Autopsy Histopathologic Lung Findings in Patients Treated With Extracorporeal Membrane Oxygenation.

CONTEXT.­: Extracorporeal membrane oxygenation (ECMO) is increasingly used in the treatment of respiratory and cardiac failure, but data describing lung histopathology in ECMO recipients are limited. OBJECTIVE.­: To examine pulmonary histopathologic findings in patients who underwent venovenous (VV) ECMO for pulmonary reasons, or venoarterial (VA) ECMO for cardiac indications shortly before death, and to determine if the pulmonary changes provided insights into therapy that may prevent complications and improve outcome. DESIGN.­: We conducted a retrospective study of lung autopsies, from VV and VA ECMO recipients and patients with acute respiratory distress syndrome (ARDS) and non-ECMO treatment, between 2008 and 2020 in Silesia Center for Heart Diseases in Zabrze, Poland. RESULTS.­: Among 83 ECMO patients (42-64 years; male, 57 [68.7%]), the most common histopathologic findings were bronchopneumonia (44 [53.0%]), interstitial edema (40 [48.2%]), diffuse alveolar damage (DAD; 32 [38.6%]), hemorrhagic infarct (28 [33.7%]), and pulmonary hemorrhage (25 [30.1%]). DAD was associated with longer ECMO treatment and longer hospital stay. The use of VV ECMO was a predictor of DAD in patients with ARDS and undergoing ECMO, but it also occurred in 21 of 65 patients (32.3%) in the VA ECMO group, even though VA ECMO was used for heart failure. CONCLUSIONS.­: Although DAD was significantly more common in lung autopsies of VV ECMO patients, one-third of VA ECMO patients had histopathologic changes characteristic of ARDS. The presence of DAD in lung autopsies of patients treated with VA ECMO indicates that in these patients, protective lung ventilation should be considered.

The use of non-invasive respiratory assistance to facilitate bronchofiberoscopy performance in patients with hypoxemic (type one) respiratory failure - Study protocol.

PURPOSE: Bronchofiberoscopy (FOB) is a procedure routinely performed for: lung cancer, obstruction, interstitial diseases, foreign bodies' removal, airway clearance, and hemoptysis. It causes acute airway narrowing leading to respiratory and cardiovascular stress. Due to increasing number of ill patients with respiratory failure (RF), conventional oxygen therapy (COT) is frequently insufficient to assure accurate oxygenation and prevent RF in patients requiring FOB. In this clinical scenario, patients may be intubated and supported with invasive mechanical ventilation (IMV) with the specific aim of allowing a safe FOB. However, this invasive strategy is associated with an increased risk of IMV-associated complications. MATERIALS AND METHODS: Our study is a planned prospective multicenter three-arm randomized controlled trial (RCT). The target number of 300 patients was calculated based on the intubation risk in RF patients, which is 0.2-2%. The patients will be assigned to each arm based on Horowitz index. In each arm, the patients will be randomly assigned to one out of two dedicated respiratory support methods in each group i.e. COT/high flow nasal cannula (HFNC), HFNC/non-invasive ventilation (NIV) and NIV/IMV. In the manuscript the current state of art in the area of respiratory support is discussed. We have underlined knowledge gaps in medical evidence which we are planning to reveal with our results. RESULTS: The results of our study are clinically crucial, because they address current gaps concerning COT/HFNC/NIV/IMV. CONCLUSION: The expected findings of this study would allow for careful selection of respiratory support method to safely perform FOB in patients with hypoxemic RF.

May noninvasive mechanical ventilation and/ or continuous positive airway pressure increase the bronchoalveolar lavage salvage in patients with pulmonary diseases? Randomized clinical trial - Study protocol.

PURPOSE: Bronchoalveolar lavage (BAL) procedure is a useful tool in the diagnosis of patients with interstitial lung disease (ILD) and is helpful in clinical research of chronic obstructive pulmonary disease (COPD) patients. Still little is known about predictors of poor BAL salvage. The trial aims to find the most efficient way to improve BAL recovery. MATERIAL AND METHODS: Our study is a prospective, multicenter, international, two-arm randomized controlled trial. We aim to obtain BAL samples from a total number of 300 patients: 150 with ILD and 150 with COPD to achieve a statistical power of 80 â€‹%. Patients with initial BAL salvage <60 â€‹% will be randomized into the non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) arm. The NIV and CPAP will be set according to the study protocol. The influence on BAL salvage will be assessed in terms of BAL volume and content. Multivariable analysis of the additional test results to determine predictors for low BAL recovery will be conducted. In a study subgroup of approximately 20 patients per specific disease, a metabolomic assessment of exhaled air condensate will be performed. All procedures will be assessed in terms of the patient's safety. The trial was registered on clinicaltrials.gov (ID# NCT05631132). Interested experienced centers are invited to join the research group by writing to the corresponding author. CONCLUSION: The results of our prospective study will address the currently unsolved problem of how to increase BAL salvage in patients with pulmonary diseases without increasing the risk of respiratory failure exacerbation.

Value, time and outcomes of elevated lactate levels in adult patients on extracorporeal membrane oxygenation.

INTRODUCTION: Lactate levels have been recognized as a reliable tool for monitoring critically ill patients requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or venovenous extracorporeal membrane oxygenation (VV ECMO) but the reasons behind the overproduction of lactate are different and the influance for survival remains controversial. We analyzed the lactate values and lactate clearance in adult patients in these two forms of extracorporeal support. METHODS: Patient demographics, ECMO duration, 30-day mortality, lactate values and lactate clearance at 24, 48 and 72 h from ECMO initiation of patients supported with VV and VA ECMO at Silesian Centre for Heart Deasese, between January 2011 and April 2020 were retrospectively analyzed. The changes in lactate levels were analyzed using the non-parametric U Mann-Whitney tests and Chi-square test. The ROC curves were draw and the area under the curve was calculated. RESULTS: The study comprised 91 adult patients, Mortality in the first 30 days from initiation of VV and VA ECMO was 39% and 66%, respectively. Lactate levels were significantly higher in non-survivors that received VV and VA ECMO (p < .001), while lactate clearance was similar (p = .256 and p = 1.000, respectively). Survival curves for patients with elevated (>2.0 mmol/L) vs normal (≤2.0 mmol/L) lactate levels at 72 h were significantly different for VV ECMO (p = .007) and VA ECMO (p = .037) but in both groups of ECMO, lactate levels above 2.0 mmol/L at 72 h from ECMO initiation predicted 30 day-mortality. CONCLUSION: This results emphasized the importance of lactate levels below 2.0 mmol/L at 72 h from both VV and VA ECMO initiation.

Mallampati Score Is an Independent Predictor of Active Oxygen Therapy in Patients with COVID-19.

Mallampati score has been identified and accepted worldwide as an independent predictor of difficult intubation and obstructive sleep apnea. We aimed to determine whether Mallampati score assessed on the first patient medical assessment allowed us to stratify the risk of worsening of conditions in patients hospitalized due to COVID-19. A total of 493 consecutive patients admitted between 13 November 2021 and 2 January 2022 to the temporary hospital in Pyrzowice were included in the analysis. The clinical data, chest CT scan, and major, clinically relevant laboratory parameters were assessed by patient-treating physicians, whereas the Mallampati score was assessed on admission by investigators blinded to further treatment. The primary endpoints were necessity of active oxygen therapy (AOT) during hospitalization and 60-day all-cause mortality. Of 493 patients included in the analysis, 69 (14.0%) were in Mallampati I, 57 (11.6%) were in Mallampati II, 78 (15.8%) were in Mallampati III, and 288 (58.9%) were in Mallampati IV. There were no differences in the baseline characteristics between the groups, except the prevalence of chronic kidney disease (p = 0.046). Patients with Mallampati IV were at the highest risk of AOT during the hospitalization (33.0%) and the highest risk of death due to any cause at 60 days (35.0%), which significantly differed from other scores (p = 0.005 and p = 0.03, respectively). Mallampati IV was identified as an independent predictor of need for AOT (OR 3.089, 95% confidence interval 1.65−5.77, p < 0.001) but not of all-cause mortality at 60 days. In conclusion, Mallampati IV was identified as an independent predictor of AOT during hospitalization. Mallampati score can serve as a prehospital tool allowing to identify patients at higher need for AOT.

Extracorporeal membrane oxygenation for severe COVID-19-associated acute respiratory distress syndrome in Poland: a multicenter cohort study.

BACKGROUND: In Poland, the clinical characteristics and outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) remain unknown. This study aimed to answer these unknowns by analyzing data collected from high-volume ECMO centers willing to participate in this project. METHODS: This retrospective, multicenter cohort study was completed between March 1, 2020, and May 31, 2021 (15 months). Data from all patients treated with ECMO for COVID-19 were analyzed. Pre-ECMO laboratory and treatment data were compared between non-survivors and survivors. Independent predictors for death in the intensive care unit (ICU) were identified. RESULTS: There were 171 patients admitted to participating centers requiring ECMO for refractory hypoxemia due to COVID-19 during the defined time period. A total of 158 patients (mean age: 46.3 ± 9.8 years) were analyzed, and 13 patients were still requiring ECMO at the end of the observation period. Most patients (88%) were treated after October 1, 2020, 77.8% were transferred to ECMO centers from another facility, and 31% were transferred on extracorporeal life support. The mean duration of ECMO therapy was 18.0 ± 13.5 days. The crude ICU mortality rate was 74.1%. In the group of 41 survivors, 37 patients were successfully weaned from ECMO support and four patients underwent a successful lung transplant. In-hospital death was independently associated with pre-ECMO lactate level (OR 2.10 per 1 mmol/L, p = 0.017) and BMI (OR 1.47 per 5 kg/m2, p = 0.050). CONCLUSIONS: The ICU mortality rate among patients requiring ECMO for COVID-19 in Poland was high. In-hospital death was independently associated with increased pre-ECMO lactate levels and BMI.

Pulmonary function, exercise capacity and dyspnea in patients 7 ​years after Nuss surgery.

PURPOSE: Pectus excavatum is a frequent thoracic malformation increasingly treated with minimally invasive methods (MIRPE), which are performed for cardio-respiratory problems and in some centers also for esthetic considerations. Theoretically, MIRPE may increase thoracic elastic recoil, work of breathing and cause emphysema. The aim of the present study was to determine whether teenagers who underwent MIRPE may expect normal thoracic cage development, cardio-respiratory function, exercise capacity and asymptomatic functioning. MATERIAL AND METHODS: Fifty five patients (21.1 â€‹± â€‹3.0 years) who underwent MIRPE between 2000 and 2010 were assessed 6.8 (±2.4) years after surgery. Controls were matched for sex, age and height to the intervention participants. Spirometry, body plethysmography, diffusion capacity and the 6 â€‹min walking test (6MWT) were performed. Anteroposterior (AP) and transverse chest diameters were measured. RESULTS: Participants who underwent MIRPE had normal pulmonary function, and exercise capacity. After adjustment for potential confounders, the intervention group had lower mean BMI [-1.88 â€‹± â€‹0.56 (kg/m2); p â€‹= â€‹0.001] and chest AP diameter [-2.79 â€‹± â€‹0.57 (cm); p â€‹< â€‹0.001], but higher residual volume (RV%) [12.98 â€‹± â€‹5.31 (%); p â€‹= â€‹0.001], RV% total lung capacity (TLC) [5.56 â€‹± â€‹0.92 (%); p â€‹< â€‹0.001], forced expiratory volume in 1 â€‹s/forced vital capacity (FEV1/FVC) [2.64 â€‹± â€‹1.28 (%); p â€‹= â€‹0.039] and 6MWT distance [29.10 â€‹± â€‹13.02 (m); p â€‹= â€‹0.025]. CONCLUSIONS: Young adults who undergo MIRPE may expect normal pulmonary function and exercise capacity. Observed differences in air trapping require further assessment in terms of emphysema development risk.

Post-tracheostomy complications: respiratory failure caused by authologic foreign body-case report.

Tracheostomy is performed frequently as a palliative treatment in patients with end-stage respiratory failure (RF). However, in patients requiring prolonged mechanical ventilation it may be difficult to recognize and can often lead to life-threatening RF. We present two cases of acute-on-chronic respiratory failure (ACRF) occurring in patients who had undergone tracheostomy [one with percutaneous dilatational tracheostomy (PDT) and the second with surgical tracheostomy (ST)]. The first case was admitted due to ACRF several months after previous successful decannulation and the second case after failure of several attempts of weaning from tracheal cannula. In both cases, noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) was able to identify and solve the tracheal stenosis secondary to stiff banana-shaped whitish foreign bodies. Histology sampling and genetic testing confirmed autologous foreign body formation-tracheal cartilage calcification. NIV-FB was found to be safe and effective in both diagnosis and treatment of the tracheal stenosis. Life-threatening RF connected with tracheal stenosis may be caused by rupture of tracheal cartilage ossification in patients with a history of ST and PDT. Bronchofiberoscopy performed with NIV will be a useful procedure to evaluate and treat the respiratory tract in patients with RF with suspected tracheal stenosis.

Novel Antibacterial Modification of Polycarbonate for Increment Prototyping in Medicine.

In the era of modern medicine, the number of invasive treatments increases. Artificial devices used in medicine are associated with an increased risk of secondary infections. Bacterial biofilm development observed on the implanted surface is challenging to treat, primarily due to low antibiotics penetration. In our study, the preparation of a new polycarbonate composite, filled with nanosilver, nanosilica and rhodamine B derivative, suitable for three-dimensional printing, is described. Polymer materials with antimicrobial properties are known. However, in most cases, protection is limited to the outer layers only. The newly developed materials are protected in their entire volume. Moreover, the antibacterial properties are retained after multiple high-temperature processing were performed, allowing them to be used in 3D printing. Bacterial population reduction was observed, which gives an assumption for those materials to be clinically tested in the production of various medical devices and for the reduction of morbidity and mortality caused by multidrug-resistant bacteria.

Epidemiology and clinical characteristics of patients discharged from the ICU in a vegetative or minimally conscious state.

PURPOSE: A significant percentage of patients are discharged from intensive care units (ICU) with disorders of counciousness (DoC). The aim of this retrospective, case-control study was to compare patients discharged from the ICU in a vegetative state (VS) or minimally conscious state (MCS) and the rest of ICU survivors, and to identify independent predictors of DoC among ICU survivors. METHODS: Data from 14,368 adult ICU survivors identified in a Silesian Registry of Intensive Care Units (active in the Silesian Region of Poland between October 2010 and December 2019) were analyzed. Patients discharged from the ICU in a VS or MCS were compared to the remaining ICU survivors. Pre-admission and admission variables that independently influence ICU discharge with DoC were identified. RESULTS: Among the 14,368 analyzed adult ICU survivors, 1,064 (7.4%) were discharged from the ICU in a VS or MCS. The percentage of patients discharged from the ICU with DoC was similar in all age groups. Compared to non- DoC ICU patients, they had a higher mean APACHE II and SAPS III score at admission. Independent variables affecting ICU discharge with DoC included unconsciousness at ICU admission, cardiac arrest and craniocerebral trauma as primary cause of ICU admission, as well as a history of previous chronic neurological disorders and cerebral stroke (p<0.001). CONCLUSION: Discharge in a VS and MCS was relatively frequent among ICU survivors. Discharge with DoC was more likely among patients who were unconscious at admission and admitted to the ICU due to cardiac arrest or craniocerebral trauma.

Risk factors of complications during noninvasive mechanical ventilation -assisted flexible bronchoscopy.

PURPOSE: Flexible bronchoscopy (FB) causes airway narrowing and may cause respiratory failure (RF). Noninvasive mechanical ventilation (NIV) is used to treat RF. Until recently, little was known about noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) risk and complications. MATERIALS AND METHODS: A retrospective analysis of NIV-FB performed in 20 consecutive months (July 1, 2018-February 29, 2020) was performed. Indications for: FB and NIV, as well as impact of comorbidities, blood gas results, pulmonary function test results and sedation depth, were analyzed to reveal NIV-FB risk. Out of a total of 713 FBs, NIV-FB was performed in 50 patients with multiple comorbidities, acute or chronic RF, substantial tracheal narrowing, or after previously unsuccessful FB attempt. RESULTS: In three cases, reversible complications were observed. Additionally, due to the severity of underlining disease, two patients were transferred to the ICU where they passed away after >48h. In a single variable analysis, PaO2 69 â€‹± â€‹18.5 and 49 â€‹± â€‹9.0 [mmHg] (p â€‹< â€‹0.05) and white blood count (WBC) 10.0 â€‹± â€‹4.81 and 14.4 â€‹± â€‹3.10 (p â€‹< â€‹0.05) were found predictive for complications. Left heart disease indicated unfavorable NIV-FB outcome (p â€‹= â€‹0.046). CONCLUSIONS: NIV-FB is safe in severely ill patients, however procedure-related risk should be further defined and verified in prospective studies.

The clinical value of the routine analysis of cardiac implantable electronic devices after the patient's death in a tertiary cardiovascular center.

INTRODUCTION: The postmortem interrogation of cardiac implantable electronic devices (CIEDs) has not been regularly practiced yet. We presumed that it can provide data not only on the mechanism of the patient's death but also on possible device malfunctions contributing to its occurrence. OBJECTIVES: The study aimed to determine the usefulness of the explantation and interrogation of CIEDs after the patient's death in routine clinical practice, when combined with autopsy findings and clinical follow­up starting from the time after device implantation. PATIENTS AND METHODS: Between August 24, 2008 and August 30, 2018, all patients who underwent autopsy in the tertiary cardiovascular center or partner facilities had the device explanted and interrogated by the qualified electrophysiologist. Clinical characteristics obtained at the time of device implantation and patients' death were obtained from medical records. Device interrogation results were then combined with autopsy report and clinical data. RESULTS: Out of 1200 autopsied patients, the device was removed and analyzed in 61 individuals. Clinical characteristics from the time of implantation and patients' death were available in 53 (86.7%) and 49 (80.3%) patients, respectively. Device­related concerns, undetected during patients' hospital stay, were noted in 6 cases (6.1%) and included 3 programming and 3 hardware issues. CONCLUSIONS: To our knowledge, this is the first study to date to combine the clinical follow­up of patients before death and on admission at the end of life, autopsy results, and postmortem CIED interrogation. Having implemented the device interrogation, we found 6 CIED­related events potentially associated with patients' death, which were not detected before its occurrence.

Extracorporeal membrane oxygenation (ECMO) - in the treatment of severe, life-threatening respiratory failure.

Extracorporeal membrane oxygenation (ECMO) is a technique involving oxygenation of blood and elimination of carbon dioxide in patients with life-threatening, but potentially reversible conditions. Thanks to the modification of extracorporeal circulation used during cardiac surgeries, this technique can be used in intensive care units. Venovenous ECMO is used as a respiratory support, while venoarterial ECMO as a cardiac and/or respiratory support. ECMO does not cure the heart and/or lungs, but it gives the patient a chance to survive a period when these organs are inefficient. In addition, extracorporeal membrane oxygenation reduces or eliminates the risk of lung damage associated with invasive mechanical ventilation in patients with severe ARDS (acute respiratory distress syndrome). ECMO is a very invasive therapy, therefore it should only be used in patients with extremely severe respiratory failure, who failed to respond to conventional therapies. According to the Extracorporeal Life Support Organization (ELSO) Guidelines, inclusion criteria are: PaO2 / FiO2 < 80 for at least 3 hours or pH < 7.25 for at least 3 hours. Proper ECMO management requires advanced medical care. This article discusses the history of ECMO development, clinical indications, contraindications, clinical complications and treatment outcomes.

The importance of fluid balance in critically ill patients: a retrospective observational study

BACKGROUND: Fluid therapy in critically ill patients remains one of the most demanding and difficult aspects of care. This is particularly important in patients admitted to the intensive care unit (ICU) due to cardiovascular disorders. AIMS: The aim of this study was to investigate whether a cumulative fluid balance (FB) affects mortality in critically ill patients hospitalized at the ICU. METHODS: Data were obtained from the medical records of the ICU at the Silesian Centre for Heart Diseases. All patients admitted to the ICU between 2012 and 2016 were evaluated. Patients who died or were discharged from the ICU within 48 hours from admission were excluded. Fluid balance and the type of fluids infused during the first 7 days were assessed. The primary outcome was ICU mortality. RESULTS: Overall, 495 patients were included in the study and 303 (61.2%) survived the ICU stay. Daily FB in the first 24, 48, and 72 hours after admission and the cumulative FB after 7 days were significantly lower in survivors. Fluid balance exceeding 1000 ml and the use of colloid solutions in the first 72 hours were independently associated with mortality, along with the diagnosis of stroke and shock on admission. CONCLUSIONS: A positive FB exceeding 1000 ml in the first 72 hours from admission to the ICU is independently associated with an increased risk of mortality in critically ill patients with cardiovascular disorders. The use of colloid solutions is associated with a higher positive FB.

Should we admit more patients not requiring invasive ventilation to reduce excess mortality in Polish intensive care units? Data from the Silesian ICU Registry.

INTRODUCTION: Mortality in Polish intensive care units (ICU) is excessively high. Only a few patients do not require intubation and invasive ventilation throughout the whole ICU treatment period. We aimed to define this population, as pre-emptive admissions of such patients may increase the population which benefits from ICU admission and reduce excessive mortality in Polish ICUs. MATERIAL AND METHODS: Data on 20 651 patients from the Silesian Registry of Intensive Care Units were analysed. Patients who did not require intubation and invasive ventilation (referred to as non-ventilated patients) were identified and compared to the remaining ICU population. Independent variables that influence being non-intubated in the ICU were identified. RESULTS: Among 20 368 analyzed adult patients, only 1233 (6.1%) were in the non-ventilated group. Non-ventilated patients were younger, with fewer comorbidities and a lower APACHE II score at admission (13.0 ±7.1 vs. 23.7 ±8.6 points, p < 0.001). Patients with cardiac arrest prior to admission were particularly rare in this group (2.6% vs. 26.8%, p < 0.001). The ICU mortality among non-ventilated patients was 6 to 7 times lower (7.0% vs. 46.7%, p < 0.001). Independent variables that influenced the ICU stay in non-ventilated patients were: obstetric complications as the primary cause of ICU admission, presence of a systemic autoimmune disease, invasive monitoring as the primary cause of ICU admission, ICU readmission and the presence of cancer. CONCLUSIONS: Non-ventilated patients have a high potential for a favourable outcome. Pre­emptive ICU admissions have a potential to reduce mortality in Polish ICUs.

Young Adults Among Patients Admitted to Polish Intensive Care Units in the Silesian ICU Registry.

BACKGROUND Patients under 30 years of age constitute a unique population in the Intensive Care Unit (ICU). The aim of this study was to obtain information on young adults admitted to Polish ICUs and to identify independent predictors of favorable outcome in this population. MATERIAL AND METHODS Data from 20 651 adult patients from the Silesian Registry of Intensive Care Units conducted in the Silesian Region of Poland since October 2010 were analyzed. Patients aged 18-29 years were identified and their data were compared to the remaining population. Preadmission and admission variables that independently influence the favorable outcome (defined as survival of ICU stay and discharge in a condition other than vegetative state or minimally conscious state) were identified. RESULTS Among 20 609 analyzed adult patients, 850 (4.1%) were under the age of 30 years. Young adults had a lower mean APACHE II and SAPS III score at admission and were more frequently admitted to the ICU due to trauma, poisonings, acute neurological disorders, and obstetric complications. ICU mortality was over 2 times lower (20.1% vs. 45.3%, p<0.001). Independent variables affecting favorable outcome in this population were: admission to ICU from the operating theatre and multiple trauma as a primary cause of admission. CONCLUSIONS The greater chance of favorable outcome in adults under the age of 30 years admitted to the ICU is due to their unique characteristics. Favorable outcome in young adults is most likely among patients admitted to the ICU following multiple trauma or admitted from the operating theatre.