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ESC Heart Failure Feb 2022Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support...
Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno-arterial extracorporeal membrane oxygenation (va-ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio-economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment. Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence- and expert consensus-based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements. Conclusions This first evidence- and expert consensus-based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.
Topics: Extracorporeal Circulation; Extracorporeal Membrane Oxygenation; Germany; Humans; Practice Guidelines as Topic; Shock
PubMed: 34811959
DOI: 10.1002/ehf2.13718 -
Intensive Care Medicine Dec 2020Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a... (Review)
Review
Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCOR) uses lower blood flow rates through smaller cannulae and provides substantial CO elimination (~ 20-70% of total CO production), albeit with marginal improvement in oxygenation. The rationale for using ECCOR in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCOR for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
Topics: Adult; Extracorporeal Circulation; Extracorporeal Membrane Oxygenation; Humans; Respiration, Artificial; Respiratory Distress Syndrome; Tidal Volume
PubMed: 33140180
DOI: 10.1007/s00134-020-06290-1 -
American Journal of Respiratory and... Mar 2020Ventilator-induced lung injury remains a key contributor to the morbidity and mortality of acute respiratory distress syndrome (ARDS). Efforts to minimize this injury... (Review)
Review
Ventilator-induced lung injury remains a key contributor to the morbidity and mortality of acute respiratory distress syndrome (ARDS). Efforts to minimize this injury are typically limited by the need to preserve adequate gas exchange. In the most severe forms of the syndrome, extracorporeal life support is increasingly being deployed for severe hypoxemia or hypercapnic acidosis refractory to conventional ventilator management strategies. Data from a recent randomized controlled trial, a analysis of that trial, a meta-analysis, and a large international multicenter observational study suggest that extracorporeal life support, when combined with lower Vt and airway pressures than the current standard of care, may improve outcomes compared with conventional management in patients with the most severe forms of ARDS. These findings raise important questions not only about the optimal ventilation strategies for patients receiving extracorporeal support but also regarding how various mechanisms of lung injury in ARDS may potentially be mitigated by ultra-lung-protective ventilation strategies when gas exchange is sufficiently managed with the extracorporeal circuit. Additional studies are needed to more precisely delineate the best strategies for optimizing invasive mechanical ventilation in this patient population.
Topics: Carbon Dioxide; Extracorporeal Circulation; Extracorporeal Membrane Oxygenation; Humans; Oxygen; Pulmonary Gas Exchange; Respiration, Artificial; Respiratory Distress Syndrome; Ventilator-Induced Lung Injury
PubMed: 31726013
DOI: 10.1164/rccm.201907-1283CI -
Journal of Applied Physiology... Mar 2022Extracorporeal membrane oxygenation (ECMO) is a procedure used to aid respiratory function in critical patients, involving extracorporeal circulation (ECC) of blood....
Extracorporeal membrane oxygenation (ECMO) is a procedure used to aid respiratory function in critical patients, involving extracorporeal circulation (ECC) of blood. There is a limited number of studies quantifying the hemodynamic effects of ECC procedures on the microcirculation. We sought to mimic veno-arterial-ECMO flow conditions by use of a scaled-down circuit primed with either lactate Ringer (LR) or 5% human serum albumin (HSA). The circuit was first tested using benchtop runs with blood, and subsequently used for in vivo experiments in Golden Syrian hamsters instrumented with a dorsal window chamber to allow for quantification of microvascular hemodynamics and functional capillary density (FCD). Results showed significant impairment in FCD, and a reduction of arteriolar and venular blood flow, with HSA providing significant higher blood flows and FCD compared with LR. Changes in hematocrit and RBC labeling after ECC reflected a shift in plasma volume, which may stem from a loss in intravascular oncotic pressure due to priming fluids. The distribution of hemoglobin oxygen saturation in the microvasculature showed a significant decrease in venules after ECC. In addition, major organs such as the kidney and heart showed increases in both inflammatory and damage markers. These results suggest that ECC impairs microvasculature function and promotes ischemia and hypoxia in the tissues, which can be vital to understanding comorbid clinical outcomes from ECC procedures such as acute kidney injury and multiorgan dysfunction. ECC reduces microvascular perfusion, with no full recovery 24 h after ECC. HSA performed better as compared with LR in terms of FCD and venule flow, as well as venule oxygen saturation. Increases in inflammatory and damage markers in key organs were observed within all organs analyzed.
Topics: Animals; Capillaries; Cricetinae; Extracorporeal Circulation; Humans; Microcirculation; Microvessels; Oxygen; Perfusion
PubMed: 35085033
DOI: 10.1152/japplphysiol.00726.2021 -
Hematology. American Society of... Nov 2018The use of extracorporeal circulation for cardiac surgery and extracorporeal life support poses tremendous challenges to the hemostatic equilibrium given its diametric... (Review)
Review
The use of extracorporeal circulation for cardiac surgery and extracorporeal life support poses tremendous challenges to the hemostatic equilibrium given its diametric tendency to trigger hyper- and hypocoagulopathy. The necessity of anticoagulant therapy to counteract the hemostatic activation by the extracorporeal circuitry compounded by unfavorable patient and surgical factors significantly increase the risk of catastrophic bleeding in patients who require extracorporeal circulation. Preoperative measures, such as stratification of high-risk bleeding patients, and optimization of the modifiable variables, including anemia and thrombocytopenia, provide a crude estimation of the likelihood and may modify the risk of catastrophic bleeding. The anticipation for catastrophic bleeding subsequently prompts the appropriate preparation for potential resuscitation and massive transfusion. Equally important is intraoperative prevention with the prophylactic application of tranexamic acid, an antifibrinolytic agent that has promising benefits in reduction of blood loss and transfusion. In the event of uncontrolled catastrophic bleeding despite preemptive strategies, all effort must be centered on regaining hemostasis through surgical control and damage control resuscitation to protect against worsening coagulopathy and end organ failure. When control of bleeding is reinstated, management should shift focus from systemic therapy to targeted hemostatic therapy aimed at the potential culprits of coagulopathy as identified by point of care hemostatic testing. This review article outlines the strategies to appropriately intervene using prediction, prevention, preparation, protection, and promotion of hemostasis in managing catastrophic bleeding in extracorporeal circulation.
Topics: Catastrophic Illness; Extracorporeal Circulation; Hemorrhage; Humans; Risk Factors
PubMed: 30504353
DOI: 10.1182/asheducation-2018.1.522 -
The Journal of Medical Investigation :... 2020
Topics: Cardiopulmonary Bypass; Extracorporeal Circulation; Humans
PubMed: 33148893
DOI: 10.2152/jmi.67.229 -
Medicina (Kaunas, Lithuania) Feb 2023: Cardiopulmonary bypass (CPB) is an extracorporeal circuit that provides surgical access to an immobile and bloodless area, allowing for technical and procedural...
: Cardiopulmonary bypass (CPB) is an extracorporeal circuit that provides surgical access to an immobile and bloodless area, allowing for technical and procedural advances in cardiothoracic surgery. CBP can alter the integrity of the blood-brain barrier and cause changes in intracranial pressure (ICP) postoperatively. Optical nerve sheath diameter (ONSD) measurement is among the alternative non-invasive methods for ICP monitoring. In this study, we aimed to evaluate the optic nerve sheath diameter measurements under the guidance of ultrasonography for ICP changes during the extracorporeal circulation process. : The study population included 21 patients over 18 years of age who required extracorporeal circulation. Demographic data of the patients, such as age, gender, comorbidity, American Society of Anesthesiologists (ASA) classification and reason for operation (coronary artery disease or mitral or aortic valve disease) were recorded. The ONSD was measured and evaluated before the extracorporeal circulation (first time) and at the 30th minute (second time), 60th minute (third time) and 90th minute (fourth time) of the extracorporeal circulation. Non-invasive ICP (ICP ONSD) values were calculated based on the ONSD values found. : The mean ONSD values measured before the extracorporeal circulation of the patients were found to be 4.13 mm (3.8-4.6) for the right eye and 4.36 mm (4.1-4.7) for the left eye. Calculated nICPONSD values of 11.0 mm Hg (1.0-21.0) for the right eye and 10.89 mm Hg (1.0-21.0) for the left eye were found. It was observed that there was a significant increase in the ONSD and nlCPONSD values recorded during the extracorporeal circulation of all patients compared to the baseline values ( < 0.005). : During extracorporeal circulation, ultrasound-guided ONSD measurement is an easy, inexpensive and low-complication method that can be performed at the bedside during the operation to monitor ICP changes.
Topics: Humans; Adolescent; Adult; Pilot Projects; Intracranial Hypertension; Optic Nerve; Intracranial Pressure; Ultrasonography; Extracorporeal Circulation
PubMed: 36984445
DOI: 10.3390/medicina59030445 -
Journal of the American College of... Apr 2022Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac... (Review)
Review
Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac surgery. The scientific advancements collectively leading to safe cardiopulmonary bypass are considered some of the most impactful advances of modern medicine. Stimulated by the work of physiologists and engineers in the late 19th century, primitive pump and oxygenator designs were the forerunners of major work by DeBakey and others in roller pump design and by Gibbon in oxygenator development. Following Gibbon's historic successful closure of an atrial septal defect in 1953 with his heart-lung machine, it was left to Lillehei and Kirklin to first successfully repair large series of cardiac malformations. The history leading to these historic events and the subsequent evolution of cardiopulmonary bypass machines for short- and longer-term support is filled with engineering and surgical brilliance, daring innovations, and serendipity.
Topics: Cardiac Surgical Procedures; Cardiopulmonary Bypass; Extracorporeal Circulation; Heart Defects, Congenital; Heart-Lung Machine; History, 20th Century; Humans
PubMed: 35450579
DOI: 10.1016/j.jacc.2022.02.027 -
Best Practice & Research. Clinical... Jun 2015Pulmonary complications after the use of extracorporeal circulation are common, and they range from transient hypoxemia with altered gas exchange to acute respiratory... (Review)
Review
Pulmonary complications after the use of extracorporeal circulation are common, and they range from transient hypoxemia with altered gas exchange to acute respiratory distress syndrome (ARDS), with variable severity. Similar to other end-organ dysfunction after cardiac surgery with extracorporeal circulation, pulmonary complications are attributed to the inflammatory response, ischemia-reperfusion injury, and reactive oxygen species liberated as a result of cardiopulmonary bypass. Several factors common in cardiac surgery with extracorporeal circulation may worsen the risk of pulmonary complications including atelectasis, transfusion requirement, older age, heart failure, emergency surgery, and prolonged duration of bypass. There is no magic bullet to prevent or treat pulmonary complications, but supportive care with protective ventilation is important. Targets for the prevention of pulmonary complications include mechanical, surgical, and anesthetic interventions that aim to reduce the contact activation, systemic inflammatory response, leukocyte sequestration, and hemodilution associated with extracorporeal circulation.
Topics: Animals; Cardiopulmonary Bypass; Extracorporeal Circulation; Humans; Lung Diseases; Postoperative Complications; Respiratory Distress Syndrome
PubMed: 26060028
DOI: 10.1016/j.bpa.2015.04.002 -
The Journal of Extra-corporeal... Sep 2014
Topics: Biomedical Technology; Extracorporeal Circulation; Humans; Societies, Medical
PubMed: 26357782
DOI: No ID Found