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Gerhardinger F, Fisser C, Malfertheiner MV, Philipp A, Foltan M, Zeman F, Stadlbauer A, Wiest C, Lunz D, Müller T, Lubnow M. Prevalence and Risk Factors for Weaning Failure From Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Insufficiency. Crit Care Med 2024; 52:54-67. [PMID: 37665263 DOI: 10.1097/ccm.0000000000006041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency. DESIGN Single-center retrospective observational study. SETTING Sixteen beds medical ICU at the University Hospital Regensburg. PATIENTS Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials. CONCLUSIONS Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure.
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Affiliation(s)
- Felix Gerhardinger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Worku E, Brodie D, Shekar K. Weaning From Venovenous Extracorporeal Membrane Oxygenation-The Regensburg Way? Crit Care Med 2024; 52:147-150. [PMID: 38095522 DOI: 10.1097/ccm.0000000000006077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Elliott Worku
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
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Jung C, Gillmann HJ, Stueber T. Modification of Respiratory Drive and Lung Stress by Level of Support Pressure and ECMO Sweep Gas Flow in Patients With Severe COVID-19-Associated Acute Respiratory Distress Syndrome: an Exploratory Retrospective Analysis. J Cardiothorac Vasc Anesth 2024; 38:221-229. [PMID: 38197786 DOI: 10.1053/j.jvca.2023.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/17/2023] [Accepted: 09/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Patients with severe acute respiratory distress syndrome (ARDS) often exhibit an unusually strong respiratory drive, which predisposes them to effort-induced lung injury. Careful titration of support pressure via the ventilator and carbon dioxide removal via extracorporeal membrane oxygenation (ECMO) may attenuate respiratory drive and lung stress. DESIGN A retrospective cohort study. SETTING At a single center, a university hospital. PARTICIPANTS Ten patients with severe COVID-19-associated ARDS (CARDS) on venovenous ECMO therapy. INTERVENTIONS Assessment of the effect of titrated support pressure and titrated ECMO sweep gas flow on respiratory drive and lung stress in spontaneously breathing patients during ECMO therapy. MEASUREMENTS AND MAIN RESULTS Airway occlusion pressure (P0.1) and the total swing of the transpulmonary pressure were determined as surrogate parameters of respiratory drive and lung stress. Ventilator-mediated elevation of support pressure decreased P0.1 but increased transpulmonary driving pressure, airway pressure, tidal volume, and end-inspiratory transpulmonary occlusion pressure. The increase in ECMO sweep gas flow lowered P0.1, transpulmonary pressures, tidal volume, and respiratory frequency linearly. CONCLUSIONS In patients with CARDS on pressure support ventilation, even moderate support pressure may lead to overassistance during assisted ventilation, which is only reflected by advanced monitoring of respiratory mechanics. Modifying carbon dioxide removal via the extracorporeal system profoundly affects respiratory effort and mechanics. Spontaneously breathing patients with CARDS may benefit from consequent carbon dioxide removal.
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Affiliation(s)
- Carolin Jung
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Stueber
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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Roncon-Albuquerque R, Gaião S, Vasques-Nóvoa F, Basílio C, Ferreira AR, Touceda-Bravo A, Pimentel R, Vaz A, Silva S, Castro G, Veiga T, Martins H, Dias F, Pereira C, Marto G, Coimbra I, Chico-Carballas JI, Figueiredo P, Paiva JA. Standardized approach for extubation during extracorporeal membrane oxygenation in severe acute respiratory distress syndrome: a prospective observational study. Ann Intensive Care 2023; 13:86. [PMID: 37723384 PMCID: PMC10506998 DOI: 10.1186/s13613-023-01185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Extubation during extracorporeal oxygenation (ECMO) in severe acute respiratory distress syndrome (ARDS) has not been well studied. Despite the potential benefits of this strategy, weaning from ECMO before liberation from invasive mechanical ventilation remains the most frequent approach. Our aim was to evaluate the safety and feasibility of a standardized approach for extubation during ECMO in patients with severe ARDS. RESULTS We conducted a prospective observational study to assess the safety and feasibility of a standardized approach for extubation during ECMO in severe ARDS among 254 adult patients across 4 intensive care units (ICU) from 2 tertiary ECMO centers over 6 years. This consisted of a daily assessment of clinical and gas exchange criteria based on an Extracorporeal Life Support Organization guideline, with extubation during ECMO after validation by a dedicated intensive care medicine specialist. Fifty-four (21%) patients were extubated during ECMO, 167 (66%) did not reach the clinical criteria, and in 33 (13%) patients, gas exchange precluded extubation during ECMO. At ECMO initiation, there were fewer extrapulmonary organ dysfunctions (lower SOFA score [OR, 0.88; 95% CI, 0.79-0.98; P = .02] with similar PaO2/FiO2) when compared with patients not extubated during ECMO. Extubation during ECMO associated with shorter duration of invasive mechanical ventilation (7 (4-18) vs. 32 (18-54) days; P < .01) and of ECMO (12 (7-25) vs. 19 (10-41) days; P = .01). This was accompanied by a lower incidence of hemorrhagic shock (2 vs. 11%; P = .05), but more cannula-associated deep vein thrombosis (49 vs. 31%; P = .02) and failed extubation (20 vs. 6%; P < .01). There were no increased major adverse events. Extubation during ECMO is associated with a lower risk of all-cause death, independently of measured confounding (adjusted logistic regression OR 0.23; 95% confidence interval 0.08-0.69, P = .008). CONCLUSIONS A standardized approach was safe and feasible allowing extubation during ECMO in 21% of patients with severe ARDS, selecting patients who will have a shorter duration of invasive mechanical ventilation, ECMO course, and ICU stay, as well as fewer infectious complications, and high hospital survival.
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Affiliation(s)
- Roberto Roncon-Albuquerque
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal.
| | - Sérgio Gaião
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Francisco Vasques-Nóvoa
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, São João University Hospital Centre, Porto, Portugal
| | - Carla Basílio
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Ana Rita Ferreira
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | | | - Rodrigo Pimentel
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Ana Vaz
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Sofia Silva
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Guiomar Castro
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Tiago Veiga
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Hélio Martins
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Francisco Dias
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Catarina Pereira
- Department of Internal Medicine, São João University Hospital Centre, Porto, Portugal
| | - Gonçalo Marto
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Isabel Coimbra
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | | | - Paulo Figueiredo
- Department of Infectious Diseases, São João University Hospital Centre, Porto, Portugal
| | - José Artur Paiva
- Department of Emergency and Intensive Care Medicine, São João University Hospital Centre, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
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Collins PD, Giosa L, Camarda V, Camporota L. Physiological adaptations during weaning from veno-venous extracorporeal membrane oxygenation. Intensive Care Med Exp 2023; 11:7. [PMID: 36759388 PMCID: PMC9911184 DOI: 10.1186/s40635-023-00493-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) has an established evidence base in acute respiratory distress syndrome (ARDS) and has seen exponential growth in its use over the past decades. However, there is a paucity of evidence regarding the approach to weaning, with variation of practice and outcomes between centres. Preconditions for weaning, management of patients' sedation and mechanical ventilation during this phase, criteria defining success or failure, and the optimal duration of a trial prior to decannulation are all debated subjects. Moreover, there is no prospective evidence demonstrating the superiority of weaning the sweep gas flow (SGF), the extracorporeal blood flow (ECBF) or the fraction of oxygen of the SGF (FdO2), thereby a broad inter-centre variability exists in this regard. Accordingly, the aim of this review is to discuss the required physiological basis to interpret different weaning approaches: first, we will outline the physiological changes in blood gases which should be expected from manipulations of ECBF, SGF and FdO2. Subsequently, we will describe the resulting adaptation of patients' control of breathing, with special reference to the effects of weaning on respiratory effort. Finally, we will discuss pertinent elements of the monitoring and mechanical ventilation of passive and spontaneously breathing patients during a weaning trial. Indeed, to avoid lung injury, invasive monitoring is often required in patients making spontaneous effort, as pressures measured at the airway may not reflect the degree of lung strain. In the absence of evidence, our approach to weaning is driven largely by an understanding of physiology.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, London, UK.
| | - Lorenzo Giosa
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
| | - Valentina Camarda
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
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Zheng M. Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome. Crit Care 2023; 27:46. [PMID: 36732812 PMCID: PMC9894747 DOI: 10.1186/s13054-023-04338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, No. 1558, Sanhuan North Road, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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Rajsic S, Breitkopf R, Rugg C, Bukumiric Z, Reitbauer J, Treml B. Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience. J Clin Med 2023; 12:jcm12031082. [PMID: 36769730 PMCID: PMC9917555 DOI: 10.3390/jcm12031082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap. METHODS We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe. RESULTS From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays. CONCLUSIONS ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Christopher Rugg
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jakob Reitbauer
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Misselbrook GP, Kanji H, Thiara S, Ronco JJ, Kalan S, Chen L, Sidhu A. Prediction of successful veno-venous extracorporeal life support liberation using the oxygen challenge test. Artif Organs 2023; 47:180-186. [PMID: 35957529 DOI: 10.1111/aor.14382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The oxygen challenge test (OCT) is an underutilized measure of lung recovery, easily performed prior to proceeding with a trial-off V-V ECLS as part of a weaning algorithm. Evidence-based thresholds for OCT results which support continuing with V-V ECLS weaning are lacking, making interpretation of these tests challenging in clinical practice. METHODS We performed a retrospective review of patients commenced on V-V ECLS as a bridge-to-recovery at Vancouver General Hospital from 2015-2019. The absolute PaO2 post-OCT and change in PaO2 proportional to incremental FiO2 change on the ventilator (∆PaO2 ) were evaluated as predictive screening metrics for identifying conditions favorable for successful trial-off of V-V ECLS. RESULTS An optimal cut-off of PaO2 ≥ 240 mm Hg post-OCT (AUC 0.77) and ∆PaO2 ≥ 250 mm Hg (AUC 0.76) was identified as a threshold for predicting successful trials-off. A total of 26 and 24 patients achieved post-OCT PaO2 and ∆PaO2 thresholds, and 100% of these patients were liberated successfully from ECLS during their admission. CONCLUSIONS The OCT can serve as an effective screen of shunt reduction and native lung recovery which can be used alongside other measures of ventilation to assess for suitability of liberation from V-V ECLS prior to a trial-off. Achieving a PaO2 ≥ 240 mm Hg post-OCT is a strong prognostic indicator for successful liberation from V-V ECLS during ICU admission.
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Affiliation(s)
- Gary P Misselbrook
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,School of Anaesthesia, Health Education England South East, Winchester, UK.,School of Medicine, Health Education England South East, Winchester, UK
| | - Hussein Kanji
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sonny Thiara
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Juan J Ronco
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Simmie Kalan
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Leo Chen
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amandeep Sidhu
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
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Complications Associated With Venovenous Extracorporeal Membrane Oxygenation-What Can Go Wrong? Crit Care Med 2022; 50:1809-1818. [PMID: 36094523 DOI: 10.1097/ccm.0000000000005673] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short- and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications. DATA SOURCES English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.
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Teijeiro-Paradis R, Pesenti A, Fan E. Weaning from Veno-Venous ECMO: Lessons from 60 Years of Weaning from Mechanical Ventilation. Am J Respir Crit Care Med 2022; 206:928-930. [PMID: 35727205 PMCID: PMC9802004 DOI: 10.1164/rccm.202206-1104ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione e Emergenza-Urgenza,Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico)Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italy,Department of Pathophysiology and TransplantationUniversity of MilanMilan, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Institute of Health Policy Management and EvaluationUniversity of TorontoToronto, Ontario, Canada
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13
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Castro DM, Morris I, Teijeiro-Paradis R, Fan E. Monitoring during extracorporeal membrane oxygenation. Curr Opin Crit Care 2022; 28:348-359. [PMID: 35275878 DOI: 10.1097/mcc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. RECENT FINDINGS Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SUMMARY Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Idunn Morris
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Discipline of Intensive Care Medicine, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Institute of Health Policy, Management and Evaluation
- Department of Medicine, University of Toronto, Toronto, Canada
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14
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Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study. Crit Care Explor 2022; 4:e0689. [PMID: 35517643 PMCID: PMC9067359 DOI: 10.1097/cce.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Zheng Y, Sun H, Mei Y, Gao Y, Lv J, Pan D, Wang L, Zhang X, Hu D, Sun F, Li W, Zhang G, Zhang H, Chen Y, Wang S, Zhang Z, Li B, Chen X, Zhang J, Lu X. Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial. Front Cardiovasc Med 2022; 8:779695. [PMID: 35071352 PMCID: PMC8777013 DOI: 10.3389/fcvm.2021.779695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/29/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO). Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL). Discussion: The CaRe-ECMO is designed to answer the question “whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO).” Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy. Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT05035797.
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Affiliation(s)
- Yu Zheng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Sun
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Mei
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yongxia Gao
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinru Lv
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dijia Pan
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Wang
- Department of Rehabilitation Medicine, Qingdao Municipal Hospital, Qingdao, China
| | - Xintong Zhang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Deliang Hu
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Sun
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Li
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huazhong Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Chen
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shenrui Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongman Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Baoquan Li
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xufeng Chen
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinsong Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao Lu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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A Daily, Respiratory Therapist Assessment of Readiness to Liberate From Venovenous Extracorporeal Membrane Oxygenation in Patients With Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0584. [PMID: 34881366 PMCID: PMC8647875 DOI: 10.1097/cce.0000000000000584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We assessed the effect of implementing a protocol-directed strategy to determine when patients can be liberated from venovenous extracorporeal membrane oxygenation on extracorporeal membrane oxygenation duration, time to initiation of first sweep-off trial, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and survival to hospital discharge. Design Single-center retrospective before and after study. Setting The medical ICU at an academic medical center. Patients One-hundred eighty patients with acute respiratory distress syndrome managed with venovenous extracorporeal membrane oxygenation at a single institution from 2013 to 2019. Interventions In 2016, our institution implemented a daily assessment of readiness for a trial off extracorporeal membrane oxygenation sweep gas ("sweep-off trial"). When patients met prespecified criteria, the respiratory therapist performed a sweep-off trial to determine readiness for discontinuation of venovenous extracorporeal membrane oxygenation. Measurements and Main Results Sixty-seven patients were treated before implementation of the sweep-off trial protocol, and 113 patients were treated after implementation. Patients managed using the sweep-off trial protocol had a significantly shorter extracorporeal membrane oxygenation duration (5.5 d [3-11 d] vs 11 d [7-15.5 d]; p < 0.001), time to first sweep-off trial (2.5 d [1-5 d] vs 7.0 d [5-11 d]; p < 0.001), duration of mechanical ventilation (15.0 d [9-31 d] vs 25 d [21-33 d]; p = 0.017), and ICU length of stay (18 d [10-33 d] vs 27.0 d [21-36 d]; p = 0.008). There were no observed differences in hospital length of stay or survival to hospital discharge. Conclusions In patients with acute respiratory distress syndrome managed with venovenous extracorporeal membrane oxygenation at our institution, implementation of a daily, respiratory therapist assessment of readiness for a sweep-off trial was associated with a shorter time to first sweep-off trial and shorter duration of extracorporeal membrane oxygenation. Among survivors, the postassessment group had a reduced duration of mechanical ventilation and ICU lengths of stay. There were no observed differences in hospital length of stay or inhospital mortality.
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Madahar P, Burkart KM, Brodie D. Standardizing the Approach to Liberation From Venovenous Extracorporeal Membrane Oxygenation. Chest 2021; 160:1583-1584. [PMID: 34743837 DOI: 10.1016/j.chest.2021.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Purnema Madahar
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Kristin M Burkart
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Martucci G, Arcadipane A, Tuzzolino F, Occhipinti G, Panarello G, Carcione C, Bertani A, Conaldi PG, Miceli V. Circulating miRNAs as Promising Biomarkers to Evaluate ECMO Treatment Responses in ARDS Patients. MEMBRANES 2021; 11:membranes11080551. [PMID: 34436314 PMCID: PMC8398026 DOI: 10.3390/membranes11080551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) has increased in the last decade. However, mortality remains high, and the complexity of ECMO requires individualized treatment. There are some biomarkers to monitor progression and predict clinical outcomes of ARDS. This project aims to advance the management of ARDS patients treated with ECMO by exploring miRNA expression in whole blood. The analysis was conducted on two groups with different length of ECMO: Group A (longer runs) and group B (shorter runs). We analyzed miRNAs before ECMO cannulation, and at 7 and 14 days of ECMO support. Our results showed that in the group B patients, 11 deregulated miRNAs were identified, and showed an opposite trend of expression compared to the group A patients. In silico analysis revealed that these 11 miRNAs were related to processes involved in the pathogenesis and evolution of ARDS. This scenario could represent homeostatic mechanisms by which, in ECMO responsive patients, pathways activated during ARDS progression are switched-off. Circulating miRNAs could represent promising biomarkers to monitor the evolution of ARDS under ECMO support. Further studies may shed light on this topic to improve a personalized approach in such a complex setting of patients.
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Affiliation(s)
- Gennaro Martucci
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Antonio Arcadipane
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Fabio Tuzzolino
- Research Department, IRCCS-ISMETT, 90127 Palermo, Italy; (F.T.); (P.G.C.)
| | - Giovanna Occhipinti
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Giovanna Panarello
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, 90127 Palermo, Italy;
| | | | - Vitale Miceli
- Research Department, IRCCS-ISMETT, 90127 Palermo, Italy; (F.T.); (P.G.C.)
- Correspondence: ; Tel.: +39-091-219-2430
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