121 results on '"Dirk Lunz"'
Search Results
2. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study
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Georg Trummer, Christoph Benk, Jan-Steffen Pooth, Tobias Wengenmayer, Alexander Supady, Dawid L. Staudacher, Domagoj Damjanovic, Dirk Lunz, Clemens Wiest, Hug Aubin, Artur Lichtenberg, Martin W. Dünser, Johannes Szasz, Dinis Dos Reis Miranda, Robert J. van Thiel, Jan Gummert, Thomas Kirschning, Eike Tigges, Stephan Willems, Friedhelm Beyersdorf, and on behalf of the Extracorporeal Multi-Organ Repair Study Group
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cardiac arrest ,cardiopulmonary resuscitation ,organ repair ,extracorporeal circulation ,extracorporeal cardiopulmonary resuscitation ,Medicine - Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6–26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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- 2023
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3. Obesity Correlates with Chronic Inflammation of the Innate Immune System in Preeclampsia and HELLP Syndrome during Pregnancy
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Julia Rimboeck, Michael Gruber, Marco Weigl, Pia Huber, Dirk Lunz, and Walter Petermichl
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HELLP ,preeclampsia ,HDP ,pregnancy ,obesity ,PMNs ,Biology (General) ,QH301-705.5 - Abstract
HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and a low platelet count and poses an increased risk to the pregnant woman and the unborn child. Individual risk factors such as obesity may alter immunocompetence and influence the course of preeclampsia (PE) or HELLP syndrome. Blood samples were collected from 21 pregnant women (7 healthy, 6 with PE, and 8 with HELLP syndrome) and polymorphonuclear neutrophils (PMNs) were subsequently isolated. Production of radical oxygen species (ROS), cell movement, and NETosis were assessed by live-cell imaging. Surface protein expression and oxidative burst were analyzed by flow cytometry. PE and HELLP patients had significantly higher BMI compared to the healthy control group. Depending on the expression of CD11b, CD62L, and CD66b on PMNs, a surface protein activation sum scale (SPASS) was calculated. PMNs from patients with high SPASS values showed prolonged and more targeted migration with delayed ROS production and NETosis. Obesity is associated with a chronic inflammatory state, which in combination with immunological triggers during pregnancy could modulate PMN functions. Pregnant women with higher BMI tend to have higher SPASS values, indicating activation of the innate immune system that could co-trigger PE or HELLP syndrome.
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- 2023
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4. Prognostic factors for favorable outcomes after veno-venous extracorporeal membrane oxygenation in critical care patients with COVID-19.
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Bärbel Kieninger, Magdalena Kilger, Maik Foltan, Michael Gruber, Dirk Lunz, Thomas Dienemann, Stephan Schmid, Bernhard Graf, Clemens Wiest, Matthias Lubnow, Thomas Müller, Bernd Salzberger, Wulf Schneider-Brachert, and Martin Kieninger
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Medicine ,Science - Abstract
BackgroundPatients with COVID-19 and severe acute respiratory failure may require veno-venous extracorporeal membrane oxygenation (VV ECMO). Yet, this procedure is resource-intensive and high mortality rates have been reported. Thus, predictors for identifying patients who will benefit from VV ECMO would be helpful.MethodsThis retrospective study included 129 patients with COVID-19 and severe acute respiratory failure, who had received VV ECMO at the University Medical Center Regensburg, Germany, between 1 March 2020 and 31 December 2021. Patient-specific factors and relevant intensive-care parameters at the time of the decision to start VV ECMO were investigated regarding their value as predictors of patient survival. In addition, the intensive-care course of the first 10 days of VV ECMO was compared between survivors and patients who had died in the intensive care unit.ResultsThe most important parameters for predicting outcome were patient age and platelet count, which differed significantly between survivors and non-survivors (age: 52.6±8.1 vs. 57.4±10.1 years, p
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- 2023
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5. Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock
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Andrea Stadlbauer, Alois Philipp, Sebastian Blecha, Matthias Lubnow, Dirk Lunz, Jing Li, Armando Terrazas, Christof Schmid, Tobias J. Lange, and Daniele Camboni
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ECMO ,Pulmonary embolism ,Quality of life ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Background Since 2019, European guidelines recommend considering extracorporeal life support as salvage strategy for the treatment of acute high-risk pulmonary embolism (PE) with circulatory collapse or cardiac arrest. However, data on long-term survival, quality of life (QoL) and cardiopulmonary function after extracorporeal membrane oxygenation (ECMO) are lacking. Methods One hundred and nineteen patients with acute PE and severe cardiogenic shock or in need of mechanical resuscitation (CPR) received venoarterial or venovenous ECMO from 2007 to 2020. Long-term data were obtained from survivors by phone contact and personal interviews. Follow-up included a QoL analysis using the EQ-5D-5L questionnaire, echocardiography, pulmonary function testing and cardiopulmonary exercise testing. Results The majority of patients (n = 80, 67%) were placed on ECMO during or after CPR with returned spontaneous circulation. Overall survival to hospital discharge was 45.4% (54/119). Nine patients died during follow-up. At a median follow-up of 54.5 months (25–73; 56 ± 38 months), 34 patients answered the QoL questionnaire. QoL differed largely and was slightly reduced compared to a German reference population (EQ5D5L index 0.7 ± 0.3 vs. 0.9 ± 0.04; p
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- 2021
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6. Reliability of prognostic biomarkers after prehospital extracorporeal cardiopulmonary resuscitation with target temperature management
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Walter Petermichl, Alois Philipp, Karl-Anton Hiller, Maik Foltan, Bernhard Floerchinger, Bernhard Graf, and Dirk Lunz
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Out-of-hospital cardiac arrest ,Extracorporeal cardiopulmonary resuscitation ,Target temperature management ,Neurological outcome ,Prehospital ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) performed at the emergency scene in out-of-hospital cardiac arrest (OHCA) can minimize low-flow time. Target temperature management (TTM) after cardiac arrest can improve neurological outcome. A combination of ECPR and TTM, both implemented as soon as possible on scene, appears to have promising results in OHCA. To date, it is still unknown whether the implementation of TTM and ECPR on scene affects the time course and value of neurological biomarkers. Methods 69 ECPR patients were examined in this study. Blood samples were collected between 1 and 72 h after ECPR and analyzed for S100, neuron-specific enolase (NSE), lactate, D-dimers and interleukin 6 (IL6). Cerebral performance category (CPC) scores were used to assess neurological outcome after ECPR upon hospital discharge. Resuscitation data were extracted from the Regensburg extracorporeal membrane oxygenation database and all data were analyzed by a statistician. The data were analyzed using non-parametric methods. Diagnostic accuracy of biomarkers was determined by area under the curve (AUC) analysis. Results were compared to the relevant literature. Results Non-hypoxic origin of cardiac arrest, manual chest compression until ECPR, a short low-flow time until ECPR initiation, low body mass index (BMI) and only a minimal need of extra-corporeal membrane oxygenation support were associated with a good neurological outcome after ECPR. Survivors with good neurological outcome had significantly lower lactate, IL6, D-dimer, and NSE values and demonstrated a rapid decrease in the initial S100 value compared to non-survivors. Conclusions A short low-flow time until ECPR initiation is important for a good neurological outcome. Hypoxia-induced cardiac arrest has a high mortality rate even when ECPR and TTM are performed at the emergency scene. ECPR patients with a higher BMI had a worse neurological outcome than patients with a normal BMI. The prognostic biomarkers S100, NSE, lactate, D-dimers and IL6 were reliable indicators of neurological outcome when ECPR and TTM were performed at the emergency scene.
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- 2021
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7. Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation
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Christoph Fisser, Corina Armbrüster, Clemens Wiest, Alois Philipp, Maik Foltan, Dirk Lunz, Karin Pfister, Roland Schneckenpointner, Christof Schmid, Lars S. Maier, Thomas Müller, and Matthias Lubnow
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ECMO ,vascular complication ,ischemia ,thrombosis ,decannulation ,bleeding ,Medicine (General) ,R5-920 - Abstract
IntroductionThe aim of this study was to investigate the prevalence of arterial and venous complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) and its risk factors at the time of cannulation and during extracorporeal membrane oxygenation (ECMO) support and to assess vascular complications in association with decannulation.Material and methodsBetween January 2010 to January 2020, out of 1,030 eligible patients requiring VA-ECMO, 427 with analyzable vascular screening were included. Duplex sonography and/or CT scan after decannulation were used to screen for thrombosis and pulmonary embolism as well as arterial complications. Near-infrared spectrometry (NIRS) was established at the time of cannulation and was continuously monitored during the ECMO therapy.ResultsThe prevalence of venous complications was 27%. Thrombosis and pulmonary embolism were observed in 21 and 7% of patients, respectively. Pulmonary embolism was more frequently diagnosed in patients with thrombosis (22 vs. 3%, p < 0.001). In multivariate analysis, cannulation in the jugular vein was determined as a risk factor for venous thrombosis in contrast to the extent of anticoagulation. The prevalence of arterial complications was 37%, mainly ischemia followed by bleeding, dissection, and compartment syndrome. Vascular surgery was necessary for 19% of the patients, of whome 1% required major amputations. A distal perfusion cannula (DPC) was implanted at cannulation in 24% of patients and secondarily in 16% of patients after cannulation as required during ECMO support. In the multivariate analysis, risk factors for leg ischemia at the time of cannulation were elevated D-dimers, lower NIRS on the cannulated leg, and lack of a DPC. The best discriminative parameter was the difference in NIRS between the non-cannulated leg and the cannulated leg. In contrast, during ECMO support, only the lack of a DPC was associated with leg ischemia. A similar rate of complications associated with decannulation, mainly arterial thrombosis, ischemia, or bleeding, was seen with percutaneous and surgical approaches (18 vs. 17%, p = 0.295).ConclusionPatients requiring VA ECMO should be routinely screened for vascular complications. The decision to insert a DPC should be evaluated individually. However, NIRS monitoring of the cannulated leg and the non-cannulated leg is essential to identify the legs at risk for critical ischemia. As complications associated with decannulation were equally distributed between percutaneous and surgical approaches, the applied method may be chosen according to local experience.
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- 2022
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8. Evaluation of comprehensiveness and reliability of electronic health records concerning resuscitation efforts within academic intensive care units: a retrospective chart analysis
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Michael S. Dittmar, Sabrina Zimmermann, Marcus Creutzenberg, Sylvia Bele, Diane Bitzinger, Dirk Lunz, Bernhard M. Graf, and Martin Kieninger
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Quality management ,Cardiopulmonary resuscitation ,Intensive care unit ,Medical documentation ,Patient data management systems ,Special situations and conditions ,RC952-1245 ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Background According to the literature, the validity and reliability of medical documentation concerning episodes of cardiopulmonary resuscitation (CPR) is suboptimal. However, little is known about documentation quality of CPR efforts during intensive care unit (ICU) stays in electronic patient data management systems (PDMS). This study analyses the reliability of CPR-related medical documentation within the ICU PDMS. Methods In a retrospective chart analysis, PDMS records of three ICUs of a single university hospital were searched over 5 y for CPR check marks. Respective datasets were analyzed concerning data completeness and data consistency by comparing the content of three documentation forms (physicians’ log, nurses’ log, and CPR incident form), as well as physiological and therapeutic information of individual cases, for missing data and plausibility of CPR starting time and duration. To compare data reliability and completeness, a quantitative measure, the Consentaneity Index (CI), is proposed. Results One hundred sixty-five datasets were included into the study. In 9% (n = 15) of cases, there was neither information on the time points of CPR initiation nor on CPR duration available in any data source. Data on CPR starting time and duration were available from at least two data sources in individual cases in 54% (n = 90) and 45% (n = 74), respectively. In these cases, the specifications of CPR starting time did differ by a median ± interquartile range of 10.0 ± 18.5 min, CPR duration by 5.0 ± 17.3 min. The CI as a marker of data reliability revealed a low consistency of CPR documentation in most cases, with more favorable results, if the time interval between the CPR episode and the time of documentation was short. Conclusions This study reveals relevant proportions of missing and inconsistent data in electronic CPR documentation in the ICU setting. The CI is suggested as a tool for documentation quality analysis and monitoring of improvements.
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- 2021
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9. Severe T cell hyporeactivity in ventilated COVID-19 patients correlates with prolonged virus persistence and poor outcomes
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Kerstin Renner, Tobias Schwittay, Sophia Chaabane, Johanna Gottschling, Christine Müller, Charlotte Tiefenböck, Jan-Niklas Salewski, Frederike Winter, Simone Buchtler, Saidou Balam, Maximilian V. Malfertheiner, Matthias Lubnow, Dirk Lunz, Bernhard Graf, Florian Hitzenbichler, Frank Hanses, Hendrik Poeck, Marina Kreutz, Evelyn Orsó, Ralph Burkhardt, Tanja Niedermair, Christoph Brochhausen, André Gessner, Bernd Salzberger, and Matthias Mack
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Science - Abstract
Perturbed T cell responses and disturbed cytokine secretion have been shown during SARS-CoV2 infection in patients. Here the authors show reduced polyclonal T cell activity in COVID-19 patients that is caused by plasma factors and linked to poor prognosis and viral persistence.
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- 2021
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10. Argatroban versus heparin in patients without heparin-induced thrombocytopenia during venovenous extracorporeal membrane oxygenation: a propensity-score matched study
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Christoph Fisser, Maren Winkler, Maximilian V. Malfertheiner, Alois Philipp, Maik Foltan, Dirk Lunz, Florian Zeman, Lars S. Maier, Matthias Lubnow, and Thomas Müller
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ECMO ,Anticoagulation ,Argatroban ,Heparin ,Thrombosis ,Bleeding ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Background During venovenous extracorporeal membrane oxygenation (vvECMO), direct thrombin inhibitors are considered by some potentially advantageous over unfractionated heparin (UFH). We tested the hypothesis that Argatroban is non-inferior to UFH regarding thrombosis and bleeding during vvECMO. Methods We conducted a propensity-score matched observational non-inferiority study of consecutive patients without heparin-induced-thrombocytopenia (HIT) on vvECMO, treated between January 2006 and March 2019 in the medical intensive care unit at the University Hospital Regensburg. Anticoagulation was realized with UFH until August 2017 and with Argatroban from September 2017 onwards. Target activated partial thromboplastin time was 50 ± 5seconds in both groups. Primary composite endpoint was major thrombosis and/or major bleeding. Major bleeding was defined as a drop in hemoglobin of ≥ 2 g/dl/day or in transfusion of ≥ 2 packed red cells/24 h, or retroperitoneal, cerebral, or pulmonary bleeding. Major thrombosis was defined as obstruction of > 50% of the vessel lumen diameter by means of duplex sonography. We also assessed technical complications such as oxygenator defects or pump head thrombosis, the time-course of platelets, and the cost of anticoagulation (including HIT-testing). Results Out of 465 patients receiving UFH, 78 were matched to 39 patients receiving Argatroban. The primary endpoint occurred in 79% of patients in the Argatroban group and in 83% in the UFH group (non-inferiority for Argatroban, p = 0.026). The occurrence of technical complications was equally distributed (Argatroban 49% vs. UFH 42%, p = 0.511). The number of platelets was similar in both groups before ECMO therapy but lower in the UFH group after end of ECMO support (median [IQR]: 141 [104;198]/nl vs. 107 [54;171]/nl, p = 0.010). Anticoagulation costs per day of ECMO were higher in the Argatroban group (€26 [13.8;53.0] vs. €0.9 [0.5;1.5], p
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- 2021
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11. Secondary hemophagocytic lymphohistiocytosis and severe liver injury induced by hepatic SARS-CoV-2 infection unmasking Wilson’s disease: Balancing immunosuppression
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Matthias Lubnow, Barbara Schmidt, Martin Fleck, Bernd Salzberger, Thomas Müller, Georg Peschel, Roland Schneckenpointner, Tobias Lange, Florian Hitzenbichler, Martin Kieninger, Dirk Lunz, Bernhard Graf, Christoph Brochhausen, Florian Weber, Florian Lüke, David Peterhoff, Philipp Schuster, Andreas Hiergeist, Robert Offner, Ute Hehr, Stefan Wallner, Frank Hanses, Stephan Schmid, Kilian Weigand, Florian Geismann, Hendrik Poeck, Tobias Pukrop, Matthias Evert, Andre Gessner, Ralph Burkhardt, Wolfgang Herr, Lars S. Maier, and Daniel Heudobler
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SARS-CoV-2 ,COVID-19 ,Liver injury ,Hemophagocytic lymphohistiocytosis ,Wilson’s disease ,Infectious and parasitic diseases ,RC109-216 - Abstract
A 21-year-old woman was hospitalized due to coronavirus disease 2019 (COVID-19)-associated respiratory and hepatic impairment concomitant with severe hemolytic anemia. Upon diagnosis of secondary hemophagocytic lymphohistiocytosis, immunosuppression with anakinra and steroids was started, leading to a hepatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and viremia. Subsequent liver biopsy revealed virus particles in hepatocytes by electron microscopy and SARS-CoV-2 virus could be isolated and cultured. Immunosuppression was stopped and convalescent donor plasma given. In the differential diagnosis, an acute crisis of Wilson’s disease was raised by laboratory and genetic testing. This case highlights the complexity of balancing immunosuppression to control hyperinflammation versus systemic SARS-CoV-2 dissemination.
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- 2021
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12. Prevalence and outcomes of patients developing heparin-induced thrombocytopenia during extracorporeal membrane oxygenation.
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Matthias Lubnow, Johannes Berger, Roland Schneckenpointner, Florian Zeman, Dirk Lunz, Alois Philipp, Maik Foltan, Karla Lehle, Susanne Heimerl, Christina Hart, Christof Schmid, Christoph Fisser, and Thomas Müller
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Medicine ,Science - Abstract
ObjectivesUnfractionated heparin (UFH) is the commonly used anticoagulant to prevent clotting of the ECMO circuit and thrombosis of the cannulated vessels. A side effect of UFH is heparin-induced thrombocytopenia (HIT). Little is known about HIT during ECMO and the impact of changing anticoagulation in ECMO patients with newly diagnosed HIT. The aim of the study was to determine the prevalence, complications, impact of switching anticoagulation to argatroban and outcomes of patients developing heparin-induced thrombocytopenia (HIT) during either veno-venous (VV) or veno-arterial (VA) ECMO.MethodsRetrospective observational single centre study of prospectively collected data of consecutive patients receiving VV ECMO therapy for severe respiratory failure and VA ECMO for circulatory failure from January 2006 to December 2016 of the Medical intensive care unit (ICU) of the University Hospital of Regensburg. Treatment of HIT on ECMO was done with argatroban.Results507 patients requiring ECMO were included. Further HIT-diagnostic was conducted if HIT-4T-score was ≥4. The HIT-confirmed group had positive HIT-enzyme-linked-immunosorbent-assay (ELISA) and positive heparin-induced-platelet-activation (HIPA) test, the HIT-suspicion group a positive HIT-ELISA and missing HIPA but remained on alternative anticoagulation until discharge and the HIT-excluded group a negative or positive HIT-ELISA, however negative HIPA. These were compared to group ECMO-control without any HIT suspicion. The prevalence of HIT-confirmed was 3.2%, of HIT-suspicion 2.0% and HIT-excluded 10.8%. Confirmed HIT was trendwise more frequent in VV than in VA (3.9 vs. 1.7% p = 0.173). Compared to the ECMO control group, patients with confirmed HIT were longer on ECMO (median 13 vs. 8 days, p = 0.002). Different types of complications were higher in the HIT-confirmed than in the ECMO-control group, but in-hospital mortality was not different (31% vs. 41%, p = 0.804).ConclusionHIT is rare on ECMO, should be suspected, if platelets are decreasing, but seems not to increase mortality if treated promptly.
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- 2022
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13. Evaluation of models for prognosing mortality in critical care patients with COVID-19: First- and second-wave data from a German university hospital.
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Martin Kieninger, Sarah Dietl, Annemarie Sinning, Michael Gruber, Wolfram Gronwald, Florian Zeman, Dirk Lunz, Thomas Dienemann, Stephan Schmid, Bernhard Graf, Matthias Lubnow, Thomas Müller, Thomas Holzmann, Bernd Salzberger, and Bärbel Kieninger
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Medicine ,Science - Abstract
BackgroundIn a previous study, we had investigated the intensive care course of patients with coronavirus disease 2019 (COVID-19) in the first wave in Germany by calculating models for prognosticating in-hospital death with univariable and multivariable regression analysis. This study analyzed if these models were also applicable to patients with COVID-19 in the second wave.MethodsThis retrospective cohort study included 98 critical care patients with COVID-19, who had been treated at the University Medical Center Regensburg, Germany, between October 2020 and February 2021. Data collected for each patient included vital signs, dosage of catecholamines, analgosedation, anticoagulation, and antithrombotic medication, diagnostic blood tests, treatment with extracorporeal membrane oxygenation (ECMO), intensive care scores, ventilator therapy, and pulmonary gas exchange. Using these data, expected mortality was calculated by means of the originally developed mathematical models, thereby testing the models for their applicability to patients in the second wave.ResultsMortality in the second-wave cohort did not significantly differ from that in the first-wave cohort (41.8% vs. 32.2%, p = 0.151). As in our previous study, individual parameters such as pH of blood or mean arterial pressure (MAP) differed significantly between survivors and non-survivors. In contrast to our previous study, however, survivors and non-survivors in this study showed significant or even highly significant differences in pulmonary gas exchange and ventilator therapy (e.g. mean and minimum values for oxygen saturation and partial pressure of oxygen, mean values for the fraction of inspired oxygen, positive expiratory pressure, tidal volume, and oxygenation ratio). ECMO therapy was more frequently administered than in the first-wave cohort. Calculations of expected mortality by means of the originally developed univariable and multivariable models showed that the use of simple cut-off values for pH, MAP, troponin, or combinations of these parameters resulted in correctly estimated outcome in approximately 75% of patients without ECMO therapy.
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- 2022
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14. Coronavirus disease 2019 induces multi‐lineage, morphologic changes in peripheral blood cells
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Florian Lüke, Evelyn Orsó, Jana Kirsten, Hendrik Poeck, Matthias Grube, Daniel Wolff, Ralph Burkhardt, Dirk Lunz, Matthias Lubnow, Barbara Schmidt, Florian Hitzenbichler, Frank Hanses, Bernd Salzberger, Matthias Evert, Wolfgang Herr, Christoph Brochhausen, Tobias Pukrop, Albrecht Reichle, and Daniel Heudobler
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blood differential count ,COVID‐19 ,hemato‐morphology ,peripheral blood smear ,SARS‐CoV‐2 ,Diseases of the blood and blood-forming organs ,RC633-647.5 - Abstract
Abstract The clinical course of coronavirus disease 2019 (COVID‐19) varies from mild symptoms to acute respiratory distress syndrome, hyperinflammation, and coagulation disorder. The hematopoietic system plays a critical role in the observed hyperinflammation, particularly in severely ill patients. We conducted a prospective diagnostic study performing a blood differential analyzing morphologic changes in peripheral blood of COVID‐19 patients. COVID‐19 associated morphologic changes were defined in a training cohort and subsequently validated in a second cohort (n = 45). Morphologic aberrations were further analyzed by electron microscopy (EM) and flow cytometry of lymphocytes was performed. We included 45 COVID‐19 patients in our study (median age 58 years; 82% on intensive care unit). The blood differential showed a specific pattern of pronounced multi‐lineage aberrations in lymphocytes (80%) and monocytes (91%) of patients. Overall, 84%, 98%, and 98% exhibited aberrations in granulopoiesis, erythropoiesis, and thrombopoiesis, respectively. Electron microscopy revealed the ultrastructural equivalents of the observed changes and confirmed the multi‐lineage aberrations already seen by light microscopy. The morphologic pattern caused by COVID‐19 is characteristic and underlines the serious perturbation of the hematopoietic system. We defined a hematologic COVID‐19 pattern to facilitate further independent diagnostic analysis and to investigate the impact on the hematologic system during the clinical course of COVID‐19 patients.
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- 2020
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15. Conservative management of COVID-19 associated hypoxaemia
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Alexander Supady, Philipp M. Lepper, Hendrik Bracht, Onnen Moerer, Ralf M. Muellenbach, Guido Michels, Mascha O. Fiedler, Armin Kalenka, Matthias Kochanek, Haitham Mutlak, Guy Danziger, Sebastian Muenz, Dirk Lunz, Sabrina Hoersch, Dawid Staudacher, Tobias Wengenmayer, and Viviane Zotzmann
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Medicine - Published
- 2021
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16. Impact of coronary angiography early after CABG for suspected postoperative myocardial ischemia
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Leopold Rupprecht, Christof Schmid, Kurt Debl, Dirk Lunz, Bernhard Flörchinger, and Andreas Keyser
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Coronary bypass surgery (CABG) ,Myocardial infarction ,Coronary angiography ,Surgery ,RD1-811 ,Anesthesiology ,RD78.3-87.3 - Abstract
Abstract Background The incidence of perioperative myocardial infarction is reported to 2–8%. The aim of the study (retrospectively registered) was to evaluate whether control coronary angiography after surgery is useful in case of suspected postoperative myocardial ischemia. Methods All patients who demonstrated signs of myocardial ischemia post CABG and underwent coronary angiography from 6/2008 to 06/2015 were retrospectively analyzed. Myocardial ischemia post CABG was defined as an increase of CK/CK-MB, occasionally associated with arrhythmias or low output syndrome. Results Overall, 108 patients (age 66 ± 9 years) demonstrated signs of myocardial ischemia post CABG and underwent coronary angiography corresponding to an incidence of 2.2%. Of them, 70 patients (65%) demonstrated graft pathologies. A therapeutic consequence was drawn in 62 Patients (57%), which consisted of redo surgery in 10 patients (9%) and PCI with stent placement in 52 patients (48%). Of the remaining 46 patients, 29 patients showed intact bypass grafts (27%), whereas 17 patients had minor pathologies (16%). Demographic data including the extent of the coronary artery disease, urgency of operation, comorbidities, EuroScore, surgical technique, postoperative lab tests and transfusion requirements were comparable among the groups. Redo surgery patients had prior PCI in 33% of patients, which was much higher than in the other groups. Patients with reintervention had a 30d-mortality rate of 13%, conservatively treated patients only 2.2%. Mortality was highest after redo surgery with 25%. Conclusions Postoperative coronary angiography is a useful tool with a significant therapeutic value. Pathological findings mandate further revascularization therapy in roughly half of the patients. PCI is a safe choice in the majority of patients, redo surgery is much less indicated.
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- 2019
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17. Lower blood pH as a strong prognostic factor for fatal outcomes in critically ill COVID-19 patients at an intensive care unit: A multivariable analysis.
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Martin Kieninger, Annemarie Sinning, Timea Vadász, Michael Gruber, Wolfram Gronwald, Florian Zeman, Dirk Lunz, Thomas Dienemann, Stephan Schmid, Bernhard Graf, Matthias Lubnow, Thomas Müller, Thomas Holzmann, Bernd Salzberger, and Bärbel Kieninger
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Medicine ,Science - Abstract
BackgroundData of critically ill COVID-19 patients are being evaluated worldwide, not only to understand the various aspects of the disease and to refine treatment strategies but also to improve clinical decision-making. For clinical decision-making in particular, prognostic factors of a lethal course of the disease would be highly relevant.MethodsIn this retrospective cohort study, we analyzed the first 59 adult critically ill Covid-19 patients treated in one of the intensive care units of the University Medical Center Regensburg, Germany. Using uni- and multivariable regression models, we extracted a set of parameters that allowed for prognosing in-hospital mortality.ResultsWithin the cohort, 19 patients died (mortality 32.2%). Blood pH value, mean arterial pressure, base excess, troponin, and procalcitonin were identified as highly significant prognostic factors of in-hospital mortality. However, no significant differences were found for other parameters expected to be relevant prognostic factors, like low arterial partial pressure of oxygen or high lactate levels. In the multivariable logistic regression analysis, the pH value and the mean arterial pressure turned out to be the most influential prognostic factors for a lethal course.
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- 2021
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18. The ‘Weekend Effect’ in adult patients who receive extracorporeal cardiopulmonary resuscitation after in- and out-of-hospital cardiac arrest
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Dirk Lunz, Daniele Camboni, Alois Philipp, Bernhard Flörchinger, Armando Terrazas, Thomas Müller, Christof Schmid, and Claudius Diez
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ECPR ,Weekend effect ,Long-term survival ,Specialties of internal medicine ,RC581-951 - Abstract
Aim: This study investigates the potentially adverse association between extracorporeal cardiopulmonary resuscitation (ECPR) after cardiac arrest on weekends versus weekdays. Methods: Single-centre, retrospective, stratified (weekday versus weekend) analysis of 318 patients who underwent in-hospital ECPR after out-of-hospital and in-hospital cardiac arrest (OHCA/IHCA) between 01/2008 and 12/2018. Weekend was defined as the period between Friday 17:00 and Monday 06:59. Results: Seventy-three patients (23%) received ECPR during the weekend and 245 arrests (77%) occurred during the weekday. Whereas survival to discharge did not differ between both groups, long-term survival was significantly lower in the weekend group (p = 0.002). In the multivariate analysis, independent risk factors associated with hospital mortality were no flow time (OR 1.014; 95% CI 1.004–1.023) and serum lactate prior ECPR (OR 1.011; 95% CI 1.006–1.012), whereas each unit serum haemoglobin above average had a protective effect on in-hospital mortality (OR 0.87; 95% CI 0.79–0.96). New onset kidney failure requiring renal replacement therapy occurred more often in the weekend group (30.1% versus 18.4%; p = 0.04). One third of patients experienced complications regardless ECPR was initiated at weekdays or weekends. Conclusion: Extracorporeal cardiopulmonary resuscitation at weekends adversely seems to impact long-term survival regardless timing (dayshift/nightshift). Duration of CPR and serum lactate prior ECPR were demonstrated as independent risk factors for in-hospital mortality. As ECPR at weekends could not be shown to be an independent outcome predictor a thorough analysis of clinical events subsequent to this intervention is warranted to understand long-term consequences of ECPR initiation after cardiac arrest.
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- 2020
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19. Factors associated with hemolysis during extracorporeal membrane oxygenation (ECMO)-Comparison of VA- versus VV ECMO.
- Author
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Hannah Appelt, Alois Philipp, Thomas Mueller, Maik Foltan, Matthias Lubnow, Dirk Lunz, Florian Zeman, and Karla Lehle
- Subjects
Medicine ,Science - Abstract
Venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) are effective support modalities to treat critically ill patients. ECMO-associated hemolysis remains a serious complication. The aim was to disclose similarities and differences in VA- and VV ECMO-associated hemolysis. This is a retrospective single-center analysis (January 2012 to September 2018) including 1,063 adult consecutive patients (VA, n = 606; VV, n = 457). Severe hemolysis (free plasma hemoglobin, fHb > 500 mg/l) during therapy occurred in 4% (VA) and 2% (VV) (p≤0.001). VV ECMO showed significantly more hemolysis by pump head thrombosis (PHT) compared to VA ECMO (9% vs. 2%; p≤0.001). Pretreatments (ECPR, cardiac surgery) of patients who required VA ECMO caused high fHb pre levels which aggravates the proof of ECMO-induced hemolysis (median (interquartile range), VA: fHb pre: 225.0 (89.3-458.0); VV: fHb pre: 72.0 (42.0-138.0); p≤0.001). The survival rate to discharge from hospital differed depending on ECMO type (40% (VA) vs. 63% (VV); p≤0.001). Hemolysis was dominant in VA ECMO patients, mainly caused by different indications and not by the ECMO support itself. PHT was the most severe form of ECMO-induced hemolysis that occurs in both therapies with low frequency, but more commonly in VV ECMO due to prolonged support time.
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- 2020
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20. Impact of dynamic changes of elevated bilirubin on survival in patients on veno-arterial extracorporeal life support for acute circulatory failure.
- Author
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Miriam Freundt, Dirk Lunz, Alois Philipp, Bernd Panholzer, Matthias Lubnow, Christine Friedrich, Leopold Rupprecht, Stephan Hirt, and Assad Haneya
- Subjects
Medicine ,Science - Abstract
Veno-arterial extracorporeal life support (ECLS) is an established method to stabilize acute circulatory failure. Parameters and data on when to ideally wean circulatory support are limited. Bilirubin is a marker of end-organ damage. Therefore, the purpose of this large study was to evaluate the impact of dynamic changes of elevated bilirubin levels on survival in patients on ECLS.We reviewed 502 consecutive cases of ECLS from 2007 to 2015. Bilirubin levels were recorded before implantation and until six days after explantation. Dynamic bilirubin changes, and hemodynamic and laboratory outcome parameters were compared in survivors and nonsurvivors. Reason for ECLS implantation was cardiac arrest with ongoing resuscitation in 230 (45.8%), low cardiac output in 174 (34.7%) and inability to wean off cardiopulmonary bypass in 98 (19.5%) patients. 307 (61.2%) patients were weaned off ECLS, however, 206 (41.0%) survived. Mean duration of ECLS was 3 (2-6) days, and survivors received significantly longer ECLS (5 vs 3 days, p < 0.001). Survivors had significantly lower baseline bilirubin levels (p = 0.003). Bilirubin started to rise from day 2 in all patients. In survivors, bilirubin levels had trended down on the day of ECLS explantation and stayed at an acceptable level. However, in weaned patients who did not survive and patients who died on ECLS bilirubin levels continued to rise during the recorded period.ECLS support improves survival in patients with acute circulatory failure. Down trending bilirubin levels on veno-arterial ECLS indicate improved chances of successful weaning and survival in hemodynamically stable patients.
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- 2017
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21. Technical-Induced Hemolysis in Patients with Respiratory Failure Supported with Veno-Venous ECMO - Prevalence and Risk Factors.
- Author
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Karla Lehle, Alois Philipp, Florian Zeman, Dirk Lunz, Matthias Lubnow, Hans-Peter Wendel, Laszlo Göbölös, Christof Schmid, and Thomas Müller
- Subjects
Medicine ,Science - Abstract
The aim of the study was to explore the prevalence and risk factors for technical-induced hemolysis in adults supported with veno-venous extracorporeal membrane oxygenation (vvECMO) and to analyze the effect of hemolytic episodes on outcome. This was a retrospective, single-center study that included 318 adult patients (Regensburg ECMO Registry, 2009-2014) with acute respiratory failure treated with different modern miniaturized ECMO systems. Free plasma hemoglobin (fHb) was used as indicator for hemolysis. Throughout a cumulative support duration of 4,142 days on ECMO only 1.7% of the fHb levels were above a critical value of 500 mg/l. A grave rise in fHb indicated pumphead thrombosis (n = 8), while acute oxygenator thrombosis (n = 15) did not affect fHb. Replacement of the pumphead normalized fHb within two days. Neither pump or cannula type nor duration on the first system was associated with hemolysis. Multiple trauma, need for kidney replacement therapy, increased daily red blood cell transfusion requirements, and high blood flow (3.0-4.5 L/min) through small-sized cannulas significantly resulted in augmented blood cell trauma. Survivors were characterized by lower peak levels of fHb [90 (60, 142) mg/l] in comparison to non-survivors [148 (91, 256) mg/l, p≤0.001]. In conclusion, marked hemolysis is not common in vvECMO with modern devices. Clinically obvious hemolysis often is caused by pumphead thrombosis. High flow velocity through small cannulas may also cause technical-induced hemolysis. In patients who developed lung failure due to trauma, fHb was elevated independantly of ECMO. In our cohort, the occurance of hemolysis was associated with increased mortality.
- Published
- 2015
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22. Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange--retrospective analysis of 265 cases.
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Matthias Lubnow, Alois Philipp, Maik Foltan, Tone Bull Enger, Dirk Lunz, Thomas Bein, Assad Haneya, Christof Schmid, Günter Riegger, Thomas Müller, and Karla Lehle
- Subjects
Medicine ,Science - Abstract
OBJECTIVES: Technical complications are a known hazard in veno-venous extracorporeal membrane oxygenation (vvECMO). Identifying these complications and predictive factors indicating a developing system-exchange was the goal of the study. METHODS: Retrospective study on prospectively collected data of technical complications including 265 adult patients (Regensburg ECMO Registry, 2009-2013) with acute respiratory failure treated with vvECMO. Alterations in blood flow resistance, gas transfer capability, hemolysis, coagulation and hemostasis parameters were evaluated in conjunction with a system-exchange in all patients with at least one exchange (n = 83). RESULTS: Values presented as median (interquartile range). Patient age was 50(36-60) years, the SOFA score 11(8-14.3) and the Murray lung injury Score 3.33(3.3-3.7). Cumulative ECMO support time 3411 days, 9(6-15) days per patient. Mechanical failure of the blood pump (n = 5), MO (n = 2) or cannula (n = 1) accounted for 10% of the exchanges. Acute clot formation within the pump head (visible clots, increase in plasma free hemoglobin (frHb), serum lactate dehydrogenase (LDH), n = 13) and MO (increase in pressure drop across the MO, n = 16) required an urgent system-exchange, of which nearly 50% could be foreseen by measuring the parameters mentioned below. Reasons for an elective system-exchange were worsening of gas transfer capability (n = 10) and device-related coagulation disorders (n = 32), either local fibrinolysis in the MO due to clot formation (increased D-dimers [DD]), decreased platelet count; n = 24), or device-induced hyperfibrinolysis (increased DD, decreased fibrinogen [FG], decreased platelet count, diffuse bleeding tendency; n = 8), which could be reversed after system-exchange. Four MOs were exchanged due to suspicion of infection. CONCLUSIONS: The majority of ECMO system-exchanges could be predicted by regular inspection of the complete ECMO circuit, evaluation of gas exchange, pressure drop across the MO and laboratory parameters (DD, FG, platelets, LDH, frHb). These parameters should be monitored in the daily routine to reduce the risk of unexpected ECMO failure.
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- 2014
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23. Extended Cellular Deposits on Gas Exchange Capillaries Are Not an Indicator of Clot Formation: Analysis of Different Membrane Oxygenators
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Ivor Dropco, Alois Philipp, Maik Foltan, Dirk Lunz, Matthias Lubnow, and Karla Lehle
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Biomaterials ,Biomedical Engineering ,Biophysics ,Bioengineering ,General Medicine - Published
- 2023
24. Major Bleeding and Thromboembolic Events in Veno-Venous Extracorporeal Membrane Oxygenation-Patients With Isolated Respiratory Failure
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Simon, Baumgartner, Matthias, Lubnow, Maximilian Valentin, Malfertheiner, Alois, Philipp, Maik, Foltan, Dirk, Lunz, Thomas, Müller, and Christoph, Fisser
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Adult ,Biomedical Engineering ,Biophysics ,Hemorrhage ,Bioengineering ,General Medicine ,Middle Aged ,Biomaterials ,Extracorporeal Membrane Oxygenation ,Thromboembolism ,Humans ,Blood Coagulation Tests ,Respiratory Insufficiency ,Retrospective Studies - Abstract
Bleeding and thromboembolic events are common during veno-venous extracorporeal membrane oxygenation (vvECMO). It is unknown whether these complications are driven by the ECMO system itself, multiorgan-failure, or both. The aim of this study was to assess the prevalence of bleeding and thromboembolic events in patients with isolated respiratory failure. Patients with vvECMO were retrospectively included from March 2009 to October 2017. Exclusion included any organ failure other than respiratory. Major bleeding was defined as a decrease in hemoglobin ≥2 g/dl per 24 hours, the requirement for transfusion of ≥2 packed red blood cell concentrates per 24 hours, any retroperitoneal, pulmonary, central nervous system bleeding, or bleeding requiring surgery. Thromboembolic events were assessed by duplex sonography or CT scan. Of 601 patients, 123 patients with a mean age of 49 ± 15 years and a median Sepsis-related Organ Failure Assessment score of 8 (7-9) were eligible for the analysis. Major bleeding was observed in 73%; 35% of all bleedings occurred on the day of or after ECMO initiation. A more pronounced decrease of PaCO2 after ECMO initiation was seen in patients with intracranial bleeding (ICB) compared with those without. Thromboembolic events were noted in 30%. The levels of activated prothrombin time, fibrinogen, platelet count, or D-dimers affected neither bleeding nor the prevalence of thromboembolic events.
- Published
- 2022
25. Outcome after veno‐arterial extracorporeal membrane oxygenation in elderly patients: A 14‐year single‐center experience
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Zdenek Provaznik, Alois Philipp, Thomas Müller, Kozakov Kostiantyn, Dirk Lunz, Christof Schmid, and Bernhard Floerchinger
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Biomaterials ,ddc:610 ,extracorporeal membrane oxygenation, long-term outcome, low cardiac output, resuscitation, survival ,Biomedical Engineering ,610 Medizin ,Medicine (miscellaneous) ,Bioengineering ,General Medicine - Abstract
Background Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in elderly patients is controversial because of presumed poor outcome. Our primary aim was to determine the influence of advanced age on short- and long-term outcome; the secondary aim was to analyze risk factors for impaired outcome. Methods Between January 2006 and June 2020, 645 patients underwent VA-ECMO implantation in our department. The patients were categorized into four groups
- Published
- 2022
26. The long-term support of COVID-19 patients with veno-venous extracorporeal membrane oxygenation
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Clemens Wiest, Alois Philipp, Dirk Lunz, Johannes F. Steinmann, Christoph Eissnert, Martin Kees, Martin Kieninger, Thomas Dienemann, Markus Ritzka, Stephan Schweiger, Annette Pross, Christoph Fisser, Maximilian V. Malfertheiner, Roland Schneckenpointner, Tobias J. Lange, Christian Schulz, Florian Geismann, Maik Foltan, Frank Schettler, Bernd Salzberger, Florian Hitzenbichler, Frank Hanses, Barbara Schmidt, Michael Arzt, Barbara Sinner, Bernhard Graf, Lars S. Maier, Thomas Müller, and Matthias Lubnow
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General Medicine - Published
- 2022
27. Outcome after veno-venous extracorporeal membrane oxygenation in elderly compared to younger patients: A 14-year retrospective observational study
- Author
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Zdenek Provaznik, Alois Philipp, Thomas Müller, Kozakov Kostiantyn, Dirk Lunz, Christof Schmid, and Bernhard Floerchinger
- Subjects
Biomaterials ,ddc:610 ,extracorporeal membrane oxygenation, long-term outcome, respiratory failure, survival ,610 Medizin ,Biomedical Engineering ,Medicine (miscellaneous) ,Bioengineering ,General Medicine - Abstract
Background The outcome after veno-venous extracorporeal membrane oxygenation in elderly patients is supposed to be unsatisfactory. Our primary aim was to determine the influence of advanced age on short- and long-term outcomes; the secondary aim was to analyze risk factors for impaired outcomes. Methods Between January 2006 and June 2020, 755 patients received V-V ECMO support at our department. Patients were grouped according to age (18–49.9, 50–59.9, 60–69.9, ≥70 years old), and then retrospectively analyzed for short- and long-term outcomes. Risk factors for in-hospital mortality and death during follow-up were assessed using multivariate regression analysis. Results Duration of V-V ECMO support was comparable between all groups median (8–10 days, p = 0.256). Likewise, the weaning rate was comparable in all age groups 68.2%–76.5%; (p = 0.354), but in-hospital mortality was significantly climbing with increasing age (
- Published
- 2022
28. Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery
- Author
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Jing Li, Andrea Stadlbauer, Bernhard Floerchinger, Zhiyang Song, Markus Goetz, Dirk Lunz, and Christof Schmid
- Subjects
Pulmonary and Respiratory Medicine ,Surgery ,Cardiology and Cardiovascular Medicine - Abstract
Introduction Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. Methods Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. Results All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. Conclusion OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.
- Published
- 2022
29. Non-elective thoracic surgery in patients supported by veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO)
- Author
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Laura Sommerauer, Dirk Lunz, Till Markowiak, Christoph Unterbuchner, Marcus Creutzenberg, Alois Philipp, Hans-Stefan Hofmann, Thomas Mueller, Michael Ried, and Sigrid Wiesner
- Subjects
medicine.medical_specialty ,business.industry ,Cardiothoracic surgery ,medicine.medical_treatment ,medicine ,Extracorporeal membrane oxygenation ,In patient ,General Medicine ,business ,Surgery - Published
- 2023
30. Interstitial lung opacities in patients with severe COVID-19 pneumonia by bedside high-resolution ultrasound in association to CO2 retention
- Author
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Mathias Müller, Christoph Fisser, Ernst-Michael Jung, B. Sinner, Franz Josef Putz, G Peschel, T Wertheimer, F. Jung, and Dirk Lunz
- Subjects
Adult ,Male ,medicine.medical_specialty ,ARDS ,Supine position ,Coronavirus disease 2019 (COVID-19) ,Physiology ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Physiology (medical) ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Aged ,Ultrasonography ,Lung ,SARS-CoV-2 ,business.industry ,COVID-19 ,Hematology ,Carbon Dioxide ,Middle Aged ,medicine.disease ,Pneumonia ,Prone position ,Cross-Sectional Studies ,medicine.anatomical_structure ,Breathing ,Cardiology ,Female ,Lung Diseases, Interstitial ,Cardiology and Cardiovascular Medicine ,business ,Arithmetic mean - Abstract
BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress Syndrome (ARDS). OBJECTIVE: This single centre cross-section study aimed to grade the severity of pneumonia by bed-side lung ultrasound (LUS). METHODS: A scoring system discriminates 5 levels of lung opacities: A-lines (0 points),≥3 B-Line (1 point), coalescent B-Lines (2 points), marked pleural disruptions (3 points), consolidations (4 points). LUS (convex 1-5âMHz probe) was performed at 6 defined regions for each hemithorax either in supine or prone position. A lung aeration score (LAS, maximum 4 points) was allocated for each patient by calculating the arithmetic mean of the examined lung areas. Score levels were correlated with ventilation parameters and laboratory markers. RESULTS: LAS of 20 patients with ARDS reached from 2.58 to 3.83 and was highest in the lateral right lobe (Mean 3.67). Ferritin levels (Mean 1885µg/l; râ=â0.467; pâ=â0.051) showed moderate correlation in spearman roh calculation. PaCO2 level (Mean 46.75 mmHg; râ=â0.632; pâ=â0.005) correlated significantly with LAS, while duration of ventilation, Horovitz-Index, CRP, LDH and IL-6 did not. CONCUSIONS: The proposed LAS describes severity of lung opacities in COVID-19 patients and correlates with CO2 retention in patients with ARDS.
- Published
- 2021
31. Severe T cell hyporeactivity in ventilated COVID-19 patients correlates with prolonged virus persistence and poor outcomes
- Author
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Dirk Lunz, Charlotte Tiefenböck, Jan-Niklas Salewski, Christine Müller, Evelyn Orsó, Maximilian V. Malfertheiner, Matthias Lubnow, Tobias Schwittay, Kerstin Renner, Tanja Niedermair, Florian Hitzenbichler, Christoph Brochhausen, Saidou Balam, Bernhard M. Graf, Bernd Salzberger, Marina Kreutz, André Gessner, Frederike Winter, Frank Hanses, Hendrik Poeck, Simone Buchtler, Matthias Mack, Ralph Burkhardt, Johanna Gottschling, and Sophia Chaabane
- Subjects
Male ,0301 basic medicine ,Neutrophils ,T-Lymphocytes ,610 Medizin ,General Physics and Astronomy ,Lymphocyte Activation ,Monocytes ,0302 clinical medicine ,030212 general & internal medicine ,Young adult ,Cells, Cultured ,Whole blood ,ddc:610 ,Multidisciplinary ,biology ,Middle Aged ,Basophils ,medicine.anatomical_structure ,Female ,Adult ,2019-20 coronavirus outbreak ,Respiratory distress syndrome ,Coronavirus disease 2019 (COVID-19) ,T cell ,Science ,Article ,General Biochemistry, Genetics and Molecular Biology ,Young Adult ,03 medical and health sciences ,medicine ,Humans ,Aged ,Inflammation ,SARS-CoV-2 ,business.industry ,COVID-19 ,Dendritic Cells ,Pneumonia ,General Chemistry ,medicine.disease ,030104 developmental biology ,Viral infection ,Polyclonal antibodies ,Immunology ,biology.protein ,business ,Viral persistence - Abstract
Coronavirus disease 2019 (COVID-19) can lead to pneumonia and hyperinflammation. Here we show a sensitive method to measure polyclonal T cell activation by downstream effects on responder cells like basophils, plasmacytoid dendritic cells, monocytes and neutrophils in whole blood. We report a clear T cell hyporeactivity in hospitalized COVID-19 patients that is pronounced in ventilated patients, associated with prolonged virus persistence and reversible with clinical recovery. COVID-19-induced T cell hyporeactivity is T cell extrinsic and caused by plasma components, independent of occasional immunosuppressive medication of the patients. Monocytes respond stronger in males than females and IL-2 partially restores T cell activation. Downstream markers of T cell hyporeactivity are also visible in fresh blood samples of ventilated patients. Based on our data we developed a score to predict fatal outcomes and identify patients that may benefit from strategies to overcome T cell hyporeactivity., Perturbed T cell responses and disturbed cytokine secretion have been shown during SARS-CoV2 infection in patients. Here the authors show reduced polyclonal T cell activity in COVID-19 patients that is caused by plasma factors and linked to poor prognosis and viral persistence.
- Published
- 2021
32. 25 Years' Experience with Redo Operations in Cardiac Surgery—Third-Time Sternotomy Procedures
- Author
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Simon Schopka, Christof Schmid, Leopold Rupprecht, Samuel Sossalla, Andreas Keyser, Michael Hilker, and Dirk Lunz
- Subjects
Reoperation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Elephant trunks ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Aortic valve replacement ,medicine ,Humans ,Myocardial infarction ,Cardiac Surgical Procedures ,Aged ,Retrospective Studies ,Heart Valve Prosthesis Implantation ,business.industry ,Incidence (epidemiology) ,Mitral valve replacement ,Middle Aged ,medicine.disease ,Sternotomy ,Surgery ,Cardiac surgery ,Treatment Outcome ,medicine.anatomical_structure ,030228 respiratory system ,Bypass surgery ,Mitral Valve ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Background Over the years, open heart surgery has become more complex, and especially reoperative surgery, more demanding. The risk of third-time or more sternotomy procedures is unclear. Methods We reviewed our institutional experience of 25 years based on two generations of cardiac surgeons in a German university medical center to document frequency, outcome, and complications of the various types of open heart procedures. Results Overall, we included 104 patients with a mean age of 64 ± 13 years. The EuroSCORE II (European System for Cardiac Operative Risk Evaluation) calculated an average mortality risk of 15.7 ± 15.4%. Subgroup comparison of isolated coronary artery bypass grafting (CABG), aortic valve replacement, and mitral valve replacement procedures did not delineate significantly different risk profiles except for the incidence of acute myocardial infarction, which was present in every second patient (53.3%) scheduled for CABG surgery. The time interval to previous surgery was 4.7 ± 6.3 years on average. Most frequent surgical procedures were valve operations, which were accomplished in 72 patients (69.2%), whereas coronary bypass surgery was performed in 23 patients (22.1%) only. Combined procedures were performed in 27 patients. Complex aortic arch replacement with a frozen elephant trunk procedure was necessary in six patients. Overall, 30-day survival was 81.7%. Conclusion In conclusion, third-time and more sternotomy procedures offer acceptable outcome and should therefore be considered in appropriate patients.
- Published
- 2020
33. Die Bedeutung von Thiamin (Vitamin B1) in der Notfallmedizin
- Author
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Norbert Wodarz, Markus Zimmermann, Matthias Lubnow, Dirk Lunz, Felix Schlachetzki, and Karl Peter Ittner
- Subjects
Emergency Medicine ,Critical Care and Intensive Care Medicine - Published
- 2020
34. A highly specific and sensitive serological assay detects SARS-CoV-2 antibody levels in COVID-19 patients that correlate with neutralization
- Author
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P Neubert, Matthias Vogel, Viola Hähnel, Matthias Lubnow, Thomas Glück, Vivian Glück, Mara Kiessling, Maren Werner, Ralph Burkhardt, Bernd Salzberger, Franz Audebert, André Gessner, Dirk Lunz, Maria Deichner, Jürgen J. Wenzel, Stefanie Frisch, S Schmid, Frank Hanses, Veruschka Albert, Philipp Schuster, Hans Helmut Niller, Ralf Wagner, Nicole Ritter, Martina Müller, Thomas Müller, Barbara Schmidt, Leon Babl, Michael Koller, Philip Pervan, Florian Hitzenbichler, Robert Offner, Jonathan Jantsch, David Peterhoff, Anja Schütz, and Bernhard M. Graf
- Subjects
0301 basic medicine ,viruses ,Assay validation ,610 Medizin ,Antibodies, Viral ,medicine.disease_cause ,Neutralization ,Antigens, Viral ,Coronavirus ,ddc:610 ,biology ,General Medicine ,Virus neutralization ,SARS-CoV-2 · COVID-19 · Antibody test · ELISA · Serology · Virus neutralization · Assay validation · Spike protein · S protein · Receptor binding domain ,Vaccination ,Serology ,Infectious Diseases ,Ectodomain ,Antibody test ,Spike Glycoprotein, Coronavirus ,ELISA ,Antibody ,Microbiology (medical) ,030106 microbiology ,Enzyme-Linked Immunosorbent Assay ,Spike protein ,Sensitivity and Specificity ,S protein ,03 medical and health sciences ,Protein Domains ,Antigen ,Neutralization Tests ,medicine ,Humans ,Seroprevalence ,Seroconversion ,Original Paper ,SARS-CoV-2 ,business.industry ,Immune Sera ,COVID-19 ,Antibodies, Neutralizing ,Virology ,Immunoglobulin A ,Cross-Sectional Studies ,030104 developmental biology ,Immunoglobulin M ,Immunoglobulin G ,biology.protein ,business ,Receptor binding domain - Abstract
ObjectiveThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic challenges national health systems and the global economy. Monitoring of infection rates and seroprevalence can guide public health measures to combat the pandemic. This depends on reliable tests on active and former infections. Here, we set out to develop and validate a specific and sensitive enzyme linked immunosorbent assay (ELISA) for detection of anti-SARS-CoV-2 antibody levels.MethodsIn our ELISA, we used SARS-CoV-2 receptor-binding domain (RBD) and a stabilized version of the spike (S) ectodomain as antigens. We assessed sera from patients infected with seasonal coronaviruses, SARS-CoV-2 and controls. We determined and monitored IgM-, IgA- and IgG-antibody responses towards these antigens. In addition, for a panel of 22 sera, virus neutralization and ELISA parameters were measured and correlated.ResultsThe RBD-based ELISA detected SARS-CoV-2-directed antibodies, did not cross-react with seasonal coronavirus antibodies and correlated with virus neutralization (R2 = 0.89). Seroconversion started at 5 days after symptom onset and led to robust antibody levels at 10 days after symptom onset. We demonstrate high specificity (99.3%;N = 1000) and sensitivity (92% for IgA, 96% for IgG and 98% for IgM; > 10 days after PCR-proven infection;N = 53) in serum.ConclusionsWith the described RBD-based ELISA protocol, we provide a reliable test for seroepidemiological surveys. Due to high specificity and strong correlation with virus neutralization, the RBD ELISA holds great potential to become a preferred tool to assess thresholds of protective immunity after infection and vaccination.
- Published
- 2020
35. Increasing use of the Impella®-pump in severe cardiogenic shock: a word of caution
- Author
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Dirk Lunz, Sergey Vasin, Daniele Camboni, Christof Schmid, Priyank Rastogi, Thomas Mueller, Bernhard Floerchinger, and Alois Philipp
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Shock, Cardiogenic ,Hemodynamics ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Internal medicine ,medicine.artery ,medicine ,Extracorporeal membrane oxygenation ,Humans ,In patient ,Impella ,business.industry ,Cardiogenic shock ,Middle Aged ,medicine.disease ,Blood pressure ,030228 respiratory system ,Descending aorta ,Circulatory system ,Cardiology ,Female ,Surgery ,Heart-Assist Devices ,Cardiology and Cardiovascular Medicine ,business - Abstract
Impella® pumps are increasingly utilized in patients in cardiogenic shock. We report on a case series where Impella support was insufficient, and a switch to venoarterial extracorporeal membrane oxygenation (VA ECMO) became necessary. ECMO patients with previous Impella devices were identified utilizing our institutional ECMO database. Since 2014, 10 patients with a mean age of 62 ± 3 years were identified. Despite correct placement of all Impella pumps, cardiogenic shock persisted with progressive multi-organ failure (Impella type 2.5/CP n = 6/4 patients). Femoro-femoral VA ECMO was implanted percutaneously on the contralateral side with the Impella initially left on standby but retracted into the descending aorta for transport reasons after a mean support time of 20 ± 8 h. All patients were able to unload their heart by left ventricular ejection with a blood pressure amplitude of 15 ± 3 mmHg on VA ECMO support. After VA ECMO implantation haemodynamic parameters improved significantly within 24 h of support (mean serum lactate levels decreased from 92 ± 17 to 44 ± 10 mg/dl, P = 0.031). Survival to hospital discharge was 70%. These data indicate that the Impella 2.5® and CP® might not be sufficient in profound cardiogenic shock. Comparative studies are necessary to specify which patient population benefits from which type of circulatory support.
- Published
- 2020
36. Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study
- Author
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Lorenzo Calabrò, Mirko Belliato, Maximilian V. Malfertheiner, Federico Pappalardo, Fabio Silvio Taccone, Enrico Contri, Dirk Lunz, Lars Mikael Broman, Anna Maria Scandroglio, Daniel Patricio, Alois Philipp, and Jacques Creteur
- Subjects
Male ,Resuscitation ,Subarachnoid hemorrhage ,medicine.medical_treatment ,Critical Care and Intensive Care Medicine ,law.invention ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Heart arrhythmia ,law ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Extracorporeal cardiopulmonary resuscitation ,Organ donation ,Aged ,Retrospective Studies ,business.industry ,030208 emergency & critical care medicine ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Intensive care unit ,Cardiopulmonary Resuscitation ,Treatment Outcome ,030228 respiratory system ,Anesthesia ,business ,Out-of-Hospital Cardiac Arrest - Abstract
The aim of this study was to assess the neurologic outcome following extracorporeal cardiopulmonary resuscitation (ECPR) in five European centers. Retrospective database analysis of prospective observational cohorts of patients undergoing ECPR (January 2012–December 2016) was performed. The primary outcome was 3-month favorable neurologic outcome (FO), defined as the cerebral performance categories of 1–2. Survival to ICU discharge and the number of patients undergoing organ donation were secondary outcomes. A subgroup of patients with stringent selection criteria (i.e., age ≤ 65 years, witnessed bystander CPR, no major co-morbidity and ECMO implemented within 1 h from arrest) was also analyzed. A total of 423 patients treated with ECPR were included (median age 57 [48–65] years; male gender 78%); ECPR was initiated for OHCA in 258 (61%) patients. Time from arrest to ECMO implementation was 65 [48–84] min. Eighty patients (19%) had favorable neurological outcome. ICU survival was 24% (n = 102); 23 (5%) non-survivors underwent organ donation procedures. Favorable neurological outcome rate was lower (9% vs. 34%, p
- Published
- 2020
37. Reliability of prognostic biomarkers after prehospital extracorporeal cardiopulmonary resuscitation with target temperature management
- Author
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Dirk Lunz, Maik Foltan, Karl-Anton Hiller, Bernhard Floerchinger, Bernhard M. Graf, Walter Petermichl, and Alois Philipp
- Subjects
medicine.medical_specialty ,Resuscitation ,Emergency Medical Services ,medicine.medical_treatment ,610 Medizin ,Critical Care and Intensive Care Medicine ,Out-of-hospital cardiac arrest, Extracorporeal cardiopulmonary resuscitation, Target temperature management, Neurological outcome, Prehospital ,medicine ,Extracorporeal membrane oxygenation ,Hospital discharge ,Humans ,Extracorporeal cardiopulmonary resuscitation ,Prehospital ,Original Research ,Retrospective Studies ,ddc:610 ,Out-of-hospital cardiac arrest ,RC86-88.9 ,business.industry ,Target temperature management ,Mortality rate ,Area under the curve ,Temperature ,Reproducibility of Results ,Medical emergencies. Critical care. Intensive care. First aid ,Oxygenation ,Prognosis ,Cardiopulmonary Resuscitation ,Neurological outcome ,Emergency medicine ,Time course ,Emergency Medicine ,business - Abstract
Background Extracorporeal cardiopulmonary resuscitation (ECPR) performed at the emergency scene in out-of-hospital cardiac arrest (OHCA) can minimize low-flow time. Target temperature management (TTM) after cardiac arrest can improve neurological outcome. A combination of ECPR and TTM, both implemented as soon as possible on scene, appears to have promising results in OHCA. To date, it is still unknown whether the implementation of TTM and ECPR on scene affects the time course and value of neurological biomarkers. Methods 69 ECPR patients were examined in this study. Blood samples were collected between 1 and 72 h after ECPR and analyzed for S100, neuron-specific enolase (NSE), lactate, D-dimers and interleukin 6 (IL6). Cerebral performance category (CPC) scores were used to assess neurological outcome after ECPR upon hospital discharge. Resuscitation data were extracted from the Regensburg extracorporeal membrane oxygenation database and all data were analyzed by a statistician. The data were analyzed using non-parametric methods. Diagnostic accuracy of biomarkers was determined by area under the curve (AUC) analysis. Results were compared to the relevant literature. Results Non-hypoxic origin of cardiac arrest, manual chest compression until ECPR, a short low-flow time until ECPR initiation, low body mass index (BMI) and only a minimal need of extra-corporeal membrane oxygenation support were associated with a good neurological outcome after ECPR. Survivors with good neurological outcome had significantly lower lactate, IL6, D-dimer, and NSE values and demonstrated a rapid decrease in the initial S100 value compared to non-survivors. Conclusions A short low-flow time until ECPR initiation is important for a good neurological outcome. Hypoxia-induced cardiac arrest has a high mortality rate even when ECPR and TTM are performed at the emergency scene. ECPR patients with a higher BMI had a worse neurological outcome than patients with a normal BMI. The prognostic biomarkers S100, NSE, lactate, D-dimers and IL6 were reliable indicators of neurological outcome when ECPR and TTM were performed at the emergency scene.
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- 2021
38. Major bleeding and thromboembolic events in veno-venous ECMO-patients with isolated respiratory failure. A retrospective analysis
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Maximilian V. Malfertheiner, Alois Philipp, Christoph Fisser, Maik Foltan, Thomas Müller, Matthias Lubnow, Dirk Lunz, and Simon Baumgartner
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medicine.medical_specialty ,Respiratory failure ,business.industry ,medicine ,Retrospective analysis ,business ,Major bleeding ,Surgery - Published
- 2021
39. Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database
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Mirko Belliato, Lorenzo Peluso, Fabio Silvio Taccone, Dirk Lunz, Katarina Halenarova, Lars Mikael Broman, Federico Pappalardo, and Maximilian V. Malfertheiner
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Male ,medicine.medical_specialty ,Mean arterial pressure ,Heart disease ,Emergency Nursing ,Body weight ,Extracorporeal Membrane Oxygenation ,Refractory ,Internal medicine ,Post-hoc analysis ,medicine ,Humans ,Extracorporeal cardiopulmonary resuscitation ,Retrospective Studies ,business.industry ,Oxygenation ,Hypothermia ,Middle Aged ,medicine.disease ,Cardiopulmonary Resuscitation ,Treatment Outcome ,Emergency Medicine ,Cardiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Out-of-Hospital Cardiac Arrest - Abstract
BACKGROUND The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR). METHODS A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5). RESULTS A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n=250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n=333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p
- Published
- 2021
40. Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study
- Author
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Simon Bourcier, Cyrielle Desnos, Marina Clément, Guillaume Hékimian, Nicolas Bréchot, Fabio Silvio Taccone, Mirko Belliato, Federico Pappalardo, Lars Mikael Broman, Maximilian Valentin Malfertheiner, Dirk Lunz, Matthieu Schmidt, Pascal Leprince, Alain Combes, Guillaume Lebreton, Charles-Edouard Luyt, CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Unité de Recherche sur les Maladies Cardiovasculaires, du Métabolisme et de la Nutrition = Research Unit on Cardiovascular and Metabolic Diseases (ICAN), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU)-Institut de Cardiométabolisme et Nutrition = Institute of Cardiometabolism and Nutrition [CHU Pitié Salpêtrière] (IHU ICAN), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-CHU Pitié-Salpêtrière [AP-HP], Université libre de Bruxelles (ULB), Fondazione IRCCS Policlinico San Matteo [Pavia], Università degli Studi di Pavia = University of Pavia (UNIPV), Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Karolinska Institutet [Stockholm], University Medical Center of Regensburg [Regensburg, Germany], University Hospital Regensburg, and Trenquier, Eva
- Subjects
Male ,Survival ,[SDV]Life Sciences [q-bio] ,Middle Aged ,Cardiac arrest ,Prognosis ,Cardiopulmonary Resuscitation ,Hospitals ,Heart Arrest ,[SDV] Life Sciences [q-bio] ,Extracorporeal Membrane Oxygenation ,In-hospital ,Humans ,Female ,ECPR ,Cardiology and Cardiovascular Medicine ,Retrospective Studies - Abstract
International audience; Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results.Results: Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts.Conclusion: Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.
- Published
- 2021
41. Lower Blood pH as a High Predisposing Factor for a Fatal Outcome in Critically Ill COVID-19 Patients at Intensive Care Unit: a Multivariable Analysis
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Dirk Lunz, S Schmid, Thomas Müller, Timea Vadász, Michael Gruber, Bernhard M. Graf, Florian Zeman, Bärbel Kieninger, Annemarie Sinning, Bernd Salzberger, Matthias Lubnow, Wolfram Gronwald, Thomas Holzmann, Thomas Dienemann, and Martin Kieninger
- Subjects
medicine.medical_specialty ,Fatal outcome ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Critically ill ,law ,Multivariable calculus ,medicine ,Intensive care medicine ,business ,Blood ph ,Intensive care unit ,law.invention - Abstract
Background: Data of critically ill COVID-19 patients are being evaluated worldwide, not only to understand the various aspects of this disease and to refine treatment strategies but also to improve clinical decision-making. For the last aspect in particular, predictors of a lethal course of disease would be highly relevant.Methods:In this retrospective cohort study, we analyzed the first 59 adult critically ill Covid-19 patients treated in one of the intensive care units of the University Medical Center Regensburg, Germany. Using uni- and multivariable regression models, we extracted a set of parameters that allowed predictions of in-hospital mortality.Results:Blood pH value, mean arterial pressure, base excess, troponin, and procalcitonin were identified as highly significant predictors (p < 0.001) of in-hospital mortality. In the multivariable logistic regression analysis, the pH value and the mean arterial pressure turned out to be the most influential predictors and thus predisposing factors for a lethal course.Conclusions:We developed a formula that enables the easy calculation of the probability of a fatal outcome in COVID-19 intensive care patients. Currently a follow-up study with a larger group of patients is in progress to re-evaluate the established predictors.
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- 2021
42. Correction to: Contribution of High Viral Loads, Detection of Viral Antigen and Seroconversion to Severe Acute Respiratory Syndrome Coronavirus 2 Infectivity
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Felix Buder, Markus Bauswein, Clara L Magnus, Franz Audebert, Henriette Lang, Christof Kundel, Karin Distler, Edith Reuschel, Matthias Lubnow, Thomas Müller, Dirk Lunz, Bernhard Graf, Stephan Schmid, Martina Müller, Hendrik Poeck, Frank Hanses, Bernd Salzberger, David Peterhoff, Jürgen J Wenzel, Barbara Schmidt, and Benedikt M J Lampl
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Infectious Diseases ,Immunology and Allergy - Published
- 2022
43. Contribution of High Viral Loads, Detection of Viral Antigen and Seroconversion to Severe Acute Respiratory Syndrome Coronavirus 2 Infectivity
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Markus Bauswein, Thomas Müller, Matthias Lubnow, Felix Buder, Frank Hanses, Jürgen J. Wenzel, Christof Kundel, E Reuschel, Franz Audebert, Benedikt M J Lampl, Martina Müller, Karin Distler, Bernhard M. Graf, Clara L Magnus, Bernd Salzberger, Henriette Lang, Hendrik Poeck, David Peterhoff, Dirk Lunz, Barbara Schmidt, and S Schmid
- Subjects
Adult ,Male ,viruses ,Context (language use) ,Antibodies, Viral ,Severity of Illness Index ,law.invention ,law ,Major Article ,Immunology and Allergy ,Medicine ,Humans ,viral antigen ,Seroconversion ,Respiratory system ,Antigens, Viral ,Infectivity ,biology ,business.industry ,infectivity ,SARS-CoV-2 ,COVID-19 ,Odds ratio ,Viral Load ,Virology ,Intensive care unit ,Infectious Diseases ,AcademicSubjects/MED00290 ,biology.protein ,RNA, Viral ,Female ,Public Health ,Antibody ,business ,Viral load - Abstract
Background From a public health perspective, effective containment strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should be balanced with individual liberties. Methods We collected 79 respiratory samples from 59 patients monitored in an outpatient center or in the intensive care unit of the University Hospital Regensburg. We analyzed viral load by quantitative real-time polymerase chain reaction, viral antigen by point-of-care assay, time since onset of symptoms, and the presence of SARS-CoV-2 immunoglobulin G (IgG) antibodies in the context of virus isolation from respiratory specimens. Results The odds ratio for virus isolation increased 1.9-fold for each log10 level of SARS-CoV-2 RNA and 7.4-fold with detection of viral antigen, while it decreased 6.3-fold beyond 10 days of symptoms and 20.0-fold with the presence of SARS-CoV-2 antibodies. The latter was confirmed for B.1.1.7 strains. The positive predictive value for virus isolation was 60.0% for viral loads >107 RNA copies/mL and 50.0% for the presence of viral antigen. Symptom onset before 10 days and seroconversion predicted lack of infectivity with negative predictive values of 93.8% and 96.0%. Conclusions Our data support quarantining patients with high viral load and detection of viral antigen and lifting restrictive measures with increasing time to symptom onset and seroconversion. Delay of antibody formation may prolong infectivity.
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- 2021
44. Does cerebral near-infrared spectroscopy (NIRS) help to predict futile cannulation in extracorporeal cardiopulmonary resuscitation (ECPR)?
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Christian Merten, Alois Philipp, Dirk Lunz, Clemens Wiest, Timo Seyfried, Maik Foltan, Sebastian Blecha, Roland Schneckenpointner, Florian Geismann, Thomas Müller, and Matthias Lubnow
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Resuscitation ,Spectroscopy, Near-Infrared ,business.industry ,medicine.medical_treatment ,Cerebral oxygen saturation ,Emergency Nursing ,Hemoglobin levels ,Cardiopulmonary Resuscitation ,Catheterization ,Extracorporeal Membrane Oxygenation ,Anesthesia ,Cohort ,Emergency Medicine ,Retrospective analysis ,Medicine ,Humans ,Extracorporeal cardiopulmonary resuscitation ,Favorable outcome ,Cardiopulmonary resuscitation ,Cardiology and Cardiovascular Medicine ,business ,Out-of-Hospital Cardiac Arrest ,Retrospective Studies - Abstract
Aim of the study Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving technique to improve cardiopulmonary resuscitation (CPR) outcomes. Identifying a readily available tool helpful for predicting patient's outcome is warranted. The aim of the study was to evaluate the capability of cranial near-infrared spectroscopy (cNIRS) to identify non-survivors or patients with unfavorable neurologic outcome prior to cannulation for ECPR to avoid futile cannulations. Methods Retrospective analysis (2015–2021) of 97 patients requiring ECPR due to cardiac arrest with prior cNIRS measurement, which was performed immediately after ECPR team arrived on scene. Lowest possible regional cerebral oxygen saturation (rSO2) is 15%. Results Mortality was 72.1% (70/97). Survivors showed in 88.9% (24/27) good neurological outcome (Cerebral Performance Category (CPC) 1 + 2). rSO2 = 15% (11/97) prior to cannulation was only found in non-survivors. Among survivors, initial rSO2 was not associated with neurological outcome. Non-shockable initial rhythm was associated with higher mortality (44/50). In survivors, time to ECPR was shorter (p = 0.006), and initial lactate was significantly lower, whereas initial pH and hemoglobin levels were higher (p = 0.001). Survivors and those with favorable neurological outcome showed lower maximal NSE levels in the first 72 hours (p Conclusion In our patient cohort, rSO2 = 15% immediately prior to cannulation for ECPR did not result in any survivors, thus might be a marker for futile cannulation in ECPR. Higher rSO2 values were not associated with favorable neurologic outcome. Lower initial lactate and lower maximal NSE within the first 72 h after arrest were associated with favorable outcome.
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- 2021
45. Argatroban versus heparin in patients without heparin-induced thrombocytopenia during venovenous extracorporeal membrane oxygenation: a propensity-score matched study
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Matthias Lubnow, Dirk Lunz, Alois Philipp, Florian Zeman, Maik Foltan, Lars S. Maier, Maximilian V. Malfertheiner, Christoph Fisser, Thomas Müller, and Maren Winkler
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Male ,medicine.medical_treatment ,610 Medizin ,030204 cardiovascular system & hematology ,Critical Care and Intensive Care Medicine ,Argatroban ,0302 clinical medicine ,Germany ,Clinical endpoint ,Medicine ,Prospective Studies ,Registries ,ddc:610 ,Sulfonamides ,medicine.diagnostic_test ,Medical emergencies. Critical care. Intensive care. First aid ,Heparin ,Middle Aged ,Thrombosis ,Pipecolic Acids ,Anesthesia ,Female ,ECMO ,medicine.drug ,Partial thromboplastin time ,Adult ,Equivalence Trials as Topic ,Arginine ,Antithrombins ,Anticoagulation ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,ECMO, Anticoagulation, Argatroban, Heparin, Thrombosis, Bleeding, Costs ,Heparin-induced thrombocytopenia ,Extracorporeal membrane oxygenation ,Humans ,Propensity Score ,RC86-88.9 ,business.industry ,Research ,Bleeding ,Anticoagulants ,medicine.disease ,Thrombocytopenia ,Costs ,030228 respiratory system ,business ,Discovery and development of direct thrombin inhibitors - Abstract
Background During venovenous extracorporeal membrane oxygenation (vvECMO), direct thrombin inhibitors are considered by some potentially advantageous over unfractionated heparin (UFH). We tested the hypothesis that Argatroban is non-inferior to UFH regarding thrombosis and bleeding during vvECMO. Methods We conducted a propensity-score matched observational non-inferiority study of consecutive patients without heparin-induced-thrombocytopenia (HIT) on vvECMO, treated between January 2006 and March 2019 in the medical intensive care unit at the University Hospital Regensburg. Anticoagulation was realized with UFH until August 2017 and with Argatroban from September 2017 onwards. Target activated partial thromboplastin time was 50 ± 5seconds in both groups. Primary composite endpoint was major thrombosis and/or major bleeding. Major bleeding was defined as a drop in hemoglobin of ≥ 2 g/dl/day or in transfusion of ≥ 2 packed red cells/24 h, or retroperitoneal, cerebral, or pulmonary bleeding. Major thrombosis was defined as obstruction of > 50% of the vessel lumen diameter by means of duplex sonography. We also assessed technical complications such as oxygenator defects or pump head thrombosis, the time-course of platelets, and the cost of anticoagulation (including HIT-testing). Results Out of 465 patients receiving UFH, 78 were matched to 39 patients receiving Argatroban. The primary endpoint occurred in 79% of patients in the Argatroban group and in 83% in the UFH group (non-inferiority for Argatroban, p = 0.026). The occurrence of technical complications was equally distributed (Argatroban 49% vs. UFH 42%, p = 0.511). The number of platelets was similar in both groups before ECMO therapy but lower in the UFH group after end of ECMO support (median [IQR]: 141 [104;198]/nl vs. 107 [54;171]/nl, p = 0.010). Anticoagulation costs per day of ECMO were higher in the Argatroban group (€26 [13.8;53.0] vs. €0.9 [0.5;1.5], p p = 0.074). Conclusion In patients without HIT on vvECMO, Argatroban was non-inferior to UFH regarding bleeding and thrombosis. The occurrence of technical complications was similarly distributed. Argatroban may have less impact on platelet decrease during ECMO, but this finding needs further evaluation. Direct drug costs were higher for Argatroban but comparable to UFH after accounting for HIT-testing and transfusions.
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- 2021
46. Out-of-center Initiation of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients
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Kerstin Brueckner, Katrin Judemann, Dirk Lunz, Matthias Lubnow, Derya Akyol, Alois Philipp, and C.L. Lassen
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Male ,Respiratory Distress Syndrome ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,SARS-CoV-2 ,business.industry ,medicine.medical_treatment ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Biomedical Engineering ,Biophysics ,COVID-19 ,Bioengineering ,General Medicine ,Middle Aged ,Biomaterials ,Extracorporeal Membrane Oxygenation ,Anesthesia ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Female ,Center (algebra and category theory) ,business - Published
- 2020
47. Incidence and Risk Factors for Cannula-Related Venous Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Adult Patients With Acute Respiratory Failure
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Dirk Lunz, Christoph Reichenbächer, Matthias Lubnow, Thomas Müller, Alois Philipp, Maximilian V. Malfertheiner, Florian Zeman, Roland Schneckenpointner, Maik Foltan, and Christoph Fisser
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Adult ,Male ,medicine.medical_treatment ,Critical Care and Intensive Care Medicine ,Severity of Illness Index ,03 medical and health sciences ,Catheters, Indwelling ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Risk Factors ,medicine ,Extracorporeal membrane oxygenation ,Humans ,Retrospective Studies ,Venous Thrombosis ,Respiratory Distress Syndrome ,medicine.diagnostic_test ,business.industry ,Hemodynamics ,030208 emergency & critical care medicine ,Middle Aged ,medicine.disease ,Cannula ,Thrombosis ,Vein occlusion ,Venous thrombosis ,030228 respiratory system ,Respiratory failure ,Anesthesia ,Female ,Complication ,business ,Partial thromboplastin time - Abstract
Objectives: Venovenous extracorporeal membrane oxygenation is indicated in patients with severe refractory acute respiratory failure. Venous thrombosis due to indwelling catheters is a frequent complication. The aim of this study was to analyze the incidence of cannula-related thrombosis and its risk factors after venovenous extracorporeal membrane oxygenation. Design: Retrospective observational study. Setting: A medical ICU at the University Hospital Regensburg. Patients: We analyzed consecutive patients with severe respiratory failure (Pao 2 /Fio 2 < 85 mm Hg and/or respiratory acidosis with pH < 7.25) who were successfully treated with venovenous extracorporeal membrane oxygenation in a medical ICU between 2010 and 2017. Intervention: None. Measurements and Main Results: After extracorporeal membrane oxygenation weaning, duplex sonography or CT was conducted to detect cannula-related thrombosis. Thrombosis was classified as a large thrombosis by vein occlusion of greater than 50%. The incidence of thrombosis was correlated with risk factors such as coagulation variables (mean activated partial thromboplastin time = 50 s, international normalized ratio antithrombin III, fibrinogen, plasma-free hemoglobin, platelets, and decline in D-dimer = 50% the day after decannulation), cannula size, time on venovenous extracorporeal membrane oxygenation, renal failure, and underlying malignant disease. Data cut-off points were identified by receiver operating characteristic analysis. One-hundred seventy-two of 197 patients (87%) were screened. One-hundred six patients (62%) showed thrombosis that was considered large in 48 of 172 (28%). The incidence of thrombosis was higher in patients with a mean aPTT of less than or equal to 50 seconds (odds ratio, 1.02; p = 0.013) and in patients with a decline in D-dimer less than or equal to 50% (odds ratio, 2.76; p = 0.041) the day after decannulation following adjustment for risk factors. Conclusions: The incidence of cannula-related venous thrombosis after venovenous extracorporeal membrane oxygenation is high. Reduced systemic anticoagulation may enhance the risk of thrombosis. Sustained elevation of D-dimer after decannulation may indicate thrombosis. Patients should undergo routine duplex sonography after extracorporeal membrane oxygenation to detect thrombosis formation in the cannulated vessel.
- Published
- 2019
48. Quantitative assessment of peripheral limb perfusion using a modified distal arterial cannula in venoarterial ECMO settings
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Karla Lehle, Alois Philipp, Laszlo Göbölös, Christof Schmid, Maik Foltan, Igor Kornilov, Andreas Holzamer, Dirk Lunz, and Roland Schneckenpointner
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Peripheral perfusion ,Ischemia ,Internal medicine ,Catheterization, Peripheral ,Quantitative assessment ,Limb perfusion ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,Radiology, Nuclear Medicine and imaging ,Aged ,Advanced and Specialized Nursing ,business.industry ,Extremities ,General Medicine ,Middle Aged ,Arterial cannula ,Peripheral ,Femoral Artery ,Perfusion ,surgical procedures, operative ,030228 respiratory system ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Safety Research - Abstract
In cases of severe cardiopulmonary deterioration, quick establishment of venoarterial extracorporeal membrane oxygenation (ECMO) represents a support modality. After successful arterial peripheral cannulation, a certain grade of peripheral limb malperfusion is a fairly common phenomenon. Detection of peripheral malperfusion is vital, since it can result in compartment syndrome or even loss of the affected limb. To prevent or resolve emerging lower limb ischaemia, a newly designed perfusion catheter is placed into the superficial femoral artery, distal to the arterial cannula via ECMO. The aim of our study was to evaluate flow and haemodynamic characteristics of this novel distal limb perfusion cannula for ECMO therapy and present these important findings for the first time. The distal perfusion cannula blood flow increases in linear correlation with ECMO blood flow The variability of distal perfusion cannula blood flow with a 15 Fr cannula ranges between 160 ± 0.40 mL min−1 at 1.5 L min−1 ECMO flow rate and 480 ± 80 mL min−1 at 5.0 L min−1 ECMO blood flow, respectively. Comparatively, the 17-Fr-sized cannula performs on a scale of 140 ± 20 to 390 ± 60 mL distal perfusion cannula blood flow at 1.5-5.0 L min−1 ECMO blood flow, respectively. The quantitative assessment of the distal perfusion cannula blood flow has revealed that distal perfusion cannula blood flow can measure up to 10% of the ECMO blood flow. Furthermore, it has been also well demonstrated that the novel distal perfusion cannula is sufficient to compensate peripheral limb ischaemia.
- Published
- 2019
49. Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation
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Dirk Lunz, Hans-Stefan Hofmann, Laura Sommerauer, Thomas Müller, Michael Ried, Alois Philipp, and Matthias Lubnow
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Male ,Pulmonary and Respiratory Medicine ,Thorax ,medicine.medical_specialty ,medicine.medical_treatment ,Hemorrhage ,030204 cardiovascular system & hematology ,Veins ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Extracorporeal membrane oxygenation ,Humans ,Medicine ,In patient ,Retrospective Studies ,business.industry ,Incidence ,Incidence (epidemiology) ,Extracorporeal circulation ,030208 emergency & critical care medicine ,Retrospective cohort study ,Middle Aged ,Surgery ,Respiratory failure ,Cardiothoracic surgery ,Female ,Respiratory Insufficiency ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation. Methods A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications. Results The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013). Conclusions Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.
- Published
- 2018
50. Nicht elektive thoraxchirurgische Operationen bei Patienten mit respiratorischer Insuffizienz und Einsatz einer venovenösen extrakorporalen Membranoxygenierung
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Alois Philipp, Michael Ried, Matthias Lubnow, Hans-Stefan Hofmann, Dirk Lunz, Thomas Müller, and Laura Sommerauer
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Gynecology ,03 medical and health sciences ,medicine.medical_specialty ,0302 clinical medicine ,business.industry ,medicine ,030208 emergency & critical care medicine ,Surgery ,030204 cardiovascular system & hematology ,business - Abstract
Zusammenfassung Hintergrund Patienten mit schwerer respiratorischer Insuffizienz und venovenöser extrakorporaler Membranoxygenierung (vv-ECMO) benötigen häufig eine diagnostische oder therapeutische thoraxchirurgische Intervention. Material und Methode Retrospektive Analyse von prospektiv erhobenen Daten (Regensburger ECMO-Register) aller Patienten im Zeitraum von Dezember 2010 bis Dezember 2016, die aufgrund eines akuten Lungenversagens (ALV) mit einer vv-ECMO behandelt wurden und bei denen eine diagnostische oder therapeutische thoraxchirurgische Operation (TCH-OP) durchgeführt wurde. Endpunkte waren die Indikation zur TCH-OP sowie die postoperative Morbidität und Letalität. Ergebnis Es wurden 418 Patienten (m = 285, 68%; mittleres Alter 50,0 ± 16,5 Jahre) mit einer vv-ECMO behandelt. Die häufigsten Indikationen zur vv-ECMO waren ein ALV bei Pneumonie (59,8%), postoperativ (18,7%), posttraumatisch (9,8%), nach Chemotherapie (2,8%) oder sonstigen Gründen (8,9%). Insgesamt wurden 102 (24,4%) Patienten unter vv-ECMO operiert, davon 29 Patienten (28,4%) thoraxchirurgisch. Die häufigste primäre Indikation für eine TCH-OP war therapeutisch bei Hämatothorax (n = 13; 44,8%), gefolgt von karnifizierender Pneumonie/Lungenabszess (n = 5; 17,2%), Pleuraempyem (n = 3; 10,3%) und sonstigen Ursachen (n = 3; 10,3%). Bei interstitieller Lungenerkrankung unklarer Genese (n = 5; 17,2%) erfolgte eine diagnostische Lungenbiopsie. Bei den Ersteingriffen wurde bei 27 Patienten eine Thorakotomie (93,1%), seltener eine VATS (n = 2; 6,9%) durchgeführt. Mindestens eine Rethorakotomie erfolgte in 15 Patienten (51,7%) und 9 Patienten (31,0%) wurden mehr als 2 × operiert. Die Letalität im Krankenhaus der Patienten mit TCH-OP (44,8%) war höher als die der Patienten ohne TCH-OP (35,7%; p = 0,326). Schlussfolgerung Die Indikationen für eine thoraxchirurgische Operation bei Patienten mit vv-ECMO sollten streng gestellt werden, da häufig postoperative Komplikationen mit einer hohen Reoperationsrate (58,6%) auftreten. Daher sollte eine ECMO-Therapie nur in spezialisierten Zentren mit thoraxchirurgischer Expertise erfolgen.
- Published
- 2018
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