The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis.

BACKGROUND: To evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO2R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV). METHODS: Retrospective ancillary cost analysis of data extracted from a recently published multicentre case-control-study (n = 42) on the use of arterio-venous ECCO2R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO2R system. RESULTS: In the group treated with ECCO2R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO2R group (19.610 vs. 46.552 €, p = 0.01). CONCLUSIONS: Additional costs for the use of arterio-venous ECCO2R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.

Molecular adsorbent recirculating system technique for liver failure due to cardiogenic shock.

BACKGROUND: Systematic data on clinical outcome in patients with liver failure due to cardiogenic shock are scarce. METHODS: We performed a monocentric retrospective data analysis in 197 cardiogenic shock patients with serum bilirubin levels above 102 µmol/L receiving molecular adsorbent recirculating system (MARS). We assessed clinical outcome, recorded laboratory parameters, and tried to assess risk factors for survival. RESULTS: The median duration of MARS was 87 hours (range, 20-315 hours) during a median time period of 9 days (range, 3-736 days). During MARS, 48 to 75% of patients developed infections and gastrointestinal, respiratory, and neurological complications, respectively. Inhospital mortality was 66% (n = 129). Baseline bilirubin levels were comparable between survivors and non-survivors. During MARS, bilirubin values decreased significantly in survivors but not in non-survivors. Of various clinical and biochemical parameters assessed at baseline, the sepsis-related Organ Failure Assessment score remained the only independent predictor of inhospital mortality. CONCLUSION: Inhospital mortality is still unsatisfyingly high in cardiogenic shock patients with liver failure. Future studies should clarify whether MARS can definitively improve survival in these patients.

Computer-assisted trajectory planning for percutaneous needle insertions.

PURPOSE: Computed tomography (CT) guided minimally invasive interventions such as biopsies or ablation therapies often involve insertion of a needle-shaped instrument into the target organ (e.g., the liver). Today, these interventions still require manual planning of a suitable trajectory to the target (e.g., the tumor) based on the slice data provided by the imaging modality. However, taking into account the critical structures and other parameters crucial to the success of the intervention--such as instrument shape and penetration angle--is challenging and requires a lot of experience. METHODS: To overcome these problems, we present a system for the automatic or semiautomatic planning of optimal trajectories to a target, based on 3D reconstructions of all relevant structures. The system determines possible insertion zones based on so-called hard constraints and rates the quality of these zones by so-called soft constraints. The concept of pareto optimality is utilized to allow for a weight-independent proposal of insertion trajectories. In order to demonstrate the benefits of our method, automatic trajectory planning was applied retrospectively to n = 10 data sets from interventions in which complications occurred. RESULTS: The efficient (graphics processing unit-based) implementation of the constraints results in a mean overall planning time of about 9 s. The examined trajectories, originally chosen by the physician, have been rated as follows: in six cases, the insertion point was labeled invalid by the planning system. For two cases, the system would have proposed points with a better rating according to the soft constraints. For the remaining two cases the system would have indicated poor rating with respect to one of the soft constraints. The paths proposed by our system were rated feasible and qualitatively good by experienced interventional radiologists. CONCLUSIONS: The proposed computer-assisted trajectory planning system is able to detect unsafe and propose safe insertion trajectories and may especially be helpful for interventional radiologist at the beginning or during their interventional training.

Respiratory parameters on diagnostic sleep studies predict survival in patients with amyotrophic lateral sclerosis.

OBJECTIVE: In amyotrophic lateral sclerosis (ALS), respiratory muscle involvement and sleep-disordered breathing relate to worse prognosis. The present study investigated whether respiratory outcomes on first-ever sleep studies predict survival in patients with ALS, specifically taking into account subsequent initiation of non-invasive ventilation (NIV). METHODS: From patients with ALS, baseline sleep study records, transcutaneous capnometry, early morning blood gas analysis, survival data and clinical disease characteristics were retrospectively analyzed. Patients were stratified according to whether enduring NIV was consecutively established ("NIV(+)") or not ("NIV(-)"). RESULTS: Among the study cohort (n = 158, 72 female, 51 with bulbar onset ALS, 105 deceased) sleep-disordered breathing was present at baseline evaluation in 97 patients. Early morning base excess (EMBE) > 2 mmol/l predicted nocturnal hypercapnia. Ninety-five patients were NIV(+) and 63 were NIV(-). Survival from baseline sleep studies was significantly reduced in NIV(-) but not in NIV(+) patients with nocturnal CO2 tension ≥ 50 mmHg, apnea hypopnea index ≥ 5/h, and EMBE > 2 mmol/l. Hazard ratio for EMBE > 2 mmol/l was increased in NIV(-) patients only, and EMBE independently predicted survival in both NIV(-) and NIV(+) patients. Furthermore, EMBE on baseline sleep studies was the only predictor for survival from symptom onset, and hazard ratio for shorter survival was markedly higher in the NIV(-) than the NIV(+) group (2.85, p = 0.005, vs. 1.71, p = 0.042). INTERPRETATION: In patients with ALS, EMBE > 2 mmol/l predicts nocturnal hypercapnia and shorter survival. Negative effects of sleep-disordered breathing on survival are statistically abolished by sustained NIV.

Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation.

PURPOSE: To evaluate whether extracorporeal carbon dioxide removal by means of a pumpless extracorporeal lung-assist (PECLA) device could be an effective and safe alternative to invasive mechanical ventilation in patients with chronic pulmonary disease and acute hypercapnic ventilatory failure not responding to noninvasive ventilation (NIV). METHODS: In this multicentre, retrospective study, 21 PECLA patients were compared with respect to survival and procedural outcomes to 21 matched controls with conventional invasive mechanical ventilation. Matching criteria were underlying diagnosis, age, Simplified Acute Physiology Score II and pH at ICU admission. RESULTS: Of the 21 patients treated with PECLA, 19 (90 %) did not require intubation. Median PaCO(2) levels and pH in arterial blood prior to PECLA were 84.0 mmHg (54.2-131.0) and 7.28 (7.10-7.41), respectively. Within 24 h, median PaCO(2) levels and pH had significantly improved to 52.1 (33.0-70.1; p < 0.001) and 7.44 (7.27-7.56; p < 0.001), respectively. Two major and seven minor bleeding complications related to the device occurred. Further complications were one pseudoaneurysm and one heparin-induced thrombocytopenia type 2. Compared to the matched control group, there was a trend toward a shorter hospital length of stay in the PECLA group (adjusted p = 0.056). There was no group difference in the 28-day (24 % vs. 19 %, adjusted p = 0.845) or 6-month mortality (33 % vs. 33 %). CONCLUSIONS: In this study the use of extracorporeal carbon dioxide removal allowed avoiding intubation and invasive mechanical ventilation in the majority of patients with acute on chronic respiratory failure not responding to NIV. Compared to conventional invasive ventilation, short- and long-term survivals were similar.