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1.
JACC Heart Fail ; 8(7): 548-556, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32417413

RESUMO

BACKGROUND: An early report of recipient heart transplantation outcomes under the new U.S. heart allocation system introduced in late 2018 found a lower post-transplant survival rate compared with that of the prior system. OBJECTIVES: The aim of this study was to examine recipient survival under the new system by using an updated dataset. METHODS: The 2015 to 2019 United Network for Organ Sharing registry was queried for adult heart transplant recipients, stratified according to whether the subjects were listed and underwent transplant before or after October 18, 2018, when the new allocation system was implemented. The association between allocation system and recipient mortality was analyzed by using the Kaplan-Meier method and multivariable Cox proportional hazards regression. RESULTS: A total of 7,119 recipients met inclusion criteria: 6,004 (84%) and 1,115 (16%) listed and undergoing transplant in the old and new allocation systems, respectively. This registry update included 576 new-system recipients, more than double the amount previously analyzed. Recipients from the new system were more likely to be bridged to transplant with temporary mechanical circulatory support devices instead of durable left ventricular assist devices and had longer graft ischemic times. After adjustment, the new system was not associated with poorer survival on Kaplan-Meier survival analysis (log-rank test; p = 0.075) or multivariable Cox proportional hazards modeling (adjusted hazard ratio: 1.18; 95% confidence interval: 0.90 to 1.55). CONCLUSIONS: The short-term survival of recipients listed and receiving a transplant under the old and new allocation systems seems to be comparable. The modification to the allocation system has resulted in several changes to the clinical profiles of patients undergoing transplants that must be closely monitored in the coming years.

2.
ASAIO J ; 65(7): 690-697, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30585874

RESUMO

An artificial placenta (AP) utilizing extracorporeal life support (ECLS) could protect premature lungs from injury and promote continued development. Preterm lambs at estimated gestational age (EGA) 114-128 days (term = 145) were delivered by Caesarian section and managed in one of three groups: AP, mechanical ventilation (MV), or tissue control (TC). Artificial placenta lambs (114 days EGA, n = 3; 121 days, n = 5) underwent venovenous (VV)-ECLS with jugular drainage and umbilical vein reinfusion for 7 days, with a fluid-filled, occluded airway. Mechanical ventilation lambs (121 days, n = 5; 128 days, n = 5) underwent conventional MV until failure or maximum 48 hours. Tissue control lambs (114 days, n = 3; 121 days, n = 5; 128 days, n = 5) were sacrificed at delivery. At the conclusion of each experiment, lungs were procured and sectioned. Hematoxylin and eosin (H&E) slides were scored 0-4 in seven injury categories, which were summed for a total injury score. Slides were also immunostained for platelet-derived growth factor receptor (PDGFR)-α and α-actin; lung development was quantified by the area fraction of double-positive tips of secondary alveolar septa. Support duration of AP lambs was 163 ± 9 (mean ± SD) hours, 4 ± 3 for early MV lambs, and 40 ± 6 for late MV lambs. Total injury scores at 121 days were 1.7 ± 2.1 for AP vs. 5.5 ± 1.6 for MV (p = 0.02). Using immunofluorescence, double-positive tip area fraction at 121 days was 0.017 ± 0.011 in AP lungs compared with 0.003 ± 0.003 in MV lungs (p < 0.001) and 0.009 ± 0.005 in TC lungs. At 128 days, double-positive tip area fraction was 0.012 ± 0.007 in AP lungs compared with 0.004 ± 0.004 in MV lungs (p < 0.001) and 0.016 ± 0.009 in TC lungs. The AP is protective against lung injury and promotes lung development compared with mechanical ventilation in premature lambs.

3.
ASAIO J ; 64(4): 552-556, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28937410

RESUMO

An artificial placenta (AP) using venovenous extracorporeal life support (VV-ECLS) could represent a paradigm shift in the treatment of extremely premature infants. However, AP support could potentially alter cerebral oxygen delivery. We assessed cerebral perfusion in fetal lambs on AP support using near-infrared spectroscopy (NIRS) and carotid arterial flow (CAF). Fourteen premature lambs at estimated gestational age (EGA) 130 days (term = 145) underwent cannulation of the right jugular vein and umbilical vein with initiation of VV-ECLS. An ultrasonic flow probe was placed around the right carotid artery (CA), and a NIRS sensor was placed on the scalp. Lambs were not ventilated. CAF, percentage of regional oxygen saturation (rSO2) as measured by NIRS, hemodynamic data, and blood gases were collected at baseline (native placental support) and regularly during AP support. Fetal lambs were maintained on AP support for a mean of 55 ± 27 hours. Baseline rSO2 on native placental support was 40% ± 3%, compared with a mean rSO2 during AP support of 50% ± 11% (p = 0.027). Baseline CAF was 27.4 ± 5.4 ml/kg/min compared with an average CAF of 23.7 ± 7.7 ml/kg/min during AP support. Cerebral fractional tissue oxygen extraction (FTOE) correlated negatively with CAF (r = -0.382; p < 0.001) and mean arterial pressure (r = -0.425; p < 0.001). FTOE weakly correlated with systemic O2 saturation (r = 0.091; p = 0.017). Cerebral oxygenation and blood flow in premature lambs are maintained during support with an AP. Cerebral O2 extraction is inversely related to carotid flow and is weakly correlated with systemic O2 saturation.


Assuntos
Órgãos Artificiais , Circulação Cerebrovascular/fisiologia , Placenta , Animais , Feminino , Feto , Humanos , Masculino , Gravidez , Carneiro Doméstico
4.
ASAIO J ; 63(2): 223-228, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27861431

RESUMO

Lung disease in children often results in pulmonary hypertension and right heart failure. The availability of a pediatric artificial lung (PAL) would open new approaches to the management of these conditions by bridging to recovery in acute disease or transplantation in chronic disease. This study investigates the efficacy of a novel PAL in alleviating an animal model of pulmonary hypertension and increased right ventricle afterload. Five juvenile lambs (20-30 kg) underwent PAL implantation in a pulmonary artery to left atrium configuration. Induction of disease involved temporary, reversible occlusion of the right main pulmonary artery. Hemodynamics, pulmonary vascular input impedance, and right ventricle efficiency were measured under 1) baseline, 2) disease, and 3) disease + PAL conditions. The disease model altered hemodynamics variables in a manner consistent with pulmonary hypertension. Subsequent PAL attachment improved pulmonary artery pressure (p = 0.018), cardiac output (p = 0.050), pulmonary vascular input impedance (Z.0 p = 0.028; Z.1 p = 0.058), and right ventricle efficiency (p = 0.001). The PAL averaged resistance of 2.3 ± 0.8 mm Hg/L/min and blood flow of 1.3 ± 0.6 L/min. This novel low-resistance PAL can alleviate pulmonary hypertension in an acute animal model and demonstrates potential for use as a bridge to lung recovery or transplantation in pediatric patients with significant pulmonary hypertension refractory to medical therapies.


Assuntos
Órgãos Artificiais , Modelos Animais de Doenças , Ventrículos do Coração/fisiopatologia , Hipertensão Pulmonar/terapia , Pulmão , Animais , Criança , Hemodinâmica , Humanos , Hipertensão Pulmonar/fisiopatologia , Pulmão/fisiopatologia , Masculino , Artéria Pulmonar , Ovinos
5.
ASAIO J ; 62(4): 470-6, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27164040

RESUMO

Although total body perfusion with extracorporeal life support (ECLS) can be maintained for weeks, individual organ perfusion beyond 12 hours has yet to be achieved clinically. Normothermic ex situ heart perfusion (ESHP) offers the potential for prolonged cardiac preservation. We developed an ESHP system to study the effect of perfusate variables on organ preservation, with the ultimate goal of extending organ perfusion for ≥24 hours. Forty porcine hearts were perfused for a target of 12 hours. Hearts that maintained electromechanical activity and had a <3× increase in vascular resistance were considered successful preservations. Perfusion variables, metabolic byproducts, and histopathology were monitored and sampled to identify factors associated with preservation failure. Twenty-two of 40 hearts were successfully preserved at 12 hours. Successful 12 hour experiments demonstrated lower potassium (4.3 ± 0.8 vs. 5.0 ± 1.2 mmol/L; p = 0.018) and lactate (3.5 ± 2.8 vs. 4.5 ± 2.9 mmol/L; p = 0.139) levels, and histopathology revealed less tissue damage (p = 0.003) and less weight gain (p = 0.072). Results of these early experiments suggest prolonged ESHP is feasible, and that elevated lactate and potassium levels are associated with organ failure. Further studies are necessary to identify the ideal perfusate for normothermic ESHP.


Assuntos
Transplante de Coração , Preservação de Órgãos/métodos , Perfusão/métodos , Animais , Suínos , Fatores de Tempo
6.
ASAIO J ; 62(1): 110-3, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26461241

RESUMO

End-stage lung disease (ESLD) causes progressive hypercapnia and dyspnea and impacts quality of life. Many extracorporeal support (ECS) configurations for CO2 removal resolve symptoms but limit ambulation. An ovine model of pumpless ECS using subclavian vessels was developed to allow for ambulatory support. Vascular grafts were anastomosed to the left subclavian vessels in four healthy sheep. A low-resistance membrane oxygenator was attached in an arteriovenous (AV) configuration. Device function was evaluated in each animal while awake and spontaneously breathing and while mechanically ventilated with hypercapnia induced. Sweep gas (FiO2 = 0.21) to the device was increased from 0 to 15 L/min, and arterial and postdevice blood gases, as well as postdevice air, were sampled. Hemodynamics remained stable with average AV shunt flows of 1.34 ± 0.14 L/min. In awake animals, CO2 removal was 3.4 ± 1.0 ml/kg/min at maximum sweep gas flow. Respiratory rate decreased from 60 ± 25 at baseline to 30 ± 11 breaths per minute. In animals with induced hypercapnia, PaCO2 increased to 73.9 ± 15.1. At maximum sweep gas flow, CO2 removal was 3.4 ± 0.4 ml/kg/min and PaCO2 decreased to 49.1 ± 6.7 mm Hg. Subclavian AV access is effective in lowering PaCO2 and respiratory rate and is potentially an effective ambulatory destination therapy for ESLD patients.


Assuntos
Dióxido de Carbono/sangue , Circulação Extracorpórea/instrumentação , Pneumopatias/terapia , Insuficiência Respiratória/terapia , Veia Subclávia , Ar , Animais , Derivação Arteriovenosa Cirúrgica , Dióxido de Carbono/metabolismo , Oxigenação por Membrana Extracorpórea , Pneumopatias/sangue , Pneumopatias/metabolismo , Oxigenadores de Membrana , Troca Gasosa Pulmonar , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Insuficiência Respiratória/sangue , Insuficiência Respiratória/metabolismo
7.
J Hand Surg Am ; 41(1): 3-12, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26710728

RESUMO

PURPOSE: To test the potential for the ex situ limb perfusion system to prolong limb allograft survival up to 24 hours. METHODS: We used 20 swine for the study. In group 1 (control), 4 limbs were perfused with heparin solution and preserved at 4°C for 6 hours. In group 2, 4 limbs were perfused with autologous blood at 27°C to 32°C for 24 hours. In both groups, limbs were transplanted orthotopically to recipients and monitored for 12 hours. In addition to perfusion parameters, we recorded perfusate gases and electrolytes (pH, pCO2, pO2, O2 saturation, Na, K, Cl, Ca, HCO3, glucose, and lactate) and obtained functional electrostimulation hourly throughout the experiment. Histology samples were obtained for TUNEL staining and single-muscle fiber contractility testing. RESULTS: In both groups, hemodynamic variables of circulation remained stable throughout the experiment. Neuromuscular electrical stimulation remained intact until the end of reperfusion in group 2 vs no response in group 1. In group 2, a gradual increase in lactate levels during pump perfusion returned to normal after transplantation. Compared with the contralateral limb in group 2, single-muscle fiber contractility testing showed no significant difference at the end of the experiment. CONCLUSIONS: We demonstrated extended limb survival up to 24 hours using normothermic pulsatile perfusion and autologous blood. CLINICAL RELEVANCE: Successful prolongation of limb survival using ex situ perfusion methods provides with more time for revascularization of an extremity.


Assuntos
Transfusão de Sangue Autóloga , Fibrinolíticos/administração & dosagem , Membro Anterior/transplante , Sobrevivência de Enxerto , Heparina/administração & dosagem , Preservação de Órgãos/métodos , Perfusão/métodos , Aloenxertos , Amputação , Animais , Biópsia , Estimulação Elétrica , Membro Anterior/irrigação sanguínea , Concentração de Íons de Hidrogênio , Contração Isométrica , Ácido Láctico/sangue , Modelos Animais , Fibras Musculares Esqueléticas/patologia , Potássio/sangue , Temperatura Cutânea , Suínos , Condicionamento Pré-Transplante/métodos
8.
ASAIO J ; 61(4): 474-9, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25851315

RESUMO

Donation from uncontrolled circulatory determination of death donors (uDCD) is impractical in United States because of the time needed to organize procurement before irreversible organ damage. Salvaging organs after prolonged warm ischemic time (WIT) may address this limitation. We evaluated the combination of extracorporeal support (ECS) and thrombolytics in a porcine uDCD renal transplant model. Nonanticoagulated uDCD sustained 60 min of WIT, and two groups were studied. Rapid recovery (RR)-uDCD renal grafts procured using the standard quick topical cooling and renal flush, and ECS-assisted donation (E-uDCD), 4 hr ECS plus thrombolytics for in situ perfusion before procurement. All kidneys were flushed and cold stored, followed by transplantation into healthy nephrectomized recipients without immunosuppression. Delayed graft function (DGF) was defined as creatinine more than 5.0 mg/dl on any postoperative day. Twelve kidneys in E-uDCD and 6 in RR-uDCD group were transplanted. All 12 E-uDCD recipients had urine production and adequate function in the first 48 hr, but two grafts (16.7%) had DGF at 96 hr. All six recipients from RR-uDCD group had DGF at 48 hr and were killed. Creatinine and blood urea nitrogen (BUN) levels were significantly lower in E-uDCD compared with RR-uDCD group at 24 hr (2.9 ± 0.7 mg/dl vs. 5.2 ± 0.9 mg/dl) and 48 hr (3.2 ± 0.9 mg/dl vs. 7.2 ± 1.0 mg/dl); BUN levels at 24 and 48 hr were 28.3 ± 6.7 mg/dl vs. 39.5 ± 7.5 mg/dl and 23.9 ± 5.0 mg/dl vs. 46 ± 12.9 mg/dl, respectively. Thrombolytics plus ECS precondition organs in situ yielding functional kidneys in a porcine model of uDCD with 60 min of WIT. This procurement method addresses logistical limitations for uDCD use in the United States and could have a major impact on the organ donor pool.


Assuntos
Transplante de Rim/métodos , Rim/irrigação sanguínea , Isquemia Quente/métodos , Animais , Modelos Animais de Doenças , Testes de Função Renal , Sus scrofa , Fatores de Tempo , Doadores de Tecidos/provisão & distribução
9.
ASAIO J ; 61(4): 453-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25905495

RESUMO

An implantable pediatric artificial lung (PAL) may serve as a bridge to lung transplantation for children with end-stage lung failure (ESLF); however, an animal model of pediatric lung failure is needed to evaluate the efficacy of PAL before it can enter clinical trials. The objective of this study was to assess ligation of the right pulmonary artery (rPA) as a model for pediatric ESLF. Seven lambs weighing 20-30 kg underwent rPA ligation and were recovered and monitored for up to 4 days. Intraoperatively, rPA ligation significantly increased physiologic dead space fraction (Vd/Vt; baseline = 48.6 ± 5.7%, rPA ligation = 60.1 ± 5.2%, p = 0.012), mean pulmonary arterial pressure (mPPA; baseline = 17.4 ± 2.2 mm Hg, rPA ligation = 28.5 ± 5.2 mm Hg, p < 0.001), and arterial partial pressure of carbon dioxide (baseline = 40.4 ± 9.3 mm Hg, rPA ligation = 57.3 ± 12.7 mm Hg, p = 0.026). Of the seven lambs, three were unable to be weaned from mechanical ventilation postoperatively, three were successfully weaned but suffered cardiorespiratory failure within 4 days, and one survived all 4 days. All four animals that were successfully weaned from mechanical ventilation had persistent pulmonary hypertension (mPPA = 28.6 ± 2.2 mm Hg) and remained tachypneic (respiratory rate = 63 ± 21 min). Three of the four recovered lambs required supplemental oxygen. We conclude that rPA ligation creates the physiologic derangements commonly seen in pediatric ESLF and may be suitable for testing and implanting a PAL.


Assuntos
Órgãos Artificiais , Modelos Animais de Doenças , Pulmão , Artéria Pulmonar/lesões , Animais , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/cirurgia , Ligadura , Respiração Artificial/instrumentação , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/cirurgia , Carneiro Doméstico , Ventiladores Mecânicos
10.
Am J Crit Care ; 24(2): 110-7, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25727270

RESUMO

BACKGROUND: Inhaled nitric oxide (iNO) is a rescue treatment for severe hypoxemia in the intensive care unit setting. OBJECTIVE: To evaluate the effectiveness and safety of iNO in adult patients with severe hypoxemia before and during transport to a tertiary care center. METHODS: Prospective data were examined in a retrospective cohort study. Patients with severe hypoxemia and cardiopulmonary failure (n=139) at referring hospitals in whom conventional therapy was unsuccessful were treated with iNO in the intensive care units in anticipation of transfer to a tertiary center. Treatment wih iNO was initiated by the critical care transport team in 114 patients and continued in 25 patients. Arterial blood gas analysis was done before and after iNO treatment. RESULTS: Patients treated with iNO had significant improvement in oxygenation: mean (SD) for PaO2 increased from 60.7 (20.2) to 72.3 (40.6) mm Hg (P=.008), and mean (SD) for ratio of PaO2 to fraction of inspired oxygen (P:F) increased from 62.4 (26.1) to 73.1 (42.6) (P= .03). Use of iNO was continued through transport in 102 patients, all of whom were transported without complication. The P:F continued to improve, with a mean (SD) of 109.7 (73.8) from 6 to 8 hours after arrival at the tertiary center (P< .001 relative to values both before and after treatment). Among patients treated with iNO, 60.2% survived to discharge. In 35 nonresponders, iNO was discontinued, and 15 patients could not be transferred owing to life-threatening hypoxemia; 2 were later transferred on extracorporeal membrane oxygenation. Of 18 patients transported without iNO, 9 (50%) survived. CONCLUSIONS: Use of iNO significantly improves oxygenation of patients with severe hypoxemia and allows safe transfer to a tertiary care center.


Assuntos
Hipóxia/terapia , Óxido Nítrico/administração & dosagem , Oxigênio/sangue , Transporte de Pacientes , Vasodilatadores/administração & dosagem , Administração por Inalação , Adulto , Algoritmos , Gasometria , Cuidados Críticos , Feminino , Humanos , Hipóxia/sangue , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Óxido Nítrico/efeitos adversos , Pressão Parcial , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/complicações , Estudos Retrospectivos , Taxa de Sobrevida , Vasodilatadores/efeitos adversos
11.
Surg Endosc ; 29(12): 3685-9, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25740644

RESUMO

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is used for nutritional support during treatment in patients with head and neck cancer, but long-term nutritional outcomes have not been reported in detail. The purpose of this study was to determine short- and long-term outcomes and success in meeting nutritional goals in patients with head and neck cancer who had PEGs placed over an 18-year period. METHODS: Medical records of all patients who had PEG procedures performed by one of the authors (REB) from 1997 through 2010 were reviewed. Demographic data, patient weights, timing of procedure in relation to cancer treatment, complications, and long-term outcomes were recorded. RESULTS: Five hundred and sixty-five patients with head and neck cancer underwent PEG. Mean age was 59.6 ± 13.6 years; 71% were men. Mean follow-up was 33 ± 38 months. 99% of PEGs were used for nutritional support. Average weight loss prior to PEG was 23 ± 17 lbs (range 0-133 lbs). Average weight loss between PEG and completion of treatment was 2.3 lbs; 44% of patients gained weight or remained stable after PEG. There were no PEG-related deaths. Complications included cellulitis in 27 (4%), pain in 14 (2.5%); leakage in 11 (2%), self-limited gastric bleeding in one patient. PEGs were used an average of 8.1 months. No PEG site tumor implants were observed. Among 366 patients treated with intention to cure, 45% were alive an average of 68 months later. CONCLUSIONS: PEG is both safe and efficacious in arresting weight loss and maintaining nutrition in patients undergoing surgery and/or chemoradiotherapy for head and neck cancer. PEG can be recommended for patients in whom dysphagia and weight loss is anticipated or in whom weight loss occurs as a result of their treatment; 20% of patients will need the PEG for a year or more.


Assuntos
Nutrição Enteral/métodos , Gastroscopia/métodos , Gastrostomia/métodos , Neoplasias de Cabeça e Pescoço/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Estudos Retrospectivos , Resultado do Tratamento
12.
Ann Thorac Surg ; 98(1): 97-102, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24856794

RESUMO

BACKGROUND: Centrifugal pumps are used increasingly for temporary mechanical support for the treatment of cardiogenic shock. However, centrifugal pumps can generate excessive negative pressure and are afterload sensitive. A previously developed modified roller pump mitigates these limitations both in vitro and in preliminary animal experiments. We report the results of intermediate-term testing of our evolving pump technology, known as the BioVAD. METHODS: The BioVAD was implanted in 6 adult male sheep (62.5±3.9 kg), with drainage from the left atrium and reinfusion into the descending aorta. The sheep were monitored for 5 days. Heparin was given during the initial implantation, but no additional anticoagulants were given. Data collected included hemodynamic status, pump flow and pressures, laboratory values to monitor end-organ function and hemolysis, pathologic specimens to evaluate for thromboembolic events and organ ischemia, and explanted pump evaluation results. RESULTS: All animals survived the planned experimental duration and there were no pump malfunctions. Mean BioVAD flow was 3.57±0.30 L/min (57.1 mL/kg/min) and mean inlet pressure was -30.51±4.25 mm Hg. Laboratory values, including plasma free hemoglobin, creatinine, lactate, and bilirubin levels, remained normal. Three animals had small renal cortical infarcts, but there were no additional thromboembolic events or other abnormalities seen on pathologic examination. No thrombus was identified in the BioVAD blood flow path. CONCLUSIONS: The BioVAD performed well for 5 days in this animal model of temporary left ventricular assistance. Its potential advantages over centrifugal pumps may make it applicable for short-term mechanical circulatory support.


Assuntos
Aorta Torácica/cirurgia , Circulação Extracorpórea/instrumentação , Coração Auxiliar , Hemodinâmica/fisiologia , Choque Cardiogênico/cirurgia , Animais , Modelos Animais de Doenças , Seguimentos , Masculino , Desenho de Prótese , Ovinos , Choque Cardiogênico/fisiopatologia , Fatores de Tempo
13.
Semin Perinatol ; 38(2): 122-9, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24580768

RESUMO

The high mortality and morbidity associated with respiratory failure among extremely low gestational age newborns (ELGANs) remains an unsolved problem. A logical strategy to avoid these complications would involve re-creating the intrauterine environment with extracorporeal membrane oxygenation (ECMO) instead of mechanical ventilation. Such a device, termed an artificial placenta, was first researched over 50 years ago. AP models vary, but all incorporate ECMO involving the umbilical vessels, lack of mechanical ventilation, and low partial pressure of oxygen to preserve fetal circulation. Current research has focused on low-volume pumpless arteriovenous circuits as well as pump-driven venovenous circuits.


Assuntos
Órgãos Artificiais , Ponte Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea/métodos , Placenta , Insuficiência Respiratória/terapia , Feminino , Humanos , Lactente Extremamente Prematuro , Recém-Nascido , Recém-Nascido Prematuro , Gravidez , Resultado do Tratamento
14.
Ann Surg ; 256(6): 1073-7, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22824856

RESUMO

OBJECTIVE: Adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis is associated with a poor prognosis. We hypothesized that extracorporeal life support (ECLS) may be an effective treatment option for the most severe cases of pancreatitis-induced ARDS. METHODS: We reviewed 8 cases of pancreatitis-induced ARDS that were treated with ECLS at our institution. We collected data on demographics, comorbidities, hemodynamic parameters, and ventilatory support used before ECLS. Our outcome measures for this study included survival to discharge, length of ECLS run, days undergoing mechanical ventilation, days in an intensive care unit, total length of hospital stay, adjunct therapies and procedures, and complications. RESULTS: Overall, 5 of the 8 patients (63%) survived to discharge. Seven of the 8 patients underwent venovenous ECLS, and 1 underwent venoarterial ECLS. The overall mean length of ECLS was 9.7 ± 10.7 days. However, the mean ECLS run length in survivors was 4.3 ± 1.8 days and the longest ECLS run in a survivor was 7.25 days. Two of the 3 patients who died had very long run lengths (28.8 and 24.7 days, respectively), whereas 1 patient had a short run (2.4 days). Five of the 8 patients (63%), including all of the 3 who died, experienced a bleeding complication of some kind. Two patients required continuous venovenous hemofiltration, 1 of whom died and 1 of whom survived. Six patients underwent tracheostomy on ECLS, 1 patient already had undergone tracheostomy, and 1 patient did not undergo tracheostomy. CONCLUSIONS: ECLS is useful in treating severe pancreatitis-induced ARDS. Pancreatic debridement can be performed during ECLS, using a comprehensive protocol to minimize bleeding complications.


Assuntos
Oxigenação por Membrana Extracorpórea , Cuidados para Prolongar a Vida/métodos , Pancreatite/complicações , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
15.
J Laparoendosc Adv Surg Tech A ; 19(4): 575-80, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19670981

RESUMO

PURPOSE: We sought to characterize our recent experience with thoracoscopic congenital diaphragmatic hernia (CDH) repair and identify patient selection factors. METHODS: We reviewed the medical records of full-term neonatal (<1 month of age) patients who underwent thoracoscopic CDH repair between 2004 and 2008 (n = 15). We obtained data on prenatal diagnosis, characteristics of the CDH and repair, complications, and outcome. RESULTS: All patients were stabilized preoperatively and underwent repair at an average of 5.7 +/- 1.3 days. Six patients were prenatally diagnosed, including the 5 inborn. Thirteen defects were left-sided. All were intubated shortly after birth and 2 required extracorporeal membrane oxygenation (ECMO). Twelve of 15 (80%) patients underwent successful thoracoscopic primary repair, including 1 of the patients who required ECMO prior to repair. Conversion to open repair occurred in 3 of 15 (20%) patients because of the need for patch closure or intraoperative instability. Among those converted to open, all had left-sided CDH defects and 3 had stomach herniation (of 5 such patients). Patients spent an average of 6.9 +/- 1.0 days on the ventilator following repair. The average time until full-enteral feeding was 16.7 +/- 2.25 days, and average length of hospital stay was 23.8 +/- 2.73 days. All patients survived to discharge, and average length of follow-up was 15.3 +/- 3.6 months. CONCLUSIONS: Thoracoscopic repair of CDH is a safe, effective strategy in patients who have undergone prior stabilization. Stomach herniation is associated with, but does not categorically predict, conversion to open repair. ECMO use prior to repair should not be an absolute contraindication to thoracoscopic repair.


Assuntos
Hérnia Diafragmática/cirurgia , Hérnias Diafragmáticas Congênitas , Toracoscopia , Estudos de Coortes , Oxigenação por Membrana Extracorpórea , Feminino , Hérnia Diafragmática/diagnóstico , Humanos , Recém-Nascido , Masculino , Seleção de Pacientes , Diagnóstico Pré-Natal , Respiração Artificial , Estudos Retrospectivos , Resultado do Tratamento
16.
J Pediatr Surg ; 44(6): 1165-71; discussion 1171-2, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19524734

RESUMO

PURPOSE: Severe congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) is associated with high mortality. Timing of CDH repair relative to ECMO therapy remains controversial. Our hypothesis was that survival would significantly differ between those who underwent repair during ECMO and those who underwent repair after ECMO therapy. METHODS: We examined deidentified data from the CDH study group (CDHSG) registry from 1995 to 2005 on patients who underwent repair and ECMO therapy (n = 636). We used Cox regression analysis to assess differences in survival between those who underwent repair during and after ECMO. RESULTS: Five covariates were significantly associated with mortality as follows: timing of repair relative to ECMO (P = .03), defect side (P = .01), ECMO run length (P < .01), need for patch repair (P = .03), birth weight (P < .01), and Apgar score at 5 minutes (P = .03). Birth year, inborn vs transfer status, diaphragmatic agenesis, age at repair, and presence of cardiac or chromosomal abnormalities were not associated with survival. Repair after ECMO therapy was associated with increased survival relative to repair on ECMO (hazard ratio, 1.407; P = .03). CONCLUSION: These data suggest that CDH repair after ECMO therapy is associated with improved survival compared to repair on ECMO, despite controlling for factors associated with the severity of CDH.


Assuntos
Oxigenação por Membrana Extracorpórea , Hérnia Diafragmática/cirurgia , Diafragma/cirurgia , Oxigenação por Membrana Extracorpórea/mortalidade , Hérnias Diafragmáticas Congênitas , Humanos , Recém-Nascido , Modelos de Riscos Proporcionais , Sistema de Registros , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
17.
J Pediatr Surg ; 44(6): 1181-5; discussion 1185, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19524736

RESUMO

PURPOSE: Chylothorax after congenital diaphragmatic hernia (CDH) repair contributes significantly to morbidity. Our aim was to identify factors contributing to chylothorax and effective treatment strategies. METHODS: We reviewed 171 patients with CDH from 1997 to 2008 and analyzed hernia characteristics, extracorporeal membrane oxygenation (ECMO) use, operative details, and treatment approaches for chylothorax. RESULTS: Ten (7%) patients developed chylothorax; all were left sided. Using univariate analysis, prenatal diagnosis, ECMO use, and patch repair were associated with development of chylothorax. Logistic regression analysis showed that patch repair was the only variable predictive of chylothorax (P = .028; confidence interval, 0.032-0.823). Although survival was not affected, patients with chylothorax had a significant increase in ventilator days and length of stay (t = 3.57; P = .000; t = 2.74; P = .007). All received thoracostomy and total parenteral nutrition. Six patients received octreotide, 5 of whom required pleurectomy because of failed medical management; the remaining patient died of overwhelming sepsis. CONCLUSIONS: The incidence of chylothorax at our institution was relatively low. Patch repair was associated with the formation of chylothorax. Morbidity was substantial, but survival was not significantly affected. Total parenteral nutrition and thoracostomy were appropriate initial treatments. Octreotide was not an effective adjunct. Refractory cases were successfully treated with pleurectomy.


Assuntos
Quilotórax/etiologia , Quilotórax/terapia , Hérnia Diafragmática/cirurgia , Complicações Pós-Operatórias , Hérnias Diafragmáticas Congênitas , Humanos , Estudos Retrospectivos , Fatores de Risco
18.
J Pediatr Surg ; 44(5): 883-7, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19433162

RESUMO

PURPOSE: The purpose of the study was to assess the treatment strategies and outcome of right-sided congenital diaphragmatic hernia (R-CDH), particularly extracorporeal membrane oxygenation (ECMO). METHODS: We reviewed the cases of 42 patients treated for R-CDH at our institution from 1991 to 2006. We gathered demographic information, documented ECMO use and the type of surgical repair, and compared outcomes with predicted survival as calculated by the CDH Study Group's equation. RESULTS: Of the 35 patients included in our statistical analysis (7 were excluded), 12 (34%) were born at our institution, all of whom were prenatally diagnosed with R-CDH. Nineteen patients (54%) required ECMO therapy. Extracorporeal membrane oxygenation was initiated after repair of the R-CDH in 2 patients (11%). Of those patients who went on ECMO before repair, 4 patients (21%) were repaired on ECMO, 9 patients (47%) underwent repair after ECMO, and 4 patients (21%) underwent ECMO but died before their R-CDH could be repaired. Primary repair of the diaphragm was possible in 15 cases (56%), and primary closure of the abdominal incision was possible in 15 of the 23 open repairs (65%). The mean predicted survival for all 35 patients was 63%, whereas 28 (80%) actually survived. Logistic regression showed a significant association between the presence of cardiac defects and mortality (odds ratio = 0.008, P = .014). CONCLUSIONS: Our data suggest that patients with R-CDH have high ECMO utilization and may experience greater relative benefit from ECMO as evidenced by their higher-than-expected overall survival. Extracorporeal membrane oxygenation may be found to have a distinctive role in managing R-CDH. More high-powered series are needed to elucidate differences between R-CDH and left-sided CDH that may dictate alternate forms of management.


Assuntos
Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Hérnia Diafragmática/cirurgia , Hérnias Diafragmáticas Congênitas , Anormalidades Múltiplas/epidemiologia , Índice de Apgar , Peso ao Nascer , Feminino , Cardiopatias Congênitas/epidemiologia , Hérnia Diafragmática/diagnóstico , Hérnia Diafragmática/mortalidade , Humanos , Recém-Nascido , Masculino , Diagnóstico Pré-Natal , Prognóstico , Estudos Retrospectivos , Risco , Taxa de Sobrevida , Resultado do Tratamento
19.
Fetal Diagn Ther ; 25(1): 163-6, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19293587

RESUMO

Although most prenatally diagnosed pulmonary sequestrations (PS) are asymptomatic, large lesions are associated with pleural effusions and pulmonary hypoplasia. We present the first reported case of a prenatally diagnosed giant extralobar pulmonary sequestration that required the ex utero intrapartum treatment (EXIT) procedure with resection and extracorporeal membrane oxygenation (ECMO). We discuss the compelling rationale for performing EXIT-resection-ECMO in the setting of a large thoracic mass and anticipated severe respiratory failure at birth.


Assuntos
Sequestro Broncopulmonar/cirurgia , Oxigenação por Membrana Extracorpórea , Adulto , Sequestro Broncopulmonar/diagnóstico por imagem , Sequestro Broncopulmonar/terapia , Feminino , Feto/irrigação sanguínea , Feto/cirurgia , Humanos , Recém-Nascido , Masculino , Gravidez , Ultrassonografia
20.
Anat Sci Educ ; 1(6): 247-51, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-19109853

RESUMO

Interactive computerized modules have been linked to improved retention of material in clinical medicine. This study examined the effects of a new series of interactive learning modules for preclinical medical education, specifically in the areas of quiz performance, perceived difficulty of concepts, study time, and perceived stress level. We randomly allocated 102 medical student volunteers into control and experimental groups. All participants studied selected anatomical and physiologic concepts using existing material (lecture notes, textbooks, etc.), while those in the experimental groups used the new interactive modules as well. All participants completed a quiz to test their knowledge of the assigned concepts and a survey to assess their subjective experiences in studying with the modules. We found a trend toward higher quiz scores in the experimental group relative to the control group, though it did not reach statistical significance (P = 0.31). Perceived concept difficulty was significantly reduced among those who studied with the modules (P < 0.001), and the number of hours spent studying the concepts was significantly increased (P = 0.028). Of those who used the modules, 83% rated them as "very helpful" or "extremely helpful." No significant differences existed between participants' reported stress levels during the course of the study (P = 0.44). Our data suggest that medical students may learn more effectively and feel less intimidated by difficult concepts when interactive modules supplement traditional instruction.


Assuntos
Anatomia/educação , Instrução por Computador/métodos , Educação de Graduação em Medicina/métodos , Avaliação Educacional/estatística & dados numéricos , Interpretação Estatística de Dados , Humanos , Estresse Psicológico , Estudantes de Medicina/psicologia
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