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Additional file 1: Supplemental Methods. Data sources, Table S1. Characteristics between patients with and without AKI at ECMO initiation, Figure S1. Distribution of CFH concentration of the study population, Figure S2. Distribution of haptoglobin concentration of the study population, Figure S3. Detailed overview of KDIGO 3 AKI components and indications for RRT in patients with acute RRT at ECMO initiation.

The Acute Respiratory Distress Syndrome (ARDS) is common in patients on the Intensive Care Unit and associated with significant mortality rates. In situations of severe respiratory insufficiency and failure of all possible conservative therapeutic approaches, veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a final option for temporary replacement of pulmonary function. ARDS as well as sepsis and VV ECMO treatment are all associated with intravascular hemolysis. The extent and relevance of intravascular hemolysis in the context of ARDS therapy is unclear. This systematic review aims to summarize the current evidence on the incidence and associated complications of intravascular hemolysis in adult patients with ARDS and treatment with VV ECMO. The databases MEDLINE, EMBASE and Web of Science were systematically searched and 19 publications fulfilled inclusion criteria. The incidence of hemolysis in patients with ARDS and treatment with VV ECMO ranged from 0 to 41% with survivors showing lower incidences and less severe hemolysis. A pump head thrombosis and high blood flows (>= 3 l/min) as well as use of dual-lumen cannulas but not different pump models were associated with increased hemolysis. In conclusion, intravascular hemolysis in patients with ARDS and treatment with VV ECMO is a common and relevant complication that appears associated with increased mortality. Apart from ECMO hardware-settings, no additional possible causes for increased red cell breakdown such as disease severity, duration of ECMO therapy, or number and quality of red blood cell transfusions were investigated. Further research is needed to determine the origin and relevance of intravascular hemolysis in patients with ARDS and treatment with VV ECMO.

Hintergrund: Für ein intraoperatives zielgerichtetes Management der Hämodynamik mittels des ösophagealen Doppler-Monitors (ODM, CardioQ-ODMTM) konnte eine Reduktion der postoperativen Komplikationen gezeigt werden. Das zielgerichtete Management zielt auf eine Optimierung des kardiovaskulären Flusses ab und basiert auf der Messung des Schlagvolumens. Neben dem ODM stehen jedoch noch zahlreiche andere Monitoringverfahren zur Erfassung des Schlagvolumens zur Verfügung, welche zu einem Großteil auf der Analyse der arteriellen Blutdruckkurve beruhen. Das Ziel der Studie war den ODM mit einem Hämodynamikmonitor, basierend auf einer kalibrierten Pulskonturanalyse (PCA, PiCCO2TM), hinsichtlich der Übereinstimmung der Schlagvolumenänderung nach einer Volumengabe innerhalb eines zielgerichteten hämodynamischen Algorithmus bei nicht-kardiochirurgischen Patienten zu untersuchen. Methoden: Die Daten wurden prospektiv bei Patientinnen mit metastasiertem Ovarialkarzinom zur Tumorreduktionsoperation erhoben. Während der Operation wurden Volumenboli gemäß des zielgerichteten hämodynamischen Algorithmus verabreicht. Die Monitore wurden hinsichtlich ihrer intrinsischen Präzision und der Übereinstimmung von Schlagvolumenänderungen (Trending) evaluiert. Klinische Charakteristika, die mit dem Trending assoziiert sind, wurden mittels einer erweiterten Regressionsanalyse untersucht. Ergebnisse: Insgesamt wurden 762 Volumenboli bei 41 Patientinnen verabreicht, sodass 1524 Messpaare in die Analyse eingingen. Die Präzision des ODM und der PCA war nicht unterschiedlich (5.7% vs. 6.0%, P=0.80). Die Polaranalyse zeigte eine schlechte Übereinstimmung des Trendings mit einer Winkelabweichung von -7.1°, Grenzen der Winkelabweichung von -58.1° bis 43.8° und einer Winkelkonkordanzrate von 67.8%. Die Noradrenalindosis [skaliert 0.1 µg kg-1 min-1] (adjustierte Odds Ratio (OR) 0.606 [95%-CI: 0.404-0.910]; P=0.016) und die Änderung des arteriellen Mitteldrucks unter Volumengabe [skaliert 10%] (OR 0.733 [95%-CI: 0.635-0.845]; P, Background: The use of a goal-directed haemodynamic management guided by the oesophageal Doppler monitor (ODM, CardioQ-ODMTM) has been shown to reduce postoperative complications. The goal-directed management aims at increasing circulatory flow and is based on measurements of stroke volume. However, except for the ODM, further haemodynamic monitors are available to measure stroke volume while most of them rely on arterial pressure waveform assessment. In this regard, we aimed to compare the oesophageal Doppler monitor (ODM, CardioQ-ODMTM) with a calibrated pulse-contour analysis (PCA, PiCCO2TM) regarding stroke volume changes after volume administration within a goal-directed haemodynamic algorithm during non-cardiac surgery. Methods: The data were prospectively obtained in patients undergoing multivisceral cytoreductive surgery due to ovarian cancer. During surgery, fluid challenges were performed according to the goal-directed haemodynamic algorithm guided by the ODM. The ODM and PCA were compared with respect to precision and trending. Extended regression analysis was used to investigate clinical characteristics being associated with trending. Results: A total of 1524 paired measurements were analysed according to 762 fluid challenges performed in 41 patients. Precision of ODM and PCA was similar (5.7% vs. 6.0%, P=0.80). Polar Plot analysis showed a poor trending between ODM and PCA with an angular bias of -7.1°, radial limits of agreement of -58.1° to 43.8° and an angular concordance rate of 67.8%. Regression analysis revealed that dose of norepinephrine [scaled 0.1 µg kg-1 min-1] (adjusted Odds ratio (OR) 0.606 [95%-CI: 0.404-0.910]; P=0.016) and changes in mean arterial pressure to a fluid challenge [scaled 10%] (adjusted OR 0.733 [95%-CI: 0.635-0.845]; P

Malignant ascites (MA) is most commonly observed in patients scheduled for epithelial ovarian cancer (EOC) surgery and is supposed as a major risk factor promoting perioperative hemodynamic deterioration. We aimed to assess the hemodynamic consequences of MA on systemic circulation in patients undergoing cytoreductive EOC surgery. This study is a predefined post-hoc analysis of a randomized controlled pilot trial comparing intravenous solutions within a goal-directed algorithm to optimize hemodynamic therapy in patients undergoing cytoreductive EOC surgery. Ascites was used to stratify the EOC patients prior to randomization in the main study. We analyzed 2 groups according to the amount of ascites (NLAS: none or low ascites [500 mL]). Differences in hemodynamic variables with respect to time were analyzed using nonparametric analysis for longitudinal data and multivariate generalized estimating equation adjusting the analysis for the randomized study groups of the main study. A total of 31 patients in the NLAS and 16 patients in the HAS group were analyzed. Although cardiac output was not different between groups suggesting a similar circulatory blood flow, the HAS group revealed higher heart rates and lower stroke volumes during surgery. There were no differences in pressure-based hemodynamic variables. In the HAS group, fluid demands, reflected by the time to reindication of a fluid challenge after preload optimization, increased steadily, whereas stroke volume could not be maintained at baseline resulting in hemodynamic instability after 1.5 h of surgery. In contrast, in the NLAS group fluid demands were stable and stroke volume could be maintained during surgery. Clinically relevant associations of the type of fluid replacement with hemodynamic consequences were particularly observed in the HAS group, in which transfusion of fresh frozen plasma (FFP) was associated to an improved circulatory flow and reduced vasopressor and fluid demands, whereas the administration of artificial infusion solutions was related to opposite effects. Malignant ascites >500 mL implies increased fluid demands and substantial alterations in circulatory blood flow during cancer surgery. Fresh frozen plasma transfusion promotes recovering hemodynamic stability in patients with malignant ascites >500 mL, in whom artificial infusion solutions could not prevent from hemodynamic deterioration.