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1.
Medicine (Baltimore) ; 99(5): e19070, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32000456

RESUMO

RATIONALE: Extracorporeal membrane oxygenation (ECMO) in multiple trauma patients with post-traumatic respiratory failure can be quite challenging because of the need for systemic anticoagulation, which may lead to excessive bleeding. In the last decade, there is a growing body of evidence that veno-venous ECMO (VV-ECMO) is lifesaving in multiple trauma patients with acute respiratory distress syndrome, thanks to technical improvements in ECMO devices. PATIENT CONCERNS: We report a case of a 17-year-old multiple trauma patient who was drunken and had confused mentality. DIAGNOSES: She was suffered from critical respiratory failure (life-threatening hypoxemia and severe hypercapnia/acidosis lasting for 70 minutes) accompanied by cardiac arrest and trauma-induced coagulopathy during general anesthesia. INTERVENTIONS: We decided to start heparin-free VV-ECMO after cardiac arrest considering risk of hemorrhage. OUTCOMES: She survived with no neurologic sequelae after immediate treatment with heparin-free VV-ECMO. LESSONS: Heparin-free VV-ECMO can be used as a resuscitative therapy in multiple trauma patients with critical respiratory failure accompanied by coagulopathy. Even in cases in which life-threatening hypoxemia and severe hypercapnia/acidosis last for >1 hours during CPR for cardiac arrest, VV-ECMO could be considered a potential lifesaving treatment.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Traumatismo Múltiplo/terapia , Adolescente , Transtornos da Coagulação Sanguínea/terapia , Feminino , Parada Cardíaca/terapia , Humanos , Síndrome do Desconforto Respiratório do Adulto/terapia
2.
Pneumologie ; 74(1): 46-49, 2020 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-31958870

RESUMO

In 2017 the German Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations were released. This article highlights emerging data and new concepts which were introduced since 2017. Among others it summarizes the current progress made in evidence-based recommendations of mechanical ventilation and extracorporeal membrane oxygenation (ECMO). In detail, the new evidence for treating severe ARDS with ECMO, phenotyping of ARDS, early neuromuscular blockade and the application of non-invasive ventilation and high-flow oxygen therapy are discussed.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Insuficiência Respiratória/diagnóstico , Doença Aguda , Humanos , Pulmão , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Insuficiência Respiratória/fisiopatologia
3.
Medicine (Baltimore) ; 98(48): e18179, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770270

RESUMO

RATIONALE: Immunoglobulin G4-related disease (IgG4-RD) is regarded as an immune-mediated systemic fibroinflammatory disease. Several studies have linked IgG4-RD to infections such as tuberculosis and actinomycosis. However, the coexistence of IgG4-RD and non-tuberculous mycobacterium (NTM) in a single pulmonary nodule has not been reported yet. PATIENT CONCERNS: A 76-year-old male patient presented with cough and sputum. A solitary pulmonary nodule suspicious of lung cancer was found on chest CT. DIAGNOSIS: Through video-assisted thoracoscopic biopsy, a diagnosis of co-existing NTM and IgG4-RD in a single nodule was made. INTERVENTIONS: Antibiotic treatment was applied for pneumonia developed after surgery. The patient was also supported by extracorporeal membrane oxygenation and mechanical ventilation since his pneumonia was refractory to medical treatment. OUTCOMES: The patient expired on the 60th postoperative day due to multiple organ failure. LESSONS: IgG4-RD can occur singularly or accompanied by other diseases. We report a solitary pulmonary nodule caused by NTM and concurrent IgG4-RD, suggesting a possible association between these 2 entities. Immunologic relations between IgG4-RD and accompanying infection should be further investigated.


Assuntos
Doença Relacionada a Imunoglobulina G4 , Infecções por Micobactéria não Tuberculosa , Micobactérias não Tuberculosas/isolamento & purificação , Pneumonia , Complicações Pós-Operatórias/tratamento farmacológico , Nódulo Pulmonar Solitário , Cirurgia Torácica Vídeoassistida/métodos , Idoso , Antibacterianos/administração & dosagem , Biópsia/métodos , Oxigenação por Membrana Extracorpórea/métodos , Evolução Fatal , Humanos , Doença Relacionada a Imunoglobulina G4/complicações , Doença Relacionada a Imunoglobulina G4/diagnóstico , Doença Relacionada a Imunoglobulina G4/fisiopatologia , Pulmão/diagnóstico por imagem , Pulmão/patologia , Masculino , Insuficiência de Múltiplos Órgãos/etiologia , Infecções por Micobactéria não Tuberculosa/complicações , Infecções por Micobactéria não Tuberculosa/diagnóstico , Infecções por Micobactéria não Tuberculosa/patologia , Infecções por Micobactéria não Tuberculosa/terapia , Pneumonia/tratamento farmacológico , Pneumonia/etiologia , Nódulo Pulmonar Solitário/complicações , Nódulo Pulmonar Solitário/microbiologia , Nódulo Pulmonar Solitário/patologia , Nódulo Pulmonar Solitário/cirurgia , Tomografia Computadorizada por Raios X/métodos
4.
Medicine (Baltimore) ; 98(42): e17650, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626151

RESUMO

INTRODUCTION: Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with a risk of acute respiratory decompensation at every stage of anesthesia. PATIENT CONCERNS: Here we describe the anesthetic management of a 67-year-old man with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms. The patient presented with progressive dyspnea that was aggravated in the supine position and was scheduled for total thyroidectomy. DIAGNOSIS: Preoperative computed tomography showed a large goiter extending into the thoracic cavity, with diffuse segmental tracheal narrowing for 6 cm. The diameter at the narrowest portion of the trachea was 4.29 mm. INTERVENTIONS: Before the induction of general anesthesia, we applied extracorporeal membrane oxygenation (ECMO) in preparation for potential difficulties in securing the airway during general anesthesia. Subsequently, anesthesia was successfully induced and maintained. OUTCOMES: After the surgical procedure, fiberoptic bronchoscopy and chest radiography showed resolution of the tracheal narrowing. ECMO was weaned 2 hours after the surgery, and the patient was extubated on the first postoperative day. He was discharged without any complication. CONCLUSION: The findings from this case suggest that the use of ECMO before the induction of general anesthesia is a safe method for maintaining oxygenation in patients with severe tracheal obstruction.


Assuntos
Anestesia Geral/métodos , Oxigenação por Membrana Extracorpórea/métodos , Bócio Subesternal/cirurgia , Posicionamento do Paciente , Tireoidectomia/métodos , Estenose Traqueal/cirurgia , Idoso , Broncoscopia/métodos , Bócio Subesternal/complicações , Bócio Subesternal/diagnóstico , Humanos , Intubação Intratraqueal/métodos , Masculino , Radiografia Torácica , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Estenose Traqueal/complicações
5.
Transplant Proc ; 51(9): 2890-2898, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31606185

RESUMO

BACKGROUND: Transplantation of kidneys from donation after cardiocirculatory death (DCD) donors is becoming an ever-increasing reality. So far, biopsy histologic assessment is the main parameter for evaluation of graft suitability, but it has several drawbacks and has poor reliability. The aim of this study is to verify if real-time renal resistance (RR) measurement during hypothermic machine perfusion (HMP) can be used as a reliable parameter to evaluate the quality of grafts from DCD and extracorporeal membrane oxygenation (ECMO) donors. METHODS: From January 2015 to September 2018, HMP has been systematically applied to all organs from DCD and ECMO donors. All grafts underwent preimplantation biopsy histologic assessment with Karpinski's score. Single kidney transplants (SKTs) or double kidney transplants (DKTs) were performed according to biopsy score results. Kidneys were considered suitable for transplant if RR reached ≤ 1.0 within 3 hours of perfusion. RR trend and postoperative outcome were analyzed considering biopsy score and donor type. RESULTS: A total of 30 kidneys (15 from DCD and 15 from ECMO donors) were used to perform 26 transplants (22 SKTs and 4 DKTs). Considering RR trend, all grafts were considered suitable for transplant within 1 hour of perfusion. Biopsy confirmed this result in all cases, and median score was 3 (range, 0-7). SKT score kidneys had lower starting RR than DKT ones (1.88 vs 2.88; P = .04) but identical final RR (0.58 vs 0.57; P = .76). DKT recipients had faster postoperative creatinine reduction than SKT recipients but similar postoperative day 30 value (1.42 vs 1.15 mg/dL; P = .20). No differences were found between DCD and ECMO grafts in terms of RR trend and postoperative outcome. CONCLUSIONS: HMP can be an alternative to histologic biopsy assessment for evaluation of transplant suitability of DCD and ECMO kidneys. If acceptability threshold is reached, SKT can be performed in all cases. ECMO donors should be considered like DCD donors.


Assuntos
Transplante de Rim/métodos , Obtenção de Tecidos e Órgãos/métodos , Transplantes/patologia , Transplantes/provisão & distribução , Biópsia , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Sobrevivência de Enxerto , Humanos , Nefropatias/diagnóstico , Nefropatias/patologia , Masculino , Pessoa de Meia-Idade , Perfusão/métodos , Projetos Piloto , Fatores de Tempo , Doadores de Tecidos/provisão & distribução , Transplantes/normas
6.
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
7.
Medicine (Baltimore) ; 98(41): e17139, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593077

RESUMO

BACKGROUND: The molecular studies showed that Nitric oxide (NO) is an essential factor which regulates pulmonary artery tension. However, the conclusions of existing clinical studies were inconsistent. OBJECTIVE: This meta-analysis is aimed to determine whether the inhalation of NO could improve oxygenation and reduce rate of death and use of extracorporeal membrane oxygenation (ECMO). METHODS: The strategies used to search PubMed, The Cochrane Central Register of Controlled trials in the Cochrane Library, Embase, Web of science, Clinical Trials Registry, and China Biology Medicine disc, from inception to February, 2018. The primary outcomes were death or use of ECMO, death before hospital discharge, use of ECMO before hospital discharge, change in PaO2 after treatment. We assess the risk of bias in each included study by Cochrane Handbook, and calculated typical estimates of RR, each with its 95% CI, and for continuous outcomes, WMD or a summary estimate for SMD, each with its 95% CI. RESULTS: Nine randomized controlled trials (RCTs) with a total of 856 participants were included in this meta-analysis. This meta-analysis revealed that the experimental group had significantly lower death or use of ECMO (RR 0.66, 95% CI 0.57-0.77, I = 0%, P < .00001) and lower use of ECMO before hospital discharge (RR 0.89, 95% CI 0.50-0.71, I = 0%, P < .00001) compared to control group. And in the infants without diaphragmatic hernia, experimental group had significantly higher change in PaO2 after treatment (MD 50.40, 95% CI 32.14-68.66, P < .00001). The meta-analysis also showing a tendency to improve in the death before hospital discharge (RR 0.89, 95% CI 0.60-1.31, I = 0%, P = .55) and the change in PaO2 after treatment of the infants with diaphragmatic hernia (MD 6.70, 95% CI -2.32 to 15.72, P < .00001, P = .15), but no difference between experimental group and control group. CONCLUSION: We found that NO inhalation can improve oxygenation and reduce rate of death and use of ECMO in this meta-analysis. Therefore, we recommend the use of NO inhalation for infants born at or near term with respiratory failure.


Assuntos
Broncodilatadores/administração & dosagem , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Óxido Nítrico/administração & dosagem , Insuficiência Respiratória/terapia , Administração por Inalação , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Idade Gestacional , Hérnias Diafragmáticas Congênitas/complicações , Hérnias Diafragmáticas Congênitas/mortalidade , Hérnias Diafragmáticas Congênitas/terapia , Humanos , Recém-Nascido , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Nascimento a Termo , Resultado do Tratamento
8.
Med. intensiva (Madr., Ed. impr.) ; 43(7): 402-409, oct. 2019. graf, tab
Artigo em Inglês | IBECS | ID: ibc-ET2-3449

RESUMO

Objective: To evaluate the clinical outcomes of patients with severe acute respiratory distress syndrome (ARDS) subjected to prone positioning before extracorporeal membrane oxygenation (ECMO). Design: A retrospective analysis of a multicenter cohort was carried out. Setting: Patients admitted to the Intensive Care Units of 11 hospitals in Korea. Patients: Patients were divided into those who underwent prone positioning before ECMO (n=28) and those who did not (n=34). Interventions: None. Variables of interest: Thirty-day mortality, ECMO weaning failure rate, mechanical ventilation weaning success rate, mechanical ventilation-free days at day 60. Results: The prone group had lower median peak inspiratory pressure and lower median dynamic driving pressure before ECMO. Thirty-day mortality was 21% in the prone group and 41% in the non-prone group (p=0.098). The prone group also showed a lower ECMO weaning failure rate, and a higher mechanical ventilation weaning success rate and more mechanical ventilation-free days at day 60. In the non-prone group, median dynamic compliance marginally decreased shortly after ECMO, but no significant change was observed in the prone group. Conclusions: Prone positioning before ECMO was not associated to increased mortality and tended to exert a protective effect


Objetivo: Evaluar los resultados clínicos de pacientes con síndrome de dificultad respiratoria aguda (SDRA) quienes fueron colocados en decúbito prono previo a la oxigenación con membrana extracorpórea (ECMO). Diseño: Análisis retrospectivo de una cohorte multicéntrico. Escenario: Pacientes admitidos en las unidades de cuidado intensivo de 11 hospitales en Corea. Pacientes: Los pacientes fueron divididos en aquellos que fueron colocados en decúbito prono antes de la ECMO (n=28) y aquellos que no fueron colocados en decúbito prono antes de la ECMO (n=34). Intervenciones: Ninguna. Variables de interés principales: Mortalidad a los 30 días, tasa de fracaso de retirada gradual de la ECMO, tasa de éxito de retirada gradual de la ventilación mecánica, días sin ventilación mecánica a los 60 días. Resultados: El grupo prono tuvo una mediana más baja de la presión inspiratoria máxima y una mediana más baja de la presión de conducción dinámica antes de la ECMO. La mortalidad a los 30 días fue 21% en el grupo prono y 41% en el grupo no prono (P = 0.098). El grupo prono también mostró un valor numérico menor de tasa de fracaso de retirada progresiva de la ECMO, y valores más altos de tasa de éxito de destete de la ventilación mecánica y días sin ventilación mecánica a los 60 días. En el grupo no prono, la mediana del cumplimiento dinámico descendió marginalmente, poco después de ECMO, pero no se observó un cambio significativo en el grupo prono. Conclusiones: La colocación en decúbito prono antes de la ECMO no se asoció con un incremento en mortalidad y tendió a ser de protección


Assuntos
Humanos , Decúbito Ventral/fisiologia , Oxigenação por Membrana Extracorpórea/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Posicionamento do Paciente/métodos , Estudos de Coortes , Estudos Retrospectivos , Fatores de Risco , Análise Multivariada , Síndrome do Desconforto Respiratório do Adulto/mortalidade
11.
Int Heart J ; 60(5): 1184-1188, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31484860

RESUMO

We report the case of a 79-year-old man with acute myocardial infarction caused by left main trunk lesion, who experienced cardiogenic shock during percutaneous coronary intervention (PCI). To reverse the cardiogenic shock, we initiated veno-arterial extra corporeal membrane oxygenation (VA-ECMO) without an intra-aortic balloon pump (IABP) due to the severe tortuosity of the left external iliac artery. Although PCI was successful, arterial pressure monitoring revealed that the pulse pressure was too low to recover from the cardiogenic shock of decreased cardiac contraction function (the left ventricular ejection fraction was 30%). Thus, we decided to use IABP from the brachial artery to improve the hemodynamics. Immediately after the deployment of a 6-Fr IABP system (Takumi) from the left brachial artery, the pulse pressure was restored and finally VA-ECMO was withdrawn from the patient without complications. Although using IABP in combination with VA-ECMO is a reasonable strategy for cardiogenic shock, the effectiveness of this combination remains controversial. In this case, IABP added to VA-ECMO clearly achieved an improvement of pulse pressure and vital signs. Based on this result, monitoring of the pulse waveform is an effective tool to determine whether the concomitant use of IABP with VA-ECMO is indicated. Moreover, when it is difficult to insert IABP from the femoral arteries, the use of a 6-Fr IABP system (Takumi) approaching from the brachial artery should be considered.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio/complicações , Intervenção Coronária Percutânea/efeitos adversos , Choque Cardiogênico/terapia , Idoso , Pressão Sanguínea/fisiologia , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Terapia Combinada , Serviço Hospitalar de Emergência , Seguimentos , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Medição de Risco , Choque Cardiogênico/etiologia , Resultado do Tratamento
12.
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
13.
Heart Surg Forum ; 22(4): E287-E288, 2019 07 03.
Artigo em Inglês | MEDLINE | ID: mdl-31398093

RESUMO

The rupture of sinus of Valsalva aneurysm (SVA) into the pericardial cavity is extremely rare and fatal. A 52-year-old man presented with an abrupt onset of chest pain and dizziness. An echocardiography and a computed tomographic angiography revealed a giant aneurysm of the noncoronary sinus (NCS) (maximum, 70 mm) and pericardial effusion in favor of tamponade with a moderate degree of aortic insufficiency. On the way to the operating room, he suffered cardiac arrest, and extracorporeal cardiopulmonary resuscitation (ECPR) was initiated immediately. While he was prepared for surgery, the patient was supported by extracorporeal life support (ECLS) until cardiopulmonary bypass (CPB) was initiated. The sinus defect was reconstructed using a Dacron patch, followed by resection of the aneurysm. ECLS and CPB were discontinued successfully in the operating room. This study reports a case of an extracardiac rupture of SVA and the successful completion of surgery following ECPR.


Assuntos
Aneurisma Aórtico/cirurgia , Ruptura Aórtica/cirurgia , Reanimação Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea/métodos , Doenças Raras/cirurgia , Seio Aórtico/cirurgia , Aneurisma Aórtico/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Angiografia por Tomografia Computadorizada , Ecocardiografia Transesofagiana , Parada Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/diagnóstico por imagem , Doenças Raras/diagnóstico por imagem , Seio Aórtico/diagnóstico por imagem
14.
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
15.
Medicine (Baltimore) ; 98(31): e16740, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374069

RESUMO

RATIONALE: Percutaneous cardiopulmonary support (PCPS) using extracorporeal membrane oxygenation (ECMO) is widely used in the critical patients with cardiopulmonary collapse. It is a representative blood-consuming procedure. In limited situations in which the option of blood transfusion is unavailable, there is no general agreement as to whether ECMO is contraindicated. PATIENT CONCERNS: A 61-year-old male Jehovah Witness with acute respiratory collapse and loss of consciousness was rushed to our emergency room. Throughout his hospital course, the patient's family refused any type of blood transfusion even at the risk of death. DIAGNOSIS: The clinical situations were secondary to a massive pulmonary thromboembolism INTERVENTIONS:: The patient underwent veno-venous ECMO via both femoral veins. The patient was recovered by intensive medical care although the level of hemoglobin (Hb) and hematocrit (Hct) was gradually decreased from 15.8 g/dl and 46.8% to 11.7 g/dl and 36.5%, respectively. OUTCOMES: On hospital day 3, ECMO was successfully removed using a blood-sparing ECMO removal technique involving the recycling of blood within the circuit by continuous saline infusion. There was no significant change in level of Hb/Hct and hemodynamic profile. At 2 days after ECMO removal, the level of Hb/Hct was elevated up to 9.2 g/dl and 30.0%, respectively without any transfusion. LESSONS: Our blood-sparing removal technique of ECMO appears to be feasible and led to no significant adverse impact on hemodynamic status. The technique might be helpful for critical patients who cannot receive blood transfusion due to any cause.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Testemunhas de Jeová , Insuficiência Respiratória/terapia , Procedimentos Médicos e Cirúrgicos de Sangue/métodos , Hematócrito , Hemoglobinas , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Insuficiência Respiratória/etiologia
16.
Transplant Proc ; 51(9): 3107-3110, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31324485

RESUMO

We report the case of a 68-year-old woman with end-stage liver disease and end-stage renal disease scheduled for simultaneous liver and kidney transplant. Intraoperatively, she became hemodynamically unstable during her liver transplant surgery, and her renal transplant had to be postponed. On the following day, she required extracorporeal membrane oxygenation and ABIOMED Impella support for managing her severe cardiovascular decompensation. At the same time, the renal transplant was conducted to use the donor kidney already allocated for this patient. The patient was successfully managed postoperatively in the cardiothoracic intensive care unit and was discharged after 2 months. This case is unique because there are no similar cases previously reported in which renal transplantation was performed with extracorporeal membrane oxygenation and Impella support following cardiogenic shock after a liver transplant.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Coração Auxiliar , Transplante de Rim/métodos , Transplante de Fígado/métodos , Idoso , Feminino , Humanos , Falência Renal Crônica/cirurgia
17.
Int Heart J ; 60(4): 845-848, 2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31308322

RESUMO

The aim of this study was to summarize the clinical experience of postoperative extracorporeal membrane oxygenation (ECMO) support in Stanford type A aortic dissection (STAAD) patients.We retrospectively reviewed 246 consecutive acute STAAD patients undergoing operations at our institution from January 2012 to December 2016. Postoperative ECMO was used in 7 patients. There were 5 males and 2 females with a mean age of 43.1 ± 9.3 years. All 7 patients with acute STAAD underwent ascending aorta replacement and total arch repair with a self-designed stent graft (Micropart Corp, Shanghai, China). Concomitant procedures were aortic root replacement in 1 patient and coronary artery bypass grafting (CABG) in 2 patients. All patients received veno-arterial ECMO through the femoral artery and vein. Five patients were extubated before being removed from ECMO. The mean ECMO supporting time was 244.5 ± 57.8 hours. All 7 patients were successfully weaned from ECMO support, and 6 (85.7%) patients survived to discharge. The average hospital time was 26.3 ± 8.8 days. One patient died of cardiac arrest after being weaned from ECMO. Two patients underwent reoperation for bleeding and 1 patient showed transient delirium. The remaining patients all survived during a median follow-up of 19 months.ECMO provides a good temporary cardiopulmonary support in STAAD patients with refractory cardiogenic shock after surgery for aortic dissection. The early use of ECMO and preventing its complications actively can improve the patient survival rate.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Oxigenação por Membrana Extracorpórea/métodos , Adulto , Aneurisma Dissecante/diagnóstico , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Angiografia por Tomografia Computadorizada , Ecocardiografia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
19.
Crit Care ; 23(1): 248, 2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288863

RESUMO

BACKGROUND: Sufentanil is commonly used for analgesia and sedation during extracorporeal membrane oxygenation (ECMO). Both ECMO and the pathophysiological changes derived from critical illness have significant effects on the pharmacokinetics (PK) of drugs, yet reports of ECMO and sufentanil PK are scarce. Here, we aimed to develop a population PK model of sufentanil in ECMO patients and to suggest dosing recommendations. METHODS: This prospective cohort PK study included 20 patients who received sufentanil during venoarterial ECMO (VA-ECMO). Blood samples were collected for 96 h during infusion and 72 h after cessation of sufentanil. A population PK model was developed using nonlinear mixed effects modelling. Monte Carlo simulations were performed using the final PK parameters with two typical doses. RESULTS: A two-compartment model best described the PK of sufentanil. In our final model, increased volume of distribution and decreased values for clearance were reported compared with previous PK data from non-ECMO patients. Covariate analysis showed that body temperature and total plasma protein level correlated positively with systemic clearance (CL) and peripheral volume of distribution (V2), respectively, and improved the model. The parameter estimates of the final model were as follows: CL = 37.8 × EXP (0.207 × (temperature - 36.9)) L h-1, central volume of distribution (V1) = 229 L, V2 = 1640 × (total plasma protein/4.5)2.46 L, and intercompartmental clearance (Q) = 41 L h-1. Based on Monte Carlo simulation results, an infusion of 17.5 µg h-1 seems to reach target sufentanil concentration (0.3-0.6 µg L-1) in most ECMO patients except hypothermic patients (33 °C). In hypothermic patients, over-sedation, which could induce respiratory depression, needs to be monitored especially when their total plasma protein level is low. CONCLUSIONS: This is the first report on a population PK model of sufentanil in ECMO patients. Our results suggest that close monitoring of the body temperature and total plasma protein level is crucial in ECMO patients who receive sufentanil to provide effective analgesia and sedation and promote recovery. TRIAL REGISTRATION: Clinicaltrials.gov NCT02581280 , December 1st, 2014.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Farmacocinética , Sufentanil/farmacocinética , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Estudos Prospectivos , Sufentanil/uso terapêutico
20.
Medicine (Baltimore) ; 98(30): e16574, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31348289

RESUMO

RATIONALE: Sodium polystyrene sulfonate is commonly administered to treat hyperkalemia. Severe pneumonia due to aspiration of this drug is rare and no survival case has thus far been reported. PATIENT CONCERNS: A 45-year-old man was hospitalized for acute decompensated heart failure and acute kidney injury with hyperkalemia. He aspirated sodium polystyrene sulfonate while consuming the drug. Severe acute respiratory distress syndrome (ARDS) developed rapidly, and he was transferred to the intensive care unit (ICU). DIAGNOSES: Chest radiography results after aspiration showed new consolidation in the left upper lung. He underwent emergency bronchoscopy, which revealed a considerable amount of yellow mud-like material in the trachea and bronchi. Chest radiography results after the bronchoscopic removal of the foreign material revealed rapid resolution of the left upper lung consolidation. INTERVENTIONS: In the ICU, mechanical ventilation with low tidal volume and high positive end-expiratory pressure was administered and extracorporeal membrane oxygenation (ECMO) was set up for treating severe ARDS. We arranged an emergency bronchoscopy for diagnosis and removal of polystyrene sulfonate. OUTCOMES: ECMO was discontinued after 10 days and the patient was discharged after approximately 2 weeks. LESSONS: Aspiration of sodium polystyrene sulfonate is not common but can be lethal. Clinicians should be cautious and appropriately inform patients of the aspiration risk while administering this drug. Mechanical ventilation and bronchoscopy were effective treatments for severe ARDS caused by aspiration of this drug.


Assuntos
Poliestirenos/efeitos adversos , Aspiração Respiratória/complicações , Síndrome do Desconforto Respiratório do Adulto/induzido quimicamente , Síndrome do Desconforto Respiratório do Adulto/terapia , Broncoscopia/métodos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Índice de Gravidade de Doença
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