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Background: Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients., Methods: We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained., Results: In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold., Conclusions: Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Objective: To identify factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation., Method: Retrospective cohort study conducted in an adult Intensive Care Unit with patients undergoing extracorporeal membrane oxygenation from 2012 to 2021. The research used the Kidney Disease Improving Global Outcomes as criteria for definition and classification of acute kidney injury. A multiple logistic regression model was developed to analyze the associated factors., Results: The sample was composed of 122 individuals, of these, 98 developed acute kidney injury (80.3%). In multiple regression, the associated factors found were vasopressin use, Nursing Activities Score, and glomerular filtration rate., Conclusion: The use of vasopressin, the Nursing Activities Score, and the glomerular filtration rate were considered as factors related to the development of acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

ABSTRACT Objective: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. Methods: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. Results: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). Conclusions: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

Objective: To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support., Methods: Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venous-venous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators., Results: Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact., Conclusion: Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal.

Multisystem inflammatory syndrome in children is a rare and potentially life-threatening disease that is associated with SARS-CoV-2 infection, characterized by hyperinflammation and multiorgan involvement. Cardiovascular involvement is common, including myocardial dysfunction often leading to cardiogenic shock. We present the case of a 17-year-old boy with fever, odynophagia, maculopapular rash and abdominal pain who developed a cardiogenic shock. Due to progressive deterioration of cardiac function despite optimized vasoactive support, veno-arterial extracorporeal membrane oxygenation support was initiated 12 hours after admission, with successful decannulation after seven days and discharge after 23 days, with normal cardiac function. The patient received corticosteroids and intravenous immunoglobulin. Early recognition and intensive care support are crucial for ensuring a successful outcome in severe cases of multisystem inflammatory syndrome. In cases of severe cardiogenic shock, extracorporeal membrane oxygenation support can be critical for survival and rapid recovery.

Objective: To describe the experience of aeromedical interhospital transport of an adult patient with severe hypoxemic respiratory failure due to SARS-CoV-2, on extracorporeal membrane oxygenation., Method: This is a case report, guided by the tool Case Report Guidelines, with a descriptive approach. Data were collected from the digital medical record and field notes after the approval by the Institution and the Human Research Ethics Committee., Results: The transport of a critically ill, unstable patient with acute respiratory syndrome 2 on extracorporeal oxygenation was an opportunity for the team to acquire new knowledge. The proper preparation of the fixed-wing aircraft and the profile of the team of specialist nurses contributed to the safety and quality in the three phases of flight: preflight, in-flight and post-flight., Conclusion: Air transport of adults on cardiopulmonary bypass to referral centers, under the care of an experienced multidisciplinary team, can contribute to positive results. The nurses' autonomy, their leadership role and expertise in process management are highlighted. Thus, success was evidenced with the patient's discharge after 45 days from the Intensive Care Unit.

Objective: To evaluate whether there was any impact on the number of pediatric extracorporeal membrane oxygenation runs and survival rates in the years subsequent to the 2009 pandemic., Methods: We studied two different periods of extracorporeal membrane oxygenation support for respiratory failure in children by analyzing datasets from the Extracorporeal Life Support Organization. Autoregressive integrated moving average models were constructed to estimate the effect of the pandemic. The year 2009 was the year of intervention (the H1N1 epidemic) in an interrupted time series model. Data collected from 2001 - 2010 were considered preintervention, and data collected from 2010 - 2017 were considered postintervention., Results: There was an increase in survival rates in the period 2010 - 2017 compared to 2001 - 2010 (p < 0.0001), with a significant improvement in survival when extracorporeal membrane oxygenation was performed for acute respiratory failure due to viral pneumonia. The autoregressive integrated moving average model shows an increase of 23 extracorporeal membrane oxygenation runs per year, prior to the point of the level effect (2009). In terms of survival, the preslope shows that there was no significant increase in survival rates before 2009 (p = 0.41), but the level effect was nearly significant after two years (p = 0.05), with a 6% increase in survival. In four years, there was an 8% (p = 0.03) increase in survival, and six years after 2009, there was up to a 10% (p = 0.026) increase in survival., Conclusion: In the years following 2009, there was a significant, global incremental increase in the extracorporeal membrane oxygenation survival rates for all runs, mainly due to improvements in the technology and treatment protocols for acute respiratory failure related to viral pneumonia and other respiratory conditions.

A healthy 55-year-old woman unvaccinated for SARS-CoV-2 was admitted to the hospital with a SARSCoV-2 infection with rapid clinical deterioration. On the 17th day of disease, she was intubated, and on the 24th day, the patient was referred and admitted to our extracorporeal membrane oxygenation center. Extracorporeal membrane oxygenation support was initially used to enable lung recovery and allow the patient to rehabilitate and improve her physical condition. Despite an adequate physical condition, the lung function was not adequate to discontinue extracorporeal membrane oxygenation, and the patient was considered for lung transplantation. The intensive rehabilitation program was implemented to improve and maintain the physical status throughout all phases. The extracorporeal membrane oxygenation run had several complications that ABSTRACT hindered successful rehabilitation: right ventricular failure that required venoarterial-venous extracorporeal membrane oxygenation for 10 days; six nosocomial infections, four with progression to septic shock; and knee hemarthrosis. To reduce the risk of infection, invasive devices (i.e., invasive mechanical ventilation, central venous catheter, and vesical catheter) were removed whenever possible, keeping only those essential for monitoring and care. After 162 days of extracorporeal membrane oxygenation support without other organ dysfunction, bilateral lobar lung transplantation was performed. Physical and respiratory rehabilitation were continued to promote independence in daily life activities. Four months after surgery, the patient was discharged. [ABSTRACT FROM AUTHOR]

Objective: To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support. Methods: Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venousvenous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators. Results: Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact. Conclusion: Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal. [ABSTRACT FROM AUTHOR]

Patients using extracorporeal membrane oxygenation (ECMO) are at greater risk of developing multiple organ dysfunction, therefore, the construction of protocols and training of professionals become essential to reduce mortality. With that in mind, a hospital trained nurses to act more assertively in the care of this patient. Report how this training took place. This is an experience report at a large private and philanthropic hospital in the city of São Paulo, on the training of nurses to assist patients with ECMO. 52 nurses were trained. The training consisted of theoretical and practical classes, in a realistic simulation environment, in addition to clinical discussion, guided study and debriefing. The training of nurses in ECMO patient care enables improvement in the quality and safety of care provided, preventing complications, ensuring early interventions and better outcomes. [ABSTRACT FROM AUTHOR]

Abstract Objective: To describe the experience of aeromedical interhospital transport of an adult patient with severe hypoxemic respiratory failure due to SARS-CoV-2, on extracorporeal membrane oxygenation. Method: This is a case report, guided by the tool Case Report Guidelines, with a descriptive approach. Data were collected from the digital medical record and field notes after the approval by the Institution and the Human Research Ethics Committee. Results: The transport of a critically ill, unstable patient with acute respiratory syndrome 2 on extracorporeal oxygenation was an opportunity for the team to acquire new knowledge. The proper preparation of the fixed-wing aircraft and the profile of the team of specialist nurses contributed to the safety and quality in the three phases of flight: preflight, in-flight and post-flight. Conclusion: Air transport of adults on cardiopulmonary bypass to referral centers, under the care of an experienced multidisciplinary team, can contribute to positive results. The nurses’ autonomy, their leadership role and expertise in process management are highlighted. Thus, success was evidenced with the patient’s discharge after 45 days from the Intensive Care Unit.

Objective: To determine micafungin plasma levels and pharmacokinetic behavior in patients treated with extracorporeal membrane oxygenation., Methods: The samples were taken through an access point before and after the membrane in two tertiary hospitals in Spain. The times for the calculation of pharmacokinetic curves were before the administration of the drug and 1, 3, 5, 8, 18 and 24 hours after the beginning of the infusion on days one and four. The area under the curve, drug clearance, volume of distribution and plasma half-life time with a noncompartmental pharmacokinetic data analysis were calculated., Results: The pharmacokinetics of the values analyzed on the first and fourth day of treatment did not show any concentration difference between the samples taken before the membrane (Cin) and those taken after the membrane (Cout), and the pharmacokinetic behavior was similar with different organ failures. The area under the curve (AUC) before the membrane on day 1 was 62.1 (95%CI 52.8 - 73.4) and the AUC after the membrane on this day was 63.4 (95%CI 52.4 - 76.7), p = 0.625. The AUC before the membrane on day 4 was 102.4 (95%CI 84.7 - 142.8) and the AUC was 100.9 (95%CI 78.2 - 138.8), p = 0.843., Conclusion: The pharmacokinetic parameters of micafungin were not significantly altered.

Among the potential complications of extracorporeal membrane oxygenation, neurological dysfunctions, including brain death, are not negligible. In Brazil, the diagnostic process of brain death is regulated by Federal Council of Medicine resolution 2,173 of 2017. Diagnostic tests for brain death include the apnea test, which assesses the presence of a ventilatory response to hypercapnic stimulus. However, gas exchange, including carbon dioxide removal, is maintained under extracorporeal membrane oxygenation, making the test challenging. In addition to the fact that the aforementioned resolution does not consider the specificities of the diagnostic process under extracorporeal membrane oxygenation, studies on the subject are scarce. This review aims to identify case studies (and/or case series) published in the PubMed® and Cochrane databases describing the process of brain death diagnosis. A total of 17 publications (2011 - 2019) were identified. The practical strategies described were to provide pretest supplemental oxygenation via mechanical ventilation and extracorporeal membrane oxygenation (fraction of inspired oxygen = 1.0) and, at the beginning of the test, titrate the sweep flow (0.5 - 1.0L/minute) to minimize carbon dioxide removal. It is also recommended to increase blood flow and/or sweep flow in the presence of hypoxemia and/or hypotension, which may be combined with fluid infusion and/or the escalation of inotropic/vasoactive drugs. If the partial pressure of carbon dioxide threshold is not reached, repeating the test under supplementation of carbon dioxide exogenous to the circuit is an alternative. Last, in cases of venoarterial extracorporeal membrane oxygenation, to measure gas variation and exclude differential hypoxia, blood samples of the native and extracorporeal (post-oxygenator) circulations are recommended.

Objectives: to identify in the literature, the predictors of ECMO complications in adult patients., Methods: integrative review of literature, including articles in Portuguese, English and Spanish published from 2014 to 2018 in five databases. Included articles which analyzed the predictive factors of ECMO complications in adult patients using multivariate analysis., Results: a total of 1629 articles were identified, of which 19 were included. Nineteen predictors were identified for neurological complications (e.g., post-ECMO hypoglycemia), seven for bleeding complications (e.g., fungal pneumonia), four for infections complications (e.g., preoperative creatinine level), three for kidney complications (e.g., the length of ICU stay> 20 days) and a combination of factors for mechanical complications (e.g., median flow)., Conclusions: different predictors were identified to ECMO complications. The knowledge of these predictors enables the individualized targeting of preventive interventions by multidisciplinary team for modifiable factors, as well as intensification of monitoring for early recognition of non-modifiable factors.

Introduction: In Portugal, extracorporeal membrane oxygenation (ECMO) is used in pediatric patients since 2010. The aim of this study was to describe the clinical characteristics of patients, indications, complications and mortality associated with the use of ECMO during the first 10-years of experience in the Pediatric Intensive Care Unit located in Centro Hospitalar Universitário Lisboa Norte. Material and Methods: Retrospective observational cohort study of all patients supported with ECMO in a Pediatric Intensive Care Unit, from the 1st of May 2010 up to 31st December 2019. Results: Sixty-five patients were included: 37 neonatal (≤ 28 days of age) and 28 pediatric patients (> 28 days). In neonatal cases, congenital diaphragmatic hernia was the main reason for ECMO (40% of neonatal patients and 23% of total). Among pediatric patients, respiratory distress was the leading indication for ECMO (47% of total). The median length of ECMO support was 12 days. Clinical complications were more frequent than mechanical complications (65% vs 35%). Among clinical complications, access site bleeding was the most prevalent with 38% of cases. The overall patient survival was 68% at the time of discharge (65% for neonatal and 71% for pediatric cases), while the overall survival rate in Extracorporeal Life Support Organization registry was 61%. The number of ECMO runs has been increasing since 2011, even though in a non-linear way (three cases in 2010 to 11 cases in 2019). Discussion: In the first 10 years we received patients from all over the country. Despite continuous technological developments, circuitrelated complications have a significant impact. The overall survival rate in the Pediatric Intensive Care Unit was not inferior to the one reported by the Extracorporeal Life Support Organization. Conclusion: The overall survival of our Pediatric Intensive Care Unit is not inferior to one reported by other international centers. Our experience showed the efficacy of the ECMO technique in a Portuguese centre.

Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.

Objective: To describe the epidemiological profile of victims of cardiac arrest assisted using a nontransporting emergency medical service vehicle and to determine whether these patients met the criteria for the use of extracorporeal membrane oxygenation., Methods: This study employed a retrospective, cohort, descriptive, and exploratory design. Data were collected in January 2018 in northern Portugal by consulting the records of nontransporting emergency medical service vehicles that provided assistance between 2012 and 2016. An observation grid was prepared that was supported by the instrument used for collecting data from the national registry of out-ofhospital cardiac arrests., Results: After applying the inclusion criteria, the sample consisted of 36 victims. Extracorporeal membrane oxygenation could have been applied to 24 victims during the period analyzed, which might have increased the odds for transplantation, survival, or both, for either the victim or other individuals., Conclusion: Nontransporting emergency medical service vehicles have the potential for inclusion in the extracorporeal membrane oxygenation network of the study area.

Introduction: Extracorporeal membrane oxygenation (ECMO) provides mechanical pulmonary and circulatory support for patients with shock refractory to conventional medical therapy. In this study we aim to describe the indications, clinical characteristics, complications and mortality associated with use of ECMO in a single tertiary hospital., Methods: We conducted a retrospective observational cohort study of all patients supported with ECMO in two different intensive care units (general and cardiac), from the first patient cannulated in April 2011 up to October 2016., Results: Overall, 48 patients underwent ECMO: 29 venoarterial ECMO (VA-ECMO) and 19 venovenous ECMO (VV-ECMO). In VA-ECMO, acute myocardial infarction was the main reason for placement. The most frequent complication was lower limb ischemia and the most common organ dysfunction was acute renal failure. In VV-ECMO, acute respiratory distress syndrome after viral infection was the leading reason for device placement. Access site bleeding and hematologic dysfunction were the most prevalent complication and organ dysfunction, respectively. Almost 70% of ECMO episodes were successfully weaned in each group. Survival to discharge was 37.9% for VA-ECMO and 63.2% for VV-ECMO. In VA-ECMO, the number of inotropic agents was a predictor of mortality., Conclusion: Patients with respiratory indications for ECMO experienced better survival than cardiac patients. The need for more inotropic drugs was a predictor of mortality in VA-ECMO. This is the first published record of the overall experience with ECMO in a Portuguese tertiary hospital., (Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To review the principles of neonatal‐pediatric extracorporeal membrane oxygenation therapy, prognosis, and its establishment in limited resource‐limited countries in Latino America. Sources: The PubMed database was explored from 1985 up to the present, selecting from highly‐indexed and leading Latin American journals, and Extracorporeal Life Support Organization reports. Summary of the findings: Extracorporeal membrane oxygenation provides “time” for pulmonary and cardiac rest and for recovery. It is used in the neonatal‐pediatric field as a rescue therapy for more than 1300 patients with respiratory failure and around 1000 patients with cardiac diseases per year. The best results in short‐ and long‐term survival are among patients with isolated respiratory diseases, currently established as a standard therapy in referral centers for high‐risk patients. The first neonatal/pediatric extracorporeal membrane oxygenation Program in Latin America was established in Chile in 2003, which was also the first program in Latin America to affiliate with the Extracorporeal Life Support Organization. New extracorporeal membrane oxygenation programs have been developed in recent years in referral centers in Argentina, Colombia, Brazil, Mexico, Perú, Costa Rica, and Chile, which are currently funding the Latin American Extracorporeal Life Support Organization chapter. Conclusions: The best results in short‐ and long‐term survival are in patients with isolated respiratory diseases. Today extracorporeal membrane oxygenation therapy is a standard therapy in some Latin American referral centers. It is hoped that these new extracorporeal membrane oxygenation centers will have a positive impact on the survival of newborns and children with respiratory or cardiac failure, and that they will be available for an increasing number of patients from this region in the near future.

Em 2009, muitos casos de infecção pulmonar com hipoxemia grave refratária às estratégias ventilatórias habitualmente utilizadas e às manobras de resgate para a síndrome do desconforto respiratório agudo foram relatados durante a epidemia por influenza A (H1N1). Em muitos desses pacientes, o uso de extracorporeal membrane oxygenation (ECMO, oxigenação extracorpórea por membrana) foi necessário, fato que fez reacender o interesse na ECMO globalmente. O Grupo De Estudos em Suporte Extracorpóreo foi criado visando a aprender a técnica e a utilizar ECMO no tratamento de pacientes com hipoxemia grave. Neste artigo, são discutidas as indicações de ECMO e é relatado o caso de uma paciente com hipoxemia refratária que foi tratada através de ECMO de forma bem sucedida.In 2009, during the influenza A (H1N1) epidemic, there were many reported cases of pulmonary infection with severe hypoxemia that was refractory to the ventilatory strategies and rescue therapies commonly used to treat patients with severe acute respiratory distress syndrome. Many of those cases were treated with extracorporeal membrane oxygenation (ECMO), which renewed international interest in the technique. The Extracorporeal Support Study Group was created in order to practice ECMO and to employ it in the treatment of patients with severe hypoxemia. In this article, we discuss the indications for using ECMO and report the case of a patient with refractory hypoxemia who was successfully treated with ECMO.

Objective: The evidence of improved survival with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome is still uncertain., Methods: This systematic review and meta-analysis was registered in the PROSPERO database with the number CRD-42018098618. We performed a structured search of Medline, Lilacs, and ScienceDirect for randomized controlled trials evaluating the use of ECMO associated with (ultra)protective mechanical ventilation for severe acute respiratory failure in adult patients. We used the Cochrane risk of bias tool to evaluate the quality of the evidence. Our primary objective was to evaluate the effect of ECMO on the last reported mortality. Secondary outcomes were treatment failure, hospital length of stay and the need for renal replacement therapy in both groups., Results: Two randomized controlled studies were included in the meta-analysis, comprising 429 patients, of whom 214 were supported with ECMO. The most common reason for acute respiratory failure was pneumonia (60% - 65%). Respiratory ECMO support was associated with a reduction in last reported mortality and treatment failure with risk ratios (RR: 0.76; 95%CI 0.61 - 0.95 and RR: 0.68; 95%CI 0.55 - 0.85, respectively). Extracorporeal membrane oxygenation reduced the need for renal replacement therapy, with a RR of 0.88 (95%CI 0.77 - 0.99). Intensive care unit and hospital lengths of stay were longer in ECMO-supported patients, with an additional P50th 14.84 (P25th - P75th: 12.49 - 17.18) and P50th 29.80 (P25th - P75th: 26.04 - 33.56] days, respectively., Conclusion: Respiratory ECMO support in severe acute respiratory distress syndrome patients is associated with a reduced mortality rate and a reduced need for renal replacement therapy but a substantial increase in the lengths of stay in the intensive care unit and hospital. Our results may help bedside decision-making regarding ECMO initiation in patients with severe respiratory distress syndrome.

Objective: To describe (1) the energy transfer from the ventilator to the lungs, (2) the match between venous-venous extracorporeal membrane oxygenation (ECMO) oxygen transfer and patient oxygen consumption (VO2), (3) carbon dioxide removal with ECMO, and (4) the potential effect of systemic venous oxygenation on pulmonary artery pressure., Methods: Mathematical modeling approach with hypothetical scenarios using computer simulation., Results: The transition from protective ventilation to ultraprotective ventilation in a patient with severe acute respiratory distress syndrome and a static respiratory compliance of 20mL/cm H2O reduced the energy transfer from the ventilator to the lungs from 35.3 to 2.6 joules/minute. A hypothetical patient, hyperdynamic and slightly anemic with VO2 = 200mL/minute, can reach an arterial oxygen saturation of 80%, while maintaining the match between the oxygen transfer by ECMO and the VO2 of the patient. Carbon dioxide is easily removed, and normal PaCO2 is easily reached. Venous blood oxygenation through the ECMO circuit may drive the PO2 stimulus of pulmonary hypoxic vasoconstriction to normal values., Conclusion: Ultraprotective ventilation largely reduces the energy transfer from the ventilator to the lungs. Severe hypoxemia on venous-venous-ECMO support may occur despite the matching between the oxygen transfer by ECMO and the VO2 of the patient. The normal range of PaCO2 is easy to reach. Venous-venous-ECMO support potentially relieves hypoxic pulmonary vasoconstriction.

Scientific and technological advances, coupled with the work of multidisciplinary teams in intensive care units, have increased the survival of critically ill patients. An essential life support resource used in intensive care is extracorporeal membrane oxygenation. Despite the increased number of studies involving critically ill patients, few studies to date have demonstrated the safety and benefits of physical therapy combined with extracorporeal membrane oxygenation support. This review identified the clinical outcomes of physical therapy in adult patients on extracorporeal membrane oxygenation support by searching the MEDLINE®, PEDro, Cochrane CENTRAL, LILACS, and EMBASE databases and by manually searching the references of the articles published until September 2017. The database search retrieved 1,213 studies. Of these studies, 20 were included in this review, with data on 317 subjects (58 in the control group). Twelve studies reported that there were no complications during physical therapy. Cannula fracture during ambulation (one case), thrombus in the return cannula (one case), and leg swelling (one case) were reported in two studies, and desaturation and mild vertigo were reported in two studies. In contrast, improvements in respiratory/pulmonary function, functional capacity, muscle strength (with reduced muscle mass loss), incidence of myopathy, length of hospitalization, and mortality in patients who underwent physical therapy were reported. The analysis of the available data indicates that physical therapy, including early progressive mobilization, standing, ambulation, and breathing techniques, together with extracorporeal membrane oxygenation, is feasible, relatively safe, and potentially beneficial for critically ill adult patients.

FUNDAMENTO: O suporte cardiopulmonar com oxigenador de membrana é um método de ressuscitação de distúrbios hemodinâmicos, pulmonares ou ambos, consagrado em centros internacionais. OBJETIVOS: Descrever diversos aspectos relacionados ao suporte cardiopulmonar com oxigenador de membrana em um serviço de cirurgia cardiovascular nacional e determinar seus resultados imediatos e tardios. MÉTODOS: Entre outubro de 2005 e janeiro de 2007, 10 pacientes foram submetidos a suporte circulatório e/ou respiratório em candidatos ou submetidos a cirurgia cardiovascular pediátrica, com idade mediana de 58,5 dias (40% de neonatos) e peso mediano de 3,9 kg. O suporte foi mantido com a intenção de recuperação e desmame, de acordo com critérios clínicos e ecocardiográficos diários. O suporte foi descontinuado nos pacientes sem indicação de transplante, com incapacidade de recuperação e com sobrevida limitada, de acordo com julgamento multidisciplinar. RESULTADOS: O suporte circulatório foi utilizado no pós-operatório de operações corretivas ou paliativas em 80% e no pré-operatório no restante. Instabilidade hemodinâmica grave irresponsiva (40%), falência miocárdica na saída de circulação extracorpórea (20%) e parada cardíaca no pós-operatório (20%) foram as indicações mais freqüentes. O tempo médio de permanência em suporte circulatório foi de 58 ± 37 horas. O suporte foi retirado com sucesso em 50% e 30% obtiveram alta hospitalar. A sobrevida atuarial foi de 40%, 30% e 20% aos 30 dias, 3 meses e 24 meses, respectivamente. CONCLUSÃO: O suporte cardiopulmonar com oxigenador de membrana foi um método eficaz e útil na ressuscitação de distúrbios cardiovasculares e pulmonares graves no perioperatório de cirurgia cardiovascular pediátrica.BACKGROUND: Extracorporeal membrane oxygenation is a well-documented resuscitation method in patients with severe hemodynamic and/or respiratory impairment. OBJECTIVE: To describe several aspects related to the use of extracorporeal membrane oxygenation in a pediatric heart center and determine its immediate and late outcomes. METHODS: Between October 2005 and January 2007, 10 patients who were submitted to pediatric cardiac surgery underwent extracorporeal membrane oxygenation implant. Median age was 58.5 days (40% neonates) and median body weight was 3.9 kg. Circulatory assistance was initiated aiming at the recovery and the weaning protocols followed daily clinical and echocardiographic criteria. Support was discontinued when transplant was contraindicated, when the patient was unable to recover or when survival was considered to be limited by a multidisciplinary team. RESULTS: Extracorporeal membrane oxygenation was employed after corrective or palliative heart surgery in 80% and preoperatively in the remaining ones. It was most often indicated for irresponsive hemodynamic instability (40%), post-cardiotomy shock (20%) and post-cardiac arrest (20%). The mean duration on support was 58 ± 37 hours. Weaning was successfully in 50% of the cases and 30% were discharged home. Actuarial survival was 40%, 30% and 20% at 30 days, 3 months and 24 months, respectively. CONCLUSION: Extracorporeal membrane oxygenation is an effective and useful tool for the resuscitation of patients presenting severe hemodynamic and/or respiratory failure in the perioperative period of pediatric cardiovascular surgery.

Objective: To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil., Methods: A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System (Sistema Único de Saúde; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation., Results: The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R$=-301.00/-14.00, with a cost of R$=-30,913.00/-1,752.00 paid per six-month quality-adjusted life-year gained and R$=-2,386.00/-90.00 per quality-adjusted life-year gained until the end of life, when all patients with severe ARDS were analyzed. Analyzing only patients with severe hypoxemia (i.e., a ratio of partial oxygen pressure in the blood to the fraction of inspired oxygen <100 mmHg), the increased cost was R$=-5,714.00/272.00, with a cost per six-month quality-adjusted life-year gained of R$=-9,521.00/293.00 and a cost of R$=-280.00/7.00 per quality-adjusted life-year gained., Conclusion: The cost-utility ratio associated with the use of extracorporeal membrane oxygenation in Brazil is potentially acceptable according to this hypothetical study.