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Background: The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications. Aim: To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno–venous ECMO. Study Design: This cross‐sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno–venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model. Results: In the study period, 114 patients were treated with veno–venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro–femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%–72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5–3.6, p =.532). Conclusions: Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence‐based care to prevent such pressure injuries in patients undergoing ECMO. Relevance to Clinical Practice: The combination of prone positioning and ECMO shows few life‐threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO)–associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients. Methods: This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time. Results: Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = −215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001). Conclusions: Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit–connected CRRT, as an equally important key factor triggering hemolysis. [ABSTRACT FROM AUTHOR]

Introduction: Gastrointestinal bleeding is a life-threatening complication in patients undergoing extracorporeal membrane oxygenation support. Despite data on increased mortality due to gastrointestinal bleeding, there is little data on the treatment of such conditions under extracorporeal membrane oxygenation, and on the possibilities of advanced endoscopic therapy to non-invasively solve these bleeding complications. No clear treatment in the case of extracorporeal membrane oxygenation support is recommended in the guidelines. Methods: Retrospective observational cohort study including 134 veno-venous extracorporeal membrane oxygenation patients for acute respiratory failure from 2009 to 2018 at IRCCS-ISMETT (Italy). Patients were divided into two groups according to gastrointestinal bleeding episodes and reviewed for type of endoscopic therapy. Gastrointestinal bleeding group was characterized for pre–extracorporeal membrane oxygenation characteristics, management variables—including amount of transfusions and clinical outcomes. Results: Fourteen (14) patients (10.4%) experienced upper (n = 13) or lower (n = 1) gastrointestinal bleeding. Gastrointestinal bleeding and no-gastrointestinal bleeding group had similar characteristics apart from higher creatinine in the gastrointestinal bleeding group (1.9 mg/dL (1.3-4.9) vs 1.2 mg/dL (0.7-1.8), p = 0.03). In 3 of the 14 patients (21%), endoscopy showed no signs of active bleeding (nasogastric or feeding tube decubitus), and no specific intervention was performed. Active bleeding was recognized in 11 of the 14 patients (79 %). No patients died of fatal bleeding in the gastrointestinal bleeding group. Endoscopic therapy was feasible, with a complete bleeding control in all the cases: five Hemospray®, two fibrin glue, two metallic clips, one combined approach metallic clips with epinephrine, and one cyanoacrylate. The extracorporeal membrane oxygenation course was significantly longer in the gastrointestinal bleeding group: 19.5 (15-36) days vs 13.5 (8-25) days, p = 0.01. No significant differences in mortality were found between the two groups (all p values > 0.05). Conclusion: Advanced endoscopic therapy during veno-venous extracorporeal membrane oxygenation may contribute to reducing the negative effects on mortality for gastrointestinal bleeding episodes. [ABSTRACT FROM AUTHOR]

Aim: To evaluate outcomes related to antiplatelet therapy in patients with ST-elevation myocardial infarction (STEMI) admitted to the San Gerardo Hospital in Monza, an extracorporeal membrane oxygenation (ECMO) reference center in the Monza-Brianza area.Methods: This retrospective study enrolled patients with STEMI hospitalized between 2013 and 2017.Results: This study included 653 patients (mean age: 67.5 years, 71% male). Across the study period, ticagrelor use showed consistent increases, from 22% of patients during 2013 to 85% in 2017. Cardiac arrest prehospitalization occurred in 100 patients (15.3%), either at home (n = 85, 13.0%) or during transfer (n = 15, 2.3%); 46 patients underwent ECMO for refractory cardiac arrest. Rates of 90-day survival (hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.3-4.4, P = .004) and ST resolution (odds ratio [OR]: 2.5, 95% CI: 1.6-4.1, P = .000) were higher with ticagrelor than with other antiplatelet agents. When analyzed by each agent, patients on ticagrelor had longer survival (HR: 0.4, 95% CI: 0.2-0.8, P = .008) than patients on clopidogrel and more frequent ST resolution than those on clopidogrel or prasugrel (OR: 0.4, 95% CI: 0.2-0.7, P = .002 and OR: 0.4, 95% CI: 0.2-0.7, P = .006). There was no difference in mortality between ticagrelor and prasugrel.Conclusions: Changes in the treatment of high-risk patients with STEMI over time are in line with changes in treatment guidelines. In these patients, ticagrelor is associated with significantly improved 90-day mortality compared with clopidogrel. [ABSTRACT FROM AUTHOR]

Introduction Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required. Purpose The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO. Methods A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study. Results Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni's technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%). The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P < .0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00--100 000], P < .0001), and mouth care score (6 [5-7] vs 8 [7-9], P < .001). Conclusion Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a technique used in the treatment of patients with severe respiratory failure. A lot of studies in the literature investigated the survival rate of patients treated with ECMO, but few are those that assess the long-term outcomes and the quality of life (QoL) of survivors. Materials and Methods: A retrospective observational study with prospective QoL assessment through administration of the questionnaire EuroQol-5 Dimension was conducted in acute respiratory distress syndrome patients who h ad ECMO as a rescue therapy for reversible refractory hypoxemia from January 2013 until December 2015 in an Italian referral ECMO center. Results: Forty patients were enrolled, but the telephone interview was possible only in 17. The interviewed patients presented a reduction in QoL in the items concerning pain (59%), followed by problems regarding mobility (47%) and anxiety (47%). The patients" perceived QoL, showed in a 0 to 100 scale (0 being the worst, 100 being the best value), is of 75% (interquartile range, 70-80). Discussion: The problems found are in agreement with the literature about this particular type of patients. Conclusion: Most ECMO patients have good physical and social functioning after hospital discharge. [ABSTRACT FROM AUTHOR]

Objective: To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation.Design: Retrospective analysis of prospectively collected data.Setting: Italian tertiary referral center medical-surgical ICU.Patients: One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015.Interventions: None.Measurements and Main Results: Ninety-two patients were included in the analysis (48.5 [37-56] years old, simplified acute physiology score II 37 [32-47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G- (48%) (4 [2-10] vs. 13 [7-23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2-35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5-78] vs. 19 [10.5-27.5] days; p = 0.003), mechanical ventilation (36.5 [20-80.5] vs. 16.5 [9-25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75-54] vs. 10 [5-13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate.Conclusions: Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients' outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility and efficacy of an apnea test (AT) technique that combines the application of positive end expiratory pressure (PEEP) with subsequent pulmonary recruitment in a large cohort of brain-dead patients.Methods: This study was a retrospective analysis of prospectively collected data on brain-dead patients admitted to our institution (Hospital San Gerardo, Monza, Italy) between January 2010 and December 2014. The rate of aborted apnea tests (ATs), occurrence of complications (i.e., pneumothorax, cardiac arrhythmias, cardiac arrest, and severe hypoxia, defined as PaO2 < 40 mmHg), ventilator settings, hemodynamics, and blood gas analyses were evaluated. Subgroup analysis was performed, with patients classified into veno-arterial extracorporeal membrane oxygenation (ECMO) or non-ECMO groups, and into hypoxic (i.e., baseline PaO2/FiO2 < 200 mmHg) and non-hypoxic (i.e., baseline PaO2/FiO2 > 200 mmHg) groups.Results: In total, 169 consecutive patients including 25 on ECMO were included in the study. No AT abortion nor severe complications were detected. The AT was completed in all patients. Fluid boluses and increases or initiation of vasoactive drugs were required in less than 10 and 3% of the AT procedures, respectively. No clinically meaningful alteration in hemodynamics was recorded. Severe hypoxia occurred during 7 (2.4%) and 4 (8%) of the ATs performed in non-ECMO and ECMO patients, respectively (p = 0.063), and it occurred more frequently in hypoxic patients than in non-hypoxic patients (11.1 vs. 4.8%, respectively; p = 0.002).Conclusions: In a large cohort of consecutive patients, including the largest patient population on ECMO reported to date, our AT technique that combines the application of PEEP with subsequent pulmonary recruitment proved to be feasible and safe. [ABSTRACT FROM AUTHOR]

Phosphorylcholine coating has a major role in the improvement of biocompatibility, durability and antihrombogenicity of the circuit for extracorporeal membrane oxygenation (ECMO). Moreover, if heparin-induced thrombocytopenia ensues, removal of all the sources of heparin is challenging if the circuit is coated with heparin.We report our preliminary experience with the new EUROSETS A.L.ONE ECMO oxygenator (Eurosets, Medolla, MO, Italy), which is aimed at providing better biocompatibility thanks to its full coating with phosphorylcholine. We retrospectively collected data on the 16 patients supported with ECMO and with the EUROSETS A.L.ONE ECMO oxygenator at San Raffaele Hospital. Mean ECMO duration was 6 ± 4 days, and 37.5% of the patients died on ECMO. Four episodes of major bleeding and three episodes of minor bleeding were recorded. The oxygenator had an excellent performance in gas exchange and the median pressure drop was 57 (26-85) mmHg at full blood flow (2.5 L/m2/min).The EUROSETS A.L.ONE ECMO oxygenator was an excellent device in our preliminary experience. Further evaluation on a larger sample is encouraged. [ABSTRACT FROM PUBLISHER]