Diastology in the intensive care unit: Challenges for the assessment and future directions.

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

Concurrent veno-pulmonary extracorporeal membrane oxygenation cannulation with ProtekDuo parallel to an in situ veno-pulmonary single-lumen cannula.

This technical report describes the successful transition from dual lumen, single site veno-venous extracorporeal membrane oxygenation ((dl)V-V ECMO) to single lumen, dual site veno-pulmonary (V-P) ECMO, and subsequently to dual lumen, single site (dl)V-P ECMO involving temporary placement of two cannulas in the main pulmonary artery. No complications were observed during these transitions. This technique could address concerns related to cannula exchanges in VP ECMO. However, caution is warranted and constant monitoring of cannula position using real-time imaging is required when using this technique due to the risk profile.

Oncostatin M for characterizing the inflammatory burden and outcome of V-V ECMO in ARDS patients.

BACKGROUND: Assessing the outcome of Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) support remains challenging as plasma lactate (pLA), the widely used tool for this purpose, has been shown unreliable. We hypothesized that plasma oncostatin M (pOSM), a sensitive marker of leukocyte activation in infection and inflammation, could address this deficiency. METHODS: Plasma OSM levels were measured by ELISA in 30 Acute Respiratory Distress Syndrome (ARDS) patients, prior to cannulation (baseline) and decannulation. RESULTS: Based on the absolute pOSM levels at presentation, patients were separated into two groups, A and B. Patients in group A had low pOSM levels (Mean ± SD; Median, 1.1 ± 3.8; 0 pg/mL), whereas group B had high pOSM levels (1548 ± 1999; 767 pg/mL) [t-test: p < 0.01]. The percentage of pOSM levels at decannulation relative to baseline OSM levels was significantly higher in those who died (116.8 ± 68.0; 85.3%) than those who survived (47.6 ± 25.5; 48.9%) [t-test: p = 0.02; Mann-Whitney U Test: p = 0.01]. Conversely, no significant difference was observed in the percentage of pLA levels between those who died (142.9 ± 179.9; 89.8%) and those who survived (79.3 ± 34.3; 81.8%) [t-test: p = 0.31; Mann-Whitney U Test: p = 0.63]. CONCLUSION: These early findings suggested critical value of absolute and relative pOSM to characterize the inflammatory burden of ARDS patients and the outcome of their V-V ECMO support.

Venoarterial extracorporeal membrane oxygenation for "protected" catheter-based embolectomy in high-risk/massive pulmonary embolism.

High-risk/massive pulmonary embolism (PE) has a high mortality rate, especially when cardiac arrest occurs. Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) can rapidly restore and maintain circulation while a decision regarding further care or performance of other interventions takes place. Catheter-based embolectomy (CBE) is a technology that allows for percutaneous access, clot removal, and potential resolution of shock while avoiding sternotomy required for traditional pulmonary embolectomy. Rapid placement of V-A ECMO in patients with high-risk/massive PE prior to CBE may confer circulatory protection before, during, and after the procedure.

The novel ProtekDuo ventricular assist device: Configurations, technical aspects, and present evidence.

The ProtekDuo, single site dual lumen cannula can be used in a multitude of configurations. In the medical literature, the ProtekDuo is described as right ventricular assist device (RVAD), as left ventricular assist device (LVAD), as biventricular assist device (BiVAD) when combined with an Impella device or other LVAD's, as double lumen drainage cannula on cardiopulmonary bypass (CPB), as RVAD with oxygenator, in veno-pulmonary (V-P) ECMO configuration, venovenous-pulmonary (VV-P) ECMO configuration with additional drainage cannula, and in veno-venopulmonary (V-VP) ECMO configuration as double lumen return cannula. Improvements in flow and oxygenation have been recognized in various settings and need further scientific evaluation. We summarized the above-mentioned configurations, technical aspects, and the present literature available for the ProtekDuo.

The ProtekDuo dual-lumen cannula for temporary acute mechanical circulatory support in right heart failure: A systematic review.

INTRODUCTION: Acute right ventricular failure (aRVF) is associated with high mortality and morbidity. Mechanical circulatory support (MCS) may be considered as an advanced treatment option. The ProtekDuo is a cannula that can be used to provide acute right ventricular support as part of a temporary percutaneous (tp) right ventricular assist device (RVAD) system. The primary objective of this systematic review is to describe patient survival and complications when the ProtekDuo cannula was used as part of an tpRVAD system. METHODS: MEDLINE, Embase, and Scopus were searched from database inception to August 26, 2022. Reference sections of studies were reviewed to screen for database omissions. RESULTS: Seven studies with 127 patients were eligible for inclusion. The studies included patients with aRVF from a variety of causes. Mean duration of support was between 10 and 58 days in five studies. Patient survival to discharge was between 60% and 85.2% in two studies. Four authors reported 30-day survival between 60% and 85.2%. Devicerelated and non-device related complications were low. CONCLUSIONS: Patients treated with RVAD using the ProtekDuo cannula have comparable survival rates and complications to other tpRVAD systems. Several advantages exist compared to other RVAD systems.

Standardized nomenclature for peripheral percutaneous cannulation of the pulmonary artery in extracorporeal membrane oxygenation: Current uptake and recommendations for improvement.

The rising application of extracorporeal membrane oxygenation (ECMO) has emphasized the need for consistent and standardized terminology, especially concerning peripheral percutaneous cannulation of the pulmonary artery (PPC-PA). The Extracorporeal Life Support Organization (ELSO) Nomenclature Task Force produced the ELSO Maastricht Treaty for extracorporeal life support (ECLS) Nomenclature to address this challenge. However, adherence to nomenclature recommendations has been poor in publications describing PPC-PA. We aim to describe common nomenclature errors and provide a user-guide for abbreviations that can be used by authors, reviewers, and journal staff to ensure properadherence to standardized nomenclature in publications describing PPC-PA.

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review.

BACKGROUND: Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. METHODS: A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. RESULTS: The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 µg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). CONCLUSIONS: Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.

Feasibility of using the ProtekDuo cannula in V-P ECMO and PROpella configurations during ground and air transport.

INTRODUCTION: Use of the ProtekDuo cannula has been described for right ventricular assist devices (RVADs) and extracorporeal membrane oxygenation (ECMO) systems. CASE REPORT: We describe remote cannulation and transport of two patients with ProtekDuo cannula. One patient had isolated acute right ventricular failure (aRVF), was cannulated with ProtekDuo cannula in venopulmonary (V-P) configuration and transported by ambulance. Another patient had biventricular failure after myocardial infarction, was supported with ProtekDuo and Impella CP in PROpella configuration, and transported by helicopter. DISCUSSION: We appear to be the first group to report remote cannulation using the ProtekDuo cannula followed by ambulance and helicopter transport, which were performed without complication. We describe the pros and cons of these configurations in comparison to the gold standard of shock management with venoarterial ECMO, as well as important considerations for transport. CONCLUSION: Use of the ProtekDuo cannula for remote cannulations and transport is feasible and appears safe.

Veno-arteriovenous extracorporeal membrane oxygenation-A single center experience.

BACKGROUND: Patients with combined circulatory shock and respiratory failure may benefit from veno-arteriovenous (V-AV) extracorporeal membrane oxygenation support (ECMO). We report our center's experience with V-AV ECMO and propose an algorithm to help identify patients that may benefit from early V-AV ECMO support. METHODS: Clinical data were extracted from electronic medical records between November 1, 2016 and November 1, 2019. RESULTS: Out of a total of 369 patients placed on extracorporeal life support (ECLS), we identified a total of 26 patients who underwent hybrid ECMO placement. Three patients were excluded from our analysis due to veno-venoarterial extracorporeal membrane oxygenation (V-VA ECMO) configuration, therefore 23 patients were included in our analysis. The median age was 53 (range 25-73) years. Hybrid ECMO support was instituted most commonly for differential hypoxemia in patients on venoarterial (V-A) ECMO support, and cardiogenic shock in patients who were initially started on venovenous (V-V) ECMO. The initial ECMO cannulation was V-A in 12 patients, V-V in 8 patients, and directly V-AV in 3 patients. Nine out of 23 patients were successfully decannulated (39.1%) and survived until hospital discharge. The main ECMO-related complications included bleeding (n = 10), circuit exchange either due to hemolysis or oxygenator failure (n = 4), ECMO cannula site infection (n = 2), deep venous thrombosis (n = 2), and death during ECMO cannula exchange (n = 1). CONCLUSIONS: V-AV ECMO represents a rescue strategy in critically ill patients with combined respiratory failure and cardio-circulatory shock.

Mechanical cardiopulmonary resuscitation for venoarterial ECMO implantation in pulmonary embolism complicated by type B aortic dissection and retroperitoneal hemorrhage.

A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high-risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.

Meta-Analysis of Electroacupuncture in Cardiac Anesthesia and Intensive Care.

BACKGROUND: Acupuncture treatment has been employed in China for over 2500 years and it is used worldwide as analgesia in acute and chronic pain. Acupuncture is also used in general anesthesia (GA). The aim of this systematic review and meta-analysis was to assess the efficacy of electroacupuncture (EA) in addition to GA in patients undergoing cardiac surgery. METHODS: We searched 3 databases (Pubmed, Cochrane Library, and Web of Science-from 1965 until January 31, 2017) for randomized controlled trials (RCTs) including patients undergoing cardiac surgery and receiving GA alone or GA + EA. As primary outcomes, we investigated the association between GA + EA approach and the dosage of intraoperative anesthetic drugs administered, the duration of mechanical ventilation (MV), the postoperative dose of vasoactive drugs, the length of intensive care unit (ICU) and hospital stay, and the levels of troponin I and cytokines. RESULTS: The initial search yielded 477 citations, but only 7 prospective RCTs enrolling a total of 321 patients were included. The use of GA + EA reduced the dosage of intraoperative anesthetic drugs (P < .05), leading to shorter MV time (P < .01) and ICU stay (P < .05) as well as reduced postoperative dose of vasoactive drugs (P < .001). In addition, significantly lower levels of troponin I (P < .01) and tumor necrosis factor α (P < .01) were observed. CONCLUSION: The complementary use of EA for open-heart surgery reduces the duration of MV and ICU stay, blunts the inflammatory response, and might have protective effects on the heart. Our findings stimulate future RCT to provide definitive recommendations.

Percutaneous venoarterial extracorporeal membrane oxygenation as a bridge to double valve implantation in acute biventricular heart failure with profound cardiogenic shock.

A 71-year-old woman was admitted with acute hypoxic and hypercapnic respiratory failure and cardiogenic shock, secondary to acute on chronic biventricular systolic and diastolic congestive heart failure and severe aortic and mitral valve stenosis. She further presented with pulmonary hypertension and moderate-to-severe tricuspid regurgitation requiring high and increasing doses of vasopressors. The patient was percutaneously cannulated for venoarterial extracorporeal membrane oxygenation (VA-ECMO) and stabilized on ECMO, with a urine output of 17.3 L within the following 8 days. Balloon valvuloplasty and/or transcatheter aortic valve replacement were discussed but ruled out by the multidisciplinary team considering the mitral valve could not be fully addressed. Though lung function was not fully optimized, a window of opportunity was identified and used for double valve replacement on day 8 of VA-ECMO support. After a 24-hour vasoplegic period, the patient was extubated to continuous positive airway pressure and further transitioned to nasal cannula, following which she recovered well.

Bivalirudin for Alternative Anticoagulation in Extracorporeal Membrane Oxygenation: A Systematic Review.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) offers therapeutic options in refractory respiratory and/or cardiac failure. Systemic anticoagulation with heparin is routinely administered. However, in patients with heparin-induced thrombocytopenia or heparin resistance, the direct thrombin inhibitor bivalirudin is a valid option and has been increasingly used for ECMO anticoagulation. We aimed at evaluating its safety and its optimal dosing for ECMO. METHODS: Systematic web-based literature search of PubMed and EMBASE performed via National Health Service Library Evidence and manually, updated until January 30, 2016. RESULTS: The search revealed 8 publications relevant to the topic (5 case reports). In total, 58 patients (24 pediatrics) were reported (18 received heparin as control groups). Bivalirudin was used with or without loading dose, followed by infusion at different ranges (lowest 0.1-0.2 mg/kg/h without loading dose; highest 0.5 mg/kg/h after loading dose). The strategies for monitoring anticoagulation and optimal targets were dissimilar (activated partial thromboplastin time 45-60 seconds to 42-88 seconds; activated clotting time 180-200 seconds to 200-220 seconds; thromboelastography in 1 study). CONCLUSION: Bivalirudin loading dose was not always used; infusion range and anticoagulation targets were different. In this systematic review, we discuss the reasons for this variability. Larger studies are needed to establish the optimal approach with the use of bivalirudin for ECMO.

The role of neuromuscular blockade in patients with traumatic brain injury: a systematic review.

Management of Traumatic Brain Injury (TBI) focuses on controlling intracranial pressure (ICP), while other treatments, such as the use of neuromuscular blocking agents (NMBAs), need scientific evidence. We conducted a systematic review to investigate the usefulness of NMBAs in the context of TBI and/or increased ICP. We searched MEDLINE and EMBASE databases up to January 31st 2014, including both clinical and experimental findings. We found a total of 34 articles, of which 22 were prospective clinical trials. No systematic review/meta-analyses were found. Seven studies evaluated NMBA boluses in preventing stimulation-related ICP surges: paralysis was effective during tracheal suctioning and physiotherapy but not during bronchoscopy. Fourteen small studies (8 to 25 patients) assessed the effect of NMBA boluses on ICP. Two studies showed an ICP increase by succinylcholine and one found a decrease in ICP after atracurium. No ICP changes were observed in the other studies. One prospective study confirmed that discontinuing paralysis increases energy expenditure. Two retrospective studies investigated mortality/morbidity: one found that early paralysis (continued for >12 h) was not beneficial and potentially associated with extra-cranial complications, while the second demonstrated a correlation between continuous infusion of NMBA and time spent with ICP > 20 mmHg. Eight animal studies were also retrieved. In most studies, NMBA bolus was beneficial in controlling ICP, especially when performing stimulating procedures. However, retrospective evidence found potential harm by continuous NMBA infusion. In the context of TBI patients, we discuss the potentially positive effects of paralysis with its negative ones. Well-conducted randomized controlled trials and/or large pharmaco-epidemiologic studies are warranted.

The selective vasopressin type 1a receptor agonist selepressin (FE 202158) blocks vascular leak in ovine severe sepsis*.

OBJECTIVE: To determine if the selective vasopressin type 1a receptor agonist selepressin (FE 202158) is as effective as the mixed vasopressin type 1a receptor/vasopressin V2 receptor agonist vasopressor hormone arginine vasopressin when used as a titrated first-line vasopressor therapy in an ovine model of Pseudomonas aeruginosa pneumonia-induced severe sepsis. DESIGN: Prospective, randomized, controlled laboratory experiment. SETTING: University animal research facility. SUBJECTS: Forty-five chronically instrumented sheep. INTERVENTIONS: Sheep were anesthetized, insufflated with cooled cotton smoke via tracheostomy, and P. aeruginosa were instilled into their airways. They were then placed on assisted ventilation, awakened, and resuscitated with lactated Ringer's solution titrated to maintain hematocrit ± 3% from baseline levels. If, despite fluid management, mean arterial pressure fell by more than 10 mm Hg from baseline level, an additional continuous IV infusion of arginine vasopressin or selepressin was titrated to raise and maintain mean arterial pressure within no less than 10 mm Hg from baseline level. Effects of combination treatment of selepressin with the selective vasopressin V2 receptor agonist desmopressin were similarly investigated. MEASUREMENTS AND MAIN RESULTS: In septic sheep, MAP fell by ~30 mm Hg, systemic vascular resistance index decreased by ~50%, and ~7 L of fluid were retained over 24 hours; this fluid accumulation was partially reduced by arginine vasopressin and almost completely blocked by selepressin; and combined infusion of selepressin and desmopressin increased fluid accumulation to levels similar to arginine vasopressin treatment. CONCLUSIONS: Resuscitation with the selective vasopressin type 1a receptor agonist selepressin blocked vascular leak more effectively than the mixed vasopressin type 1a receptor/vasopressin V2 receptor agonist arginine vasopressin because of its lack of agonist activity at the vasopressin V2 receptor.

Technique for Weaning From Peripheral Venopulmonary Extracorporeal Membrane Oxygenation in Combined Cardiopulmonary Failure.

Venopulmonary (VP) extracorporeal membrane oxygenation (ECMO) is a mode capable of supporting both pulmonary and right ventricular (RV) functions. Weaning patients from VP ECMO requires careful assessment of both RV and respiratory system recovery, which may occur at different rates. The weaning strategy described herein begins with weaning of respiratory ECMO support, followed by discontinuation of RV support. We also discuss situations in which the standard weaning strategy may require modification.

The ProtekDuo Cannula: A Comprehensive Review of Efficacy and Clinical Applications in Right Ventricular Failure.

Right ventricular failure (RVF) is a clinical challenge associated with various underlying acute and chronic medical conditions, necessitating diverse management strategies including mechanical circulatory support (MCS). The ProtekDuo cannula represents an important advancement in medical devices for MCS in the setting of RVF. When combined with an extracorporeal blood pump, the dual-lumen design allows for direct bypass of the RV using simultaneous drainage and return of blood using percutaneous, single-site access. Studies have reported favorable outcomes with the ProtekDuo cannula and low device-related complications, but comparative studies with other MCS devices are limited. Still, the ProtekDuo cannula has numerous advantages; however, it is not without challenges, and opportunities for further research exist. The ProtekDuo cannula holds significant potential for future advancements in the field of MCS, offering promising solutions for RVF management.