observation period. CONCLUSIONS: Our data strongly suggested that a strict hemodynamic monitoring schedule allows the achievement of donor goals both in older and in younger brain death donors. We confirmed our previous findings that hemodynamic management in brain death donors is influenced by age. A strict hemodynamic monitoring schedule of brain death donors is useful to consistently achieve donor goals.

Brain Death Donors on Extracorporeal Membrane Oxygenation Support.

OBJECTIVES: We investigated donors with brain death on extracorporeal membrane oxygenation support, a clinically challenging situation due to hemodynamic instability frequently encountered in these donors, which may threaten organ function. MATERIALS AND METHODS: We described our experience with 15 utilized brain death donors on extracorporeal membrane oxygenation support, consecutively admit-ted in our intensive care unit (which is a referral center for extracorporeal membrane oxygenation) from 2018 to 2023. We investigated whether utilization rate for brain death donors on extracor-poreal membrane oxygenation was affected by the introduction of a monitoring hemodynamic schedule during the 6-hour observation period. RESULTS: The utilization rate was 78% in period 1 and 88% in period 2. No statistically significant differences were observed for age, sex, and the incidence of cardiovascular risk factors between period 1 and period 2. The cause of death was postanoxic encephalopathy in all but 1 donor, who was on venovenous extracorporeal membrane oxygenation for refractory respiratory failure and developed cerebral hemorrhage. Number of organs per donor was 2 in all the population with no significant differences between period 1 and period 2. In the overall population, 15 livers were transplanted, 11 kidneys, 1 heart, and 1 pancreas. In our population, left ventricular ejection fraction severe dysfunction was observed in all donors except in the donor on venovenous extracorporeal membrane oxygenation; the organ from this donor was deemed unsuitable for transplant. No significant differences were observed in hemodynamic data between the 2 subgroups. All donors were on 2 vasoactive drugs (norepinephrine and vasopressin) to maintain adequate perfusion (mean arterial pressure >60 mm Hg). Three donors were oligoanuric (due to postarrest acute renal failure). CONCLUISONS: In our series of 15 consecutive brain death donors on extracorporeal membrane oxygenation, a strict monitoring regimen during the 6-hour obser-vation period was associated with a higher utilization rate.

Clinical Significance of Right Ventricle Echocardiographic Patterns in Critically-Ill COVID-Related Acute Respiratory Distress Syndrome "On Behalf of Protecting the Right Ventricle Network (PRORVnet)".

We assessed whether right ventricle (RV) alterations and their development may have clinical significance in critically-ill Coronavirus Disease (COVID) patients, as detected by serial echocardiograms during Intensive Care Unit (ICU) course. This observational single center study included 98 consecutive patients with COVID-related acute respiratory distress syndrome (ARDS). Three subgroups were considered: RV Dysfunction (Dys) on admission (10/98, 10%), developed RV Dys (17/98, 17%), and no RV Dys (71/98, 73%). Overall mortality at 3 months was 46.9%. The first subgroup was characterized by the highest need for Extracorporeal Membrane Oxygenation (ECMO) support (P < .001) and a systemic inflammatory activation (as indicated by increased D-dimer), the second one by the lowest PaO2/FiO2 (P/F). At multivariate regression analysis, age and Sequential Organ Failure Assessment score were independent predictors for mortality. Different RV echo patterns were observed in critically ill patients presenting with COVID-related ARDS during ICU stay. RV Dys on admission was characterized by a high inflammatory activation while patients who developed RV Dys during ICU stay showed lowest P/F. Both these two subgroups identify patients with a severe COVID disease which in a high percentage of cases was unresponsive to standard treatment and required the use of ECMO.

Haemodynamic management in brain death donors: Influence of aetiology of brain death.

BACKGROUND: In brain death donors (BDDs), donor management is the key in the complex donation process. Donor management goals, which are standards of care or clinical parameters, have been considered an acceptable barometer of successful donor management. AIM: To test the hypothesis that aetiology of brain death could influence haemody namic management in BDDs. METHODS: Haemodynamic data (blood pressure, heart rate, central venous pressure, lactate, urine output, and vasoactive drugs) of BDDs were recorded on intensive care unit (ICU) admission and during the 6-h observation period (Time 1 at the beginning; Time 2 at the end). RESULTS: The study population was divided into three groups according to the aetiology of brain death: Stroke (n = 71), traumatic brain injury (n = 48), and postanoxic encephalopathy (n = 19). On ICU admission, BDDs with postanoxic encephalopathy showed the lowest values of systolic and diastolic blood pressure associated with higher values of heart rate and lactate and a higher need of norepinephrine and other vasoactive drugs. At the beginning of the 6-h period (Time 1), BDDs with postanoxic encephalopathy showed higher values of heart rate, lactate, and central venous pressure together with a higher need of other vasoactive drugs. CONCLUSION: According to our data, haemodynamic management of BDDs is affected by the aetiology of brain death. BDDs with postanoxic encephalopathy have higher requirements for norepinephrine and other vasoactive drugs.

Right ventricle dysfunction does not predict mortality in patients with SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support.

BACKGROUND: The prognostic role of right ventricle dilatation and dysfunction (RVDD) has not been elucidated in patients with coronavirus disease (COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation (ECMO) support. AIM: To assess whether pre veno-venous (VV) ECMO RVDD were related to in-intensive care unit (ICU) mortality. METHODS: We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU (an ECMO referral center) from 31th March 2020 to 31th August 2021. An echocardiographic exam was performed immediately before VV ECMO implantation. RESULTS: Males were prevalent (73.8%) and patients with a body mass index > 30 kg/m2 were the majority (46/61, 75%). The overall in-ICU mortality rate was 54.1% (33/61). RVDD was detectable in more than half of the population (34/61, 55.7%) and associated with higher simplified organ functional assessment (SOFA) values (P = 0.029) and a longer mechanical ventilation duration prior to ECMO support (P = 0.046). Renal replacement therapy was more frequently needed in RVDD patients (P = 0.002). A higher in-ICU mortality (P = 0.024) was observed in RVDD patients. No echo variables were independent predictors of in-ICU death. CONCLUSION: In patients with COVID-related respiratory failure on ECMO support, RVDD (dilatation and dysfunction) is a common finding and identifies a subset of patients characterized by a more severe disease (as indicated by higher SOFA values and need of renal replacement therapy) and by a higher in-ICU mortality. RVDD (also when considered separately) did not result independently associated with in-ICU mortality in these patients.

Urgent coronary angiography in out-of-hospital cardiac arrest: a retrospective single centre investigation.

AIMS: The role of immediate coronary angiography (CAG) with percutaneous coronary intervention (PCI) in patients who present with ST-segment elevation myocardial infarction (STEMI) and cardiac arrest is well recognized. However, the role of immediate angiography in patients after cardiac arrest without STEMI is less clear. We assessed whether urgent (<6 h) CAG and PCI (whenever needed) was associated with improved early survival in out-of-hospital cardiac arrest (OHCA). METHODS: In our single-centre, retrospective, observational study, we included all consecutive OHCA patients admitted to the A&E of the Careggi University Hospital between 1 June 2016 and 31 July 2020. One hundred and forty-four OHCA patients were submitted to CAG and constituted our study population. RESULTS: Among the 221 consecutive OHCA patients, 69 (31%) had refractory cardiac arrest treated with extracorporeal cardiopulmonary resuscitation (eCPR) in 37 (37/69, 56%) patients. The mortality rate was significantly higher in the no CAG subgroup (P < 0.00001). In the CAG subgroup, coronary artery disease was detected in the 70% (92 patients), among whom the left main coronary artery was involved in 10 patients (10.8%). At multivariable regression analysis (CAG subgroup, outcome ICU survival), witnessed cardiac arrest was independently associated with survival. CONCLUSION: A high incidence of coronary artery disease was observed at CAG in the real-world of OHCA patients. Better planning of revascularization and treatment in patients studied with CAG may explain, at least in part, their lower mortality rate.

Coupling of right ventricular function to pulmonary circulation as an independent predictor for non invasive ventilation failure in SARSCoV 2-related acute respiratory distress syndrome.

Study objectives: To assess whether echocardiography, systematically performed, could help in risk stratifying patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV2 (COVID) infection for non invasive ventilation (NIV) failure. Design: Observational single center investigation. Setting: Intensive care unit. Interventions: Echocardiography. Outcome measures: NIV failure. Main results: Seventy-five patients were included in our study. In respect to patients who did not need mechanical ventilation (NIV success), those in the NIV failure subgroup (31 patients, 41 %) were older, with more comorbidities and showed a higher SOFA score and LOS. Higher values of NTpro BNP, CRP and D-dimer were observed in the NIV failure subgroup who exhibited a higher ICU mortality rate. At echocardiographic examination, the NIV failure subgroup showed higher values of RV/LV ratio, systolic pulmonary arterial pressure (sPAP) and lower values of tricuspid annular plane systolic excursion (TAPSE)/SPAP, and PaO2/FiO2. At logistic regression analysis TAPSE/sPAP resulted an independent predictor of NIV failure. At receiving operating characteristic curve analysis, the TAPSE/SPAP cut-off of 0.575 mm/mm Hg showed a sensitivity of 97 % and a specificity of 48 %. Conclusions: Our results documented a marked uncoupling of right ventricular function from the pulmonary circulation (as indicated by TAPSE/sPAP) in COVID-related ARDS treated with non invasive ventilation and the measurement of this parameter, performed on ICU admission, provides independent prognostic relevance for NIV failure.

Ventilatory and ECMO treatment of H1N1-induced severe respiratory failure: results of an Italian referral ECMO center.

BACKGROUND: Since the first outbreak of a respiratory illness caused by H1N1 virus in Mexico, several reports have described the need of intensive care or extracorporeal membrane oxygenation (ECMO) assistance in young and often healthy patients. Here we describe our experience in H1N1-induced ARDS using both ventilation strategy and ECMO assistance. METHODS: Following Italian Ministry of Health instructions, an Emergency Service was established at the Careggi Teaching Hospital (Florence, Italy) for the novel pandemic influenza. From Sept 09 to Jan 10, all patients admitted to our Intensive Care Unit (ICU) of the Emergency Department with ARDS due to H1N1 infection were studied. All ECMO treatments were veno-venous. H1N1 infection was confirmed by PCR assayed on pharyngeal swab, subglottic aspiration and bronchoalveolar lavage. Lung pathology was evaluated daily by lung ultrasound (LUS) examination. RESULTS: A total of 12 patients were studied: 7 underwent ECMO treatment, and 5 responded to protective mechanical ventilation. Two patients had co-infection by Legionella Pneumophila. One woman was pregnant. In our series, PCR from bronchoalveolar lavage had a 100% sensitivity compared to 75% from pharyngeal swab samples. The routine use of LUS limited the number of chest X-ray examinations and decreased transportation to radiology for CT-scan, increasing patient safety and avoiding the transitory disconnection from ventilator. No major complications occurred during ECMO treatments. In three cases, bleeding from vascular access sites due to heparin infusion required blood transfusions. Overall mortality rate was 8.3%. CONCLUSIONS: In our experience, early ECMO assistance resulted safe and feasible, considering the life threatening condition, in H1N1-induced ARDS. Lung ultrasound is an effective mean for daily assessment of ARDS patients.

Echocardiographic assessment of the right ventricle in COVID -related acute respiratory syndrome.

In patients with the novel coronavirus (COVID-19) infection, the echocardiographic assessment of the right ventricle (RV) represents a pivotal element in the understanding of current disease status and in monitoring disease progression. The present manuscript is aimed at specifically describing the echocardiographic assessment of the right ventricle, mainly focusing on the most useful parameters and the time of examination. The RV direct involvement happens quite often due to preferential lung tropism of COVID-19 infection, which is responsible for an interstitial pneumonia characterized also by pulmonary hypoxic vasoconstriction (and thus an RV afterload increase), often evolving in acute respiratory distress syndrome (ARDS). The indirect RV involvement may be due to the systemic inflammatory activation, caused by COVID-19, which may affect the overall cardiovascular system mainly by inducing an increase in troponin values and in the sympathetic tone and altering the volemic status (mainly by affecting renal function). Echocardiographic parameters, specifically focused on RV (dimensions and function) and pulmonary circulation (systolic pulmonary arterial pressures, RV wall thickness), are to be measured in a COVID-19 patient with respiratory failure and ARDS. They have been selected on the basis of their feasibility (that is easy to be measured, even in short time) and usefulness for clinical monitoring. It is advisable to measure the same parameters in the single patient (based also on the availability of valid acoustic windows) which are identified in the first examination and repeated in the following ones, to guarantee a reliable monitoring. Information gained from a clinically-guided echocardiographic assessment holds a clinical utility in the single patients when integrated with biohumoral data (indicating systemic activation), blood gas analysis (reflecting COVID-19-induced lung damage) and data on ongoing therapies (in primis ventilatory settings).