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Long B, Bridwell RE, DeVivo A, Gottlieb M. Transvenous Pacemaker Placement: A Review for Emergency Clinicians. J Emerg Med 2024; 66:e492-e502. [PMID: 38453595 DOI: 10.1016/j.jemermed.2023.11.018] [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: 04/24/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine. OBJECTIVE This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting. DISCUSSION Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire. CONCLUSIONS An understanding of transvenous pacemaker placement is essential for emergency clinicians.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Anthony DeVivo
- Department of Emergency Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at The Mount Sinai Hospital, New York, New York
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University, Chicago, Illinois
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Li B, Fan W, Yang Y, Qu X, Tong J, Liu Y, Tan J, Jiang W, Yu B. Peri-procedural variables and outcomes of long-period hemodynamic instability after carotid artery angioplasty and stenting. Vascular 2023; 31:892-901. [PMID: 35466838 DOI: 10.1177/17085381221091369] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The aim of this study is to identify the peri-procedural risk factors and outcomes of hemodynamic instability (HI) after carotid artery stenting (CAS). METHODS A single-center, retrospective study was performed in 168 patients who underwent CAS procedure between September 2017 and September 2020. The presence of HI, as defined by hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg), and/or bradycardia (heart rate <60 bpm), was recorded. Long-period HI was defined as persistent HI lasting more than 24 h. Patient demographics, comorbidities, peri-procedural variables, and risk factors were recorded. Clinical outcomes including cerebral hyperperfusion syndrome, hemorrhage, transient ischemic attack (TIA), stroke, myocardial infarction, and mortality within 30 days of the procedure were evaluated. Logistic regression was used to analyze the independent risk factors of long-period HI following CAS. RESULTS Among 168 patients (mean age, 68.2 ± 8.3 years; 81.5% male), the frequency of post-procedural long-period HI was noted in 42 patients (25.0%). Male was prone to experience HI (odds ratio, 9.156, p = 0.021). Aggressive inflation pressure (>7 atm) and 5 mm balloon for pre-dilatation were risk factors of long-period HI (OR, 7.372, p = 0.035; OR, 3.527, p = 0.023). Intraoperative peak blood pressure and larger-sized stents remained independent predictors for the development of HI (OR, 1.043, p = 0.027, and OR, 1.973, p = 0.015). Patients with prolonged HI were more likely to suffer TIA and stroke compared to other patients and significant difference was found in the occurrence of TIA (p < 0.05). Non-significance was found in mortality rate and other outcomes. CONCLUSIONS CAS-induced HI occurs in a considerable percentage while several peri-procedural variables are determined as independent predictors to develop long-period HI. Patients with prolonged HI are associated with increased risk of neurologic events and thus standardized intervention as well as management of long-period HI are of critical importance during clinical process.
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Affiliation(s)
- Bo Li
- Medical College of Soochow University, Suzhou, P. R. China
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
| | - Weijian Fan
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, P. R. China
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, P. R. China
| | - Yihan Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
| | - Xiaofeng Qu
- Department of Neurology, Yancheng City No.1 People's Hospital, Yancheng, P.R. China
| | - Jindong Tong
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, P. R. China
| | - Yizhi Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, P.R. China
| | - Jinyun Tan
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Fudan Zhangjiang Institute, Shanghai, P.R. China
| | - Weijian Jiang
- New Era Stroke Care and Research Institute, The PLA Force Characteristic Medical Center, Beijing, P. R. China
| | - Bo Yu
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, P. R. China
- Fudan Zhangjiang Institute, Shanghai, P.R. China
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Chen M, Wang Z, Wang S, Zhu T, Liu Z, Li X, Wu Z, Liu Q, Zhou S. Bedside temporary transvenous cardiac pacing lead placement in patients with tricuspid valve surgery without guidance of X‐ray: A single‐center experience. Ann Noninvasive Electrocardiol 2022; 27:e13006. [DOI: 10.1111/anec.13006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/15/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mingxian Chen
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
| | - Zhuo Wang
- Department of Cardiology Wuhan Renmin Hospital of Wuhan University Wuhan China
| | - Songyun Wang
- Department of Cardiology Wuhan Renmin Hospital of Wuhan University Wuhan China
| | - Tongjian Zhu
- Department of Cardiology Wuhan Renmin Hospital of Wuhan University Wuhan China
| | - Zhenjiang Liu
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
| | - Xuping Li
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
| | - Zhihong Wu
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
| | - Qiming Liu
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
| | - Shenghua Zhou
- Department of Cardiology The Second Xiangya Hospital of Central South University Changsha China
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Comparative evaluation of the clinical safety and efficiency of supraclavicular and infraclavicular approaches for subclavian venous catheterization in adults: A meta-analysis. Am J Emerg Med 2020; 38:1475-1480. [DOI: 10.1016/j.ajem.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/25/2020] [Accepted: 04/03/2020] [Indexed: 12/28/2022] Open
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Bush RL, Lin PH, Bianco CC, Hurt JE, Lawhorn TI, Lumsden AB. Reevaluation of Temporary Transvenous Cardiac Pacemaker Usage During Carotid Angioplasty and Stenting: A Safe and Valuable Adjunct. Vasc Endovascular Surg 2016; 38:229-35. [PMID: 15181504 DOI: 10.1177/153857440403800306] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although many current series document the safety of carotid angioplasty and stenting procedures (CAS), several acknowledge clinically significant hemodynamic disturbances in 25–71% of patients. We report herein the safety and efficacy of prophylactic percutaneous temporary transvenous cardiac pacemaker insertion during CAS for the prevention of hemodynamic changes. At a community-based institution, 48 patients undergoing 51 attempted CAS procedures from March 1999 to August 2002 for carotid artery occlusive disease were retrospectively reviewed. Thirty-one percent of patients had procedures performed for either recurrent disease or a history of neck radiation; 62.5% had significant coronary disease. Temporary transvenous pacemakers were inserted as an adjunctive procedure in the authors’ CAS protocol. The pacers were set to capture a heart rate decrease below 60 beats per minute. Demographics, cardiac risk, and outcomes were analyzed. CAS was successfully performed in 96% (49 lesions). In the intent-to-treat group, the patients had a mean age of 71 ±9 years and angiographic stenoses of 88 ±8%, with 29% having symptomatic lesions. Significant bradycardia or asystole to trigger ventricular pacing occurred in 11 (22%) procedures, thus, triggering ventricular pacing. Pharmacologic support for concomitant hypotension was temporarily necessary in only 4 (8%) cases. No patient required prolonged pacing or medication therapy following CAS. Neither presence of carotid-related symptoms nor disease etiology was related to need for intraprocedural pacing. Furthermore, there was no occurrence of pacemaker failure or other complication secondary to venous catheterization. Hemodynamic changes may occur during mechanical dilation of the carotid artery and bulb, with reports in the literature of the need for prolonged pharmacologic support. In selected patients, the prophylactic placement of a transvenous pacemaker is a safe, feasible, and expeditious method to treat periprocedural hemodynamic changes with a decrease in additional pharmacologic support during CAS.
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Affiliation(s)
- Ruth L Bush
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine and The Methodist Hospital, Houston, TX, USA.
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Sullivan BL, Bartels K, Hamilton N. Insertion and Management of Temporary Pacemakers. Semin Cardiothorac Vasc Anesth 2015; 20:52-62. [PMID: 26134176 DOI: 10.1177/1089253215584923] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.
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L'italien AJ. Critical cardiovascular skills and procedures in the emergency department. Emerg Med Clin North Am 2013. [PMID: 23200332 DOI: 10.1016/j.emc.2012.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The management of cardiovascular emergencies is a fundamental component of the practice of an emergency practitioner. Delays in the evaluations and management can lead to significant morbidity or mortality. It is of vital importance to be familiar with procedures such as pericardiocentesis, cardioversion, defibrillation, temporary pacing, and options for the management of tachyarrhythmias. This article discusses the most common cardiovascular procedures encountered in an emergency setting, including the indications, contraindications, equipment, technique, and complications for each procedure.
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Affiliation(s)
- Anita J L'italien
- Department of Emergency Medicine, Wake Emergency Physicians, PA, 3000 New Bern Avenue, Medical Office Building, Raleigh, NC 27610, USA. l'
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Mylonas SN, Moulakakis KG, Antonopoulos CN, Kakisis JD, Liapis CD. Carotid Artery Stenting–Induced Hemodynamic Instability. J Endovasc Ther 2013; 20:48-60. [DOI: 10.1583/12-4015.1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Yamauchi M, Sasaki H, Yoshida T, Niiya T, Mizuno E, Narimatsu E, Yamakage M. Ultrasound-guided supraclavicular central venous catheterization in patients with malignant hematologic diseases. J Anesth 2012; 26:775-8. [DOI: 10.1007/s00540-012-1401-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/17/2012] [Indexed: 10/28/2022]
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Edwards EndoVent as a pacing catheter for minimally invasive aortic valve surgery: a novel approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 6:253-6. [PMID: 22437984 DOI: 10.1097/imi.0b013e31822c9f88] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The placement of epicardial pacing wires before weaning from bypass during port-access heart surgery can be difficult or impossible. Sometimes, it is necessary to pacing the patient to wean from bypass, and it is problematic to exchange the Edwards pulmonary vent (EndoVent) for a pace catheter under the drapes. Our objective was to devise an effective means of pacing the patient using the pulmonary vent catheter. METHODS All patients having aortic valve minimally invasive port-access surgery have a pacing wire deployed through the Edwards EndoVent catheter. We did a retrospective chart analysis of these cases. RESULTS After reviewing the anesthesia records, we determined that we were able to reliably convert the pulmonary vent catheter, which is beneficial for the surgery, into a pacing catheter before weaning from bypass 100% of the time. The mean pacing threshold current was 1.60 mA with the wire in the right ventricular apex. CONCLUSIONS We found that in all 25 patients we were able to rapidly convert the vent catheter into a reliable pacing catheter without any complications.
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Risgaard B, Elming H, Jensen GV, Johansen JB, Toft JC. Waiting for a pacemaker: is it dangerous? Europace 2012; 14:975-80. [PMID: 22333242 DOI: 10.1093/europace/eus016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS To determine waiting period-related morbidity, mortality, and adverse events in acute patients waiting for a permanent pacemaker (PPM). METHODS AND RESULTS A retrospective chart review of all PPM implantations in Region Zealand, Denmark, in 2009 was conducted. Patients were excluded if they were discharged from the hospital during the waiting period or referred from the outpatient department. Adverse events were tracked. Four hundred and eighty-seven PPM implantations were identified. Of these, 259 patients (53.2%) required acute PPM implantation and waited a mean of 5.1 days from PPM indication to implantation. A lack of implantation capacity was responsible for 4.5 of the waiting days. Twenty-nine patients (11.2%) developed infection while waiting, primarily urinary tract infections. Thirteen patients (5.0%) suffered non-sustained ventricular tachycardia, and eight patients (3.1%) suffered clinical cardiac arrest followed by successful resuscitation. Three patients (1.2%) died during the waiting period before successful implantation. Forty-eight patients (18.5%) received the sympathomimetic beta-adrenergic agent, isoprenaline, and seven patients (13.7%) had malignant arrhythmias or cardiac arrest, reaching statistical significance (P < 0.05). Twenty-eight patients (10.8%) had a temporary transvenous-pacing catheter applied acutely. CONCLUSIONS The patients awaited acute PPM implantations for a mean of 4.5 days because of capacity problems. Overall, 83 patients (32.0%) experienced at least one adverse event during the waiting period. The present study indicates that a waiting period is dangerous as it is associated with an increased risk of adverse events. Acute PPMs should be implanted with a 24-h pacemaker implantation service capacity.
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Affiliation(s)
- Bjarke Risgaard
- Department of Cardiology, Roskilde Hospital, Koegevej 7-13, 4000 Roskilde, Denmark.
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Kocum A, Sener M, Calıskan E, Bozdogan N, Atalay H, Aribogan A. An Alternative Central Venous Route for Cardiac Surgery: Supraclavicular Subclavian Vein Catheterization. J Cardiothorac Vasc Anesth 2011; 25:1018-23. [DOI: 10.1053/j.jvca.2011.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Indexed: 11/11/2022]
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Kraidin JL, Pantin EJ, Anderson MB, Zhou BL, Solina AR. Edwards EndoVent as a Pacing Catheter for Minimally Invasive Aortic Valve Surgery a Novel Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jonathan L. Kraidin
- Department of Anesthesia, Robert Wood Johnson University Hospital, UMDNJ-RWJ Medical School, New Brunswick, NJ USA
| | - Enrique J. Pantin
- Department of Anesthesia, Robert Wood Johnson University Hospital, UMDNJ-RWJ Medical School, New Brunswick, NJ USA
| | - Mark B. Anderson
- Department of Anesthesia, Robert Wood Johnson University Hospital, UMDNJ-RWJ Medical School, New Brunswick, NJ USA
| | - Bo-Lu Zhou
- Department of Anesthesia, Robert Wood Johnson University Hospital, UMDNJ-RWJ Medical School, New Brunswick, NJ USA
| | - Alann R. Solina
- Department of Anesthesia, Robert Wood Johnson University Hospital, UMDNJ-RWJ Medical School, New Brunswick, NJ USA
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Affiliation(s)
- A Ricci
- Service de chirurgie digestive, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
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Im SH, Han MH, Kim SH, Kwon BJ. Transcutaneous Temporary Cardiac Pacing in Carotid Stenting:Noninvasive Prevention of Angioplasty-Induced Bradycardia and Hypotension. J Endovasc Ther 2008; 15:110-6. [DOI: 10.1583/07-2244.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Locker GJ, Losert H, Schellongowski P, Thalhammer F, Knapp S, Laczika KF, Burgmann H, Staudinger T, Frass M, Muhm M. Bedside exclusion of clinically significant recirculation volume during venovenous ECMO using conventional blood gas analyses. J Clin Anesth 2003; 15:441-5. [PMID: 14652122 DOI: 10.1016/s0952-8180(03)00108-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To investigate prospectively whether blood gas samples drawn from extracorporeal membrane oxygenation (ECMO) cannulae help to exclude at least clinically significant recirculation volumes in patients with acute respiratory failure. DESIGN Feasibility study. SETTING Intensive care unit at a university-affiliated hospital. PATIENTS Ten consecutive adult patients suffering from severe respiratory failure and undergoing ECMO. INTERVENTIONS The drawing (venous) ECMO cannula was placed into the inferior vena cava via a femoral vein, and the oxygenated blood was returned via the right subclavian vein by supraclavicular access directly into the right atrium. Blood gas samples were obtained from both cannulae. MEASUREMENTS AND MAIN RESULTS The median arterial oxygen tension (PaO(2)) obtained from the arterial cannula was 537 mmHg (range, 366 to 625 mmHg), the median mixed venous oxygen tension (PvO(2)) drawn from the venous cannula was 42 mmHg (range, 25 to 54 mmHg), which was less than 10% of that observed in the arterial cannula, and also within the physiologic range of PvO(2). The ECMO flow necessary to maintain patients' oxygen saturation above 90% (4.1 L/min; range, 1.95 to 5.8 L/min) was significantly lower than the patients' cardiac output (CO; 6.2 L/min; range, 4.1 to 7.9 L/min; p < 0.001). CONSLUSIONS; We recommend obtaining blood gas samples-immediately after initiation of ECMO-from both cannulae. A PvO(2) within physiologic range and below 10% of PaO(2) rules out any clinically relevant recirculation volume.
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Affiliation(s)
- Gottfried J Locker
- Department of Internal Medicine I, Intensive Care Unit, University Hospital of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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