This observational report depicts typical problems of extracorporeal membrane oxygenation cannulation from a large case series of a single center.
We analysed our experience with 720 consecutive ...patients receiving veno-venous or veno-arterial extracorporeal membrane oxygenation focusing on the spectrum of complications occurring in a subset of 159 patients treated with percutaneous veno-arteria extracorporeal membrane oxygenation in our institution between January 2009 to December 2014.
The main problems were: vascular complications or ischemia of the corresponding extremity (leading to surgical revision in 16.9 % of patients); blood loss and/or relocation of cannulas. Hypoxia of the upper body (Harlequin syndrome) occurred in 8.8 % of patients. Cannulation failure and malfunction were infrequent. Careful insertion technique, close surveillance and monitoring are compelling.
As lack of experience is the trigger of many complications, adequate training of cannulation techniques is essential to minimize adverse events.
Type A aortic dissection with true lumen collapse and malperfusion downstream is associated with a devastating prognosis. This study compares the clinical outcomes of two operative strategies for ...this disease: hybrid approach of ascending aorta (and hemiarch replacement) supplemented with retrograde stenting of the descending aorta (thoracic endovascular aortic repair TEVAR) and standard ascending aorta (and hemiarch) replacement without stent placement.
From January 1, 2016 to December 31, 2019, 81 patients with type A aortic dissection were studied. The hybrid technique was applied in 30 patients (group 1), while 51 patients received standard surgical repair (group 2). Patient demographics, clinical and operative findings, postoperative outcome, follow-up interventions, and mid-term survival were analyzed.
Baseline characteristics were similar among the groups, except that more preoperative malperfusion was evident in group 1. The postoperative incidence of visceral malperfusion (0 vs. 15.7%,
= 0.02) and low cardiac output syndrome requiring extracorporeal membrane oxygenation support (3.3 vs. 19.6%,
= 0.04) was significantly less in group 1. In-hospital mortality was also significantly lower in group 1 as in group 2 (13.3 vs. 33.3%,
= 0.04). At follow-up, the need for secondary endovascular stenting (3.3 vs. 7.8%,
= 0.65) and surgical aortic reintervention (6.7 vs. 2.0%,
= 0.55) was comparable. One-year, 2-year, and 3-year survival rates were 83.3, 83.3, and 62.5% in group 1, and 58.7, 58.7, and 52.6% in group 2 (
= 0.05), respectively.
The combination of open surgical replacement of the ascending aorta (and hemiarch) with TEVAR of the descending aorta for true lumen compromise is a feasible treatment option for patients with type A aortic dissection and is associated with a better perioperative outcome and improved mid-term survival rate.
Tobacco smoking remains the leading cause of preventable death worldwide and current smoking cessation medications have limited efficacy. Thus, there is a clear need for translational research ...focused on identifying novel pharmacotherapies for nicotine addiction. Our previous studies demonstrated that acute administration of an acetylcholinesterase inhibitor (AChEI) attenuates nicotine taking and seeking in rats and suggest that AChEIs could be repurposed for smoking cessation. Here, we expand upon these findings with experiments designed to determine the effects of repeated AChEI administration on voluntary nicotine taking in rats as well as smoking behavior in human smokers. Rats were trained to self-administer intravenous infusions of nicotine (0.03 mg kg(-1) per 0.59 ml) on a fixed-ratio-5 schedule of reinforcement. Once rats maintained stable nicotine taking, galantamine or donepezil was administered before 10 consecutive daily nicotine self-administration sessions. Repeated administration of 5.0 mg kg(-1) galantamine and 3.0 mg kg(-1) donepezil attenuated nicotine self-administration in rats. These effects were reinforcer-specific and not due to adverse malaise-like effects of drug treatment as repeated galantamine and donepezil administration had no effects on sucrose self-administration, ad libitum food intake and pica. The effects of repeated galantamine (versus placebo) on cigarette smoking were also tested in human treatment-seeking smokers. Two weeks of daily galantamine treatment (8.0 mg (week 1) and 16.0 mg (week 2)) significantly reduced smoking rate as well as smoking satisfaction and reward compared with placebo. This translational study indicates that repeated AChEI administration reduces nicotine reinforcement in rats and smoking behavior in humans at doses not associated with tolerance and/or adverse effects.
Extracorporeal life-support systems are valuable tools to treat patients with acute cardiopulmonary failure in intensive care facilities, and are highly suitable for the interhospital transfer of ...critically ill patients to specialized centers. This article reviews the cannulation strategies and associated vascular complications in our institution.
Between January 2004 and December 2009, 464 extracorporeal life-support systems were implanted via percutaneous cannulation at our institution. The type and incidence of adverse events related to the percutaneous access to femoral, subclavian vessels and the jugular vein were retrospectively analyzed. The primary focus was on bleeding and limb ischemia.
464 patients (340 male, 124 female) with isolated pulmonary or combined cardiopulmonary failure were connected to extracorporeal gas exchange systems. Most patients (n = 196) were connected to a PECLA system; 158 patients to a veno-arterial ECMO. Use of a veno-venous ECMO system was necessary in 110 cases. Thirty-two patients (6.9 %) suffered bleeding complications after cannula insertion, predominantly after PECLA placement (3.9 %). After implantation, limb ischemia developed in 15 cases (3.2 %), mostly in the veno-arterial ECMO group (n = 13). Demographic data and cannula size show no significant difference between patient groups with and without ischemic complications ( P = 0.57). A prophylactic fasciotomy was performed in the 15 cases with limb ischemia. Survival was independent of ischemic (leg) complications.
With proper vessel visualization, exposure and cannulation, and accurate cannula placement, optimal flows and minimal complication rates can be achieved, rendering percutaneous extracorporeal life support a safe procedure.
Respiratory acidosis can become a serious problem during protective ventilation of severe lung failure. A pumpless arteriovenous interventional lung assist (iLA) for extracorporeal carbon dioxide ...removal has been used increasingly to control critical respiratory situations. The present study sought to evaluate the factors determining the efficacy of iLA and calculate its contribution to gas exchange. In a cohort of 96 patients with severe acute respiratory distress syndrome, haemodynamic parameters, oxygen consumption and carbon dioxide production as well as gas transfer through the iLA were analysed. The measurements demonstrated a significant dependency of blood flow via the iLA device on cannula size (mean+/-sd 1.59+/-0.52 L x min(-1) for 15 French (Fr), 1.94+/-0.35 L x min(-1) for 17 Fr, and 2.22 +/-0.45 L x min(-1) for 19 Fr) and on mean arterial pressure. Oxygen transfer capacity averaged 41.7+/-20.8 mL x min(-1), carbon dioxide removal was 148.0+/-63.4 mL x min(-1). Within two hours of iLA treatment, arterial oxygen partial pressure/inspired oxygen fraction ratio increased significantly and a fast improvement in arterial carbon dioxide partial pressure and pH was observed. Interventional lung assist eliminates approximately 50% of calculated total carbon dioxide production with rapid normalisation of respiratory acidosis. Despite limited contribution to oxygen transfer it may allow a more protective ventilation in severe respiratory failure.
Summary
The effects of the combination of a ‘lowest’ lung ventilation with extracorporeal elimination of carbon dioxide by interventional lung assist are described in a patient presenting with severe ...acute respiratory distress syndrome due to fulminant pneumonia. Reducing tidal volume to 3 ml.kg−1 together with interventional lung assist resulted in a decrease in severe hypercapnia without alveolar collapse or hypoxaemia but with a decrease in serum levels of interleukin‐6. This approach was applied for 12 days with recovery of the patient, without complications. Extracorporeal removal of carbon dioxide by interventional lung assist may be a useful tool to enable ‘ultraprotective’ ventilation in severe acute respiratory distress syndrome.
Die Anwendung einer venoarteriellen extrakorporalen Membranoxygenierung (v.-a.-ECMO), auch „extracorporeal life support“ (ECLS) genannt, hat in den letzten Jahren eine deutliche Zunahme erfahren. Das ...Verständnis der ECMO-Physiologie ist nicht immer einfach, und in der Behandlung komplexer klinischer Situationen sind noch viele Fragen offen. Dieser Beitrag beleuchtet die aktuellen Entwicklungen und technischen Aspekte der v.-a.-ECMO-Therapie.
Zusammenfassung
Die Anwendung einer venoarteriellen extrakorporalen Membranoxygenierung (v.-a.-ECMO), auch „extracorporeal life support“ (ECLS) genannt, hat in den letzten Jahren eine deutliche ...Zunahme erfahren. Das Verständnis der ECMO-Physiologie ist nicht immer einfach, und in der Behandlung komplexer klinischer Situationen sind noch viele Fragen offen. Dieser Beitrag beleuchtet die aktuellen Entwicklungen und technischen Aspekte der v.-a.-ECMO-Therapie.
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