Search

Blood stream infection (BSI) is a potentially lethal complication in patients receiving extracorporeal membrane oxygenation (ECMO). It may be particularly common in patients with veno-venous ECMO due to their long hospitalization in the intensive care unit. Given that these patients have concurrent indwelling central venous catheters (CVC), it is unclear whether the ECMO circuit, CVC, or both, contribute to BSI. This study evaluated the risk factors associated with BSI in patients receiving veno-venous ECMO in a single institution study of 61 patients from 2016 through 2019. All ECMO catheters and the circuit oxygenator fluid were aseptically collected and analyzed for microorganisms at the time of decannulation. New BSI was diagnosed in 15 (24.6%) patients and increased mortality by threefold. None of the ECMO catheters or oxygenator fluid were culture positive. BSI increased with CVC use of over 8 days and was significantly lowered when CVC were exchanged by day 8 compared with patients with exchanges at later points (15.0% vs. 42.8%, p = 0.02). Median length of CVC use in the BSI-negative and BSI-positive group were 6.3 ± 5.0 and 9.4 ± 5.1, respectively (p = 0.04). In summary, BSI is a potentially lethal complication in patients receiving ECMO. Indwelling CVC, not the ECMO circuitry, is the likely contributor for BSI, and exchanging CVC by day 8 can reduce the incidence of BSI.

Background. Innovative advances in cardiac surgery to reduce the negative impact of cardiopulmonary bypass (CPB) require a comprehensive solution. The ultimate questions of present interest remain the prevention of hypoxia, the composition of the priming volume of the oxygenator, the state of erythrocytes and their energy potential, the level of hemolysis, the pathogenetic approach to the correction of electrolytes during perfusion, as well as the biocompatibility of the extracorporeal circuit. The study aimed to create the protocol for cardiopulmonary bypass, which includes the possibility of reducing the negative effects of synthetic polymers of the extracorporeal circuit; reducing the hydrodynamic load on the tissue; carrying out a more physiological correction of the acid-base state; improving the energy potential of cells; correction of electrolyte balance during cardiopulmonary bypass ta­king into account the stages of the surgical operation. Materials and methods. The study included 225 patients who underwent cardiac surgery using cardiopulmonary bypass. The patients were divided into three groups. The first group consisted of 75 people, whose extracorporeal contour was treated with the adaptive composition by a special technique. After centrifuging the patient’s blood, serum was obtained, which was diluted in a solution of 0.9% NaCl and treated with the oxygenator circuit. The second group included patients (n = 75) in whom fructose-1,6-diphosphate (FPD) was used in the perfusion regimen. The drug was administered intravenously at a dose of 10 g at a rate of 10 ml/min in two stages: 5 g of FPD were injected immediately before the start of perfusion and 5 g before the patient was warmed up. The third group was the control group. Perfusion was performed using a membrane oxygenator in a non-pulsating blood flow mode with a prime of 1.3–1.6 L to achieve moderate hemodilution (Ht — 25 ± 2 g/L). A hyperosmolar priming volume with a total osmolarity of up to 510.6 mmol/L was used. The basic solutions were volutens, reosorbilact, mannitol 15%, Soda-buffer 4.2%. Hemogram (Hb, Ht, MCV, MCH, MCHC, RDWa, RDW%, hemolysis), oxygen transport: saturation of arterial (SaO2%) and venous blood (SvO2%), partial pressure of oxygen in arterial (PaO2) and venous blood (PvO2), oxygen delivery index (IDO2), oxygen consumption index (IVO2), oxygen extraction (O2ER), and oxygen extraction index (O2EI) were studied. The research of morphological changes in erythrocytes was carried out. Results. Our study aimed to develop and implement into practice an optimized cardiopulmonary bypass protocol based on the results obtained. The previous studies have shown that treatment of the oxy-genator circuit with the adaptive composition creates a protective layer of autoalbumin on the inner surface of the extracorporeal circuit, and the use of a drug with the active fructose-1,6-diphosphate ingredient during perfusion allows correcting hypophosphatemia, reducing the energy deficiency of the cells. In these two groups, in comparison with the control one, after CPB, there was a lower level of hemolysis, a lower number of echinocytes, and spherocytes. The three groups used the hyperosmolar priming ­volume. Before perfusion, there were the following indices: IDO2 — 332.00 ± ± 84.84 ml/(min • m2), IVO2 — 76.07 ± 28.34 ml/(min • m2), O2ЕR — 22.91 ± 6.33 %, O2EI — 22.47 ± 6.32 %, BE = –0.78 ± 2.13 mmol/L. At 10 min after CPB, there were the following indices: IDO2 — 579.7 ± 112.3 ml/(min • m2), IVO2 — 30.91 ± 13.31 ml / (min • m2), O2ER — 5.35 ± 2.07 %, O2EI — 5.26 ± ± 2.08 %, BE = 0.82 ± 2.03 mmol/L. IDO2 increased due to the oxygenator gas exchange, and the decrease in IVO2, O2ЕR, O2EI can be explained by the patient’s cooling. At the warming stage, there were the indices: IDO2 — 598.8 ± 114.9 ml/(min • m2), IVO2 — 108.10 ± 33.11 ml/(min • m2), O2ER — 18.04 ± 4.14 %, O2EI — 17.95 ± 4.15 %, BE = –0.11 ± 8.88 mmol/L. IDO2 — 305.7 ± 60.9 ml / min • m2), IVO2 — 77.15 ± 24.29 ml/(min • m2), O2ЕR — 25.36 ± 6.5 %, O2EI — 25.34 ± 6.5 %, BE = –0.36 ± 2.20 mmol/L. After CPB, the rate of diuresis was 11.88 ± 5.31 ml/kg/h, the relative hydrobalance after CPB was 9.67 ± 8.12 ml/kg. Our proposed protocol for cardiopulmonary bypass includes the basic points: 1) treatment of the oxygenator contour with the adaptive composition; 2) in patients with an initially low level of phosphorus, administration of the drug of fructose-1,6-diphosphate by the scheme; 3) the use of a hyperosmolar priming volume of the oxygenator; 4) correction of electrolytes taking into account the stages of cardiac surgery. Conclusions. The proposed procedure for the treatment of the extracorporeal oxygenator circuit is simple and affordable, improves the biocompatibility of the oxygenator. The use of a hyperosmolar priming volume avoids the volume load and provides an adequate gas transport function of the blood. The application of FPD makes it possible to reduce hemolysis and protect erythrocytes, correct electrolytes by taking into account the stages of operations and the peculiarities of CPB., Актуальність. Сучасний підхід до зменшення негативного впливу штучного кровообігу (ШК) вимагає комплексного вирішення. Найбільш актуальними питаннями залишаються профілактика й усунення гіпоксії, склад первинного об’єму заповнення оксигенатора, стан еритроцитів і їх енергетичний потенціал, рівень гемолізу, патогенетичний підхід до корекції електролітів під час перфузії, а також біосумісність екстракорпорального контура. Мета: створити протокол проведення штучного кровообігу, який включав би можливість зниження негативного впливу синтетичних полімерів екстракорпорального контура; зменшення гідродинамічного навантаження на тканини; проведення більш фізіологічної корекції кислотно-лужного стану; усунення енергетичного дефіциту клітин; проведення корекції електролітного балансу під час штучного кровообігу з урахуванням етапів операції. Матеріали та методи. У дослідження увійшло 225 хворих, яким виконані кардіохірургічні операції з використанням штучного кровообігу. Пацієнти були розподілені на 3 групи. У першу групу ввійшли пацієнти (n = 75), у яких екстракорпоральний контур оброблявся адаптуючою композицією за спеціальною методикою. У результаті центрифугування крові пацієнта отримували сироватку, яку розводили в розчині 0,9% NaCl, і обробляли контур оксигенатора. До другої групи були включені пацієнти (n = 75), у яких у схемі проведення перфузії використовувався препарат фруктозо-1,6-дифосфат (ФДФ). Препарат вводили внутрішньовенно в дозі 10 г зі швидкістю 10 мл/хв у два етапи: 5 г ФДФ вводилися безпосередньо перед початком перфузії і 5 г — перед зігріванням пацієнта. Третя група була контрольною. Перфузія проводилась за допомогою мембранного оксигенатора в режимі непульсуючого кровотоку з первинним об’ємом заповнен-ня 1,3–1,6 л для досягнення помірної гемодилюції (Ht – 25 ± 2 г/л). Використовували гіперосмолярний первинний об’єм заповнення оксигенатора із загальною осмолярністю до 510,6 ммоль/л. Базисними розчинами були волютенз, реосорбілакт, маніт 15%, сода-буфер 4,2%. Досліджували гемограму (Hb, Ht, MCV, MCH, MCHC, RDWa, RDW%, гемоліз), кисневий транспорт: сатурацію артеріальної (SaO2) і венозної крові (SvO2), парціальний тиск кисню в артеріальній (PaO2) і венозній крові (PvO2), індекс доставки кисню (IDO2), індекс споживання кисню (IVO2), екстракцію кисню (O2ER) та індекс екстракції кисню (O2EI). Відповідно до мазків крові проводили вивчення морфологічних змін еритроцитів. Результати. Наші дослідження були спрямовані на те, щоб за їх результатом розробити й увести в практику оптимізований протокол проведення штучного кровообігу. У попередніх роботах було показано, що обробка контура оксигенатора адаптуючою композицією створює захисний шар з автоальбуміну на внутрішній поверхні екстракорпорального контура, а використання під час перфузії препарату з діючою речовиною фруктозо-1,6-дифосфат дозволяє скорегувати гіпофосфатемію, усунути енергетичний дефіцит клітини. У цих двох групах порівняно з контрольною після закінчення перфузії був менший рівень гемолізу, менша кількість ехіноцитів і сфероцитів. У трьох групах використовували гіперосмолярний первинний об’єм заповнення оксигенатора. До перфузії показники були такими: IDO2 — 332,0 ± ± 84,84 мл/(хв ∙ м2), IVO2 — 76,07 ± 28,34 мл/(хв ∙ м2), O2ЕR — 22,91 ± 6,33 %, O2EI — 22,47 ± 6,32 %, BE = –0,78 ± 2,13 ммоль/л. На 10-й хвилині ШК IDO2 — 579,7 ± 112,3 мл/(хв ∙ м2), IVO2 — 30,91 ± ± 13,31мл/(хв ∙ м2), O2ЕR — 5,35 ± 2,07 %, O2EI — 5,26 ± 2,08 %, BE = 0,82 ± 2,03 ммоль/л. IDO2 виріс за рахунок роботи оксигенатора, а зниження IVO2, O2ЕR, O2EI можна пояснити охолодженням хворого. На етапі зігрівання: IDO2 — 598,8 ± 114,9 мл/(хв ∙ м2), IVO2 — 108,1 ± 33,11 мл/(хв ∙ м2), O2ЕR — 18,04 ± ± 4,14 %, O2EI — 17,95 ± 4,15 %, BE = –0,11 ± 8,88 ммоль/л. Після ШК: IDO2 — 305,7 ± ± 60,90 мл/(хв ∙ м2), IVO2 — 77,15 ± 24,29 мл/(хв ∙ м2), O2ЕR — 25,36 ± 6,5 %, O2EI — 25,34 ± 6,5 %,BE = –0,36 ± 2,20 ммоль/л. Після перфузії темп діурезу становив 11,88 ± 5,31 мл/кг/год, відносний гідробаланс — 9,67 ± 8,12 мл/кг. Запропонований нами протокол проведення штучного кровообігу включає основні ланки: 1) обробка контура оксигенатора адаптуючою композицією; 2) введення за схемою препарату фруктозо-1,6-дифосфату пацієнтам з початковим низьким рівнем фосфору; 3) використання гіпер-осмолярного первинного об’єму заповнення оксигенатора; 4) корекція електролітів з урахуванням етапів кардіохірургічної операції. Висновки. Запропонована методика обробки екстракорпорального контура оксигенатора є простою і доступною, вона покращує біосумісність оксигенатора, застосування гіперосмолярного первинного об’єму заповнення оксигенатора дозволяє уникнути волемічного навантаження й забезпечує адекватну газотранспортну функцію крові, використання фруктозо-1,6-дифосфату сприяє зменшенню гемолізу й захисту еритроцитів, корекція електролітів з урахуванням етапів операцій враховує особливості штучного кровообігу.

Thrombocytosis has been feared as a source of thrombotic complications during the conduct of cardiopulmonary bypass (CPB) for patients undergoing cardiac procedures. We present a patient urgently requiring repair/replacement of three heart valves that had preexisting myelofibrosis with thrombocytosis (platelet count of 800,000 per µl) and neutrophilia (40,000 per µl). Despite achieving an activated clotting time > 500 s with heparin and antithrombin concentrate administration prior to CPB, the pump oxygenator and reservoir demonstrated significant clot just prior to restoration of the patient’s circulation. The patient subsequently suffered a severe protamine reaction that was successfully managed. A review of the literature of similar patients and the relevant cellular and biochemical mechanisms in this setting are presented, with potential therapeutic approaches to prevent such complications noted.

Cardiopulmonary bypass (CPB) circuits can significantly sequester intravenous anesthetics. Adsorption of medications by our institution's standard circuit (Terumo CAPIOX FX05 oxygenator; noncoated polyvinylchloride tubing) has not been described. We prepared ex vivo CPB circuits with and without oxygenators. Medication combinations studied included midazolam (0.5 mg), fentanyl (50 [micro]g), midazolam (0.5 mg) with morphine (0.5 mg), and midazolam (0.5 mg) with fentanyl (50 [micro]g). Medications were administered after obtaining baseline samples. Samples were drawn at 2, 5, 15, 30, 60, 120, and 180 minutes, and analyzed for concentration of injected medications. Midazolam demonstrated no sequestration after 180 minutes. Fentanyl concentration at 180 minutes was lower with an oxygenator (52.7 +/- 12.5 vs. 110.9 +/- 12.0 ng/ml, P = 0.00432). More fentanyl was found in solution after 180 minutes when given with midazolam compared to fentanyl given alone in the presence of an oxygenator (101 +/- 22.3 vs. 52.7 +/- 12.5 ng/ml, P = 0.044). Less midazolam was present after 180 minutes when given with morphine compared to midazolam given alone in the absence of an oxygenator (1264.9 +/- 425.6 vs. 2124 +/- 254 ng/ml, P = 0.037). We successfully characterized the adsorption of various combinations of midazolam, fentanyl, and morphine to our CPB circuit, showing that fentanyl and midazolam behave differently based on other medications present.

Acute lung injury and acute respiratory distress syndrome are characterized by rapid-onset respiratory failure following a variety of direct and indirect insults to the parenchyma or vasculature of the lungs. Extracorporeal membrane oxygenation is a form of extracorporeal life support where an external artificial circulator carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patients circulation. The potential advantages of ECMO over conventional manajement may extend beyond its role in supporting patients with ARDS. ECMO may facilitate and enhance the application of lung-protective ventilation by minimizing ventilator-induced lung injury.

Introduction: To determine the oxygenator impact on alterations of meropenem (MEM)/vaborbactam (VBR) in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extra corporeal membrane oxygenation (ECMO) circuit including the Quadrox-i® oxygenator. Methods: 1/4-inch and 3/8-inch, simulated closed-loop ECMO circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. A one-time dose of MEM/VBR was administered into the circuits and serial pre- and post-oxygenator concentrations were obtained at 5 minutes, 1, 2, 3, 4, 5, 6, 8, 12, and 24-hour time points. MEM/VBR was also maintained in a glass vial and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation. Results: For the 1/4-inch circuit, there was an approximate mean 55% MEM loss with the oxygenator in series and a mean 33%–40% MEM loss without an oxygenator in series at 24 hours. For the 3/8-inch circuit, there was an approximate mean 70% MEM loss with the oxygenator in series and a mean 30%–38% MEM loss without an oxygenator in series at 24 hours. For both the 1/4-inch circuit and 3/8-inch circuits with and without an oxygenator, there was Conclusions: This ex-vivo investigation demonstrated substantial MEM loss within an ECMO circuit with an oxygenator in series with both sizes of the Quadrox-i oxygenator at 24 hours and no significant VBR loss. Further evaluations with multiple dose in-vitro and in-vivo investigations are needed before specific MEM/VBR dosing recommendations can be made for clinical application with ECMO.

The objective of this study was to determine if propofol administration to veno-venous (VV) extracorporeal membrane oxygenation (ECMO) patients was associated with more incidents of oxygenator failure when compared to patients who did not receive propofol. This was a single center, retrospective cohort study. The primary outcome of the study is oxygenator exchanges per ECMO day in patients who received propofol versus those who did not receive propofol. Patients were 18 years or older on VV-ECMO support between January 1, 2015 and January 31, 2018. Patients were excluded if they required ECMO support for less than 48 h or greater than 21 days. There were five patients in the propofol arm that required oxygenator exchanges and seven patients in the control arm. The total number of oxygenator exchanges per ECMO day was not significantly different between groups ( p = 0.50). When comparing those who required an oxygenator exchange and those who did not, there was no difference in the cumulative dose of propofol received per ECMO hour (0.64 mg/kg/h vs 0.96 mg/kg/h; p = 0.16). Propofol use in patients on VV-ECMO does not appear to increase the number of oxygenator exchanges.

Extracorporeal carbon dioxide removal (ECCO2R) is increasingly considered a viable therapeutic approach in the management of hypercapnic lung failure to avoid intubation or to allow lung-protective ventilator settings. This study aimed to analyze efficacy and safety of a minimal-invasive ECCO2R device, the Homburg lung. The Homburg lung is a pump-driven system for veno-venous ECCO2R with ¼″ tubing and a 0.8 m surface oxygenator. Vascular access is usually established via a 19F/21 cm bilumen cannula in the right internal jugular vein. For this work, we screened patient registries from two German centers for patients who underwent ECCO2R with the Homburg lung because of hypercapnic lung failure since 2013. Patients who underwent extracorporeal membrane oxygenation before ECCO2R were excluded. Patients who underwent ECCO2R more than one time were only included once. In total, 24 patients (aged 53.86 ± 12.49 years; 62.5% male) were included in the retrospective data analysis. Ventilatory failure occurred because of chronic obstructive pulmonary disease (50%), cystic fibrosis (16.7%), acute respiratory distress syndrome (12.5%), and other origins (20.8%). The system generated a blood flow of 1.18 ± 0.23 liters per minute (lpm). Sweep gas flow was 3.87 ± 2.97 lpm. Within 4 hours, paCO2 could be reduced significantly from 82.05 ± 15.57 mm Hg to 59.68 ± 12.27 mm Hg, thereby, increasing pH from 7.23 ± 0.10 to 7.36 ± 0.09. Cannulation-associated complications were transient arrhythmia (1/24 patients) and air embolism (1/24). Fatal complications did not occur. In conclusion, the Homburg lung provides effective carbon dioxide removal in hypercapnic lung failure. The cannulation is a safe procedure, with complication rates comparable to those in central venous catheter implantation.

Objectives The main objective of the study was to determine the prevalence of venous thromboembolism events in patients infected with severe acute respiratory syndrome coronavirus 2 requiring venovenous extracorporeal membrane oxygenation. The secondary objective was to compare venous thromboembolism events and coagulation variables in patients requiring venovenous extracorporeal membrane oxygenation according to the pathogen. Design Retrospective observational analysis at a single center. Setting Tertiary referral university teaching hospital. Patients Patients with severe acute respiratory syndrome coronavirus 2-related severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation therapy with an injected CT scan performed after extracorporeal membrane oxygenation retrieval. Interventions None. Measurements and main results We included 13 severe acute respiratory syndrome coronavirus 2 patients requiring venovenous extracorporeal membrane oxygenation. All of these patients experienced venous thromboembolism: 10 patients (76.9%) had isolated cannula-associated deep vein thrombosis, two patients (15.4%) had isolated pulmonary embolism, and one patient (7.7%) had both cannula-associated deep vein thrombosis and pulmonary embolism. Eleven patients (84.6%) had cannula-associated deep vein thrombosis. A jugular associated cannula-associated deep vein thrombosis was identified in seven patients (53.8%), a femoral associated cannula-associated deep vein thrombosis was identified in 10 patients (76.9%), and six patients (46.2%) had both femoral and jugular cannula-associated deep vein thrombosis. A pulmonary embolism was found in three patients (23.1%). No patient had central venous catheter-related deep vein thrombosis. One patient had thrombotic occlusion of the centrifugal pump, and one had oxygenator thrombosis requiring circuit replacement. Three patients (23.1%) had significant bleeding. Three patients (23.1%) had laboratory-confirmed heparin-induced thrombocytopenia, and all of them developed cannula-associated deep vein thrombosis. These three patients had femoral cannula-associated deep vein thrombosis, and two had an oxygenator or pump thrombosis. The mean activated partial thromboplastin time ratio was higher in the severe acute respiratory syndrome coronavirus 2 group than in the influenza group and the community-acquired pneumonia group (1.91 vs 1.48 vs 1.53; p = 0.001), which was also found in regard to the percentage of patients with an activated partial thromboplastin time ratio greater than 1.8 (47.8% vs 20% vs 20.9%; p = 0.003) and the mean prothrombin ratio (86.3 vs 61.6 vs 67.1; p = 0.003). There was no difference in baseline characteristics or venous thromboembolism events. Conclusions We report a 100% occurrence of venous thromboembolism in critically ill patients supported by venovenous extracorporeal membrane oxygenation for severe acute respiratory syndrome coronavirus 2-related acute respiratory distress syndrome using CT scan imaging despite a high target and close monitoring of anticoagulation.

Rationale: Mesenchymal stromal cell (MSC) therapy is a promising intervention for acute respiratory distress syndrome (ARDS), although trials to date have not investigated its use alongside extracorporeal membrane oxygenation (ECMO). Recent preclinical studies have suggested that combining these interventions may attenuate the efficacy of ECMO.Objectives: To determine the safety and efficacy of MSC therapy in a model of ARDS and ECMO.Methods: ARDS was induced in 14 sheep, after which they were established on venovenous ECMO. Subsequently, they received either endobronchial induced pluripotent stem cell-derived human MSCs (hMSCs) (n = 7) or cell-free carrier vehicle (vehicle control; n = 7). During ECMO, a low Vt ventilation strategy was employed in addition to protocolized hemodynamic support. Animals were monitored and supported for 24 hours. Lung tissue, bronchoalveolar fluid, and plasma were analyzed, in addition to continuous respiratory and hemodynamic monitoring.Measurements and Main Results: The administration of hMSCs did not improve oxygenation (PaO2/FiO2 mean difference = -146 mm Hg; P = 0.076) or pulmonary function. However, histological evidence of lung injury (lung injury score mean difference = -0.07; P = 0.04) and BAL IL-8 were reduced. In addition, hMSC-treated animals had a significantly lower cumulative requirement for vasopressor. Despite endobronchial administration, animals treated with hMSCs had a significant elevation in transmembrane oxygenator pressure gradients. This was accompanied by more pulmonary artery thromboses and adherent hMSCs found on explanted oxygenator fibers.Conclusions: Endobronchial hMSC therapy in an ovine model of ARDS and ECMO can impair membrane oxygenator function and does not improve oxygenation. These data do not recommend the safe use of hMSCs during venovenous ECMO.

Introduction: To determine the oxygenator impact on alterations of voriconazole in a contemporary neonatal/pediatric (1/4 inch) and adolescent/adult (3/8 inch) extracorporeal membrane oxygenation circuit including the Quadrox-i® oxygenator. Methods: Simulated closed-loop extracorporeal membrane oxygenation circuits (1/4 and 3/8 inch) were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. In addition, 1/4- and 3/8-inch circuits were also prepared without an oxygenator in series. A one-time dose of voriconazole was administered into the circuits, and serial pre- and post-oxygenator concentrations were obtained at 5 minutes, 1, 2, 3, 4, 5, 6, and 24 hour time points. Voriconazole was also maintained in a glass vial and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation Results: For the 1/4-inch circuit, there was an approximate mean of 64-67% voriconazole loss with the oxygenator in series and mean of 15-20% voriconazole loss without an oxygenator in series at 24 hours. For the 3/8-inch circuit, there was an approximate mean of 44-51% voriconazole loss with the oxygenator in series and a mean of 8-12% voriconazole loss without an oxygenator in series at 24 hours. The reference voriconazole concentrations remained relatively constant during the entire study period demonstrating that the drug loss in each size of the extracorporeal membrane oxygenation circuit with or without an oxygenator was not a result of spontaneous drug degradation. Conclusion: This ex vivo investigation demonstrated substantial voriconazole loss within an extracorporeal membrane oxygenation circuit with an oxygenator in series with both sizes of the Quadrox-i oxygenator at 24 hours and no significant voriconazole loss in the absence of an oxygenator. Further evaluations with multiple dose in vitro and in vivo investigations are needed before specific voriconazole dosing recommendations can be made for clinical application with extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) requires constant management of coagulation. Whereas unfractionated heparin remains the anticoagulant of choice, experienced centers report high bleeding rates. Biocompatibility of the extracorporeal circuit enables management of anticoagulation with subcutaneous low-molecular-weight heparins only. The aim of this study was to evaluate the safety and feasibility of anticoagulation with subcutaneous nadroparin compared with unfractionated heparin during respiratory ECMO in patients. We assessed for thrombotic complications and number of bleeding and life-threatening bleeding events. Additionally, we evaluated the change in resistance to flow in the oxygenator and the number of transfused blood products. Nadroparin and unfractionated heparin were comparable in terms of number of bleeding (34 vs. 53%; p = 0.12), life-threatening bleeding (2.8 vs. 9.3%; p = 0.26) events, and daily red blood cell transfusion rates (0.79 units/patient/day vs. 0.71 units/patient/day in nadroparin group; p = 0.87) during respiratory ECMO. The relative change in resistance to flow in the oxygenator was similar between groups (8.03 vs. 11.6%; p = 0.27). Nadroparin seemed equivalent to unfractionated heparin in the number of thrombotic and hemorrhagic events as well as in the daily red blood cell transfusion rates during venovenus-ECMO.

Objectives To determine the oxygenator impact on alterations of ceftolozane/tazobactam in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extracorporeal membrane oxygenation circuit including the Quadrox-i oxygenator (Maquet, Wayne, NJ). Design A 1/4-inch and 3/8-inch, simulated closed-loop extracorporeal membrane oxygenation circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. A one-time dose of ceftolozane/tazobactam was administered into the circuits and serial preoxygenator and postoxygenator concentrations were obtained at 5 minutes, 1, 2, 3, 4, 5, 6, and 24-hour time points. Ceftolozane/tazobactam was also maintained in a glass vial and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation SETTING:: A free-standing extracorporeal membrane oxygenation circuit. Patients None. Interventions Single-dose administration of ceftolozane/tazobactam into closed-loop extracorporeal membrane oxygenation circuits prepared with and without an oxygenator in series with serial preoxygenator, postoxygenator, and reference samples obtained for concentration determination over a 24-hour study period. Measurements and main results For the 1/4-inch circuit, there was approximately 92% ceftolozane and 22-25% tazobactam loss with the oxygenator in series and 19-30% ceftolozane and 31-34% tazobactam loss without an oxygenator in series at 24 hours. For the 3/8-inch circuit, there was approximately 85% ceftolozane and 29% tazobactam loss with the oxygenator in series and 25-27% ceftolozane and 23-26% tazobactam loss without an oxygenator in series at 24 hours. The reference ceftolozane and tazobactam concentrations remained relatively constant during the entire study period demonstrating the drug loss in each size of the extracorporeal membrane oxygenation circuit with or without an oxygenator was not a result of spontaneous drug degradation. Conclusions This ex vivo investigation demonstrated substantial ceftolozane loss within an extracorporeal membrane oxygenation circuit with an oxygenator in series with both sizes of the Quadrox-i oxygenator at 24 hours and significant ceftolozane loss in the absence of an oxygenator. Tazobactam loss was similar regardless of the presence of an oxygenator. Further evaluations with multiple dose in vitro and in vivo investigations are needed before specific drug dosing recommendations can be made for clinical application with extracorporeal membrane oxygenation.

BACKGROUND Cefepime is a first-line therapy for gram-negative infections in children on extracorporeal membrane oxygenation. Cefepime pharmacokinetics (PK) in children on extracorporeal membrane oxygenation still needs to be better established. METHODS This was a prospective single-center PK study. A maximum of 12 PK samples per patient were collected in children

Background: Extracorporeal membrane oxygenation (ECMO) provides cardiopulmonary support for critically ill patients. Portable ECMO devices can be applied in both in-hospital and out-of-hospital emergency conditions. We evaluated the safety and biocompatibility of a novel centrifugal pump and ECMO device of the OASSIST ECMO System (Jiangsu STMed Technologies Co., Suzhou, China) in a 168-h ovine ECMO model.Methods: The portable OASSIST ECMO system consists of the control console, the pump drive, and the disposable centrifugal pump. Ten healthy sheep were used to evaluate the OASSIST ECMO system. Five were supported on veno-venous ECMO and five on veno-arterial ECMO, each for 168 h. The systemic anticoagulation was achieved by continuous heparin infusion to maintain the activated clotting time (ACT) between 220 and 250 s. The rotary speed was set at 3,200–3,500 rpm. The ECMO configurations and ACT were recorded every 6 hours (h). The free hemoglobin (fHb), complete blood count, and coagulation action test were monitored, at the 6th h and every 24 h after the initiation of the ECMO. The dissection of the pump head and oxygenator were conducted to explore thrombosis.Results: Ten sheep successfully completed the study duration without device-related accidents. The pumps ran stably, and the ECMO flow ranged from 1.6 ± 0.1 to 2.0 ± 0.11 L/min in the V-V group, and from 1.8 ± 0.1 to 2.4 ± 0.14 L/min in the V-A group. The anticoagulation was well-performed. The ACT was maintained at 239.78 ± 36.31 s, no major bleeding or thrombosis was observed during the ECMO run or in the autopsy. 3/5 in the V-A group and 4/5 in the V-V group developed small thrombus in the bearing pedestal. No obvious thrombus formed in the oxygenator was observed. The hemolytic blood damage was not significant. The average fHb was 0.17 ± 0.12 g/L. Considering hemodilution, the hemoglobin, white blood cell, and platelets didn't reduce during the ECMO runs.Conclusions: The OASSIST ECMO system shows satisfactory safety and biocompatibility for the 168-h preclinical evaluation in the ovine model. The OASSIST ECMO system is promising to be applied in clinical conditions in the future.

RATIONALE Increased cytokine response is common in patients receiving extracorporeal life support and is often a poor prognostic indicator. There is interest in using adjunctive cytokine adsorption technologies to reduce inflammatory burden, However, it is debated whether extracorporeal membrane oxygenation (ECMO) itself provides therapeutic benefit beyond gas exchange. Thus, we sought to characterize the inflammatory profile of ECMO in the first 72-96 h of and quantify its effect on cytokine levels in a case series of patients undergoing ECMO. METHODS Eight patients initiating ECMO were studied. Of these, we measured cytokines pre- and post-oxygenator over 96 h. Comparisons of cytokine levels were made across the oxygenator and over time. RESULTS The average age of patients was 64.3 years with 62% being male. Centrally cannulated patients had higher IL-6 levels (820.43 vs. 6907.53 pg/ml, p

Extracorporeal membrane oxygenation (ECMO) has become a mainstay of therapy for patients suffering from severe respiratory failure. Ambulatory ECMO systems aim to provide long-term out-of-hospital respiratory support. As a patient’s activity level changes, the required level of ECMO support varies with oxygen consumption and metabolic fluctuations. To compensate for such changes, an Auto-Regulatory ECMO system (AR-ECMO) has been developed and its performance was evaluated as a proof-of-concept in an acute ovine model. The AR-ECMO system consists of a regular ECMO circuit and an electromechanical control system. A custom fuzzy-logic control algorithm was implemented to adjust the blood flow and sweep gas flow of the ECMO circuit to meet the varying respiratory demand by utilizing two noninvasive sensors for venous oxyhemoglobin saturation and the oxygenator exhaust gas CO2 concentration. Disturbance responses of the AR-ECMO to induced acute respiratory distress were assessed for six hours in four juvenile sheep cannulated with a veno-pulmonary artery ECMO configuration, including acute ventilator shutoff, ventilator step-change (off-on-off), and forced desaturation. All sheep survived for the study duration. The AR-ECMO system was able to respond and maintain stable hemodynamics and physiological blood gas contents (SpO(2) = 96.3 % ± 4.29, pH = 7.44 ± 0.09, pCO(2) = 38.9 ± 9.9 mmHg, and pO(2) =237.9 ± 123.6 mmHg) during simulated respiratory distress. Acceptable correlation between oxygenator exhaust gas CO(2) and oxygenator outlet pCO(2) were observed (R(2)= 0.84). In summary, the AR-ECMO system successfully maintained physiologic control of peripheral oxygenation and carbon dioxide over the study period, utilizing only measurements taken directly from the ECMO circuit. The range of system response necessitates an adaptable system in the setting of variable metabolic demands. The ability of this system to respond to significant disturbances in ventilator support is encouraging. Future work to evaluate our AR-ECMO system in long-term, awake animal studies is necessary for further refinement.

Background Self-made Y-connector jet-oxygenation devices with wide-bore expiratory port have been described but not evaluated in infant models. Little is known about the effect of oxygen flow rates on jet oxygenation via transtracheal cannula. Aims The aim of this study was to compare two self-made Y-connector jet-oxygenation devices against the ENK oxygen flow modulator™, and the effects of three different oxygen flow rates based on body weight, in both unobstructed and obstructed airways, on the time to re-oxygenate in a rabbit infant model. The aim was also to assess the effectiveness of an oxygen flow rate of 1 L/min, for re-oxygenation using ENK oxygen flow modulator™. Methods Nine rabbits were grouped in threes: Group 1 had a Y-connector attached to an intravenous infusion tubing, Group 2 the same Y-connector attached to a perfusion oxygenator tubing and Group 3, ENK oxygen flow modulator™. From oxygen saturations of 75%, the rabbits were jet oxygenated using their assigned device for 10 minutes at each flow rate of 1 L/kg/min, 1.5 L/kg/min and 2 L/kg/min with their airways unobstructed and later, obstructed. Group 3 had additional experiments involving an absolute oxygen flow rate of 1 L/min. Results All devices resulted in rapid re-oxygenation within 40 seconds at flow rates of 1 L/kg/min. Oxygen flow rates beyond 1 L/kg/min in obstructed airways resulted in high airway pressures. All rabbits in Group 3 with obstructed airways died from barotrauma when jet oxygenated at a flow rate of 1.5 L/kg/min. When an oxygen flow rate of 1 L/min was used in Group 3, there was a failure to re-oxygenate to SpO2 90% within 120 seconds in some rabbits. Conclusion Our animal model results suggest that self-made Y-connector jet-oxygenation devices with wide-bore expiratory port are efficacious and perhaps safer than ENK oxygen flow modulator™ in obstructed airways, and jet oxygenation with minimal oxygen flow rates starting at 1 L/kg/min or (age [years] + 4) L/min, whichever lower, should be considered.

Extracorporeal membrane oxygenation is a life-saving intervention, but bleeding complications are frequent. Given that the combination of platelet loss and dysfunction is a major contributor to this acquired bleeding diathesis, efforts to combat these phenomena are of great clinical importance. In this study, we investigated the effects of nitric oxide (NO) added to the sweep gas of an extracorporeal circuit in a neonatal ovine model. Eight lambs (age 9.6 ± 1.9 days) were cannulated via the neck vessels and maintained on a pumpless arteriovenous extracorporeal membrane oxygenation circuit with blood flow restricted to 100 ml/min for 72 hours. All animals were heparinized, and a subset (n = 4) also received NO in the sweep gas at a concentration of 200 ppm. We observed no adverse effects from NO administration, and methemoglobin levels remained unchanged. Platelet counts significantly declined in all animals over the course of the study; however, mean counts were higher in the NO-treated group, and this difference was statistically significant at 24 hours (62 ± 3% vs. 32 ± 7% of baseline, P < 0.01). Likewise, mean plasma levels of beta-thromboglobulin, a marker of platelet activation, were lower in the NO-treated group, and this difference was also significant at the 24 hour time point (9.5 ± 2.2 vs. 19.7 ± 6.5 pg/mL/10 platelets, P < 0.05). We conclude that 200 ppm NO can be safely blended into the oxygenator sweep gas of a low-flow extracorporeal circuit and that it may transiently attenuate platelet consumption and activation.

The outbreak of the novel coronavirus pandemic (COVID-19) has resulted in dramatic changes to the conduct of surgery both from a patient management perspective and in protecting healthcare providers. The current study reports on the status of COVID-19 infections in patients presenting for cardiac surgery with cardiopulmonary bypass (CPB) on circuit complications. A tracking process for monitoring the presence of COVID-19 in adult cardiac surgery patients was integrated into a case documentation system across United States hospitals where out-sourced perfusion services were provided. Assessment included infection status, testing technique employed, surgery status and CPB complications. Records from 5612 adult patients who underwent cardiac surgery between November 1, 2020 and January 18, 2021 from 176 hospitals were reviewed. A sub-cohort of coronary artery bypass graft patients (3283) was compared using a mixed effect binary logistic regression analysis. 4297 patients had negative test results (76.6%) while 49 (0.9%) tested positive for COVID-19, and unknown or no results were reported in 693 (12.4%) and 573 (10.2%) respectively. Coagulation complications were reported at 0.2% in the negative test results group versus 4.1% in the positive test result group (p

Background Extracorporeal membrane oxygenation (ECMO) research using large animals requires a significant amount of resources, slowing down the development of new means of ECMO anticoagulation. Therefore, this study developed and evaluated a new rat ECMO model using a 3D-printed mock-oxygenator. Methods The circuit consisted of tubing, a 3D-printed mock-oxygenator, and a roller pump. The mock-oxygenator was designed to simulate the geometry and blood flow patterns of the fiber bundle in full-scale oxygenators but with a low (2.5 mL) priming volume. Rats were placed on arteriovenous ECMO at a 1.9 mL/min flow rate at two different heparin doses (n = 3 each): low (15 IU/kg/h for eight hours) versus high (50 IU/kg/h for one hour followed by 25 IU/kg/h for seven hours). The experiment continued for eight hours or until the mock-oxygenator failed. The mock-oxygenator was considered to have failed when its blood flow resistance reached three times its baseline resistance. Results During ECMO, rats maintained near-normal mean arterial pressure and arterial blood gases with minimal hemodilution. The mock-oxygenator thrombus weight was significantly different (p Conclusions This model is a simple, inexpensive system for investigating new anticoagulation agents for ECMO and provides low and high levels of anticoagulation that can serve as control groups for future studies.

Objective To explore special coagulation characteristics and anticoagulation management in extracorporeal membrane oxygenation (ECMO)–assisted patients with coronavirus disease 2019 (COVID-19). Design Single-center, retrospective observation of a series of patients. Participants Laboratory-confirmed severe COVID-19 patients who received venovenous ECMO support from January 20–May 20, 2020. Interventions This study analyzed the anticoagulation management and monitoring strategies, bleeding complications, and thrombotic events during ECMO support. Measurements and Main Results Eight of 667 confirmed COVID-19 patients received venovenous ECMO and had an elevated D-dimer level before and during ECMO support. An ECMO circuit pack (oxygenator and tubing) was replaced a total of 13 times in all 8 patients, and coagulation-related complications included oxygenator thrombosis (7/8), tracheal hemorrhage (5/8), oronasal hemorrhage (3/8), thoracic hemorrhage (3/8), bleeding at puncture sites (4/8), and cannulation site hemorrhage (2/8). Conclusions Hypercoagulability and secondary hyperfibrinolysis during ECMO support in COVID-19 patients are common and possibly increase the propensity for thrombotic events and failure of the oxygenator. Currently, there is not enough evidence to support a more aggressive anticoagulation strategy.

The importance of microbial colonization during extracorporeal membrane oxygenation (ECMO) is unclear. We prospectively cultured ECMO oxygenators and retrospectively reviewed the culture results, clinical outcomes, and associated factors in 112 ECMO patients (122 oxygenators, 1,196 ECMO days). Of the oxygenators, 11.6% (n = 13) had positive cultures. The most common pathogen was Klebsiella pneumoniae, followed by Acinetobacter baumannii and Staphylococcus epidermidis. Nine (69%) cases showed catheter colonization, and five (38%) bloodstream infection (BSI) with the same microorganism. Most of the microorganisms were multidrug resistant. BSI tended to be associated with oxygenator colonization (r = 0.172, p = 0.070). The patients were divided into oxygenator colonization (n = 13) and no colonization groups (n = 99). Successful weaning from ECMO and survival to discharge were significantly lower in the oxygenator colonization group (weaning 30.8% vs. 90.9%, p < 0.001, survival 23.1% vs. 76.8%; p < 0.001). In multivariate analyses, age (per decade) (odds ratio [OR] = 1.95, 95% CI = 1.28-2.95; p = 0.002), oxygenator colonization (OR = 15.49, 95% CI = 3.31-72.46; p < 0.001), and renal replacement therapy (OR = 4.61, 95% CI = 1.69-12.58; p = 0.003) were significantly associated with mortality. Oxygenator colonization was associated with poor outcomes in ECMO patients. These results support the early exchange and culture of oxygenators in patients with persisting bacteremia.

Patients with the coronavirus disease 2019 (COVID-19) sometimes develop refractory respiratory failure and may require venovenous extracorporeal membrane oxygenation (VV-ECMO). It is known that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sometimes present in the blood of COVID-19 patients. VV-ECMO is often used for several weeks, and plasma leaks can occur, albeit rarely. Hence, in terms of infection control, a concern is that SARS-CoV-2 may leak from the gas outlet port of the oxygenator during ECMO support of critically ill COVID-19 patients. The aim of this study was to clarify whether SARS-CoV-2 leaks from the oxygenator during ECMO support. Five patients with critical COVID-19 pneumonia were placed on VV-ECMO. Silicone-coated polypropylene membrane oxygenators were used in the ECMO circuits for these patients. SARS-CoV-2 ribonucleic acid (RNA) was measured by quantitative reverse transcription polymerase chain reaction in serum and at the gas outlet port of the ECMO circuit at the time of circuit replacement or liberation from ECMO. SARS-CoV-2 RNA was detected in the gas outlet port of the ECMO circuit for three of the five patients. None of the medical staff involved in the care of these five patients has been infected with COVID-19. In conclusion, SARS-CoV-2 could leak to the gas outlet port of the ECMO circuit through silicone-coated polypropylene membranes during ECMO support of critically ill COVID-19 patients.

Background Extracorporeal membrane oxygenation (ECMO) support in acute respiratory failure may be lifesaving, but bleeding and thromboembolic complications are common. The optimal anticoagulation strategy balancing these factors remains to be determined. This retrospective study compared two institutional anticoagulation management strategies focussing on oxygenator changes and both bleeding and thromboembolic events. Methods We conducted a retrospective observational cohort study between 04/2015 and 02/2020 in two ECMO referral centres in Germany in patients receiving veno-venous (VV)-ECMO support for acute respiratory failure for > 24 h. One centre routinely applied low-dose heparinization aiming for a partial thromboplastin time (PTT) of 35–40 s and the other routinely used a high-dose therapeutic heparinization strategy aiming for an activated clotting time (ACT) of 140–180 s. We assessed number of and time to ECMO oxygenator changes, 15-day freedom from oxygenator change, major bleeding events, thromboembolic events, 30-day ICU mortality, activated clotting time and partial thromboplastin time and administration of blood products. Primary outcome was the occurrence of oxygenator changes depending on heparinization strategy; main secondary outcomes were the occurrence of severe bleeding events and occurrence of thromboembolic events. The transfusion strategy was more liberal in the low-dose centre. Results Of 375 screened patients receiving VV-ECMO support, 218 were included in the analysis (117 high-dose group; 101 low-dose group). Disease severity measured by SAPS II score was 46 (IQR 36–57) versus 47 (IQR 37–55) and ECMO runtime was 8 (IQR 5–12) versus 11 (IQR 7–17) days (P = 0.003). There were 14 oxygenator changes in the high-dose group versus 48 in the low-dose group. Freedom from oxygenator change at 15 days was 73% versus 55% (adjusted HR 3.34 [95% confidence interval 1.2–9.4]; P = 0.023). Severe bleeding events occurred in 23 (19.7%) versus 14 (13.9%) patients (P = 0.256) and thromboembolic events occurred in 8 (6.8%) versus 19 (19%) patients (P = 0.007). Mortality at 30 days was 33.3% versus 30.7% (P = 0.11). Conclusions In this retrospective study, ECMO management with high-dose heparinization was associated with lower rates of oxygenator changes and thromboembolic events when compared to a low-dose heparinization strategy. Prospective, randomized trials are needed to determine the optimal anticoagulation strategy in patients receiving ECMO support.

KEY POINTS The margin of human viability has extended to the extremes of gestational age (

Cardiac surgery is uniquely complex, as it requires a significant amount of artificial support, because the heart is exposed to extreme manipulation and incisions. Most cardiac operations use an extra-corporeal device, called the heart-lung machine, to provide cardiopulmonary bypass (CPB).

Patients receiving extracorporeal membrane oxygenation (ECMO) may display large decreases in drug concentrations due to increases in volume of distribution and drug binding to ECMO circuits, tubing, oxygenator, and coating materials. We report a case of a critically ill male with a 10-month status post-deceased donor renal transplant and being treated with voriconazole for suspected aspergillosis. Initially, multiple dose increases, up to 11.3 mg/kg/dose, were required while on ECMO therapy to obtain goal voriconazole trough concentrations between 2 and 5.5 mcg/mL. The patient's voriconazole dose requirement subsequently decreased to 7.3 mg/kg/dose after ECMO discontinuation, which represented a 45% reduction in voriconazole dose requirement. Based upon this experience, voriconazole appears to bind to artificial surfaces on ECMO devices. In addition to close monitoring of trough levels, it may be appropriate to empirically reduce the voriconazole dose in patients after ECMO discontinuation.

Background: There is wide variability in anticoagulation strategies for veno-venous (VV-) extracorporeal membrane oxygenation (ECMO) for acute respiratory failure. Methods: We conducted a retrospective comparison of unfractionated heparin (UFH)-based anticoagulation strategies between two ECMO centers: 1 - high dose (HD) group: Two hourly ACT-based therapeutic anticoagulation with a target of 140-180s. 2 - low dose (LD) group: Thrice daily PTT-based prophylactic anticoagulation with UFH with a pro-thrombin time (PTT) target of 35-40s. The primary outcome was number of oxygenator changes per patient. Secondary outcomes were coagulation studies, and severe bleeding and thromboembolic events. Results: 215 patients were included (HD group 116, LD group 99). Disease severity in both groups was comparable (SAPS score 47.4±13.7 vs 48.0±12.9, p=0.710). Consistent with the chosen strategy, the mean PTT was longer in the HD group (51±17s vs 39±8s, p Conclusion: A LD heparinization strategy in VV-ECMO was associated with more oxygenator changes and more thromboembolic events compared to HD heparinization. No differences were seen regarding severe bleeding events and in-hospital mortality. Overall, the data favor the HD strategy, at least in patients not at high risk of bleeding.

Background. Cardiopulmonary bypass (CPB) has a significant effect on the patient’s body. The first potential factor that can negatively affect the functions of organs and tissues du­ring perfusion is the CPB prime of the oxygenator. Even with the modern development of perfusion support, there is no single protocol regarding which solutions and in what proportion should be used in priming program. Therefore, the question of the search for composition of prime solutions is very important in order to avoid factors causing complications after CPB. Materials and methods. At the premises of the surgical center at State Scientific Institution “Scien­tific and Practical Center of Preventive and Clinical Medicine” of the Agency of State Affairs, the multicomponent hyperosmolar CPB prime was used in 90 patients during cardiac surgeries. There were 69 men (76.6 %) and 21 women (23.4 %) aged 37 to 81 years, on average 65.0 ± 2.5 years. The weight of patients ranged from 55 to 115 kg, an average of 86.40 ± 5.85 kg. According to the New York Heart Association functional classification, patients were divided as follows: II functional class — 79 (87.7 %) people, III functional class — 11 (12.3 %). In 73 patients, the operations were performed for ventricular fibrillation (group 1), in 17 individuals, the surgeries were carried out using a cardioplegic solution custodiol (group 2). When choosing solutions for CPB prime, an integrated method was used. The basic solution was volutenz, the basis of which is 4% modified gelatin, other hyperosmolar pri­ming volume solutions were rheosorbilact and 15% mannit, a 4.2% soda-buffer solution was used to correct acid-base imbalance. For intravenous infusion during the operation, Ringer’s isotonic malate was used, which contains acetate and malate as a carrier of reserve alkalinity. The total volume of solutions in the perfusate was 1600–1200 ml. The total osmolarity of the solutions in the perfusate was 817.4 mosmol in 1600 ml, which amounted to 510.9 mosmol/l. Results. A positive result was noted when using CPB prime. The study of the gas transport function of the blood reflects the current metabolic needs of the body. When assessing the oxygen transport function of the circulatory system, it was found that at the preperfusion stage (10 mi­nutes before the start of CPB), the level of oxygen delivery was normal — 571.70 ± 30.35 ml/(min • m2) (p < 0.001), but the level of its consumption was slightly reduced — 74.20 ± 6.32 ml/(min • m2) (p < 0.001), due to the vasodilation effect of sevoflurane and a decrease in total peripheral resistance, in the intensity of the general metabolism due to anesthesia and spontaneous cooling of patients on the operating table. After 10 minutes of cardiopulmonary bypass, DO2 decreased to 336.50 ± 24.03 ml/(min • m2), this is caused by a reduced oxygen content in arterial blood, which occurs due to a decrease in hemoglobin to 84.8 ± 8.6 g/l as a result of hemodilution. Oxygen consumption VO2 at this stage reached 23.85 ± 3.79 ml/(min • m2) due to a reduced metabolism at a patient’s body temperature of 32.6 ± 0.4 °C. After the main stage of the operation and warming the patient, DO2 was 348.60 ± 18.02 ml/(min • m2), VO2 increased to 101.90 ± 13.04 ml/(min • m2) at body temperature of 36.8 ± 0.2 °C. Thirty minutes after CPB, hemoglobin level was 96.7 ± 9.9 g/l, DO2 — 478.70 ± 29.12 ml/(min • m2), which corresponded to the normal level. The oxygen extraction index in our study was in line with stages of the surgery, the temperature status and the physiological norm at the end of the operation. When ­using a multicomponent hyperosmolar priming solution, the average perfusion pressure was 68.4 ± 5.7 mmHg, and its sharp fluctuation was not observed. The relative fluid balance after CPB in operations performed for atrial fibrillation and in surgeries performed with the use of custodiol was +2.7 ± 1.1 ml/kg and +5.1 ± 2.4 ml/kg, respectively, which indicates the absence of a volemic load after CPB. Conclusions. The use of CPB prime is aimed at preventing tissue edema with the onset of cardiopulmonary bypass, capillary leak syndrome, contributes to a more physiological correction of electrolytes and acid-base balance, and allows us to reduce of a volemic load in the perioperative period against the background of stable indicators of central hemodynamics., Актуальность. Искусственное кровообращение (ИК) оказывает существенное влияние на организм пациентов. Первым потенциальным фактором, способным негативно влиять на функции органов и тканей при перфузии, является первичный объем заполнения (ПОЗ) оксигенатора. Даже при современном развитии перфузиологического обеспечения нет единого протокола относительно того, какие растворы и в каком соотношении необходимо использовать в программе первичного заполнения оксигенатора. Поэтому вопрос поиска растворов для заполнения контура оксигенатора очень важен во избежание факторов, вызывающих осложнения после ИК. Материалы и методы. На базе хирургического центра ГНУ «Научно-практический центр профилактической и клинической медицины» ГУД был использован многокомпонентный гиперосмолярный ПОЗ у 90 пациентов во время кардиохирургических операций в усло­виях искусственного кровообращения. Мужчин было 69 (76,6 %), женщин — 21 (23,4 %) в возрасте от 37 до 81 года, в среднем 65,0 ± 2,5 года. Вес пациентов составил от 55 до 115 кг, в среднем 86,40 ± 5,85 кг. По функциональному классу (ФК) по NYHA пациенты распределились таким образом: II ФК — 79 (87,7 %), III ФК — 11 (12,3 %). У 73 пациентов операции выполнены на фибрилляции желудочков (группа 1), у 17 пациентов операции выполнены с использованием кардиоплегического раствора кустодиол (группа 2). При выборе растворов для ПОЗ оксигенатора использовали комплексный подход. Базовым раствором был препарат волютенз, основой которого является 4% модифицированный желатин, другими базовыми гиперосмолярными растворами были реосорбилакт и маннит 15%, для коррекции нарушений кислотно-щелочного состояния применяли раствор сода-буфер 4,2%. Для внутривенной инфузии по ходу операции использовали Рингера малат изотонический, который в качестве носителя резервной щелочности содержит ацетат и малат. Суммарный объем растворов в перфузате составил 1600–1200 мл. Суммарная осмолярность растворов в перфузате — 817,4 мосмоль в 1600 мл, что составило 510,9 мосмоль/л. Результаты. Отмечен положительный результат при использовании многокомпонентного гиперосмолярного ПОЗ. Изучение газотранспортной функции крови отражает текущие метаболические потребности организма. При оценке кислородно-транспортной функции системы кровообращения было выявлено, что на предперфузионном этапе (за 10 мин до начала ИК) отмечался нормальный уровень доставки кислорода 571,70 ± 30,35 мл/(мин • м2) (р < 0,001), но уровень его потребления был несколько снижен — 74,20 ± 6,32 мл/(мин • м2) (p < 0,001) за счет вазодилатационного эффекта севофлюрана и уменьшения общего периферического сопротивления, снижения интенсивности общего метаболизма за счет анестезии и спонтанного охлаждения пациентов на операционном столе. На 10-й минуте искусственного крово­обращения индекс доставки кислорода (IDO2) снизился до 336,50 ± 24,03 мл/(мин • м2), это связано с уменьшением содержания кислорода в артериальной крови, которое происходит из-за снижения гемоглобина до 84,8 ± 8,6 г/л в результате гемодилюции. Индекс потребления кислорода (IVO2) на этом этапе достиг 23,85 ± 3,79 мл/(мин • м2) за счет снижения метаболизма при температуре тела больного 32,6 ± 0,4 °С. После выполнения основного этапа операции и согревания пациента IDO2 был 348,60 ± 18,02 мл/(мин • м2), IVO2 увеличился до 101,90 ± 13,04 мл /(мин • м2) при температуре 36,8 ± 0,2 °С. Через 30 минут после ИК гемоглобин был 96,7 ± 9,9 г/л, DO2 — 478,70 ± 29,12 мл/(мин • м2), что соответствует уровню нормальных показателей. Индекс экстракции кислорода в нашем исследовании соответствовал этапам операции, температурному статусу и в конце операции — физиологической норме. При использовании многокомпонентного гиперосмолярного первоначального объема заполнения оксигенатора среднее перфузионное давление составляет 68,4 ± 5,7 мм рт.ст., не наблюдается его резкого колебания. Относительный гидробаланс после ИК для операций, выполненных на фибрилляции сердца, и операций, выполненных на кустодиоле, составил +2,7 ± 1,1 мл/кг и +5,1 ± 2,4 мл/кг соответственно, что свидетельствует об отсутствии волемической нагрузки после ИК. Выводы. Использование многокомпонентного гиперосмолярного ПОЗ направлено на предупреждение отека тканей с началом искусственного кровообращения, синдрома капиллярной утечки, способствует более физиологичной коррекции электролитов и кислотно-щелочного состояния, позволяет снизить объем волемической нагрузки в периоперационном периоде на фоне стабильных показателей центральной гемодинамики., Актуальність. Штучний кровообіг (ШК) справляє істотний вплив на організм пацієнтів. Першим потенційним фактором, здатним негативно впливати на функції органів і тканин під час перфузії, є первинний об’єм заповнення (ПОЗ) оксигенатора. Навіть при сучасному розвитку перфузіологічного забезпечення немає єдиного протоколу щодо того, які розчини і в якому співвідношенні необхідно використовувати в програмі первинного заповнення оксигенатора. Тому питання пошуку розчинів для заповнення контура оксигенатора дуже важливе для уникнення факторів, що спричиняють ускладнення після ШК. Матеріали та методи. На базі хірургічного центру ДНУ «Науково-практичний центр профілактичної та клінічної медицини» ДУС був застосований багатокомпонентний гіперосмолярний ПОЗ у 90 пацієнтів під час кардіохірургічних операцій в умовах штучного кровообігу. Чоловіків було 69 (76,6 %), жінок — 21 (23,4 %), вік пацієнтів — від 37 до 81 року, у середньому 65,0 ± 2,5 року. Вага пацієнтів — від 55 до 115 кг, у середньому 86,40 ± 5,85 кг. За функціональним класом (ФК) за NYHA пацієнти розподілилися таким чином: II ФК — 79 (87,7 %), III ФК — 11 (12,3 %). У 73 пацієнтів операції виконані на фібриляції шлуночків (група 1), у 17 пацієнтів операції виконані з використанням кардіоплегічного розчину кустодіол (група 2). При виборі розчинів для ПОЗ оксигенатора використовували комплексний підхід. Базовим розчином був препарат волютенз, основою якого є 4% модифікований желатин, іншими гіперосмолярними розчинами первинного об’єму заповнення оксигенатора були реосорбiлакт і маніт 15%, для корекції порушень кислотно-лужного балансу застосовували розчин сода-буфер 4,2%. Для внутрішньовенної інфузії під час операції використовували Рінгера малат ізотонічний, який як носій резервної лужності містить ацетат і малат. Сумарний об’єм розчинів у перфузаті становив 1600–1200 мл. Сумарна осмолярність розчинів у перфузаті — 817,4 мосмоль у 1600 мл, що становило 510,9 мосмоль/л. Результати. Відзначений позитивний результат при використанні багатокомпонентного гіперосмолярного ПОЗ. Вивчення газотранспортної функції крові відображає поточні метаболічні потреби організму. При оцінці кисневотранспортної функції системи кровообігу було виявлено, що на передперфузійному етапі (за 10 хв до початку ШК) відзначався нормальний рівень доставки кисню — 571,70 ± 30,35 мл/(хв • м2) (р < 0,001), але рівень його споживання був дещо знижений — 74,20 ± 6,32 мл/(хв • м2) (p < 0,001) за рахунок вазодилатаційного ефекту севофлюрану й зменшення загального периферичного опору, зниження інтенсивності загального метаболізму через анестезію і спонтанне охолодження пацієнтів на операційному столі. На 10-й хвилині штучного кровообігу індекс доставки кисню (IDO2) знизився до 336,5 ± 24,03 мл/(хв • м2), це пов’язано зі зменшенням вмісту кисню в артеріальній крові, що відбувається через зниження гемоглобіну до 84,8 ± 8,6 г/л унаслідок гемодилюції. Індекс споживання кисню (IVO2) на цьому етапі досягав 23,85 ± 3,79 мл/(хв • м2) за рахунок зниження метаболізму при температурі тіла хворого 32,6 ± 0,4 °С. Після виконання основного етапу операції і зігрівання пацієнта IDO2 був 348,60 ± 18,02 мл/(хв • м2), IVO2 збільшився до 101,90 ± 13,04 мл/(хв • м2) при температурі 36,8 ± 0,2 °С. Через 30 хв після ШК кровообігу показник гемоглобіну становив 96,7 ± 9,9 г/л, IDO2 — 478,70 ± 29,12 мл/(хв • м2), що відповідає рівню нормальних показників. Індекс екстракції кисню в нашому дослідженні відповідав етапам операції, температурному статусу і наприкінці операції — фізіологічній нормі. При використанні багатокомпонентного гіперосмолярного первинного об’єму заповнення оксигенатора середній перфузійний тиск становить 68,4 ± 5,7 мм рт.ст., не спостерігається різкого коливання тиску. Відносний гідробаланс після ШК для операцій, виконаних на фібриляції серця, і для операції, виконаних на кустодіолі, становив +2,7 ± 1,1 мл/кг і +5,1 ± 2,4 мл/кг відповідно, що свідчить про відсутність волемічного навантаження після ШК. Висновки. Використання багатокомпонентного гіперосмолярного ПОЗ, спрямоване на запобігання набряку тканин з початком штучного кровообігу, синдрому капілярного витоку, сприяє більш фізіологічній корекції електролітів і кислотно-лужного стану, дозволяє знизити обсяг волемічного навантаження в періопераційному періоді на тлі стабільних показників центральної гемодинаміки.

Introduction Venovenous extracorporeal membrane oxygenation (VV‐ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID‐19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV‐ECMO failure are not yet understood well. Case Series Here, seven patients with COVID‐19‐induced ARDS who underwent VV‐ECMO introduced and causes of VV‐ECMO failure discussed. Medical records of seven COVID‐19 patients treated with VV‐ECMO were retrospectively evaluated to determine the clinical outcomes of VV‐ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV‐ECMO decannulation was done in three patients, however finally one patient survived. Conclusions Hypercoagulability state and oxygenator failure were the most main etiologies for VV‐ECMO failure in our study. All patients with COVID‐19 undergoing VV‐ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV‐ECMO.

Sedation management during extracorporeal membrane oxygenation(ECMO) is a common challenge encountered by treating intensivists. Data about the safety of propofol use during ECMO has been contradictory. We aimed to investigate associated risks of propofol use on oxygenator lifespan and to explore the effect of propofol use on oxygenator membranes when therapeutic anticoagulation was omitted. Adult respiratory ECMO patients who received propofol were retrospectively compared with those who did not, and outcomes were assessed by means of duration of oxygenator functionality before requiring an exchange, and number of exchanges during propofol use and/or ECMO support. Out of the 63patients included in the analysis, 46%received propofol during ECMO as part of sedation regimen. The use of propofol was not found to be associated with an increased incidence of oxygenator failure when compared with cohorts who did not receive propofol (21% propofol arm vs. 6% control, p = 0.13). When analyzed for anticoagulation omission effects, propofol did not increase the risk of oxygenator failure (p = 0.63). The only predictor that statistically predicted the risk of oxygenator failure was development of heparin-induced thrombocytopenia (HIT) during ECMO. The results of this study further support the previously reported safety of propofol utilization during respiratory ECMO even in the absence of anticoagulation.

Objective: Patients on extracorporeal membrane oxygenation are frequently in need for sedation. Use of propofol has been associated with impaired oxygenator function due to adsorption to the membrane as well as lipid load. The aim of our retrospective analysis was to compare two different sedation regimens containing either propofol or midazolam with respect to oxygenator running time. Methods: Midazolam was used in 73 patients whereas propofol was used in 49 patients, respectively. In the propofol group, veno-arterial–extracorporeal membrane oxygenation was used predominantly (84%), while veno-venous–extracorporeal membrane oxygenation was used more often in the midazolam group (64%). Results: Oxygenator running time until first exchange was 7 days in both groups ( p = 0.759). No statistically significant differences could be observed between the subgroup of patients receiving lipid-free (n = 24) and lipid-containing (n = 31) parenteral nutrition, respectively. Laboratory parameters like triglycerides, free hemoglobin, fibrinogen, platelets, and activated partial thromboplastin time were not significantly different between both sedation regimens ( p = 0.462, p = 0.489, p = 0.960, p = 0.134, and p = 0.843) and were not associated with oxygenator running time. Conclusion: The use of propofol as sedative seems suitable in patients undergoing extracorporeal membrane oxygenation therapy.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary life support frequently utilized in catastrophic lung and or cardiac failure. Patients on ECMO often receive vancomycin therapy for treatment or prophylaxis against Gram-positive organisms. It is unclear if ECMO affects vancomycin pharmacokinetics, thus we modeled the pharmacokinetic behavior of vancomycin according to ECMO-specific variables. METHODS: Adult patients receiving vancomycin and Veno-Arterial-ECMO between 12/1/2016 and 10/1/2017 were prospectively enrolled. Extracorporeal membrane oxygenation settings and four sets of pre- and post-oxygenator vancomycin concentrations were collected for each patient. Compartmental models were built and assessed ECMO flow rates on vancomycin clearance and potential circuit sequestration. Bayesian posterior concentrations of the pre- and post-oxygenator concentrations were obtained for each patient, and summary pharmacokinetic parameters were calculated. Simulations were performed from the final model for efficacy and toxicity predictions. RESULTS: Eight patients contributed 64 serum concentrations. Patients were a median (interquartile range) age of 58.5 years (50.8–62.3) with a calculated creatinine clearance of 39 mL/min (29.5–62.5) and ECMO flow rates of 3980 mL/min (interquartile range = 3493.75–4132.5). A three-compartment model best fit the data (Bayesian: plasma pre-oxygenation R(2) = 0.99, post-oxygenation R(2) = 0.99). Vancomycin clearance was not impacted by ECMO flow rate (p = 0.7). Simulations demonstrated that vancomycin 1 g twice daily was rarely sufficient for minimum inhibitory concentrations > 0.5 mg/L. Doses ≥ 1.5 g twice daily often exceeded toxicity thresholds for exposure. CONCLUSIONS: Extracorporeal membrane oxygenation flow rates did not influence vancomycin clearance between flow rates of 3500 and 5000 mL/min and vancomycin was not sequestered in ECMO. Common vancomycin regimens resulted in sub-optimal efficacy and/or excessive toxicity. Individual therapeutic drug monitoring is recommended for patients on ECMO.

Purpose Volatile anesthetics (VAs) protect myocardial cells in cardiovascular surgery. A recent clinical trial of cardiopulmonary bypass (CPB) surgery reported no significant difference in mortality rates between the use of VAs and total intravenous anesthetics at 1 year postoperatively. However, oxygenator function may affect the VA pharmacokinetics. Thus, we measured the VA blood concentrations during CPB in patients managed with four different microporous polypropylene hollow fiber membrane oxygenators. Methods Twenty-four patients scheduled for elective CPB were randomly allocated to one of the two VA groups (desflurane and sevoflurane groups) and, then, randomly divided into one of four oxygenator groups: Terumo, LivaNova, Medtronic, and Senko (n = 3). Additionally, in each VA group, three patients were randomly selected and redundantly allocated to the human lung group (for control blood VA concentration without oxygenator). Blood samples collected 20 min after starting 6.0 vol% desflurane or 1.7 vol% sevoflurane were analyzed using gas chromatography. Oxygenator-related complications and structural changes in the membrane surface of each oxygenator after surgery were evaluated. Results The mean (standard deviation) concentrations of desflurane and sevoflurane in the human lung were 182.4 (23.2) and 54.0 (9.6) μg/ml, respectively; not significantly different from those in the four oxygenator groups. No oxygenator-related complications occurred. Structural changes in membrane fibers did not occur after clinical use, except for difficulty in image acquisition with Senko products. Conclusion Our results demonstrated that the blood concentrations of desflurane and sevoflurane passing through oxygenators used during CPB were similar to those in the human lung control. Electronic supplementary material The online version of this article (10.1007/s00540-020-02844-1) contains supplementary material, which is available to authorized users.

Our objective was to assess the effect of nitric oxide added to the sweep gas of the oxygenator during cardiopulmonary bypass (CPB) in infants on platelet count, platelet function, clinical outcomes, and safety. A randomized, double-blinded, placebo-controlled clinical trial in infants less than a year of age undergoing cardiac surgery requiring CPB was undertaken. Nitric oxide at a dose of 20 ppm was added to the sweep gas in the treatment group. Blood was collected at baseline and prior to separation from CPB to measure platelet count and function as determined by responsiveness to specific agonists. Clinical outcomes were observed through hospital discharge. Methemoglobin levels were measured preoperatively, at the conclusion of CPB, and upon admission to the ICU. Forty patients consented and were randomized in the trial. Eighteen patients were randomized to the treatment group and 22 were included in the placebo group. The groups were similar in terms of age, weight, gender, and surgical complexity. No significant differences were found in measures of platelet count, platelet response to agonist, or clinical outcomes. Patients in the treatment group had higher methemoglobin levels after receiving nitric oxide, but no levels approached toxicity (maximum 2.4%). Nitric oxide added to the sweep gas of the oxygenator during CPB in infants did not have an appreciable effect on the preservation of platelet count, platelet responsiveness to agonist, or clinical outcomes. Methemoglobin levels were increased after receiving nitric oxide but were far below a toxic level of 15%.

OBJECTIVES Extracorporeal circulation induces cellular and humoral inflammatory reactions, thus possibly leading to detrimental secondary inflammatory responses. Previous data have demonstrated the bioactive potential of methane and confirmed its anti-inflammatory effects in model experiments. Our goal was to investigate the in vivo consequences of exogenous methane administration on extracorporeal circulation-induced inflammation. METHODS Two groups of anaesthetized Vietnamese minipigs (non-treated and methane treated, n = 5 each) were included. Standard central cannulation was performed, and extracorporeal circulation was maintained for 120 min without cardiac arrest or ischaemia, followed by an additional 120-min observation period with haemodynamic monitoring. In the methane-treated group, 2.5% v/v methane–normoxic air mixture was added to the oxygenator sweep gas. Blood samples through the central venous line and tissue biopsies from the heart, ileum and kidney were taken at the end point to determine the whole blood superoxide production (chemiluminometry) and the activity of xanthine-oxidoreductase and myeloperoxidase, with substrate-specific reactions. RESULTS Methane treatment resulted in significantly higher renal blood flow during the extracorporeal circulation period compared to the non-treated group (63.9 ± 16.4 vs 29.0 ± 9.3 ml/min). Whole blood superoxide production (548 ± 179 vs 1283 ± 193 Relative Light Unit (RLU)), ileal myeloperoxidase (2.23 ± 0.2 vs 3.26 ± 0.6 mU/(mg protein)) and cardiac (1.5 ± 0.6 vs 4.7 ± 2.5 pmol/min/mg), ileal (2.2 ± 0.6 vs 7.0 ± 3.4 pmol/min/mg) and renal (1.2 ± 0.8 vs 13.3 ± 8.0 pmol/min/mg) xanthine-oxidoreductase activity were significantly lower in the treated group. CONCLUSIONS The addition of bioactive gases, such as methane, through the oxygenator of the extracorporeal circuit represents a novel strategy to influence the inflammatory effects of extracorporeal perfusion in cardiac surgical procedures.

Limited data exist on the effects of extracorporeal membrane oxygenation on pharmacokinetics of cefepime in critically ill pediatric patients. The objective was to describe cefepime disposition in children treated with extracorporeal membrane oxygenation using population pharmacokinetic modeling.Multicenter, prospective observational study.The pediatric and cardiac ICUs of six sites of the Collaborative Pediatric Critical Care Research Network.Seventeen critically ill children (30 d to2 yr old) on extracorporeal membrane oxygenation who received cefepime as standard of care between January 4, 2014, and August 24, 2015, were enrolled.None.A pharmacokinetic model was developed to evaluate cefepime disposition differences due to extracorporeal membrane oxygenation. A two-compartment model with linear elimination, weight effects on clearance, intercompartmental clearance (Q), central volume of distribution (V1), and peripheral volume of distribution (V2) adequately described the data. The typical value of clearance in this study was 7.1 mL/min (1.9 mL/min/kg) for a patient weighing 5.8 kg. This value decreased by approximately 40% with the addition of renal replacement therapy. The typical value for V1 was 1,170 mL. In the setting of blood transfusions, V1 increased by over two-fold but was reduced with increasing age of the extracorporeal membrane oxygenation circuit oxygenator.Cefepime clearance was reduced in pediatric patients treated with extracorporeal membrane oxygenation compared with previously reported values in children not receiving extracorporeal membrane oxygenation. The model demonstrated that the age of the extracorporeal membrane oxygenation circuit oxygenator is inversely correlated to V1. For free cefepime, only 14 of the 19 doses (74%) demonstrated a fT_minimum inhibitory concentration of 16 mg/L, an appropriate target for the treatment of pseudomonal infections, for greater than 70% of the dosing interval. Pediatric patients on extracorporeal membrane oxygenation might benefit from the addition of therapeutic drug monitoring of cefepime to assure appropriate dosing.

Extra-corporeal membrane oxygenation (ECMO) therapy could affect effective drug concentrations via adsorption onto the oxygenator or associated circuit. We describe a case of a 25-year-old female who required a veno-arterial ECMO therapy for refractory cardiac arrest due to massive pulmonary embolism. She had mild renal dysfunction as a result of the cardiac arrest. A total of 2 g of intravenous cefazolin 8-hourly was administered. Pre- and post-oxygenator blood samples were collected at 0, 1, 4, and 8 h post antibiotic administration. Samples were analyzed for total and unbound cefazolin concentrations. Protein binding was ∼60%. Clearance was reduced due to impaired renal function. The pharmacokinetics of cefazolin appear to not be affected by ECMO therapy and dosing adjustment may not be required.

Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, p

Objectives To evaluate the effects of ultrasound contrast agent (UCA) administration on hemodynamic parameters and support equipment in in vitro and in vivo models of extracorporeal support. Methods In vitro, incrementally increasing bolus doses of a UCA were administered proximal to a membrane oxygenator, and ultrasound cine clips were obtained. The rates of microbubble destruction across the oxygenator and over time were calculated from time-intensity-curves. Measurements across the membrane oxygenator were recorded and compared by a repeated-measures analysis of variance. In vivo, 7 premature fetal lambs were transferred from placental support to the extrauterine environment for neonatal development. Contrast agent boluses were administered for contrast-enhanced ultrasound (CEUS) examinations. Hemodynamic parameters and serum laboratory values were evaluated before and after the examinations by paired t tests. For oxygenator staining, oxygenator membranes from the in vitro circuit, study animals (n = 4), and control animals (n = 4) were stained for the adherent UCA. Results In vitro, with all doses (0.1-4 mL), there was no difference in measured parameters across the oxygenator (P ≥ .09). Contrast agent destruction (3%-14%) across the oxygenator was observed at the first pass with a progressive decline in contrast intensity over time. In vivo, there was no difference in hemodynamic parameters or serum laboratory values (P ≥ .08) with any CEUS examination (n = 17). For oxygenator staining, all oxygenator membranes were negative for UCA with lipid staining. Conclusions The UCA had no detectable effect on the oxygenator or measured parameters in in vitro and in vivo studies, thus providing additional safety data to support the use of CEUS in the setting of extracorporeal support.

To determine the oxygenator impact on alterations of ceftaroline in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extracorporeal membrane oxygenation circuit including the Quadrox-i oxygenator (Maquet, Wayne, NJ).Quarter-inch and 3/8-inch, simulated closed-loop extracorporeal membrane oxygenation circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. An one-time dose of ceftaroline was administered into the circuits, and serial pre- and postoxygenator concentrations were obtained at 5 minutes, 1-, 2-, 3-, 4-, 5-, 6-, and 24-hour time points. Ceftaroline was also maintained in a glass vial, and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation.A free-standing extracorporeal membrane oxygenation circuit.None.Single dose administration of ceftaroline into closed-loop extracorporeal membrane oxygenation circuits prepared with and without an oxygenator in series with serial preoxygenator, postoxygenator, and reference samples obtained for concentration determination over a 24-hour study period.For the 1/4-inch circuit with an oxygenator, there was 79.8% drug loss preoxygenator and 82.5% drug loss postoxygenator at 24 hours. There was a statistically significant difference (p0.01) in the amount of ceftaroline remaining at 24 hours when compared with each prior time point for the 1/4-inch circuit. For the 1/4-inch circuit without an oxygenator, there was no significant drug loss at any study time point. For the 3/8-inch circuit with an oxygenator, there was 76.2% drug loss preoxygenator and 77.6% drug loss postoxygenator at 24 hours. There was a statistically significant difference (p0.01) in the amount of ceftaroline remaining at 24 hours when compared with each prior time point for the 3/8-inch circuit. For the 3/8-inch circuit without an oxygenator, there was no significant drug loss at any study time point. The reference ceftaroline concentrations remained relatively constant during the entire study period demonstrating the ceftaroline loss in each size of the extracorporeal membrane oxygenation circuit with or without an oxygenator was not a result of spontaneous drug degradation and primarily the result of the oxygenator.This ex vivo investigation demonstrated significant ceftaroline loss within an extracorporeal membrane oxygenation circuit with an oxygenator in series with both sizes of the Quadrox-i oxygenator at 24 hours. Therapeutic concentrations of ceftaroline in the setting of extracorporeal membrane oxygenation may not be achieved with current U.S. Food and Drug Administration-recommended doses, and further evaluation is needed before specific drug dosing recommendations can be made for clinical application with extracorporeal membrane oxygenation.

Objective. Investigation of modern possibilities of the bloodless technique of surgical treatment of the mitral valve failure (МVF) in environment of artificial blood circulation (ABC). Маterials and methods. There were examined 727 patients, suffering MVF. All the patients were divided into two groups: the main and a comparative one. The main group have consisted of 637 patients, in whom various variants of the blood preservation without its transfusion were applied, without application of a cell-saver, hemoconcentrating columns and the blood ultrafiltration; and a comparative one group have consisted of 90 patients, to whom the blood preparations were transfused. The procedure depicted have provided the anesthesia and the perfusion measures during operation of the mitral valve change, including аs well the peculiarities of the intraoperative infusion therapy management in the ABC conditions. Results. In the main group of patients the rate of postoperative infectious complications have constituted 1.2%, while in a comparative one - 9.9%. Median duration of stay on the artificial pulmonary ventilation have constituted (6.7 ± 2.3) and (12.3 ± 8.4) hours accordingly. The average duration of stay in reanimation department was (58.4 ± 12.4) and (116.3 ± 45.2) hours, accordingly (р < 0.05). The intraoperative blood loss volume in the main group was significantly lesser, than in a comparative one: (261.2 ± 33.8) and (533.1 ± 131.6) ml, accordingly (р < 0.05). On all stages of the operation and in postoperative period the level of hemoglobin have persisted in a compensation period range, what constitutes a safe level of the blood oxygen capacity. Conclusion. Introduction of intraoperative variants of the autologous blood reservation without application of the donor’s blood, сеll-saver and hemoconcentration columns is not accompanied with lowering of the oxygen delivery and consumption, as well as development of lactate-acidosis. The improved procedure of anesthesiological support consisted of the infusion-transfusion therapy conduction with stimulation of diuresis, the water balance control, applying combination of an acute normovolemic hemodilution with ABC, and lowering of hemodilution due to retrograde filling of oxygenator by autologous blood. As well there were applied various methods of the autologous blood exfusion and its components combinations, change of tactics in the infusion hemostatic therapy; a central venous pressure control and support of median arterial pressure. Introduction of the procedure depicted have guaranteed a good clinical effect without complications of transfusion on a hospital stage of the patients’ management.