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Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J 2021; 67:476-484. [PMID: 32657828 DOI: 10.1097/mat.0000000000001216] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal life support (ECLS) is indicated in refractory acute respiratory or cardiac failure. According to the need for anticoagulation, bleeding conditions (e.g., in trauma, pulmonary bleeding) have been considered a contraindication for the use of ECLS. However, there is increasing evidence for improved outcomes after ECLS support in hemorrhagic patients based on the benefits of hemodynamic support outweighing the increased risk of bleeding. We conducted a systematic literature search according to the PRISMA guidelines and reviewed publications describing ECLS support in hemorrhagic conditions. Seventy-four case reports, four case series, seven retrospective database observational studies, and one preliminary result of an ongoing study were reviewed. In total, 181 patients were identified in total of 86 manuscripts. The reports included patients suffering from bleeding caused by pulmonary hemorrhage (n = 53), trauma (n = 96), postpulmonary endarterectomy (n = 13), tracheal bleeding (n = 1), postpartum or cesarean delivery (n = 11), and intracranial hemorrhage (n = 7). Lower targeted titration of heparin infusion, heparin-free ECLS until coagulation is normalized, clamping of the endotracheal tube, and other ad hoc possibilities represent potential beneficial maneuvers in such conditions. Once the patient is cannulated and circulation restored, bleeding control surgery is performed for stabilization if indicated. The use of ECLS for temporary circulatory or respiratory support in critical patients with refractory hemorrhagic shock appears feasible considering tailored ECMO management strategies. Further investigation is needed to better elucidate the patient selection and ECLS management approaches.
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Affiliation(s)
- Anne Willers
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Mariusz Kowalewski
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Paolo Meani
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Federica Jiritano
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Matteo Matteucci
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dario Fina
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Samuel Heuts
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Elham Bidar
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ehsan Natour
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Sels
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Thijs Delnoij
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Roberto Lorusso
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation 2018; 133:108-117. [PMID: 30336233 DOI: 10.1016/j.resuscitation.2018.10.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting. DISCUSSION Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction. CONCLUSION Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.
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Thistlethwaite PA, Madani MM, Kemp AD, Hartley M, Auger WR, Jamieson SW. Venovenous Extracorporeal Life Support After Pulmonary Endarterectomy: Indications, Techniques, and Outcomes. Ann Thorac Surg 2006; 82:2139-45. [PMID: 17126125 DOI: 10.1016/j.athoracsur.2006.07.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 07/05/2006] [Accepted: 07/06/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pulmonary endarterectomy is the accepted therapy for thromboembolic pulmonary hypertension. A recognized complication of this surgery is the postoperative development of reperfusion edema, a potentially fatal cause of respiratory failure. Because reperfusion edema can be a reversible process, temporizing support measures may be life saving. METHODS We retrospectively reviewed our experience with venovenous extracorporeal life support (V-V ECLS) from July 1990 to February 2006, in 20 adult patients (mean age 50.5 +/- 14.5 years) presenting with potentially reversible respiratory failure after pulmonary endarterectomy. This subset of patients comprised 1.12% of our total pulmonary endarterectomy experience during that time (1,790 cases). RESULTS Overall in-hospital survival was 30.0% for patients requiring ECLS support after pulmonary endarterectomy versus 94.2% for patients who underwent pulmonary endarterectomy alone during the same timeframe. V-V ECLS was instituted at a mean of 86.8 hours after surgery. The mean duration of V-V ECLS was 123.4 +/- 71.3 hours. The most common cause of death in ECLS patients after pulmonary endarterectomy was pulmonary hemorrhage. Survival was greater in patients cannulated within 120 hours of surgery (46.2% survival; 6 of 13 patients) compared with those cannulated after 120 hours (0 of 7 patients). Multiple logistic regression identified long duration of mechanical ventilation pre-ECLS and severity of preoperative pulmonary hypertension together as predictors of mortality. CONCLUSIONS A small subset of patients undergoing pulmonary endarterectomy develop temporary life-threatening respiratory failure secondary to severe reperfusion edema. In those patients with satisfactory hemodynamic outcome, V-V ECLS is a therapeutic option when all other conventional strategies have been exhausted.
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Affiliation(s)
- Patricia A Thistlethwaite
- Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California 92103-8892, USA.
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Goins WA. Morbidity and Mortality After Traumatic Pneumonectomy: The Effect of Compromised Oxygenation and Cardiac Function. J Intensive Care Med 1995. [DOI: 10.1177/088506669501000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
I describe the pathophysiological and hemodynamic events that occur after an emergency pneumonectomy for trauma and how they impact on subsequent mortality. Four patients were identified as requiring an emergency right pneumonectomy for trauma at a level 1 Urban Trauma Center within a 39-month period. A retrospective review of their hospital course served as the basis for our analysis. Three patients sustained gunshot wounds and one patient was a victim of blunt trauma. Hemodynamic data were available for three patients who survived more than 24 hours. All patients presented in shock and required massive transfusion. One patient died in the operating room due to air embolism and shock. After pneumonectomy, there was an increase in pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) more than 2 times normal, which coincided with a decrease in stroke volume, cardiac output, and right and left ventricular stroke work (RVSW/LVSW). The RVSW gradually increased to above normal levels by postoperative day 5, whereas the LVSWI remained below normal. Adult respiratory distress syndrome (ARDS) developed in all patients early in the postoperative period. There was evidence of oxygen delivery (DO2) dependent of oxygen consumption (VO2) and the DO2 remained below normal despite inotrope administration. The remaining three patients died 7 to 13 days after surgery due to various combinations of ARDS, cardiac failure, and sepsis. Until we have better methods to decrease PAP selectively, traumatic pneumonectomy should be avoided if possible, especially when it involves the right side or is associated with a contralateral lung injury. Early operative intervention and control of the pulmonary hilum may lessen the severity of shock. The hemodynamic changes that occur after pneumonectomy for trauma becomes additive in the presence of ARDS. This combination results in inadequate cardiac function, oxygen transport, and, ultimately, death.
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Affiliation(s)
- Wendell A. Goins
- Department of Surgery, Howard University College of Medicine, and General Surgery and Surgical Critical Care, District of Columbia General Hospital, Washington, DC
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