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1.
Crit Care Resusc ; 22(1): 26-34, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32102640

RESUMO

BACKGROUND: Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial). METHODS: Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected). RESULTS: Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39-65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38-73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24-108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035). CONCLUSION: ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.


Assuntos
Reanimação Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea , Parada Cardíaca/terapia , Reperfusão Miocárdica , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Reanimação Cardiopulmonar/mortalidade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Parada Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(45): e17910, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702668

RESUMO

To evaluate the safety and efficacy of total percutaneous closure of the femoral artery access site after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with the Perclose ProGlide device.This retrospective observational study during an almost 2-year period included 21 patients who underwent VA-ECMO in whom the femoral artery puncture site was closed percutaneously with Perclose ProGlide devices. Technical success was defined as successful arterial closure of the common femoral artery, without the need for additional surgical or endovascular procedures. Access site complications were recorded at 24 hours and 30 days after arterial closure, such as major bleeding requiring transfusion or surgical intervention, minor bleeding, groin infection, pseudoaneurysm, and lymphocele.Technical success was achieved in 20 patients (95.2%). One patient required surgical repair for an access site pseudoaneurysm. Eighteen femoral arteries were closed with 2 devices each, while 3 patients required the use of a third device for femoral artery access site closure to achieve adequate hemostasis. No arterial thrombosis, arterial dissection, arterial stenosis, groin infection, or arteriovenous fistula occurred during the periprocedural period (within 24 hours of arterial closure) or during 30-day follow-up.Percutaneous closure with the Perclose ProGlide device is a feasible procedure for closing femoral arterial access sites after VA-ECMO, with a low incidence of access site complications.


Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Artéria Femoral/cirurgia , Hemostasia Cirúrgica/instrumentação , Adulto , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Punções/efeitos adversos , Estudos Retrospectivos
3.
Orv Hetil ; 160(42): 1655-1662, 2019 Oct.
Artigo em Húngaro | MEDLINE | ID: mdl-31608689

RESUMO

Introduction: Most modern thoracic operations are performed with single-lung ventilation balancing between convenient surgical approach and adequate gas exchange. The technical limitations include difficult airways or insufficient parenchyma for the intraoperative single-lung ventilation. Earlier, cardiopulmonary bypass was the only solution, however, today the extracorporeal membrane oxygenation is in the forefront. Aim: We retrospectively analysed our elective operations by use of venovenous ECMO to assess the indication, safety, perioperative morbidity and mortality. Patients and method: 12 patients were operated using venovenous (VV-) ECMO between 28 April 2014 and 30 April 2018 in the National Institute of Oncology. The main clinicopathological characteristics, data regarding the operation, the use of ECMO and survival were collected. Results: The mean age was 45 years, 2 patients had benign and 10 had malignant diseases. Extreme tracheal stricture was the indication for ECMO in 3 cases, while 4 patients had previous lung resection and lacked enough parenchyma for single-lung ventilation. 5 patients had both airway and parenchymal insufficiency. The average time of apnoea was 142 minutes without interruption in any of the cases. We did not experience any ECMO-related complication. We had no intraoperative death and 30-day mortality was 8.33%. Conclusion: In case of technical inoperability, when there is no airway or insufficient parenchyma for gas exchange, but pulmonary vascular bed is enough and there is no need for great-vessel resection, VV-ECMO can safely replace the complete gas exchange without further risk of bleeding. The use of VV-ECMO did not increase the perioperative morbidity and mortality. Previously inoperable patients can be operated with VV-ECMO. Orv Hetil. 2019; 160(42): 1655-1662.


Assuntos
Obstrução das Vias Respiratórias/terapia , Oxigenação por Membrana Extracorpórea/métodos , Cirurgia Torácica/métodos , Procedimentos Cirúrgicos Torácicos/métodos , Adulto , Idoso , Obstrução das Vias Respiratórias/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Hungria , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Resultado do Tratamento
4.
Cardiol Young ; 29(10): 1307-1309, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31475664

RESUMO

We report a neonatal case of the use of alteplase for the lysis of a large aortic arch thrombus formed during extracorporeal membrane oxygenation support. Alteplase (0.1-0.15 mg/kg/hour) was infused for thrombolysis, and meanwhile, unfractionated heparin was administrated at 5-10 U/kg/hour for the anticoagulation purpose. Alteplase was successfully administered to this neonate after the repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation, and the patient survived without apparent catastrophic long-term complications. It is reasonable to consider alteplase therapy during extracorporeal membrane oxygenation support in this setting.


Assuntos
Aorta Torácica , Oxigenação por Membrana Extracorpórea/efeitos adversos , Hérnias Diafragmáticas Congênitas/diagnóstico , Complicações Intraoperatórias , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Ecocardiografia , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Hérnias Diafragmáticas Congênitas/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Recém-Nascido , Trombose/diagnóstico , Trombose/etiologia , Ultrassonografia Pré-Natal
5.
Heart Surg Forum ; 22(4): E281-E282, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31398091

RESUMO

We report a 62-year-old male who had severe aortic insufficiency after a homograft root replacement, requiring venoarterial extracorporeal membrane oxygenation prior to surgery due to profound cardiogenic shock. Severe aortic insufficiency is a contraindication for venoarterial extracorporeal membrane oxygenation, but we were able to stabilize the patient and successfully perform an urgent reoperative surgery.


Assuntos
Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Oxigenação por Membrana Extracorpórea/métodos , Complicações Pós-Operatórias/cirurgia , Falha de Prótese/efeitos adversos , Reoperação , Choque Cardiogênico/etiologia , Aloenxertos , Insuficiência da Valva Aórtica/etiologia , Contraindicações de Procedimentos , Ponte de Artéria Coronária , Oxigenação por Membrana Extracorpórea/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Terapia de Salvação/métodos , Choque Cardiogênico/cirurgia
6.
J Cardiothorac Surg ; 14(1): 153, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438988

RESUMO

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used increasingly to support patients with cardiogenic shock (CS). There has been growing recognition of the favorable and unfavorable hemodynamic effects of this therapy and recent interest in the use of other percutaneous circulatory support devices to offset some of the potentially harmful hemodynamic effects. Herein, we provide visual evidence of the effects of intra-aortic balloon pump (IABP) counterpulsation for a patient with peripheral VA-ECMO cannulation. CASE PRESENTATION: A 68 year old man who had undergone orthotopic heart transplantation presented with 2 days of fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, he was tachycardic, hypotensive and hypoxic with cool extremities, consistent with CS. Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with a left ventricular ejection fraction of 15%, right heart catheterization demonstrated elevated filling pressures and low output. An IABP was inserted via the left femoral artery with minimal improvement in hemodynamics. He was escalated to VA-ECMO. Repeat TTE demonstrated aortic valve (AV) opening with each cardiac cycle and mild MR. With placement of the IABP on standby Additional file 1: Video 1 (video 0:03), the AV no longer opened. Re-initiation of balloon counterpulsation resulted in resumed AV opening with each beat Additional file 1: Video 1 (video 0:17). He was treated for presumed acute allograft rejection with methylprednisolone, thymoglobulin, intravenous immunoglobulin and plasmapheresis with improvement in allograft function. However, he developed an Enterobacter aerogenes pneumonia and rapidly fatal septic shock. CONCLUSIONS: This case visually demonstrates effective LV decompression by IABP counterpulsation in VA-ECMO support. While the overall effects of LV decompression in patients on VA-ECMO with IABP are still unclear, this report demonstrates one potential mechanism of benefit in the prevention of stagnation of blood flow that may lead to intra-cardiac or aortic root thrombus formation.


Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Balão Intra-Aórtico , Choque Cardiogênico/terapia , Idoso , Descompressão Cirúrgica , Evolução Fatal , Transplante de Coração/efeitos adversos , Ventrículos do Coração/cirurgia , Hemodinâmica , Humanos , Masculino , Choque Cardiogênico/etiologia , Função Ventricular Esquerda/fisiologia
7.
Crit Care ; 23(1): 266, 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31362770

RESUMO

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested.This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.


Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Extremidades/irrigação sanguínea , Isquemia/prevenção & controle , Isquemia/terapia , Cateterismo Periférico/instrumentação , Oxigenação por Membrana Extracorpórea/métodos , Extremidades/fisiopatologia , Humanos , Incidência , Isquemia/epidemiologia , Fatores de Risco
8.
Anesth Analg ; 129(3): 659-666, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31425204

RESUMO

BACKGROUND: There is a paucity of data on the underlying procoagulant-anticoagulant balance during extracorporeal membrane oxygenation (ECMO). We hypothesized that adult ECMO patients would have an imbalance between procoagulant and anticoagulant factors, leading to an abnormal underlying thrombin generation (TG) pattern. METHODS: Twenty adult venoarterial (VA) ECMO patients had procoagulant and anticoagulant factor levels measured temporally on ECMO day 1 or 2, day 3, and day 5. In heparin-neutralized plasma, underlying TG patterns, and sensitivity to activated protein C were assessed using calibrated automated thrombogram. TG parameters including lag time, peak TG, and endogenous thrombin potential (ETP) were compared against 5 normal plasma controls (3 males and 2 females) obtained from a commercial supplier. Thrombomodulin (TM) was added to some samples to evaluate for activated protein C resistance. RESULTS: Procoagulant factors (factor [F] II, FV, and FX) were mostly in normal reference ranges and gradually increased during the first 5 ECMO days (P = .022, <.001, <.001). FVIII levels were elevated at all time points and did not change (P = .766). In contrast, FXI was in the low-normal range but did not increase during ECMO (P = .093). Antithrombin (AT) and protein C levels were below normal but increased during the first 5 ECMO days (P = .002 and P = .014). Heparinase-treated samples showed prolonged lag time, increased peak TG, and increased ETP compared to controls; mean difference in lag time on ECMO day 1 or 2 = 6.0 minutes (99% confidence interval [CI], 2.8-9.2), peak TG = 193.4 (99% CI, 122.5-264.3), and ETP = 1170.4 (99% CI, 723.2-1617.6). After in vitro TM treatment, differences in TG parameters were accentuated and ECMO samples appeared insensitive to TM treatment; mean difference in lag time on ECMO day 1 or 2 = 9.3 minutes (99% CI, 6.2-12.4), peak TG = 233.0 (99% CI, 140.9-325.1), and ETP = 1322.5 (99% CI, 764.8-1880.2). Similar differences in TG parameters were observed on ECMO days 3 and 5. CONCLUSIONS: Contact activation occurs during ECMO, but procoagulant factor levels are generally preserved. Although heparin-neutralized TG is delayed, peak TG and ETP are supranormal in the setting of high FVIII and low AT and protein C levels. Resistance to TM is also apparent. These changes demonstrate a possible mechanism for hypercoagulability during adult VA ECMO.


Assuntos
Fatores de Coagulação Sanguínea/metabolismo , Oxigenação por Membrana Extracorpórea/tendências , Trombina/metabolismo , Adulto , Idoso , Biomarcadores/sangue , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
9.
J Surg Res ; 243: 399-409, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31277018

RESUMO

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), a rescue therapy for pulmonary failure, has traditionally been limited by anticoagulation requirements. Recent practice has challenged the absolute need for anticoagulation, expanding the role of ECMO to patients with higher bleeding risk. We hypothesize that mortality, bleeding, thrombotic events, and transfusions do not differ between heparin-sparing and full therapeutic anticoagulation strategies in veno-venous (VV) ECMO management. MATERIALS AND METHODS: Adult VV ECMO patients between October 2011 and May 2018 at a single center were reviewed. A heparin-sparing strategy was implemented in October 2014; we compared outcomes in an as-treated fashion. The primary end point was survival. Secondary end points included bleeding, thrombotic complications, and transfusion requirements. RESULTS: Forty VV ECMO patients were included: 17 (147 circuit-days) before and 23 (214 circuit-days) after implementation of a heparin-sparing protocol. Patients treated with heparin-sparing anticoagulation had a lower body mass index (28.5 ± 7.1 versus 38.1 ± 12.4, P = 0.01), more often required inotropic support before ECMO (82 versus 50%, P = 0.05), and had a lower mean activated clotting time (167 ± 15 versus 189 ± 15 s, P < 0.01). There were no significant differences in survival to decannulation (59 versus 83%, P = 0.16) or discharge (50 versus 72%, P = 0.20), bleeding (32 versus 33%, P = 1.0), thromboembolic events (18 versus 39%, P = 0.17), or transfusion requirements (median 1.1 versus 0.9 unit per circuit-day, P = 0.48). CONCLUSIONS: Survival, bleeding, thrombotic complications, and transfusion requirements did not differ between heparin-sparing and full therapeutic heparin strategies for management of VV ECMO. VV ECMO can be a safe option in patients with traditional contraindications to anticoagulation.


Assuntos
Anticoagulantes/efeitos adversos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Trombose/prevenção & controle , Adulto , Contraindicações de Medicamentos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/etiologia , Adulto Jovem
10.
J Card Surg ; 34(10): 1110-1113, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31269305

RESUMO

Mechanical circulatory support is increasingly used and may bring about unique challenges. Most support systems require systemic anticoagulation and the need for anticoagulation must be balanced against the increased risk for bleeding. We report the case of a young man awaiting heart retransplantation, who was supported with a temporary extracorporeal ventricular assist device with the addition of an oxygenator. He developed hemoptysis that forced the cessation of anticoagulation exposing to increased thromboembolic risk. We discuss this distinct clinical scenario with no clearly defined solution and explore the risks and benefits of the different treatment options.


Assuntos
Remoção de Dispositivo/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar/efeitos adversos , Hemoptise/etiologia , Hemorragia Pós-Operatória/etiologia , Alvéolos Pulmonares/patologia , Adulto , Biópsia , Hemoptise/diagnóstico , Hemoptise/cirurgia , Humanos , Masculino , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/cirurgia , Alvéolos Pulmonares/irrigação sanguínea , Tomografia Computadorizada por Raios X
11.
Cardiovasc Pathol ; 42: 59-63, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31351216

RESUMO

This article reviews the surgical considerations of cardiac allograft rejection after heart transplantation and describes current treatment modalities for the failing graft. Cardiac allograft rejection can be a moribund diagnosis, especially when it is acute and high grade. It is broadly categorized into hyperacute, acute cellular, and antibody-mediated rejection. Treatment includes a multitude of medical and immunomodulation therapies for graft recovery. Severe rejection requires mechanical circulatory support for hemodynamic stability to maintain end-organ function. Retransplantation for graft loss is the ultimate therapy; however, it portends poor outcomes.


Assuntos
Oxigenação por Membrana Extracorpórea , Rejeição de Enxerto/terapia , Sobrevivência de Enxerto/efeitos dos fármacos , Cardiopatias/terapia , Transplante de Coração/efeitos adversos , Coração Auxiliar , Imunossupressores/uso terapêutico , Oxigenação por Membrana Extracorpórea/efeitos adversos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/patologia , Rejeição de Enxerto/fisiopatologia , Cardiopatias/etiologia , Cardiopatias/patologia , Cardiopatias/fisiopatologia , Humanos , Imunossupressores/efeitos adversos , Recuperação de Função Fisiológica , Reoperação , Fatores de Risco , Resultado do Tratamento
12.
Nutrients ; 11(6)2019 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-31238536

RESUMO

BACKGROUND: A poor nutritional status has been gathering intense clinical interest recently as it has been suggested to associate with adverse outcomes in patients in the intensive care unit (ICU). However, there is still no established nutritional index dominantly used in clinical practice. We have previously proposed a novel nutritional index, which can be calculated using serum levels of triglycerides, total cholesterol, and body weight (TCBI). In this study, to expand the application of TCBI for critical patients, we investigated the usefulness of TCBI to predict prognosis in hemodynamically unstable patients with percutaneously implantable mechanical circulatory support (MCS) devices in the ICU. PATIENTS AND METHODS: This is a retrospective analysis of a multicenter registry consisting of three Juntendo University hospitals in Japan involving patients who received MCS devices, including intra-aortic balloon pumping (IABP) with or without veno-arterial extracorporeal membrane oxygenation (VA-ECMO), between 2012 and 2016 (n = 439). The median follow-up period was 298 days. RESULTS: Spearman's correlation coefficient between TCBI and the geriatric nutritional risk index (GNRI) was 0.44 (p < 0.0001), indicating a moderate positive correlation for these two variables. Unadjusted Kaplan-Meier analysis demonstrated reduced risks of all-cause and cardiovascular mortalities in patients with higher tertiles of TCBI. Furthermore, adjusted multivariate Cox proportional hazard analyses revealed that the highest tertile TCBI was an independent predictor for the reduced risk of all-cause mortality (hazard ratio (HR): 0.22, 95% confidence interval: 0.10-0.48, p < 0.0001) and cardiovascular mortality (0.20, 0.09-0.45, p < 0.0001). CONCLUSION: A novel and simple to calculate nutritional index, TCBI, can be applicable as a prognostic indicator in hemodynamically unstable patients requiring MCS devices.


Assuntos
Oxigenação por Membrana Extracorpórea , Cardiopatias/terapia , Coração Auxiliar , Hemodinâmica , Balão Intra-Aórtico , Avaliação Nutricional , Estado Nutricional , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Peso Corporal , Colesterol/sangue , Estado Terminal , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Cardiopatias/diagnóstico , Cardiopatias/mortalidade , Cardiopatias/fisiopatologia , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Japão , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Triglicerídeos/sangue
13.
Arch Cardiovasc Dis ; 112(6-7): 441-449, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31253558

RESUMO

Emergent implantation of temporary mechanical circulatory support using venoarterial ECMO (ECLS for extracorporeal Life Support) is increasingly adopted in various indications of acute circulatory failure refractory to optimal medical treatment. To implant such devices, but also to provide appropriate daily management, expertise and adapted technical platform are required. Organization, coordination and regulation of such program are not clearly established in our country. We propose a dedicated territorial organization to improve and facilitate management of these specific and most severe patients.


Assuntos
Prestação Integrada de Cuidados de Saúde/normas , Oxigenação por Membrana Extracorpórea/normas , Choque/terapia , Doença Aguda , Consenso , Prestação Integrada de Cuidados de Saúde/organização & administração , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/mortalidade , França , Humanos , Modelos Organizacionais , Equipe de Assistência ao Paciente/normas , Choque/diagnóstico , Choque/mortalidade , Choque/fisiopatologia , Resultado do Tratamento
14.
Pediatr Cardiol ; 40(6): 1266-1274, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31250046

RESUMO

Left heart distension during venoarterial extracorporeal membrane oxygenation (VA ECMO) often necessitates decompression to facilitate myocardial recovery and prevent life-threatening complications. The objectives of this study were to compare clinical outcomes between patients who did and did not undergo left atrial (LA) decompression, quantify decompression efficacy, and identify risk factors for development of left heart distension. This was a single-center retrospective case-control study. Pediatric VA ECMO patients who underwent LA decompression from June 2004 to March 2016 were identified, and a control cohort of VA ECMO patients who did not undergo LA decompression were matched based on diagnosis, extracorporeal cardiopulmonary resuscitation, and age. Among 194 VA ECMO cases, 21 (11%) underwent LA decompression. Compared to the control cohort, patients with decompression had longer hospital length of stay (60 ± 55 vs. 27 ± 23 days, p = 0.012), but similar in-hospital mortality (29% vs. 38%, p = 0.513). Decompression successfully decreased mean LA pressure (24 ± 11 to 14 ± 4 mmHg, p = 0.022) and LA:RA pressure gradient (10 ± 7 to 0 ± 1 mmHg, p = 0.011). No significant differences in early quantitative measures of cardiac function were observed between cases and controls to identify risk factors for left heart distension. Despite higher qualitative risk for impaired cardiac recovery, patients who underwent LA decompression had comparable outcomes to those who did not. Given that traditional quantitative measures of cardiac function are insufficient to predict development of eventual left heart distension, a combination of clinical history, radiographic findings, hemodynamic monitoring, and laboratory markers should be used during the evaluation and management of these patients.


Assuntos
Descompressão Cirúrgica/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Átrios do Coração/cirurgia , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/cirurgia , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Descompressão Cirúrgica/mortalidade , Feminino , Átrios do Coração/patologia , Mortalidade Hospitalar , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco
15.
Rev Port Cir Cardiotorac Vasc ; 26(1): 45-50, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31104376

RESUMO

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. RESULTS: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. CONCLUSIONS: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.


Assuntos
Cateterismo Periférico/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Artéria Femoral/lesões , Doença Arterial Periférica/etiologia , Adulto , Cateterismo Periférico/métodos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco
17.
J Card Surg ; 34(6): 447-452, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31058374

RESUMO

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. METHODS: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. RESULTS: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. CONCLUSIONS: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.


Assuntos
Artéria Axilar , Cateterismo Periférico/métodos , Circulação Cerebrovascular/fisiologia , Oxigenação por Membrana Extracorpórea/métodos , Ultrassonografia Doppler/métodos , Idoso , Velocidade do Fluxo Sanguíneo , Cateterismo Periférico/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Artéria Femoral , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/terapia
18.
Pediatr Cardiol ; 40(5): 1072-1083, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31079193

RESUMO

Extracorporeal membrane oxygenation (ECMO) is lifesaving for many critically ill children with congenital heart disease (CHD). However, limited information is available about their ensuing neurodevelopmental (ND) outcomes. We describe early ND outcomes in a cohort of children supported with ECMO for cardiac indications. Twenty-eight patients supported with ECMO at age < 36 months underwent later ND testing at 12-42 months of age using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). ND scores were compared with normative means and with ND outcomes of a matched cohort of 79 children with CHD undergoing cardiac surgery but not requiring ECMO support. Risk factors for worse ND outcomes were identified using multivariable linear regression models. Cardiac ECMO patients had ND scores at least one standard deviation below the normative mean in the gross motor (61%), language (43%), and cognitive (29%) domains of the Bayley-III. Cardiac ECMO patients had lower scores on the motor, language, and cognitive domains as compared to the matched non-ECMO group and clinically important (1/2 SD) differences in the motor domain persisted after controlling for primary caregiver education and number of cardiac catheterizations. Risk factors of worse ND outcomes among cardiac ECMO patients in more than one developmental domain included older age at first cannulation and more cardiac catheterization and cardiac surgical procedures prior to ND assessment. Overall, children supported on ECMO for cardiac indications have significant developmental delays and warrant close ND follow-up.


Assuntos
Deficiências do Desenvolvimento/diagnóstico , Oxigenação por Membrana Extracorpórea/efeitos adversos , Cardiopatias Congênitas/terapia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Estudos de Casos e Controles , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Testes Neuropsicológicos , Estudos Retrospectivos , Fatores de Risco
19.
Blood Purif ; 48(3): 203-214, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31096211

RESUMO

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support are increasingly used for treating various forms of shock, lung failure, protected interventions and life support including resuscitation. Most patients on ECMO are affected by a systemic inflammatory response caused by the underlying disease as well as the ECMO support itself, which contributes to vasoplegia, multi-organ failure, deterioration and death. Unfortunately, effective strategies for control of inflammation and related organ failure and shock on ECMO are lacking. Recently, a new polystyrene-based device for hemoadsorption, which aims to reduce excessive levels of inflammatory molecules such as interleukins, cytokines as well as damage- and pathogen-associated molecular patterns, has become available. Here we summarize the rationale, available data and technical aspects of polystyrene-based hemoadsorption during ECMO support, and give recommendations based on existing experience.


Assuntos
Adsorção , Oxigenação por Membrana Extracorpórea/métodos , Citocinas/isolamento & purificação , Equipamentos e Provisões/normas , Oxigenação por Membrana Extracorpórea/efeitos adversos , Humanos , Insuficiência de Múltiplos Órgãos/etiologia , Poliestirenos
20.
Pediatr Cardiol ; 40(5): 1041-1045, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31065758

RESUMO

Extracorporeal membrane oxygenation (ECMO) is one of the primary reasons systemic hypertension is experienced in hospitalized neonates. Commonly used antihypertensive agents have resulted in significant adverse effects in neonatal and pediatric populations. Nicardipine is a desirable option because of its rapid and titratable antihypertensive properties and low incidence of adverse effects. However, data for use in neonatal ECMO are limited. We conducted a retrospective review of patients less than 44 weeks post-menstrual age who received a nicardipine infusion for first-line treatment of systemic hypertension while on ECMO at our institution between 2010 and 2016. Systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressures were evaluated for 48-h after nicardipine initiation. Eight neonates received a nicardipine infusion while on ECMO during the study period. Nicardipine was initiated at a mean dose of 0.52 ( ± 0.22) mcg/kg/min and titrated to a maximum dose of 1.1 ( ± 0.85) mcg/kg/min. The median duration of nicardipine use was 51 (range 4-227) hours. Significant decreases in SBP, DBP, and MAP occurred within one hour of initiation of nicardipine and were sustained through the majority of the 48-h evaluation period. No patients experienced hypotension. Prospective studies are warranted to evaluate the optimal dose, safety, and efficacy of nicardipine in neonates who require ECMO.


Assuntos
Anti-Hipertensivos/administração & dosagem , Hipertensão Essencial/tratamento farmacológico , Oxigenação por Membrana Extracorpórea/efeitos adversos , Doenças do Recém-Nascido/tratamento farmacológico , Nicardipino/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Hipertensão Essencial/etiologia , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Infusões Intravenosas , Masculino , Estudos Prospectivos , Estudos Retrospectivos
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