RESUMO
Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac surgery. The scientific advancements collectively leading to safe cardiopulmonary bypass are considered some of the most impactful advances of modern medicine. Stimulated by the work of physiologists and engineers in the late 19th century, primitive pump and oxygenator designs were the forerunners of major work by DeBakey and others in roller pump design and by Gibbon in oxygenator development. Following Gibbon's historic successful closure of an atrial septal defect in 1953 with his heart-lung machine, it was left to Lillehei and Kirklin to first successfully repair large series of cardiac malformations. The history leading to these historic events and the subsequent evolution of cardiopulmonary bypass machines for short- and longer-term support is filled with engineering and surgical brilliance, daring innovations, and serendipity.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias Congênitas , Procedimentos Cirúrgicos Cardíacos/história , Ponte Cardiopulmonar , Circulação Extracorpórea , Cardiopatias Congênitas/cirurgia , Máquina Coração-Pulmão/história , História do Século XX , HumanosRESUMO
BACKGROUND: Utilization of extracorporeal membrane oxygenation (ECMO) support in the post-cardiotomy setting is vital to successful perioperative outcomes following pediatric cardiac surgery. Specific analysis of protocolized management strategies and staff preparedness is imperative to optimizing institutional ECMO outcomes. METHODS: All patients requiring post-cardiotomy ECMO support at a single institution from 2013 to 2019 were retrospectively reviewed. In 2015, several modifications were made to the ECMO support paradigm that addressed deficiencies in equipment, critical care protocols, and staff preparedness. Cases were stratified according to era of ECMO support; patients supported prior to paradigm change from 2013 to 2015 (Group EARLY, n = 20), and patients supported following the implementation of systematic modifications from 2016 to 2019 (Group LATE, n = 26). The primary outcomes of interest were survival to decannulation and hospital discharge. RESULTS: Median age at cannulation was 24.5 days (IQR 7-96) and median duration of support was 4 days (IQR 2-8). Overall survival to decannulation was 78.3% (65% EARLY vs. 88.5% LATE, P = .08) and overall survival to hospital discharge was 58.7% (35% EARLY vs. 76.9% LATE, P = .004). CONCLUSION: Systematic modifications to ECMO support strategy and staff preparation are associated with a significant increase in perioperative survival for pediatric patients requiring post-cardiotomy ECMO support.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Oxigenação por Membrana Extracorpórea , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Criança , Humanos , Alta do Paciente , Pericardiectomia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Perioperative transfusion of blood products is associated with increased morbidity and mortality after pediatric cardiac surgery. We report the results of a quality improvement project aimed at decreasing perioperative blood product administration and bleeding after pediatric cardiopulmonary bypass (CPB) surgery. A multidisciplinary team evaluated baseline data from 99 consecutive CPB patients, focusing on the variability in transfusion management and bleeding outcomes, to create a standardized bleeding and transfusion management protocol. A total of 62 subsequent patients were evaluated after implementation of the protocol: 17 with single pass hemoconcentrated (SPHC) blood transfusion and 45 with modified ultrafiltration (MUF). Implementation of the protocol with SPHC blood led to significant decrease in transfusion of every blood product in the cardiovascular operating room and first 6 hours in cardiovascular intensive care unit ([CVICU] p < .05). Addition of MUF to the protocol led to further decrease in transfusion of all blood products compared to preprotocol. Patients <2 months old had 49% decrease in total blood product administration: 155 mL/kg preprotocol, 117 mL/kg protocol plus SPHC, and 79 mL/kg protocol plus MUF (p < .01). There were significant decreases in postoperative bleeding in the first hour after CVICU admission: 6 mL/kg preprotocol, 3.8 mL/kg protocol plus SPHC, and 2 mL/kg protocol plusMUF (p = .02). There was also significantly decreased incidence of severe postoperative bleeding (>10 mL/kg) in the first CVICU hour for protocol plus MUF patients (p < .01). Implementation of a multidisciplinary bleeding and transfusion protocol significantly decreases perioperative blood product transfusion and improves some bleeding outcomes.
Assuntos
Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos , Equipe de Assistência ao Paciente , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Pré-Escolar , Implementação de Plano de Saúde , Hemofiltração/métodos , Humanos , Incidência , Lactente , Comunicação Interdisciplinar , Equipe de Assistência ao Paciente/organização & administração , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/terapia , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , UltrafiltraçãoRESUMO
Neonates and young infants exposed to extracorporeal circulation during extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass are at risk of developing a systemic inflammatory response syndrome with multi-organ dysfunction. We used a piglet model of ECMO to investigate the hypothesis that epithelial apoptosis is an early event that precedes villous damage during ECMO-related bowel injury. Healthy 3-week-old piglets were subjected to ECMO for up to 8 h. Epithelial apoptosis was measured in histopathological analysis, nuclear imaging, and terminal deoxynucleotidyl transferase dUTP nick end labeling. Plasma intestinal fatty acid-binding protein (I-FABP) levels were measured by enzyme immunoassay. Intestinal mast cells were isolated by fluorescence-assisted cell sorting. Cleaved caspase-8, caspase-9, phospho-p38 MAPK, and fas ligand expression were investigated by immunohistochemistry, western blots, and reverse transcriptase-quantitative PCR. Piglet ECMO was associated with increased gut epithelial apoptosis. Extensive apoptotic changes were noted on villus tips and in scattered crypt cells after 2 h of ECMO. After 8 h, the villi were denuded and apoptotic changes were evident in a majority of crypt cells. Increased circulating I-FABP levels, a marker of gut epithelial injury, showed that epithelial injury occurred during ECMO. We detected increased cleaved caspase-8, but not cleaved caspase-9, in epithelial cells indicating that the extrinsic apoptotic pathway was active. ECMO was associated with increased fas ligand expression in intestinal mast cells, which was induced through activation of the p38 mitogen-activated protein kinase. We conclude that epithelial apoptosis is an early event that initiates gut mucosal injury in a piglet model of ECMO.
Assuntos
Apoptose/fisiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Mucosa Intestinal/lesões , Mucosa Intestinal/fisiopatologia , Animais , Animais Recém-Nascidos , Western Blotting , Caspase 8/metabolismo , Caspase 9/metabolismo , Núcleo Celular/ultraestrutura , Primers do DNA/genética , Ensaio de Imunoadsorção Enzimática , Proteína Ligante Fas/metabolismo , Proteínas de Ligação a Ácido Graxo/sangue , Citometria de Fluxo , Imuno-Histoquímica , Marcação In Situ das Extremidades Cortadas , Mucosa Intestinal/citologia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Estatísticas não Paramétricas , Suínos , Proteínas Quinases p38 Ativadas por Mitógeno/metabolismoRESUMO
Ventricular assist devices (VADs) are used in children with severe heart failure as a bridge to heart transplantation or recovery. Severe pulmonary dysfunction may preclude their use, leaving extracorporeal membrane oxygenation (ECMO) as the most frequently used option for combined cardiac and respiratory failure. There are few case reports describing the use of an oxygenator in combination with VAD support, but none that describes long-term utilization. We report the successful use of a low-resistance oxygenator placed into the right-sided VAD (RVAD) circuit of an infant with life-threatening respiratory failure. The oxygenator enabled immediate reversal of hypoxaemia and hypercarbia and recovery of the RVAD function. The oxygenator remained within the VAD circuit for 15 days, facilitating complete lung recovery. An oxygenator used in conjunction with a VAD may be a life-saving therapy, allowing adequate oxygenation and ventilation in severe respiratory and cardiac failure. Extended use may facilitate the prevention of ventilator-associated lung injury and organ dysfunction. This therapy may be an attractive intermediate step in the transition from, or alternative to ECMO, in patients requiring VAD placement with associated acute lung injury.
Assuntos
Lesão Pulmonar Aguda/terapia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Oxigenação por Membrana Extracorpórea , Cardiopatias Congênitas/cirurgia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Lesão Pulmonar Aguda/diagnóstico , Lesão Pulmonar Aguda/etiologia , Evolução Fatal , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Humanos , Lactente , Desenho de Prótese , Síndrome do Desconforto Respiratório do Recém-Nascido/diagnóstico , Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia.
Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Artéria Femoral/cirurgia , Isquemia/prevenção & controle , Perna (Membro)/irrigação sanguínea , Adolescente , Adulto , Anastomose Cirúrgica , Cateterismo , Humanos , Isquemia/etiologia , Masculino , Procedimentos Cirúrgicos Vasculares/métodos , Adulto JovemRESUMO
Extracorporeal membrane oxygenation (ECMO) is universally accepted as a potential lifesaving therapy for neonates suffering severe cardiorespiratory failure, with survival reported as 81% weaning off ECMO and 69% to hospital discharge in this population. Although ECMO may reduce mortality in certain neonatal patients, it is associated with significant complications. Air in the circuit complicates 4.9% of neonatal ECMO runs, and it is crucial that all ECMO caregivers are trained in the prevention of air embolism and possess the knowledge necessary to efficiently identify and remove air from the ECMO circuit to prevent life threatening consequences. We present a fatal case of neonatal systemic air embolism leading to massive entrainment of air into the ECMO venous return cannula of a neonatal patient with acute respiratory distress syndrome following repair of obstructed total anomalous pulmonary venous connection. We describe the pathophysiology and presentation of this rare condition and the importance of early recognition, due to its high mortality rate.
Assuntos
Embolia Aérea/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Síndrome do Desconforto Respiratório/terapia , Embolia Aérea/diagnóstico , Evolução Fatal , Feminino , Humanos , Recém-NascidoRESUMO
Extracorporeal membrane oxygenation (ECMO) is a life-saving support system used in neonates and young children with severe cardiorespiratory failure. Although ECMO has reduced mortality in these critically ill patients, almost all patients treated with ECMO develop a systemic inflammatory response syndrome (SIRS) characterized by a 'cytokine storm', leukocyte activation, and multisystem organ dysfunction. We used a neonatal porcine model of ECMO to investigate whether rising plasma concentrations of inflammatory cytokines during ECMO reflect de novo synthesis of these mediators in inflamed tissues, and therefore, can be used to assess the severity of ECMO-related SIRS. Previously healthy piglets (3-week-old) were subjected to venoarterial ECMO for up to 8 h. SIRS was assessed by histopathological analysis, measurement of neutrophil activation (flow cytometry), plasma cytokine concentrations (enzyme immunoassays), and tissue expression of inflammatory genes (PCR/western blots). Mast cell degranulation was investigated by measurement of plasma tryptase activity. Porcine neonatal ECMO was associated with systemic inflammatory changes similar to those seen in human neonates. Tumor necrosis factor-alpha (TNF-alpha) and interleukin-8 (IL-8) concentrations rose rapidly during the first 2 h of ECMO, faster than the tissue expression of these cytokines. ECMO was associated with increased plasma mast cell tryptase activity, indicating that increased plasma concentrations of inflammatory cytokines during ECMO may result from mast cell degranulation and associated release of preformed cytokines stored in mast cells. TNF-alpha and IL-8 concentrations rose faster in plasma than in the peripheral tissues during ECMO, indicating that rising plasma levels of these cytokines immediately after the initiation of ECMO may not reflect increasing tissue synthesis of these cytokines. Mobilization of preformed cellular stores of inflammatory cytokines such as in mucosal mast cells may have an important pathophysiological role in ECMO-related SIRS.