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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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Other Cardiovascular Devices. Biomater Sci 2013. [DOI: 10.1016/b978-0-08-087780-8.00069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kasten KR, Makley AT, Kagan RJ. Update on the critical care management of severe burns. J Intensive Care Med 2011; 26:223-36. [PMID: 21764766 DOI: 10.1177/0885066610390869] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.
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Affiliation(s)
- Kevin R Kasten
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45229, USA
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Respiratory dialysis: Reduction in dependence on mechanical ventilation by venovenous extracorporeal CO2 removal*. Crit Care Med 2011; 39:1382-7. [DOI: 10.1097/ccm.0b013e31820eda45] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee WS, Chee HK, Song MG, Kim YH, Shin JK, Kim JS, Lee SA, Hwang JJ. Short-term Mechanical Circulatory Support with a Centrifugal Pump - Results of Peripheral Extracorporeal Membrane Oxygenator According to Clinical Situation. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:9-17. [PMID: 22263118 PMCID: PMC3249283 DOI: 10.5090/kjtcs.2011.44.1.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 09/19/2010] [Accepted: 01/20/2011] [Indexed: 12/01/2022]
Abstract
Background A peripheral extracorporeal membrane oxygenator (p-ECMO) has been developed to support patients who are dying due to a serious cardiopulmonary condition. This analysis was planned to define the clinical situation in which the patient benefits most from a p-ECMO. Material and Methods Between June 2007 and Aug 2009, a total of 41 adult patients used the p-ECMO. There were 23 males and 18 females (mean age 54.4±15.1 years). All patients had very unstable vital signs with hypoxia and complex cardiac problems. We divided the patients into 4 groups. In the first group, a p-ECMO was used as a bridge to cardiac operation. In the second group, patients did not have the opportunity to undergo any cardiac procedures; nevertheless, they were treated with a p-ECMO. In the third group, patients mostly had difficulty in weaning from CPB (cardiopulmonary bypass) after cardiac operation. The fourth group suffered from many complications, such as pneumonia, bleeding, infections, and LV dysfunction with underlying cardiac problems. All cannulations were performed by the Seldinger technique or cutting down the femoral vessel. A long venous cannula of DLP® (Medtronic Inc, Minneapolis, MN) or RMI® (Edwards Lifesciences LLC, Irvine, CA) was used together with a 17~21 Fr arterial cannula and a 21 Fr venous cannula. As a bypass pump, a Capiox emergency bypass system (EBS®; Terumo, Tokyo, Japan) was used. We attempted to maintain a flow rate of 2.4~3.0 L/min/m2 and an activated clotting time (ACT) of around 180 seconds. Results Nine patients survived by the use of the p-ECMO. Ten patients were weaned from a p-ECMO but they did not survive, and the remainder had no chance to be weaned from the p-ECMO. The best clinical situation to apply the p-ECMO was to use it as a bridge to cardiac operation and for weaning from CPB after cardiac operation. Conclusion Various clinical results were derived by p-ECMO according to the clinical situation. For the best results, early adoption of the p-ECMO for anatomical correction appears important.
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Affiliation(s)
- Woo Surng Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Korea
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Sanchez-Lorente D, Go T, Jungebluth P, Rovira I, Mata M, Ayats MC, Macchiarini P. Single double-lumen venous–venous pump-driven extracorporeal lung membrane support. J Thorac Cardiovasc Surg 2010; 140:558-63, 563.e1-2. [DOI: 10.1016/j.jtcvs.2009.12.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 11/08/2009] [Accepted: 12/12/2009] [Indexed: 11/12/2022]
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Gómez-Caro A, Badia JR, Ausin P. [Extracorporeal lung assist in severe respiratory failure and ARDS. Current situation and clinical applications]. Arch Bronconeumol 2010. [PMID: 20937437 DOI: 10.1016/s1579-2129(11)60006-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite improvements in ventilation support techniques, lung protection strategies, and the application of new support treatment, acute respiratory distress syndrome continues to have a high mortality rate. Many strategies and treatments for this syndrome have been investigated over the last few year. However, the only therapeutic measure that has systematically shown to be able to improve survival is that of low volume lung protective ventilation. Thus, using a low tidal volume prevents added lung damage by the same mechanical ventilation that is essential for life support. In this context, the use of extracorporeal lung assist systems is considered an exceptional use rescue treatment in extreme cases. On the other hand, it could be a potentially useful complementary method for an ultra-protective ventilation strategy, that is, by using even lower tidal volumes. The currently available extracorporeal lung assist systems are described in this article, including high flow systems such as traditional extracorporeal membrane oxygenation, CO₂ removal systems (interventional lung assist or iLA, with or without associated centrifugal pumps), and the new low flow and less invasive systems under development. The aim of this review is to update the latest available clinical and experimental data, the indications for these devices in adult respiratory distress syndrome (ARDS), and their potential indications in other clinical situations, such as the bridge to lung transplantation, multiple organ dysfunction syndrome, or COPD.
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Affiliation(s)
- Abel Gómez-Caro
- Instituto del Tórax, Hospital Clínic de Barcelona, Universidad de Barcelona, CIBER de enfermedades respiratorias CIBERES, España.
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Gómez-Caro A, Badia JR, Ausin P. [Extracorporeal lung assist in severe respiratory failure and ARDS. Current situation and clinical applications]. Arch Bronconeumol 2010; 46:531-7. [PMID: 20937437 DOI: 10.1016/j.arbres.2010.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 04/19/2010] [Accepted: 05/03/2010] [Indexed: 11/17/2022]
Abstract
Despite improvements in ventilation support techniques, lung protection strategies, and the application of new support treatment, acute respiratory distress syndrome continues to have a high mortality rate. Many strategies and treatments for this syndrome have been investigated over the last few year. However, the only therapeutic measure that has systematically shown to be able to improve survival is that of low volume lung protective ventilation. Thus, using a low tidal volume prevents added lung damage by the same mechanical ventilation that is essential for life support. In this context, the use of extracorporeal lung assist systems is considered an exceptional use rescue treatment in extreme cases. On the other hand, it could be a potentially useful complementary method for an ultra-protective ventilation strategy, that is, by using even lower tidal volumes. The currently available extracorporeal lung assist systems are described in this article, including high flow systems such as traditional extracorporeal membrane oxygenation, CO₂ removal systems (interventional lung assist or iLA, with or without associated centrifugal pumps), and the new low flow and less invasive systems under development. The aim of this review is to update the latest available clinical and experimental data, the indications for these devices in adult respiratory distress syndrome (ARDS), and their potential indications in other clinical situations, such as the bridge to lung transplantation, multiple organ dysfunction syndrome, or COPD.
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Affiliation(s)
- Abel Gómez-Caro
- Instituto del Tórax, Hospital Clínic de Barcelona, Universidad de Barcelona, CIBER de enfermedades respiratorias CIBERES, España.
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Oshima K, Kunimoto F, Hinohara H, Ohkawa M, Mita N, Tajima Y, Saito S. Extracorporeal membrane oxygenation for respiratory failure: Comparison of venovenous versus venoarterial bypass. Surg Today 2010; 40:216-22. [DOI: 10.1007/s00595-008-4040-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Accepted: 12/24/2008] [Indexed: 11/29/2022]
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Lee SJ, Chee HK, Hwang JJ, Kim JS, Lee SA, Kim JS. Application of Veno-venoarterial Extracorporeal Membrane Oxygenation in Multitrauma Patient with ARDS -A case report-. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.1.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sung Jun Lee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
| | - Jae Joon Hwang
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
| | - Jun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
| | - Song Am Lee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
| | - Jin Sik Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital
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Key questions in ventilator management of the burn-injured patient (second of two parts). J Burn Care Res 2009; 30:211-20. [PMID: 19165105 DOI: 10.1097/bcr.0b013e318198a33f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Iglesias M, Jungebluth P, Petit C, Matute MP, Rovira I, Martínez E, Catalan M, Ramirez J, Macchiarini P. Extracorporeal lung membrane provides better lung protection than conventional treatment for severe postpneumonectomy noncardiogenic acute respiratory distress syndrome. J Thorac Cardiovasc Surg 2008; 135:1362-71. [DOI: 10.1016/j.jtcvs.2007.08.074] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 08/01/2007] [Accepted: 08/27/2007] [Indexed: 10/22/2022]
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Abstract
Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. Injuries to the heart, the aorta, the esophagus, and the diaphragm are rare. Lung contusion and laceration cause parenchymal hemorrhage and consolidation sometimes accompanied by pneumothorax and/or hemothorax. Tracheobronchial disruption is rare but life-threatening. Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.
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Iglesias M, Martinez E, Badia JR, Macchiarini P. Extrapulmonary ventilation for unresponsive severe acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 2008; 85:237-44; discussion 244. [PMID: 18154817 DOI: 10.1016/j.athoracsur.2007.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 05/18/2007] [Accepted: 06/01/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the feasibility of integrating an artificial, pumpless extracorporeal membrane ventilator (Novalung) to near static mechanical ventilation and its efficacy in patients with severe postresectional acute respiratory distress syndrome (ARDS) unresponsive to optimal conventional treatment. METHODS Indications were severe postresectional and unresponsive acute respiratory distress syndrome, hemodynamic stability, and no significant peripheral arterial occlusive disease or heparin-induced thrombocytopenia. Management included placement of the arteriovenous femoral transcutaneous interventional lung-assist membrane ventilator, lung rest at minimal mechanical ventilator settings, and optimization of systemic oxygen consumption and delivery. RESULTS Among 239 pulmonary resections performed between 2005 and 2006, 7 patients (2.9%) experienced, 4 +/- 0.8 days after 5 pneumonectomies and 2 lobectomies, a severe (Murray score, 2.9 +/- 0.3) acute respiratory distress syndrome unresponsive to 4 +/- 2 days of conventional therapy. The interventional lung-assist membrane ventilator was left in place 4.3 +/- 2.5 days, and replaced only once for massive clotting. During this time, 29% +/- 0.3% or 1.4 +/- 0.36 L/min of the cardiac output perfused the device, without hemodynamic impairment. Using a sweep gas flow of 10.7 +/- 3.8 L/min, the device allowed an extracorporeal carbon dioxide removal of 255 +/- 31 mL/min, lung(s) rest (tidal volume, 2.7 +/- 0.8 mL/kg; respiratory rate, 6 +/- 2 beats/min; fraction of inspired oxygen, 0.5 +/- 0.1), early (<24 hours) significant improvement of respiratory function, and reduction of plasmatic interleukin-6 levels (p < 0.001) and Murray score (1.25 +/- 0.1; p < 0.003). All but 1 patient (14%) who died of multiorgan failure were weaned from mechanical ventilation 8 +/- 3 days after removal of the interventional lung-assist membrane ventilator, and all of them were discharged from the hospital. CONCLUSIONS The integration of this device to near static mechanical ventilation of the residual native lung(s) is feasible and highly effective in patients with severe and unresponsive acute respiratory distress syndrome after pulmonary resection.
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Affiliation(s)
- Manuela Iglesias
- Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Ostrea EM, Villanueva-Uy ET, Natarajan G, Uy HG. Persistent pulmonary hypertension of the newborn: pathogenesis, etiology, and management. Paediatr Drugs 2007; 8:179-88. [PMID: 16774297 DOI: 10.2165/00148581-200608030-00004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is characterized by severe hypoxemia shortly after birth, absence of cyanotic congenital heart disease, marked pulmonary hypertension, and vasoreactivity with extrapulmonary right-to-left shunting of blood across the ductus arteriosus and/or foramen ovale. In utero, a number of factors determine the normally high vascular resistance in the fetal pulmonary circulation, which results in a higher pulmonary compared with systemic vascular pressure. However, abnormal conditions may arise antenatally, during, or soon after birth resulting in the failure of the pulmonary vascular resistance to normally decrease as the circulation evolves from a fetal to a postnatal state. This results in cyanosis due to right-to-left shunting of blood across normally existing cardiovascular channels (foramen ovale or ductus arteriosus) secondary to high pulmonary versus systemic pressure. The diagnosis is made by characteristic lability in oxygenation of the infant, echocardiographic evidence of increased pulmonary pressure, with demonstrable shunts across the ductus arteriosus or foramen ovale, and the absence of cyanotic heart disease lesions. Management of the disease includes treatment of underlying causes, sedation and analgesia, maintenance of adequate systemic blood pressure, and ventilator and pharmacologic measures to increase pulmonary vasodilatation, decrease pulmonary vascular resistance, increase blood and tissue oxygenation, and normalize blood pH. Inhaled nitric oxide has been one of the latest measures to successfully treat PPHN and significantly reduce the need for extracorporeal membrane oxygenation.
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Abstract
Extracorporeal membrane oxygenation (ECMO) is the utilization of a modified heart-lung machine to provide temporary support for patients with severe respiratory or cardiac failure. In contrast to patients managed with traditional cardiopulmonary bypass, patients on ECMO undergo cannulation of relatively accessible blood vessels, are maintained at normal body temperature, and only require partial anticoagulation with heparin. Although first developed for use in adults, ECMO has been most successful in the treatment of newborn infants with life-threatening pulmonary failure. Since 1974, over 17,000 infants have received ECMO with a 78% survival rate. There is a 15%-20% incidence of neurodevelopmental disabilities among ECMO survivors.
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Affiliation(s)
- Philip J Wolfson
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Langham MR, Kays DW, Beierle EA, Chen MK, Stringfellow K, Talbert JL. Expanded application of extracorporeal membrane oxygenation in a pediatric surgery practice. Ann Surg 2003; 237:766-72; discussion 772-4. [PMID: 12796572 PMCID: PMC1514689 DOI: 10.1097/01.sla.0000067740.05989.45] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the breadth of application and resulting outcomes in a university-based extracorporeal membrane oxygenation (ECMO) program directed by pediatric surgeons. SUMMARY BACKGROUND DATA Several randomized control trials have supported the use of ECMO in neonates with respiratory failure. No comparable data exist for older children and young adults who may be afflicted with a variety of uncommon conditions. The indications for ECMO in these patients remain controversial. METHODS Patient data were recorded prospectively and reported to the Extracorporeal Life Support Organization. These data were analyzed by indications and outcomes on all patients treated since the inception of the program. RESULTS Two hundred sixteen patients were treated with 225 courses of ECMO. Neonates (188 [87%]) outnumbered 28 older patients (aged 6 weeks to 22 years). Overall, 174 patients survived (81%). Sixty-four of 65 (98.5%) neonates with meconium aspiration syndrome survived. ECMO support after heart (3), lung (2), heart-lung (1), and liver (1) transplant yielded a 57% survival to discharge. ECMO also resulted in survival of patients with uncommon conditions, including severe asthma (1), hydrocarbon aspiration (1/2), congestive heart failure due to a cerebral arteriovenous malformation (1), tracheal occlusion incurred during endoscopic stent manipulation (2), meningitis (1), and viral pneumonia (3/5). CONCLUSIONS ECMO can potentially eliminate mortality for meconium aspiration syndrome. Survival for other causes of respiratory failure in neonates and older children, while not as dramatic, still surpasses that anticipated with conventional therapy. Moreover, survival of transplant patients has been comparable to that achieved in other children.
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Affiliation(s)
- Max Raymond Langham
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, J-100286, Gainesville, FL 32610-0286, USA.
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Borovetz HS, Burke JF, Chang TMS, Colas A, Cranin AN, Curtis J, Gemmell CH, Griffith BP, Hallab NJ, Heller J, Hoffman AS, Jacobs JJ, Ideker R, Katz JL, Kennedy J, Lemons JE, Malchesky PS, Morgan JR, Padera RE, Patel AS, Reffojo MF, Roby MS, Rohr TE, Schoen FJ, Sefton MV, Sheridan RT, Smith DC, Spelman FA, Tarcha PJ, Tomapkins RG, Venugopalan R, Wagner WR, Yager P, Yarmush ML. Application of Materials in Medicine, Biology, and Artificial Organs. Biomater Sci 1996. [DOI: 10.1016/b978-012582460-6/50010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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