Doubts and concerns about COVID-19 uncertainties on imaging data, clinical score, and outcomes.

BACKGROUND: COVID-19 is a pandemic disease affecting predominantly the respiratory apparatus with clinical manifestations ranging from asymptomatic to respiratory failure. Chest CT is a crucial tool in diagnosing and evaluating the severity of pulmonary involvement through dedicated scoring systems. Nonetheless, many questions regarding the relationship of radiologic and clinical features of the disease have emerged in multidisciplinary meetings. The aim of this retrospective study was to explore such relationship throughout an innovative and alternative approach. MATERIALS AND METHODS: This study included 550 patients (range 25-98 years; 354 males, mean age 66.1; 196 females, mean age 70.9) hospitalized for COVID-19 with available radiological and clinical data between 1 March 2021 and 30 April 2022. Radiological data included CO-RADS, chest CT score, dominant pattern, and typical/atypical findings detected on CT examinations. Clinical data included clinical score and outcome. The relationship between such features was investigated through the development of the main four frequently asked questions summarizing the many issues arisen in multidisciplinary meetings, as follows 1) CO-RADS, chest CT score, clinical score, and outcomes; 2) the involvement of a specific lung lobe and outcomes; 3) dominant pattern/distribution and severity score for the same chest CT score; 4) additional factors and outcomes. RESULTS: 1) If CT was suggestive for COVID, a strong correlation between CT/clinical score and prognosis was found; 2) Middle lobe CT involvement was an unfavorable prognostic criterion; 3) If CT score < 50%, the pattern was not influential, whereas if CT score > 50%, crazy paving as dominant pattern leaded to a 15% increased death rate, stacked up against other patterns, thus almost doubling it; 4) Additional factors usually did not matter, but lymph-nodes and pleural effusion worsened prognosis. CONCLUSIONS: This study outlined those radiological features of COVID-19 most relevant towards disease severity and outcome with an innovative approach.

Echocardiography Before Extracorporeal Membrane Oxygenation in Refractory Respiratory Failure: SARS-CoV-2 Infection Versus Other Etiologies.

OBJECTIVES: The study authors hypothesized that in patients with SARS-CoV-2, COVID-19-related refractory respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support echocardiographic findings (just before ECMO implantation) would be different from those observed in patients with refractory respiratory failure from different etiologies. DESIGN: A single-center observational study. SETTING: At an intensive care unit (ICU). PARTICIPANTS: A total of 61 consecutive patients with refractory COVID-19-related respiratory failure (COVID-19 series) and 74 patients with refractory acute respiratory disease syndrome from other etiologies (no COVID-19 series), all needing ECMO support. INTERVENTIONS: Echocardiogram pre-ECMO. MEASUREMENTS AND MAIN RESULTS: Right ventricle dilatation and dysfunction were defined in the presence of the RV end-diastolic area and/or left ventricle end-diastolic area (LVEDA >0.6 and tricuspid annular plane systolic excursion [TAPSE] <15 mm. Patients in the COVID-19 series showed a higher body mass index (p < 0.001) and a lower Sequential Organ Failure Assessment score (p = 0.002). In-ICU mortality rates were comparable between the 2 subgroups. Echocardiograms performed in all patients before ECMO implantation revealed an incidence of RV dilatation that was higher in patients in the COVID-19 series (p < 0.001), and they also showed higher values of systolic pulmonary artery pressure (sPAP) (p < 0.001) and lower TAPSE and/or sPAP (p < 0.001). The multivariate logistic regression analysis showed that COVID-19-related respiratory failure was not associated with early mortality. The presence of RV dilatation and the uncoupling of RV function and pulmonary circulation were associated independently with COVID-19 respiratory failure. CONCLUSIONS: The presence of RV dilatation and an altered coupling between RVe function and pulmonary vasculature (as indicated by TAPSE and/or sPAP) are associated strictly with COVID-19-related refractory respiratory failure needing ECMO support.

Regional Cerebral Oxygen Saturation to Predict Favorable Outcome in Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to investigate the role of regional cerebral oxygen saturation (rSO2) in predicting survival and neurologic outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN: The study authors performed a systematic review and meta-analysis of all available literature. SETTING: The authors searched relevant databases (Pubmed, Medline, Embase) for studies measuring precannulation rSO2 in patients undergoing ECPR and reporting mortality and/or neurologic outcomes. PARTICIPANTS: The authors included both in-hospital and out-of-hospital cardiac arrest patients receiving ECPR. They identified 3 observational studies, including 245 adult patients. INTERVENTIONS: The authors compared patients with a low precannulation rSO2 (≤15% or 16%) versus patients with a high (>15% or 16%) precannulation rSO2. In addition, the authors carried out subgroup analyses on out-of-hospital cardiac arrest (OHCA) patients. MEASUREMENTS AND MAIN RESULTS: A high precannulation rSO2 was associated with an overall reduced risk of mortality in ECPR recipients (98 out of 151 patients [64.9%] in the high rSO2 group, v 87 out of 94 patients [92.5%] in the low rSO2 group, risk differences [RD] -0.30; 95% CI -0.47 to -0.14), and in OHCA (78 out of 121 patients [64.5%] v 82 out of 89 patients [92.1%], RD 0.30; 95% CI -0.48 to -0.12). A high precannulation rSO2 also was associated with a significantly better neurologic outcome in the overall population (42 out of 151 patients [27.8%] v 2 out of 94 patients [2.12%], RD 0.22; 95% CI 0.13-0.31), and in OHCA patients (33 out of 121 patients [27.3%] v 2 out of 89 patients [2.25%] RD 0.21; 95% CI 0.11-0.30). CONCLUSIONS: A low rSO2 before starting ECPR could be a predictor of mortality and survival with poor neurologic outcomes.

Persistent Right Ventricle Dilatation in SARS-CoV-2-Related Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation Support.

OBJECTIVES: Venovenous extracorporeal membrane oxygenation (ECMO) support may be considered in experienced centers for patients with acute respiratory distress syndrome (ARDS) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection refractory to conventional treatment. In ECMO patients, echocardiography has emerged as a clinical tool for implantation and clinical management; but to date, little data are available on COVID-related ARDS patients requiring ECMO. The authors assessed the incidence of right ventricular dilatation and dysfunction (RvDys) in patients with COVID-related ARDS requiring ECMO. DESIGN: Single-center investigation. SETTING: Intensive care unit (ICU). PARTICIPANTS: A total of 35 patients with COVID-related ARDS requiring ECMO, consecutively admitted to the ICU (March 1, 2020, to February 28, 2021). INTERVENTIONS: Serial echocardiographic examinations. RvDys was defined as RV end-diastolic area/LV end-diastolic area >0.6 and tricuspid annular plane excursion <15 mm. MEASUREMENTS AND MAIN RESULTS: The incidence of RvDys was 15/35 (42%). RvDys patients underwent ECMO support after a longer period of mechanical ventilation (p = 0.006) and exhibited a higher mortality rate (p = 0.024) than those without RvDys. In nonsurvivors, RvDys was observed in all patients (n = nine) who died with unfavorable progression of COVID-related ARDS. In survivors, weaned from ECMO, a significant reduction in systolic pulmonary arterial pressures was detectable. CONCLUSIONS: According to the authors' data, in COVID-related ARDS requiring ECMO support, RvDys is common, associated with increased ICU mortality. Overall, the data underscored the clinical role of echocardiography in COVID-related ARDS supported by venovenous ECMO, because serial echocardiographic assessments (especially focused on RV changes) are able to reflect pulmonary COVID disease severity.

Perinatal outcomes of pregnant women with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO): a case series and literature review.

PURPOSE: Pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a higher risk of hospitalization, admission to intensive care unit (ICU) and invasive ventilation, and of acute respiratory distress syndrome (ARDS). In case of ARDS and critical severe coronavirus disease 2019 (COVID-19), the use of extracorporeal membrane oxygenation (ECMO) is recommended when other respiratory support strategies (oxygen insufflation, non-invasive ventilation [NIV], invasive ventilation through an endotracheal tube) are insufficient. However, available data on ECMO in pregnant and postpartum women with critical COVID-19 are very limited. METHODS: A case series of three critically ill pregnant women who required ECMO support for COVID-19 in pregnancy and/or in the postpartum period. RESULTS: The first patient tested positive for COVID-19 during the second trimester, she developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a cesarean-section [CS] at term was performed for obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation. During ECMO, she experienced a precipitous vaginal delivery at 31 weeks and 6 days of gestation. She was discharged 1 month later in good general conditions. The third patient, an obese 43-year-old woman, tested positive at 38 weeks and 2 days of gestation. Because of the worsening of clinical condition, a CS was performed, and she underwent ECMO. 143 days after the CS, she died because of sepsis and multiple organ failure (MOF). Thrombosis, hemorrhage and infections were the main complications among our patients. Neonatal outcomes have been positive. CONCLUSION: ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19.

Severe neurological nicotine intoxication by e-cigarette liquids: Systematic literature review.

Electronic cigarettes are a popular, easily purchased, alternative source of nicotine that is considered safer than conventional tobacco. However, Intentional or accidental exposure to e-liquid substances, mainly nicotine, can lead to serious, potentially fatal toxicity. Emergency and critical care physicians should keep in mind acute intoxication of this poison with a biphasic toxic syndrome. We highlight its potentially fatal outcome and suggest monitoring the adverse effects of nicotine according to a multimodal protocol integrating somatosensory evoked potentials, electroencephalography and neuroimaging data with anamnestic report and toxicological and laboratory data.

Electrodiagnostic findings in patients with non-COVID-19- and COVID-19-related acute respiratory distress syndrome.

BACKGROUND: Critical illness polyneuropathy and myopathy (CIPNM) is a frequent neurological manifestation in patients with acute respiratory distress syndrome (ARDS) from coronavirus disease 2019 (COVID-19) infection. CIPNM diagnosis is usually limited to clinical evaluation. We compared patients with ARDS from COVID-19 and other aetiologies, in whom a neurophysiological evaluation for the detection of CIPNM was performed. The aim was to determine if there were any differences between these two groups in frequency of CINPM and outcome at discharge from the intensive care unit (ICU). MATERIALS AND METHODS: This was a single-centre retrospective study performed on mechanically ventilated patients consecutively admitted (January 2016-June 2020) to the ICU of Careggi Hospital, Florence, Italy, with ARDS of different aetiologies. Neurophysiological evaluation was performed on patients with stable ventilation parameters, but marked widespread hyposthenia (Medical Research Council score <48). Creatine phosphokinase (CPK), lactic dehydrogenase (LDH) and mean morning glycaemic values were collected. RESULTS: From a total of 148 patients, 23 with COVID-19 infection and 21 with ARDS due to other aetiologies, underwent electroneurography/electromyography (ENG/EMG) recording. Incidence of CIPNM was similar in the two groups, 65% (15 of 23) in COVID-19 patients and 71% (15 of 21) in patients affected by ARDS of other aetiologies. At ICU discharge, subjects with CIPNM more frequently required ventilatory support, regardless the aetiology of ARDS. CONCLUSION: ENG/EMG represents a useful tool in the identification of the neuromuscular causes underlying ventilator wean failure and patient stratification. A high incidence of CIPNM, with a similar percentage, has been observed in ARDS patients of all aetiologies.

Delayed graft function and perfusion parameters of kidneys from uncontrolled donors after circulatory death.

Better preservation and evaluation of kidneys from donors after circulatory death serve to increase the number of kidneys available for transplantation and hypothermic machine perfusion has been shown to decrease ischemia reperfusion injury and delayed graft function. Data on relation between hemodynamic parameters during hypothermic machine perfusion and delayed graft function in kidneys from donors after circulatory death are so far scarce and not univocal. We aimed at assessing whether hemodynamic parameters measured during hypothermic machine perfusion (flow, mean perfusion pressure, and renal resistance) are associated with delayed graft function in 26 kidneys retrieved from uncontrolled donors after circulatory death. In our series, the incidence of delayed graft function was 57.7% (15/26). Recipients who developed delayed graft function had a longer warm ischemic time (p = 0.04). All hemodynamic parameters measured during hypothermic machine perfusion were comparable between recipients with delayed graft function and those without. According to our data, in kidneys from uncontrolled donors after circulatory death, a longer warm ischemic time (that is the overall time of no flow, as the sum of the no-flow and the no-touch period) is associated with delayed graft function. This finding underscores the pivotal role of ischemic injury in terms of absence of flow in affecting graft function. No association was detectable between hemodynamic parameters during hypothermic machine perfusion and the development of delayed graft function in our series.

Utilization rate of uncontrolled donors after circulatory death-a 3-year single-center investigation.

BACKGROUND: Effectiveness of uncontrolled donation after circulatory death (uDCD) has been recently reported to be 75% according to data coming from some European countries in 2016, but few data are to date available on this topic. METHODS: We assessed the utilization rate (as the percentage of donors who were converted into actual donors) in 37 uDCDs consecutively enrolled at our Center (Careggi Teaching Hospital) from June 2016 to June 2019. RESULTS: In three cases, the family did not give consent for donation (3/37, 8.1%). Among the 37 potential uDCDs, 22 became actual donors (22/37, 59%), with 10 livers and 38 kidneys being transplanted, respectively. Fifteen livers were recovered (15/37, 68%), and 10 livers were transplanted (10/15, 67%). Forty-two kidneys were procured and 38 organs transplanted. The overall effectiveness was 78%. CONCLUSIONS: According to our 3-year experience, uncontrolled DCDs do represent an additional means of increasing the number of transplanted organs (kidneys and livers) with an acceptable utilization rate. Research on organ viability assessment (for both livers and kidneys from uDCDs) is still in its infancy, and there is probably space for a further wider use of organs from uDCDs.

Right Ventricular Hypertrophy in Refractory Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation Support.

OBJECTIVE: In severe acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO), right ventricular (RV failure) and dilation have been investigated with the use of echocardiography, whereas RV hypertrophy has not been addressed in the literature. The present study assessed the incidence of RV hypertrophy using echocardiography before ECMO treatment and at intensive care unit (ICU) discharge in severe ARDS patients. DESIGN: Observational, retrospective, single-center study. SETTING: A single ECMO center. PARTICIPANTS: The study comprised 46 consecutive patients with severe ARDS. INTERVENTION: Echocardiographic evaluation and ECMO support. MEASUREMENTS AND MAIN RESULTS: A dual-lumen cannula was implanted in most patients (38/46 [82.6%]). Before the start of ECMO, RV hypertrophy was present in 28 patients (60.8%) with no significant differences in baseline characteristics between the 2 subgroups. The ICU mortality rate was 30.4% (14/46), with no difference between patients with RV hypertrophy and those without. At ICU discharge, all patients showed RV hypertrophy. CONCLUSIONS: In severe ARDS treated with ECMO support, RV hypertrophy is a common finding and patients with normal RV wall thickness developed RV hypertrophy after ECMO support. The latter finding may suggest that during ECMO support, the right ventricle still may be subjected to increased afterload. However, additional research should be performed to elucidate the spectrum of mechanism(s) involved in the genesis of RV hypertrophy.

Activities of an ECMO Center for Severe Respiratory Failure: ECMO Retrieval and Beyond, A 4-Year Experience.

OBJECTIVE: Beyond retrieval and management of patients with severe acute respiratory distress syndrome, an extracorporeal membrane oxygenation (ECMO) center also encompasses several other actions, such as on-call consultations, advice, and counseling, to the physicians at the peripheral centers, but few data are available on this topic. Therefore, the authors describe the composite activities of retrieval and counseling of an ECMO center since 2014. DESIGN: The referral calls addressed to the authors' ECMO center for patients with respiratory failure were prospectively recorded in a dedicated database. Referral call frequency, patient data, and results of the calls were analyzed. SETTING: The 12-bed intensive care unit of Careggi Hospital in Florence, the ECMO referral center for Tuscany, and the center of Italy, with a mobile ECMO team. PARTICIPANTS: Patients from intensive care units of peripheral hospitals for whom a referral call was addressed to the authors' ECMO center. INTERVENTIONS: Many possible responses were given after a referral call, varying from ECMO team deployment to advice or to refusal. MEASUREMENTS AND MAIN RESULTS: From January 1, 2014, to December 31, 2017, 231 calls were received at the authors' ECMO center, of which 220 calls were for acute respiratory failure cases. Throughout the study period the overall number of calls did not vary, but the percentage of ECMO retrievals decreased, whereas the percentage of ARF patients from peripheral hospital admitted to our ECMO center on conventional ventilation increased. Fifty-five patients were treated by the mobile ECMO team and were transferred on ECMO; 59 were admitted on ventilatory support. In flu periods the overall calls were more frequent than in the no-flu periods (171 v 82 calls), and more ECMO retrieval missions were deployed. CONCLUSIONS: During the study period, a decreased number of patients retrieved on ECMO was observed, whereas patients transferred on ventilation increased, with an overall unchanged number of referred patients.

A metabolic approach during normothermic regional perfusion in uncontrolled donors after circulatory death-A pilot study.

The use of donation after circulatory death (DCD) has increased significantly to face the persistent mismatch between supply and demand of organs for transplantation. While controlled (c) DCDs have warm ischemic time (WIT) that can be estimated, the WIT is often inexact and extended in uncontrolled DCD (uDCD), making assessment of injury difficult. We aimed at investigating the effects of cold ischemia on potential donor organ damage in the course of nRP by assessing the dynamic variations of transaminases and creatinine values in 17 uDCD donors. In our series, lactate values did not show significant changes during the study period (P = 0.147). Creatinine values did not significantly changed while transaminases progressive increased throughout the study period, even if it was significant only for AST (P = 0.035). According to our data, nRP duration affects splanchnic organs, being the liver sensitive to hypoperfusion, and serial biochemical measurements could help in detecting organ functional status.

Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.

PURPOSE: Speckle tracking echocardiography is a novel echocardiographic technique to assess RV myocardial function but no data are so far available in patients with acute respiratory distress syndrome (ARDS), and we aimed at assessing the feasibility of 2 dimensional (2D) speckle tracking echocardiography and the prognostic role of RV free wall speckle tracking strain in 30 consecutive patients with moderate-severe ARDS MATERIALS AND METHODS: In an observational prospective study, 30 consecutive patients with moderate-severe ARDS were enrolled. Echocardiography was performed within 12 hours from ICU admission. RESULTS: Mortality rate was 33% (10/30). Non-survivors showed lower values of pH (7.32 ± 0.09, P = 0.03) and higher troponin I levels (0.32 (0.08-0.46), P = 0.04), NT-pro BNP (3091 (2662-7128), P = 0.009), and SAPS II (60.3 ± 9.6, P < 0.001). At echocardiographic examination, non-survivors showed lower values of TAPSE (18.3 ± 3, P = 0.034) and higher systolic pulmonary arterial pressure (49.6 ± 16, P = 0.05). Two patients (6.6%) did not show valid acoustic windows. Only three patients showed normal values of RV strain free wall (22%, 25%, and 28% absolute values, respectively), among whom one patient died. When compared to survivors, non-survivors showed significantly lower values of RV strain free wall (-10.4 ± 0.10, P < 0.001). CONCLUSIONS: In mechanically ventilated moderate-severe ARDS, 2D speckle tracking is feasible even though difficult acoustic windows are common. Further studies are needed to confirm our findings in a larger cohort of patients.

The 8-Year Experience of the Florence Referral ECMO Center and Retrieval Team for Acute Respiratory Failure.

OBJECTIVE: Many extracorporeal membrane oxygenation (ECMO) centers for respiratory failure and ECMO mobile teams were instituted during the H1N1 pandemic. Data on transportation are scarce and heterogeneous. The authors therefore described the experience of their referral ECMO center for severe respiratory failure from 2009 to 2016 and gave a comprehensive report of transfers performed by their mobile ECMO team. DESIGN: Observational retrospective study. SETTING: An intensive care unit (ECMO referral center) in a teaching hospital. PARTICIPANTS: One hundred and sixty consecutive patients with acute respiratory distress syndrome refractory to conventional treatment requiring veno-venous (VV)-ECMO. INTERVENTION: VV-ECMO implantation. MEASUREMENTS AND MAIN RESULTS: In this series, the transferred patients on ECMO averaged 57%, with annual percentages ranging from 28% to 90% over the years. No adverse event was observed during transportation. A progressive increase in simplified acute physiology score (SAPS) values and in the use of norepinephrine were detectable (p = 0.048 and p = 0.037, respectively) as well as in neuromuscular blockers use (p = 0.004). Dual-lumen cannule were more frequently used in recent years (p < 0.001). The overall mortality rate was 40% (64/160), with no differences over the years or between transferred and local patients. Body mass index and pre-ECMO neuromuscular blockers and SAPS were independent predictors for early mortality (when adjusted for age). CONCLUSIONS: The workload of the authors' referral center and mobile team did not change, documenting that severe respiratory failure requiring VV-ECMO support is still a clinical need. No difference in mortality rate was detectable during this period or between transferred and local patients who were managed by the same team.

Bilirubin in the early course of venovenous extracorporeal membrane oxygenation support for refractory ARDS.

Bilirubin is known as a marker of hepatic dysfunction and is incorporated in scoring algorithms to assess prognosis in critically ill patients. No data are so far available on the prognostic role of hepatic dysfunction in patients with severe ARDS on venovenous extracorporeal membrane oxygenation (VV-ECMO) support. In 112 consecutive patients with severe ARDS treated with VV-ECMO, we aimed at assessing whether increased bilirubin during the first 72 h could affect early death. Increased serum bilirubin (≥1.2 mg/dl) was detectable in 29 patients (25.9%) who were older (p = 0.031), exhibited a higher SOFA score (p = 0.006), were more frequently given pre-ECMO muscular blockers (p = 0.001) and supported with ECMO for a longer period (p = 0.024), when compared to patients with normal bilirubin. No difference in in-ICU mortality rate was observed between the two subgroups. In survivors, bilirubin showed a progressive and significant decrease (p = 0.032) during the first 72 h of ECMO support, while it increased in dead patients (p = 0.007).The mortality rate was higher in patients with increased bilirubin at 24, 48 and 72 h after ECMO start in respect to that of patients with normal values. Pre-ECMO increased bilirubin values (≥1.2 mg/dl), being detectable in about one-fourth of the entire population, is not associated with increased in-ICU mortality, while the persistence of increased bilirubin values after 24 h of ECMO start and within the first 3 days identified a subgroup of patients at higher risk of death.

Right ventricular dysfunction and Pre Implantation Vasopressors in Refractory ARDS Supported by VV-ECMO.

BACKGROUND: Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients. METHODS: We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation. RESULTS: In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups. CONCLUSIONS: In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support.

Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support.

BACKGROUND: Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients. METHODS: We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS. RESULTS: The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024). CONCLUSIONS: In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).