Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single-center experience.

This study aims to investigate the outcomes of venoarterial extracorporeal life support (VA-ECLS) in a large single-center patient cohort regarding survival and adverse events. Between June 2009 and March 2019, 462 consecutive patients received VA-ECLS. The mean age was 66.2 ± 11.9 years. Two patient groups were identified: Group 1-patients with ECLS due to postcardiotomy shock (PCS) after cardiac surgery (PCS, n = 357); Group 2-patients with ECLS due to cardiogenic shock (CS) without previous surgery (nonPCS, n = 105). The primary end point was overall in-hospital survival, while secondary end points were adverse events during the study period. Overall, the in-hospital survival rate was 26%. There was no statistically significant difference between the groups: 26.3% for PCS and 24.8% for nonPCS, respectively (P > .05). Weaning from VA-ECLS was possible in 44.3% for PCS and in 29.5% for nonPCS (P = .004). The strong predictors of overall mortality were postoperative hepatic dysfunction (OR = 14.362, 95%CI = 1.948-105.858), cardiopulmonary resuscitation > 30 minutes (OR = 6.301, 95%CI = 1.488-26.673), bleeding with a need for revision (OR = 2.123, 95%CI = 1.343-3.355), and previous sternotomy (OR = 2.077, 95%CI = 1.021-4.223). Despite its low survival rates, VA-ECLS therapy is the last resort and the only lifesaving option for patients in refractory CS. In contrast, there is still a lack of evidence for VA-ECLS in PCS patients. Future studies are warranted to evaluate the outcomes of VA-ECLS therapy after cardiac surgery.

Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study.

BACKGROUND: Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients. MATERIALS AND METHODS: We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications. RESULTS: ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications. CONCLUSIONS: -ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.

Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS: A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS: Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION: Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE: Systematic Review, level II.

The role of extracorporeal membrane oxygenator therapy in the setting of Type A aortic dissection.

BACKGROUND AND AIM: Patients presenting with type A aortic dissection (TAAD) present with a wide clinical spectrum ranging from hemodynamic stability to multiorgan malperfusion with cardiovascular collapse. Extracorporeal membrane oxygenator (ECMO) therapy is increasingly being utilized as salvage therapy in patients with acute cardiopulmonary failure and for post-cardiotomy shock. We sought to determine the utility of ECMO implementation post-TAAD repair. METHODS: The Pennsylvania Health Care Cost Containment Council (PHC4) database, maintained by an independently functioning state agency, was retrospectively reviewed from 2004 to 2014. Patients with a primary diagnosis of aortic dissection requiring ECMO support during the same hospital visit were included in the analysis. RESULTS: Thirty-nine patients were identified with diagnosis/procedure codes for TAAD repair and ECMO, of which four patients did not undergo TAAD repair. Of the remaining 35, 31 patients underwent open repair, and four patients underwent TEVAR. ECMO was instituted on the same day of TAAD surgery in 27 (69.2%) patients, and on post-operative day >1 in eight (20.5%) patients. Overall mortality in patients who were on ECMO the same day was 88.9% and 87.5% when it was done after the first post-operative day. All four patients with TAAD who underwent ECMO only died. Median time from ECMO implantation to death was 1.0 day. CONCLUSIONS: Requirement for ECMO support in acute aortic dissection is associated with extremely high mortality irrespective of when the intervention is performed.

Multidisciplinary mechanical supports improve outcome in a shock patient with cardiac amyloidosis: a case report.

Shock patients with restrictive cardiomyopathy due to cardiac amyloidosis are refractory to medical treatment. Here, we report a case of early initiation of intra-aortic balloon pumping (IABP) in a patient with cardiac amyloidosis who developed postoperative shock. Continuous hemodiafiltration was also applied to control circulating fluid volume. The mechanical treatments allowed reduction of the doses of catecholamine and diuretics and resulted in full recovery. It is reasonable to initiate IABP and hemofiltration dialysis during the early stages for the appropriate control of hemodynamics and fluid in shock patients with cardiac amyloidosis.

Advances in resuscitation strategies.

Shock, regardless of etiology is characterized by decreased delivery of oxygen and nutrients to the tissues and our interventions are directed towards reversing the cellular ischemia and preventing its consequences. The treatment strategies that are most effective in achieving this goal obviously depend upon the different types of shock (hemorrhagic, septic, neurogenic and cardiogenic). This brief review focuses on the two leading etiologies of shock in the surgical patients: bleeding and sepsis, and addresses a number of new developments that have profoundly altered the treatment paradigms. The emphasis here is on new research that has dramatically altered our treatment strategies rather than the basic pathophysiology of shock.

[Relative adrenocortical insufficiency in intensive care patients]. / Relatieve bijnierschorsinsufficiëntie bij intensive-carepatiënten.

Unexplained shock developed after a major vascular operation in a man aged 67 who used inhalation corticosteroids for a chronic obstructive pulmonary disease, and after pancreaticoduodenectomy in a man aged 56. Both had relative adrenocortical insufficiency, combated with corticosteroid supplementation. The condition of a relative adrenocortical insufficiency is considered to exist if a test dose of corticosteroids leads to rapid weaning from sympathicomimetics. A subnormal rise of plasma cortisol after stimulation with adrenocorticotropic hormone supports the diagnosis. Routine corticosteroid substitution in intensive care patients is inadvisable, because it enhances the risk of complications related to use of steroids.

Metabolic basis for the management of patients undergoing major surgery.

After reviewing our current knowledge of the metabolic response to major abdominal surgery, we present two new studies in which we have followed the changes in body composition, physiologic function, and psychological function for up to 1 year after major surgery. In the first study, 46 patients had changes in body composition, physiologic function, and psychological function measured perioperatively and again at intervals up to 1 year. There was an average loss of weight of 3000 grams (maximum at 2 weeks), and the tissue composition of this weight loss was composed of 1400 grams fat, 600 grams protein, and 1000 grams water. Normal body composition had returned to normal in most patients by 6 months. In the second study of 84 patients, deficits of skeletal muscle function and fatigue were found to be greatest at postoperative day 7. Most patients were back to preoperative levels of muscle function and fatigue 30 days after surgery, and nearly all had normal values 90 days after surgery. Based on these studies we outline our management program for the metabolic care of patients undergoing major abdominal surgery.

Hemodynamic changes after resection of thoracic duct for en bloc resection of esophageal cancer.

An en bloc resection of esophageal cancer is one of the most radical forms of esophagectomy, and includes the resection of the thoracic duct, but a relatively high hospital mortality rate has been reported. There is very little knowledge on the pathophysiological changes after resection of the thoracic duct. We examined 24 patients who underwent en bloc resection. Some patients developed severe tachycardia or shock postoperatively which subsided after a massive infusion of plasma. Analysis of the fluid balance revealed that much more fluid was necessary during surgery and the postoperative 24 h than in patients treated by a standard esophagectomy. Postoperative lymphangiography or CT revealed abnormal collateral lymphatics around the kidneys or in the pelvic cavity. This suggests the development of the lymphaticovenous shunts, which differed depending on the anatomy of each patient. One patient with chronic hepatitis developed uncontrollable ascites. These are important findings which can hopefully reduce the high rate of hospital death after this operation.

[Mediators and their antagonists in shock therapy]. / Mediatoren und ihre Antagonisten in der Schocktherapie.

The list of shock mediators currently comprises more than 150 candidates. A careful analysis using the criteria of Koch-Dale together with decision trees for exclusion of bias revealed that only histamine, C5a, beta-endorphin, tumor necrosis factor (TNF) thromboxane B2, platelet-activating factor (PAF), and oxygen free radicals are shown to be causally associated with shock symptoms. Although experimental studies with inhibitors of these mediators were convincing, there is still a lack of evidence under clinical conditions (exception histamine: anaphylactic shock). Combinations of antagonists against different causal mediators are the most promising future approaches.

[Severe postoperative pulmonary hypertensive crisis in a case of ventricular septal defect with Down's syndrome].

We encountered the episode of severe postoperative pulmonary hypertensive crisis in a case of ventricular septal defect with Down's syndrome. A 1 year 11 month old female with ventricular septal defect and pulmonary hypertension underwent open heart surgery. On the operative day after tracheal suction she experienced bradycardia, hypotension and pulmonary hypertension followed by shock condition. In spite of vigorous medical therapy clinical aspects were not improved. But only blood transfusion directly into the left atrium and administration of tolazoline hydrochlorides through pulmonary artery were very effective to improvement of hemodynamics and reduction of pulmonary hypertension. Moreover, after this episode pulmonary artery pressure showed elevation at the tracheal suction and the weaning from the respirator. We discussed the cause and treatment of postoperative pulmonary hypertensive crisis.

Anti-endotoxin in the treatment of severe surgical septic shock. Results of a randomized double-blind trial.

A randomized double-blind trial of human antilipopolysaccharide (anti-LPS)-specific globulin (LG-1) versus placebo (albumin) in the treatment of severe septic shock of surgical origin was carried out over a 6-month period from June to December 1983. Hospital mortality was 10 patients (59%) out of 17 in the control group and 9 out of 17 (53%) in the treated group. Irreversible shock was the cause of death in 4 patients (23,5%) in the control group and 5 (29,4%) in the treated group. Duration of hospital stay of the survivors averaged 44 days for the control group and 62 for the treated group. Measurement of serum endotoxin and anti-LPS levels at the time of admission to the study and 24 hours later revealed no significant difference between controls and treated patients. Significantly higher mortality rates were observed in patients who were endotoxemic after 24 hours of treatment compared with those who were not (chi 2 = 4,80; P less than 0,025).