Search

Résumé: La circulation extracorporelle avec oxygénateur à membrane veino-artérielle (ECMO-VA) est de plus en plus utilisée pour la prise en charge des chocs cardiogéniques réfractaires, mais reste associée à une mortalité élevée et à de nombreuses complications. La réinjection par une canule artérielle fémorale entraîne un flux rétrograde dans l'aorte descendante qui s'oppose au débit cardiaque propre du patient. Ceci est à l'origine d'une augmentation de la post-charge du ventricule gauche et favorise la survenue de dilatation ventriculaire gauche, la formation de thrombus intracavitaires et l'œdème pulmonaire. Ces complications constituent une problématique centrale lors de la prise charge des patients sous ECMO-VA et leur prévention et prise en charge ont un impact sur le pronostic des patients. Les principales stratégies préventives consistent en la baisse du débit d'ECMO, la mise en place d'une réinjection antérograde, d'un ballon de contre-pulsion intra-aortique ou encore d'une Impella®. La prise en charge curative repose sur la décharge du ventricule gauche par voie chirurgicale ou percutanée. The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic choc keeps growing but its mortality and complication rates remains high. Reinjection through a femoral artery cannula causes retrograde flow in the descending aorta that opposes the patient's own cardiac output. It leads to an increased left ventricular afterload and favors the occurrence of left ventricular dilation, the formation of intracavitary thrombi and pulmonary edema. These complications are a central issue in the management of patients assisted by VA-ECMO and their prevention and management has an impact on patient's prognosis. The main preventive strategies are based on reducing ECMO flow, setting up an antegrade reinjection flow, an intra-aortic balloon pump or an Impella®. The curative management is based on the discharge of the left ventricle by surgical or percutaneous methods. [ABSTRACT FROM AUTHOR]

Résumé: Objectif: Décrire l’utilisation de facteur VII activé recombinant (rFVIIa) chez des patients sous ECMO centrale veino-artérielle avec une attention particulière sur les complications thrombotiques associées. Conception de l’étude: Étude rétrospective monocentrique. Patients et méthodes: Nous avons étudié les dossiers des 91 patients mis sous ECMO entre 2005 et 2010. Durant cette période, huit patients ont présenté une hémorragie réfractaire et ont reçu du rFVIIa comme thérapeutique de sauvetage. Résultats: Chez six patients, l’hémorragie a été jugulée. Une diminution du saignement a été mise en évidence après l’administration de rFVIIa (pré-rFVIIa : 40,1±33,1mL/kg par trois heures versus 5,4±3,2mL/kg par trois heures (p =0,01). Les besoins transfusionnels ont été diminués après administration de rFVIIa. Aucun évènement thrombotique n’a été détecté. Le fibrinogène, les d-dimères, la numération des plaquettes et les lactates n’ont pas été modifiés par le traitement. Deux patients ont été sevrés de l’ECMO. Un est décédé 17jours après le sevrage. L’autre patient a survécu sans séquelles neurologiques. Conclusion: Le rFVIIa est un traitement d’exception chez le patient traité avec une ECMO centrale veino-artérielle. Il ne doit pas être administré avant que toutes les thérapeutiques conventionnelles n’aient été tentées, mais peut être une solution de sauvetage en présence d’une hémorragie massive. [ABSTRACT FROM AUTHOR]

Résumé: Objectif: Le transport de patients instables aux Antilles-Guyane représente un défi particulier ; pour assurer une continuité territoriale des soins, le service de chirurgie cardiaque de Fort-de-France a créé une unité mobile d’assistance circulatoire. Le but de ce travail est de décrire les aspects logistiques, techniques et financiers des transferts interhospitaliers de patients assistés par circulation extracorporelle temporaire. Patients et méthodes: Tout patient sous assistance circulatoire temporaire aux Antilles-Guyane, rapatrié secondairement vers le CHU de Fort-de-France, a été inclus du 29 décembre 2009 au 30 septembre 2011. L’indication et le type d’assistance utilisée, le lieu de prise en charge, le vecteur de transfert, les complications inhérentes au transport, la mortalité à la sortie de l’hôpital et le coût direct de prise en charge ont été recueillis. Résultats: Dix-neuf patients ont été pris en charge par l’UMAC (sex-ratio 0,63) à distance de notre centre (âge médian 34ans [16–64]), 12 assistés par ECMO pour un SDRA réfractaire et sept par ECLS pour un choc cardiogénique réfractaire. Quatre patients ont été transférés par ambulance (7–29km), sept par hélicoptère (190–440km), huit par avion (440–1430km). Aucun décès ni évènement indésirable grave n’est à déplorer durant ces transferts. Quinze patients ont survécu à l’hospitalisation. Une étude médicoéconomique a été réalisée. Conclusion: Le transfert interhospitalier de patients assistés par ECMO/ECLS est techniquement réalisable de manière parfaitement sécurisée aux Antilles-Guyane. La coordination préalable d’une telle activité permet de l’organiser pour un coût acceptable. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Indications for short-term circulatory and/or respiratory support (STCRS) increased during the last years. The goal of this survey was to characterize this activity in France in 2009. Study design: Observational retrospective pluricentral. Materiel and methods: Each center of cardiothoracic surgery received a questionnaire validated by the Société française de perfusion about the activity, materials and organization used for STCRS. Data were expressed as percentages or median (25–75 percentiles). Results: Forty-one centers on 61 (67%) answered. STCRS was performed respectively by 33 (80.5 %), 36 (87.8 %) and 39 (95.1 %) of centers in 2007, 2008 and 2009 including 10 [4–26], 18 [6–29] and 18 [5–33] cases/center per year. In 2009, types of STCRS installed were veno-arterial in 39 centres (95.1 %), veno-venous in 27 (65.9 %) and Novalung® in four (9.8 %), including 18 [5–32], five [2–7] and 15 [1–17] cases respectively. Twenty-nine centers (70.7%) installed STCRS outside the operating theater, and 24 (58.5%) in non-cardiothoracic surgery. A mobile circulatory support unit was created in eight centers (19.5%), however 21 (51.2%) have installed STCRS externally, at distances between 10 [5–55] to 100 [15–200] km, using emergency vehicles in most of the cases (90.5%), but helicopter seldom (19%). Conclusion: STCRS has increased over the last few years in France. Externalized activity outside the operating theater was important, time-consuming and used hospital resources therefore modifying the professional activity of perfusionists. [Copyright &y& Elsevier]

Abstract: We reported the case of a young adult with a Lemierre syndrome, which was complicated by septic shock and ARDS. Because of rapid onset of a life-threatening hypoxemia (PaO2/FiO2 =60) in the course of the ARDS despite mechanical ventilation, ECMO was started with jugular and femoral cannulas, as rescue therapy. Good control of hypoxemia was obtained and ECMO was set up for six days. No significant complication was observed. The course was nevertheless complicated by acute renal failure and a pleural fistula that necessitated separate-lung ventilation during 24hours. After 48days left in the ICU, the patient was sent to a rehabilitation unit. [Copyright &y& Elsevier]

Abstract: Objectives: High-flow nasal oxygen (Optiflow™) is validated in paediatric intensive care but not in adults’ patients for severe hypoxemia. The aim of this study was to evaluate this oxygen system delivery in adults’ patients for postoperative hypoxemia after cardiac surgery. Study design: Prospective, open study for evaluation of medical practice. Patients and methods: Patients operated upon for cardiac surgery with immediate postoperative hypoxemia characterized by SpO2 <0.96 with 50% oxygen with a Venturi mask were treated with the high-flow nasal oxygen system (O group) when it was available or with the classical high-flow oxygen face mask (M group). Gas exchanges were measured at the end of the surgery, at the beginning of the treatment and 1 hour, 6 hours after the inclusion and at day 1 and 2 post-treatment. Parameters studied were: duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Tolerance was evaluated with measurement of pain (visual scale), satisfaction (visual scale), and dryness of mouth. Results: Forty patients were included, 19 in group O, 21 in group M. Patient''s characteristics did not differ between the two groups before treatment. There were no significant differences between groups for duration of hypoxemia (3.8±2.2 days in O group versus 4.3±2.3 days in M group), duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Pain was not significantly different between groups, satisfaction was better (P <0.001) and mouth drier (P <0.001) in group O than in group M. Conclusion: These results give good arguments for an improvement in gas exchange and better tolerance of high-flow nasal oxygen (Optiflow™) versus classical high-flow oxygen face mask in postoperative cardiac patients. These results must be confirmed by a randomised study with a larger population. [Copyright &y& Elsevier]

Abstract: Objective: Severely impaired patients may wait in France on a special and temporary high emergency national list (called SU). Some of these patients need mechanical circulatory support with ECMO. In order to compare two groups of patients on SU, who acceeded to heart transplantation (HT) with or without ECMO, we reviewed retrospectively 20 consecutive patients transplanted on SU between January2004 and September2007 in Rennes. Patients and methods: Among them, 10 were transplanted without ECMO and 10 others were implanted with a femoro-femoral ECMO before HT. Results: (1) Considering the group SU without pretransplantation ECMO: 2years survival rate was 70%. Mean hospital stay was 26.4 days. Three patients were implanted with ECMO for graft dysfunction during postoperative course, without inherent complication. None graft dysfunction occurred after initial hospitalization; (2) considering the group SU with pretransplantation ECMO: 2years survival rate was 90% (one early death). Mean hospital stay was 45 days with multiple complications due to the ECMO (leg''s ischemia: n =2; lung oedema: n =1; lymphorrhea: n =3, low flow requiring change of canulae: n =1). None graft dysfunction occurred after initial hospitalization. Conclusion: Althought we didn’t reach statistical significance, it seems that ECMO for patients in SU may be useful as bridge to transplant but with a higher morbidity than for similar patients transplanted without ECMO. Additional data from other transplant centers are needed to confirm our findings. [Copyright &y& Elsevier]

Abstract: Cardiogenic shock is the leading cause of in-hospital death for myocardial infarction. Despite therapeutic improvements, such as medical treatment with inotropes, myocardial revascularization, circulatory assistance can be an option. Intra-aortic balloon pumping is highly recommended in the presence of haemodynamic impairment. If the patient continues to deteriorate and cardiac function cannot maintain adequate circulation to prevent end-organ failure, several mechanical circulatory assist devices can be considered: extracorporeal membrane oxygenator (ECMO), Impella®… These devices should be used at tertiary centres either as bridge to recovery or as bridge to transplantation or as bridge to long-term left ventricle assist device. [ABSTRACT FROM AUTHOR]

Abstract: Novel influenza A (H1N1) at the origin of the 2009 pandemic flu developed mainly in subjects of less than 65 years contrary to the seasonal influenza, which usually developed in elderly patients of more than 65 years. Elderly subjects are partly protected by old meetings with close stocks. Influenza A(H1N1) can arise in serious forms within 60 to 80% of cases a fulminant acute respiratory distress syndrome (ARDS) “malignant and fulminant influenza” in subjects without any comorbidity, which makes the gravity and the fear of this influenza. The fact that this influenza A (H1N1) can develop in healthy young patients and evolve in few hours to a severe ARDS with a refractory hypoxemia gave to the foreground the possible interest of the recourse to extracorporeal oxygenation (ECMO) in some selected severe ARDS (5–10%). The first publications of patients admitted in intensive care unit (ICU) for severe influenza A (H1N1) often associated to an ARDS reported a mortality rate from 15 to 40%. This mortality variability may be explained in part by different studied populations, ARDS characteristics and human and material resources in the ICUs between the countries. Indeed, the highest mortality rates (30–40%) have been reported by in Mexico which were affected the first by pandemic flu and which were not prepared. A bacterial pneumonia was associated to H1N1 influenza in approximately 30% of the cases as at admission in ICU or following the days of the admission justifying an early antibiotherapy associated to the antiviral treatment by oseltamivir (Tamiflu®). Obesity, pregnancy and respiratory diseases (asthma, COPD) seem to be associated to the development of a severe viral pneumonia due to influenza A (H1N1) often with ARDS. Older age, high APACHE II and SOFA scores and a delay of initiation of the antiviral treatment by oseltamivir are associated to higher morbidity and mortality. Other analyses of the results obtained from the first published papers included more patients and future studies would permitted to better define the role of therapeutics such as steroids and ECMO. [Copyright &y& Elsevier]

Abstract: Between August and September 2009, on Reunion Island, our Intensive Care Unit (ICU) treated several severe Influenza A (H1N1) S-OIV cases. We report the following case: a 23-year-old female patient with no prior medical history presented a severe respiratory distress that required high frequency oscillation ventilation and finally Extracorporeal Membrane Oxygenation (ECMO). She was hospitalized in the ICU for 41 days. Recovery was complete. It is important to note the stead of each technique in those types of respiratory distresses and describe the practical details of the ECMO''s set up by a non-trained medical crew. We want to underline, within the current context of severe respiratory distresses due to Influenza A pandemic, the necessity to develop a multidisciplinary care network, or to reinforce the existing channels between well-trained medical crews familiar with ECMO''s technics and the ICU that are not. [Copyright &y& Elsevier]

Abstract: Pertussis is a leading cause of death from community infections in infant. Life-threatening clinical presentations of pertussis can associate multiple organ system failure with respiratory distress. The question of the optimal management of these severe forms of pertussis, in order to reduce the high mortality rate, is raised by the clinicians caring for such patients. We report the case of a 1month infant who was admitted to the pediatric intensive care unit (PICU) for a severe pertussis. He presented with an acute respiratory distress syndrome, a severe pulmonary hypertension was treated initially with mechanical ventilation and nitric oxide. At day 4 (D4), a cardiogenic shock occurred and, despite epinephrine and norepinephrine infusion, fluid expansion, the hemodynamic condition worsened with two episodes of cardiac arrest. The child was then successfully resuscitated, and, facing the extreme hemodynamic instability, extracorporeal membrane oxygenation (ECMO) was considered. ECMO allowed epinephrine and norepinephrine to be progressively discontinued, and protective mechanical ventilation. ECMO withdrawal was possible at D9, with milrinone as the sole inotropic agent. Weaning from mechanical ventilation was possible on D15 and the total length of stay in PICU was 20days. While the analysis of the literature, through limited experiences on the use of ECMO in children with severe pertussis does not allow concluding definitively on the utility of ECMO in this situation, the contribution of ECMO in the favourable outcome for our patient was considerable. This is an argument, to our opinion, for considering ECMO in the management of those very instable patients. [Copyright &y& Elsevier]

Abstract: We report a case of Lemierre''s syndrome complicated with pulmonary septic abscesses, leading to necrotizing pneumonia. In spite of administration of appropriate antibiotics and a protective ventilation strategy, the patient had several bilateral pneumothoraces. In this setting, the mechanical ventilation was unsuccessful leading to two hypoxia-related cardiac arrests. An extracorporeal CO2 removal was then carried out for 34-days duration. The patient was weaned from mechanical ventilation on day 68. He was then transferred to the chest surgery unit on day 83. [Copyright &y& Elsevier]

Abstract: Objectives: To assess the prognosis of newborn infants with refractory hypoxemia who required extracorporeal membrane oxygenation (ECMO). Methods: Eighty-nine newborn infants treated by ECMO during more than 24 hours over a 8-year period (1996–2003) were included in this observational cohort study with a 9-month and 24-month evaluation. Results: Respiratory failure mainly resulted from meconium aspiration syndrome (MAS, 43%), congenital diaphragmatic hernia (CDH, 15%) and sepsis (15%). Overall survival at hospital discharge was 67%. Infants with MAS had the best survival rate (82%) and those with CDH had the worst (46%). Of the remaining 60 survivors, 53% remained oxygen dependent at 28 days and 33% at 45 days. At the age of 2 years, only 1 infant remained oxygen dependent (but did not required oxygen at 3 years) and only 3 infants had significant neurodevelopmental problems. CDH group was associated with a prolonged duration in supplementary oxygen (P <0.001) and a prolonged duration for tube feeding (P =0.01) as compared with other diagnoses. Regarding neurologic outcome, CDH infants had the poorer neurological acquisition rate at 9 months but a very good evolution by the time of the 24-month evaluation. Conclusions: Morbidity in ECMO survivors is low considering the severity of illness in the newborn period, mainly related to pulmonary and feeding dysfunctions during the first months, in particular for the CDH group. Outcome at the age of 2 years of CDH infants is most often favourable regarding growth and neurodevelopmental evolution. [Copyright &y& Elsevier]

Over the last decade, several new therapies including exogenous surfactant therapy, inhaled nitric oxide and high-frequency ventilation have become available for the treatment of neonatal pulmonary failure. The aim of this retrospective study was to evaluate to what extent these modalities have impacted the use of neonatal extracorporeal membrane oxygenation at our institution and to discuss the role of ECMO in 2003 in the management of newborn infants with refractory hypoxemia.Population and methods. – Two hundred and twenty six newborn infants treated by ECMO before 15 days of life and during more than 24 h in our intensive care unit were retrospectively included from two time periods (group 1: 1988–1993 and group 2: 1996–2003).Results. – As compared with the first group, the number of newborns supported by ECMO in the second group has clearly diminished and their severity has increased. Overall survival rate was 80% in the first group and 69% in the second group. Meconium aspiration syndrome remains the major indication for ECMO (44%). Pulmonary sequelae, assessed by bronchopulmonary dysplasia rate (41%) are more frequent that neurologic sequelae (4.8%).Conclusion. – ECMO remains an useful technique in the management of newborn infants with refractory hypoxemia, with a consideration to institute ECMO early in order to increase survival rate. [Copyright &y& Elsevier]

Résumé: Le syndrome de tako-tsubo est une cardiomyopathie rare, secondaire à la toxicité de hauts niveaux de catécholamines circulantes responsables d’une sidération myocardique. De sévères complications peuvent survenir telles qu’un choc cardiogénique ou une fibrillation ventriculaire. Nous présentons ici le cas d’une patiente de 32ans victime d’un syndrome de tako-tsubo avec choc cardiogénique sévère au cours d’une césarienne en urgence pour souffrance fœtale. Cette patiente a bénéficié d’une assistance circulatoire par Extracorporeal Membrane Oxygenation (ECMO) devant le caractère réfractaire de l’état de choc. [ABSTRACT FROM AUTHOR]

Résumé: Les traumatismes crâniens graves sont particulièrement sensibles à l’hypoxémie. Les moyens de recouvrir une oxygénation adéquate chez les patients associant des lésions crâne-poumon sont peu décrits. Nous rapportons le cas d’un recours à l’ECMO chez une jeune patiente neurolésée, en hypoxémie réfractaire dans les suites d’un polytraumatisme. [ABSTRACT FROM AUTHOR]

Abstract: The concept of reproduction without uterus, or ectogenesis, has long been considered a myth. Nowadays, however, the in vitro conception (IVF) and embryo culture before implantation are largely used in humans with more than 50,000 IVF and ICSI procedures yearly in France, but also in ruminants where about 400,000 bovine embryos are produced in vitro worldwide each year. In order to proceed with gestation, a 3D structure enabling implantation is needed. Ex-vivo implantation of human embryos was obtained both in a perfused ex-vivo uterus and in a 3 dimensional culture of endometrial cells, but these experiments were stopped because of ethical concerns. The implantation of a mouse embryo in a similar 3D structure has been reported but did not lead to the production of a live pup. Another interest for an artificial uterus or placenta would be to use it for ex-vivo maturation of very premature fetuses. Extra-corporal membrane oxygenation (ECMO) was developed for many years but its use remains disappointing in preterm infants when compared to the important progress made with more classical clinical care. In any case, goat fetuses have been maintained alive up to 9 days in an artificial amniotic pouch, being oxygenated via ECMO. [Copyright &y& Elsevier]

Abstract: Phaeochromocytoma and paraganglioma are chromaffine tumours secreting catecholamines. They are usually revealed by a paroxystic hypertensive crisis associated with headaches, palpitation and sweats. We reported a case of a young patient presenting a state of life threatening cardiogenic shock as unusual revelation of this tumour, requiring the implementation of an extracorporeal life support until myocardial recovery. [Copyright &y& Elsevier]

Abstract: Respiratory support using extra corporeal membrane oxygenation (ECMO) is rarely used in the setting of adult lung surgery, with the exception of lung transplantation. We report the case of a patient with pulmonary aspergilloma, for whom selective bronchial intubation was required to facilitate surgery. Intolerance to unilateral ventilation was anticipated due to poor underlying lung function. Intra-operatively, an attempt to lung exclusion was responsible for severe hypoxemia. The use of veno-venous ECMO allowed to improve oxygenation and lung resection was carried out successfully at the expense of major intra-operative bleeding. [Copyright &y& Elsevier]

Hypertrophic cardiomyopathy is a common complication in infants born to diabetic mothers but it is rarely life threatening.Case report. – A neonate born to a diabetic mother with a severe hypertrophic cardiomyopathy with life threatening respiratory and haemodynamic distress was successfully supported by extracorporeal membrane oxygenation.Conclusion. – Extracorporeal membrane oxygenation can be an efficient transitory therapy for very severe hypertrophic cardiomyopathy in infants of diabetic mothers. [ABSTRACT FROM AUTHOR]

Résumé: Une table ronde, organisée par la Société française de perfusion (Sofraperf) lors du congrès national français sur les circulations extracorporelles (Perfusion 2013), a réuni perfusionnistes, anesthésistes, réanimateurs et chirurgiens autour du thème de l’assistance respiratoire veino-veineuse et circulatoire veino-artérielle avec oxygénation extracorporelle en réanimation. Le débat a été mené de manière participative sous formes de questions–réponses bidirectionnelles entre modérateurs et assistance. Les auteurs rapportent les prises en charge de ce type de thérapeutique qui ne sont pas parfaitement homogènes en s’appuyant sur les données de la littérature. Canulation, insertion, circuit, oxygénateur, anticoagulation, contrôle, surveillance, sevrage font l’objet de paragraphes à entrée définie dont les contenus se complètent dans l’ensemble du document. [ABSTRACT FROM AUTHOR]

Abstract: In order to effectively deal with the increase in cardiac and/or respiratory services outside of Lille CHU (University Hospital), an interdisciplinary medical/surgical procedure has been put in place in collaboration with the emergency medical service (SAMU). This organization makes it possible to respond rapidly to a demand outside the University Hospital, while ensuring safe management of patients. [Copyright &y& Elsevier]

Abstract: Since the 1970s, it has become possible to handle patients with serious pulmonary and cardiac failure with extracorporeal membrane oxygenation (ECMO) when conventional treatment fails, but only in specialized centers. When the latter were too far away, the risks of such transport were considered too high until the Mobile Cardiac Assistance Unit (MCAU) and Mobile Respiratory Assistance Unit (MRAU) were created. We are first going to expose the point of view of the pre-hospital Emergency Medical Services (EMS). The M.D. in need of such assistance should call the cardiac surgeon of the reference center : if the indication is confirmed, they will call the EMS (Service d’Aide Médicale Urgente, SAMU), and decide together which means is the most appropriate for a quick transportation of the team and the ECMO to the patient''s bedside, and then back to the ECMO center, depending on the problems raised by ground vehicles on the one hand and aircrafts or helicopters on the other. Then, we are going to evaluate the cost of such transportation, which is quite considerable. As a conclusion, because of its high cost, the mobile inter-hospital ECMO. service should only be used when the patient is considered too ill to be transported on conventional therapy : in that case, this procedure represents huge progress. [Copyright &y& Elsevier]

Abstract: Mobile ECMO support for remote cardiac or respiratory assistance (MESRCA and MESRRA) allows mobilization of the medical and paramedical team 24/7 in a very large geographical area. Mobility and autonomy require adapted devices. During many years, teams had to deal with non useful equipment. Recently, thanks to interest of medical world and laboratories, many materials especially suitable for this activity are developed. We describe our local experience and solutions we tented to fi nd to deal with material diffi culties. [Copyright &y& Elsevier]