RESUMO
INTRODUCTION: Patients who develop severe acute respiratory distress syndrome (ARDS) despite full medical management may require veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory function. Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) during VV ECMO for isolated severe respiratory failure in adult populations. METHODS: A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with university institutional review board (IRB) approval. Patients supported by veno-arterial ECMO were excluded. AKI was defined by acute renal failure receiving CRRT and the outcomes of patients on VV ECMO were compared between the AKI and non-AKI groups. RESULTS: We identified 54 ARDS patients supported by VV ECMO (mean ECMO days 12 ± 6.7) with 16 (30%) in the AKI group and 38 (70%) in the non-AKI group. No patient had previous renal failure and the serum creatinine was not significantly different between the two groups at the time of ECMO initiation. The AKI group showed a greater incidence of complications during ECMO, including liver failure (38% vs. 5%, p=0.002) and hemorrhage (94% vs. 45%, p=0.0008). ECMO survival of the AKI group (56% [9/16]) was inferior to the non-AKI group (87% [33/38], p=0.014). CONCLUSIONS: Our study demonstrated that VV ECMO successfully manages patients with severe isolated lung injury. However, once patients develop AKI during VV ECMO, they are likely to further develop multi-organ dysfunction, including hepatic and hematological complications, leading to inferior survival.
Assuntos
Injúria Renal Aguda/complicações , Injúria Renal Aguda/terapia , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório/complicações , Síndrome do Desconforto Respiratório/terapia , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: Interventions in patients with a left ventricular assist device (LVAD) in the intensive care unit (ICU) are typically performed based on the results of conventional monitoring, such as vital signs and Swan-Ganz catheter (SGC) and LVAD parameters. These variables might not always accurately reflect a patient's cardiac function, volume status, and interventricular septal configuration, however. To assess the accuracy of standard monitoring, we performed routine continuous hemodynamic transesophageal echocardiography (hTEE) to evaluate cardiac function, volume status, and septal position. METHODS: Between 2011 and 2015, 93 HeartMate II LVADs were implanted. The study group comprised 30 patients with an SGC in place who were monitored routinely by hTEE in the ICU every 1 to 3 hours until extubation. A total of 147 hTEE studies were analyzed retrospectively to observe differences between conventional monitoring and hTEE. RESULTS: Among the 30 patients studied, 26 (87%) had at least 1 disagreement between conventional monitoring and hTEE findings. In 22 patients (73%), at least 1 of the hTEE studies was abnormal whereas conventional parameters were normal. Abnormal hTEE findings included a shift in the interventricular septum in 19 patients (63%), abnormal ventricular volume status in 22 patients (73%), and right ventricular failure in 9 patients (30%). Based on conventional monitoring, none of the patients required an LVAD speed change, whereas hTEE showed that 14 patients (47%) needed an LVAD speed adjustment. CONCLUSIONS: Conventional monitoring in the ICU might not provide an accurate representation of cardiac function, ventricular volume status, or septal position in patients with LVAD. Continuous monitoring with hTEE in patients with an LVAD may help guide optimal intervention in the ICU setting during the early postoperative period.
Assuntos
Cateterismo de Swan-Ganz , Ecocardiografia Transesofagiana , Insuficiência Cardíaca/terapia , Coração Auxiliar , Hemodinâmica , Monitorização Ambulatorial/métodos , Função Ventricular Esquerda , Adulto , Idoso , Feminino , Nível de Saúde , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Desenho de Prótese , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Septo Interventricular/diagnóstico por imagem , Septo Interventricular/fisiopatologia , Adulto JovemRESUMO
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.
Assuntos
Cateterismo Periférico/instrumentação , Oxigenação por Membrana Extracorpórea/efeitos adversos , Isquemia/prevenção & controle , Perna (Membro)/irrigação sanguínea , Perfusão/instrumentação , Dispositivos de Acesso Vascular , Adulto , Idoso , Amputação Cirúrgica , Angioplastia , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/mortalidade , Protocolos Clínicos , Desenho de Equipamento , Oxigenação por Membrana Extracorpórea/mortalidade , Fasciotomia , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Perfusão/efeitos adversos , Perfusão/mortalidade , Imagem de Perfusão/métodos , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Espectroscopia de Luz Próxima ao Infravermelho , Trombectomia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Tracheal injury is a rare but highly morbid complication of endotracheal intubation. Recent reviews have advocated conservative management of these injuries without operative intervention. Extracorporeal membrane oxygenation may be a useful tool in non-operative management of tracheal injury in the setting of severe respiratory failure and need for prolonged intubation. We present a morbidly obese 33 year-old-female with H1N1 influenza pneumonia complicated by acute respiratory distress syndrome and bacterial super-infection who sustained a post-intubation tracheal injury. Concomitant tracheal injury and acute lung injury pose a difficult ventilation dilemma. This patient was successfully managed by venovenous extracorporeal membrane oxygenation, high frequency oscillator ventilation, proning position and tube thoracostomy. The venovenous extracorporeal membrane oxygenation and ventilator management were essential for this patient's recovery.
RESUMO
BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been used for profound cardiogenic shock to bridge to decision, ventricular assist device(s) (VADs), or transplant. To assess ventricular function and volume status along with hemodynamics during ECMO weaning, we developed a standardized weaning protocol, guided by a miniaturized transesophageal echocardiography probe designed for continuous hemodynamic monitoring (hemodynamic transesophageal echocardiography [hTEE]). We reviewed our experience with this weaning protocol with hTEE guidance to assess if we could predict patient outcomes. METHODS: During the academic year of 2011, hTEE-guided ECMO weaning was performed in 21 patients on VA ECMO. Left and right ventricular function and volume status were assessed by continuous hTEE, while attempting to wean ECMO after a standardized protocol. The clinical outcomes, management, and positive predictive value of the device were investigated and analyzed for this cohort of patients. RESULTS: Of the 21 patients, 6 (29%) had left and right ventricular recovery and underwent optimal medical therapy or revascularization for underlying coronary artery disease; 7 (33%) had nonrecoverable left and right ventricular function; and 8 (38%) had right ventricular recovery without improvement of the left ventricular function. These 8 patients underwent left VAD placement; none subsequently developed profound right ventricular failure. The positive predictive value for ventricular recovery by hTEE was 100% using our standardized ECMO weaning protocol (95% confidence interval, 73%-100%). CONCLUSIONS: The hTEE-guided ECMO weaning protocol accurately predicted the ability to wean ECMO to decision. This protocol can be applied by cardiac intensivists as a part of standard bedside intensive care unit assessment.