Background
Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured ...to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation.
Methods
We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described.
Results
A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57–68) and 68% (95% CI 60–75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported.
Conclusion
Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients.
Abstract Purpose To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. ...Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes. Methods A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated. Results In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 7-43 vs 11 5-27 days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011). Conclusions In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes.
Abstract Purpose Inorganic apparent strong ion difference (SIDai) improves chloride-associated acidosis recognition in dysnatremic patients. We investigated whether the difference between sodium and ...chloride (Na+ -Cl− ) or the ratio between chloride and sodium (Cl− /Na+ ) could be used as SIDai surrogates in mixed and dysnatremic patients. Patients and Methods Two arterial blood samples were collected from 128 patients. Physicochemical analytical approach was used. Correlation, agreement, accuracy, sensitivity, and specificity were measured to examine whether Na+ -Cl− and Cl− /Na+ could be used instead of SIDai in the diagnosis of acidosis. Results Na+ -Cl− and Cl− /Na+ were well correlated with SIDai ( R = 0.987, P < 0.001 and R = 0.959, P < 0.001, respectively). Bias between Na+ -Cl− and SIDai was high (6.384 with a limit of agreement of 4.463-8.305 mEq/L). Accuracy values for the identification of SIDai acidosis (<38.9 mEq/L) were 0.989 (95% confidence interval CI, 0.980-0.998) for Na+ -Cl− and 0.974 (95% CI, 0.959-0.989) for Cl− /Na+ . Receiver operator characteristic curve showed that values revealing SIDai acidosis were less than 32.5 mEq/L for Na+ -Cl− and more than 0.764 for Cl− /Na+ with sensitivities of 94.0% and 92.0% and specificities of 97.0% and 90.0%, respectively. Na+ -Cl− was a reliable SIDai surrogate in dysnatremic patients. Conclusions Na+ -Cl− and Cl− /Na+ are good tools to disclose SIDai acidosis. In patients with dysnatremia, Na+ -Cl− is an accurate tool to diagnose SIDai acidosis.
Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal ...support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution.
Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output.
Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions.
Abstract Objectives To characterize the provision of early mobilization therapy in critically ill patients in a Brazilian medical intensive care unit (ICU) and to investigate the relationship between ...physical activity level and clinical outcomes. Methods Intensive care unit and physiotherapy data were collected retrospectively from 275 consecutive patients. Here we report on the subset of patients (n = 120) who were mechanically ventilated during their ICU stay (age, 49 ± 18 years; Simplified Acute Physiology Score 3, 45 25). Results Median (interquartile range) time of mechanical ventilation and ICU length of stay were 3 (4) and 8 (10) days, respectively. Intensive care unit and 1-year mortality were 31% and 50%, respectively. During the ICU stay, these patients all received respiratory physiotherapy and 90% (n = 108) received mobilization therapy. When intubated and ventilated, mobilization therapy was performed in 76% (n = 92) of the patients with no adverse events. The most common activity was in-bed exercises (55%), and the number of out-of-bed activities (sitting out of bed, standing, or walking) was small (29%) and more prevalent in patients with tracheostomy than with an endotracheal tube (27% × 2%, respectively). Conclusion In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in-bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed.
Soon after the first plasmapheresis session (in which 1.5 volemia was exchanged), the blood viscosity was lower (1.8 cP), and the hyperechoic image could not be seen anymore (Fig. 1D). ...we have ...attributed the image found to the blood hyperviscosity.
In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ...ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation. RESUMO Em pacientes com insuficiência respiratória grave (hipoxêmica ou hipercápnica), o suporte somente com ventilação mecânica pode ser insuficiente para suas necessidades, especialmente quando se tenta evitar o uso de parâmetros ventilatórios que possam causar danos aos pulmões. Nesses pacientes, extracorporeal membrane oxygenation (ECMO, oxigenação extracorpórea por membrana), que também é muito eficaz na remoção de dióxido de carbono do sangue, pode manter a vida, permitindo o uso de ventilação pulmonar protetora. No presente artigo de revisão, objetivamos explorar alguns dos aspectos mais relevantes do suporte respiratório por ECMO. Discutimos a história do suporte respiratório por ECMO em adultos; evidências clínicas; custos; indicações; instalação do equipamento; parâmetros ventilatórios; cuidado diário do paciente e do sistema; solução de problemas comuns; desmame e descontinuação.
Abstract Purpose This study aimed to test the hypothesis that intensive care unit survivors and nonsurvivors differ with regard to type and severity of acid-base disorders. Materials and Methods ...Prospective, observational, cohort study of 107 consecutive patients admitted in a 7-bed intensive care unit during a 6-month period that stayed at least 4 days. All acid-base variables for the first 3 days and the day of discharge were analyzed. Results Survivors had significant metabolic acidosis upon admission, which was due to hyperlactatemia, an excess of unmeasured anions, and principally, hyperchloremia. A progressive decrease in these anions in the presence of constant hypoalbuminemia led to normal standard base excess at discharge. Nonsurvivors had greater metabolic acidosis upon admission with acidifying variables in similar proportions to that of the survivors. On the day of death, nonsurvivors had a similar degree of metabolic acidosis but a different proportion of the anions (less chloride and more lactate) compared with the day of admission. Unmeasured anions were greater in nonsurvivors both on the day of admission and on the day of death. Conclusions Intensive care unit survivors and nonsurvivors differed in the severity of metabolic acidosis; however, the proportion of the different anions causing the acidosis on admission was similar between these 2 groups.
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