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This review focuses on recirculation in the context of Veno-Venous Extracorporeal Life Support in adults. The methods employed to calculate and quantify the extent of recirculation, as well as factors affecting recirculation and interventions that could reduce recirculation, are detailed. As recirculation may significantly reduce extracorporeal oxygen delivery, leading to refractory hypoxemia, detecting and quantifying the recirculation fraction is fundamental in order to optimize VV-ECMO lung support. Although it is necessary to assess extracorporeal oxygen delivery, quantifying the amount of recirculation may be difficult. Besides mathematical methods, different experimental techniques for the direct measurement of recirculation are in development at present. Moreover, specific interventions and ECMO configurations could significantly reduce recirculation, and innovative systems are under study in this regard. Nevertheless, further human studies are needed to validate and standardize their use in clinical practice, and there remain limited data on their effectiveness and safety. More pre-clinical and clinical studies are required to assess the results obtained thus far and to improve the technologies to minimize the potential complications associated with their use. [ABSTRACT FROM AUTHOR]

Acute Respiratory Distress Syndrome (ARDS) is initiated by a primary insult that triggers a cascade of pathological events, including damage to lung epithelial and endothelial cells, extracellular matrix disruption, activation of immune cells, and the release of pro-inflammatory mediators. These events lead to increased alveolar-capillary barrier permeability, resulting in interstitial/alveolar edema, collapse, and subsequent hypoxia and hypercapnia. ARDS not only affects the lungs but also significantly impacts the cardiovascular system. We conducted a comprehensive literature review on heart-lung crosstalk in ARDS, focusing on the pathophysiology, effects of mechanical ventilation, hypoxemia, and hypercapnia on cardiac function, as well as ARDS secondary to cardiac arrest and cardiac surgery. Mechanical ventilation, essential for ARDS management, can increase intrathoracic pressure, decrease venous return and right ventricle preload. Moreover, acidemia and elevations in transpulmonary pressures with mechanical ventilation both increase pulmonary vascular resistance and right ventricle afterload. Cardiac dysfunction can exacerbate pulmonary edema and impair gas exchange, creating a vicious cycle, which hinders both heart and lung therapy. In conclusion, understanding the heart-lung crosstalk in ARDS is important to optimize therapeutic strategies. Future research should focus on elucidating the precise mechanisms underlying this interplay and developing targeted interventions that address both organs simultaneously. [ABSTRACT FROM AUTHOR]

Blastomycosis can result in lung injury with high mortality rates. The literature on veno-venous extracorporeal membrane oxygenation (VV-ECMO) used as a rescue therapy is limited to case reports and small case series collected over extended time periods. This report describes the clinical course and post-hospitalization outcomes among patients with blastomycosis-induced respiratory failure requiring VV-ECMO in the most recent time frame. The data were collected retrospectively from the health records of eight patients with blastomycosis-induced respiratory failure admitted to a tertiary care center between 2019 and 2023. The mean time from the start of mechanical ventilation to ECMO initiation was 57 h. All patients survived to ECMO decannulation, and seven of them survived to hospital discharge. All six patients whose post-discharge follow-up information was available were weaned from mechanical ventilation and lived at home while two required supplemental oxygen. This includes a case where the provision of adequate ECMO support was challenging due to the patient's morbid obesity. The most common residual imaging abnormalities included pulmonary infiltrates and pneumatoceles. The study demonstrates the feasibility of VV-ECMO as a rescue therapy in patients with blastomycosis-related refractory respiratory failure. Rapid initiation of ECMO support in eligible patients may have contributed to the good outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Lysinuric protein intolerance (LPI) is a multi-organ metabolic disorder characterized by the imbalance in absorption and excretion of cationic amino acids like lysine, ornithine and arginine. Infants with LPI typically present with recurrent vomiting, poor growth, interstitial lung disease or renal impairment. The early onset of pulmonary alveolar proteinosis (PAP) has been reported to be associated with a severe form of LPI. Treatment of PAP most commonly consists of whole-lung lavage (WLL) and in autoimmune PAP, granulocyte-macrophage colony stimulating factor (GM-CSF) administration. Nevertheless, GM-CSF therapy in LPI-associated PAP has not been scientifically justified. Case presentation We describe the case of an 8-month-old infant presenting with respiratory failure due to LPI associated with PAP, who was twice treated with WLL; firstly, while on veno-venous ECMO assistance and then by the use of a selective bronchial blocker. After the two treatments with WLL, she was weaned from daytime respiratory support while on initially subcutaneous, then on inhaled GM-CSF therapy. Conclusions This case supports the notion that GM-CSF therapy might be of benefit in patients with LPI-associated PAP. Further studies are needed to clarify the exact mechanism of GM-CSF in patients with LPI-associated PAP.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement. [ABSTRACT FROM AUTHOR]

Acute Respiratory Distress Syndrome (ARDS) is initiated by a primary insult that triggers a cascade of pathological events, including damage to lung epithelial and endothelial cells, extracellular matrix disruption, activation of immune cells, and the release of pro-inflammatory mediators. These events lead to increased alveolar-capillary barrier permeability, resulting in interstitial/alveolar edema, collapse, and subsequent hypoxia and hypercapnia. ARDS not only affects the lungs but also significantly impacts the cardiovascular system. We conducted a comprehensive literature review on heart-lung crosstalk in ARDS, focusing on the pathophysiology, effects of mechanical ventilation, hypoxemia, and hypercapnia on cardiac function, as well as ARDS secondary to cardiac arrest and cardiac surgery. Mechanical ventilation, essential for ARDS management, can increase intrathoracic pressure, decrease venous return and right ventricle preload. Moreover, acidemia and elevations in transpulmonary pressures with mechanical ventilation both increase pulmonary vascular resistance and right ventricle afterload. Cardiac dysfunction can exacerbate pulmonary edema and impair gas exchange, creating a vicious cycle, which hinders both heart and lung therapy. In conclusion, understanding the heart-lung crosstalk in ARDS is important to optimize therapeutic strategies. Future research should focus on elucidating the precise mechanisms underlying this interplay and developing targeted interventions that address both organs simultaneously.

Introduction: In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center. Analysis: All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9 days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%). Conclusion: These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required. [ABSTRACT FROM AUTHOR]

This review focuses on recirculation in the context of Veno-Venous Extracorporeal Life Support in adults. The methods employed to calculate and quantify the extent of recirculation, as well as factors affecting recirculation and interventions that could reduce recirculation, are detailed. As recirculation may significantly reduce extracorporeal oxygen delivery, leading to refractory hypoxemia, detecting and quantifying the recirculation fraction is fundamental in order to optimize VV-ECMO lung support. Although it is necessary to assess extracorporeal oxygen delivery, quantifying the amount of recirculation may be difficult. Besides mathematical methods, different experimental techniques for the direct measurement of recirculation are in development at present. Moreover, specific interventions and ECMO configurations could significantly reduce recirculation, and innovative systems are under study in this regard. Nevertheless, further human studies are needed to validate and standardize their use in clinical practice, and there remain limited data on their effectiveness and safety. More pre-clinical and clinical studies are required to assess the results obtained thus far and to improve the technologies to minimize the potential complications associated with their use.

Abstract Background Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. Methods This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1–2 mL/kg of predicted body weight), low respiratory rate (5–10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). Results The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). Conclusions Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www.clinicaltrials.gov ( NCT03918603 ). Registered 17 April 2019.

Recent advances in veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) technology and management have enabled us to support patients with cardiac and/or pulmonary failure, who may have previously been considered untreatable. VA ECMO and VV ECMO are by definition transient therapies and serve as a bridge to recovery, bridge to decision, bridge to transplant, or bridge to no recovery. Weaning ECMO should be considered for all patients once native cardiac and pulmonary function show signs of recovery. Currently, there are no universally accepted protocols for weaning VA and VV ECMO, and consequently, each individual center follows their own weaning protocols. The aim of this review article is to describe different approaches to safely wean from VA and VV ECMO. [ABSTRACT FROM AUTHOR]

Background: The incidence of candidemia in severe COVID-19 patients (0.8–14%) is two- to ten-fold higher than in non-COVID-19 patients. Methods: This retrospective analysis aimed to analyse the incidence of bloodstream infections (BSI) due to Candida in a cohort of COVID-19 patients supported with ECMO. Results: Among 138 intubated and ventilated patients hospitalized for ≥10 days in the intensive care unit of a teaching hospital, 45 (32.6%) patients received ECMO support, while 93 patients (67.4%) did not meet ECMO criteria and were considered the control group. In the ECMO group, 16 episodes of candidaemia were observed, while only 13 in patients of the control group (36.0% vs. 14.0%, p-value 0.004). It was confirmed at the survival analysis (SHR: 2.86, 95% CI: 1.39–5.88) and at the multivariable analyses (aSHR: 3.91, 95% CI: 1.73–8.86). A higher candida score seemed to increase the hazard for candidemia occurrence (aSHR: 3.04, 95% CI: 2.09–4.42), while vasopressor therapy was negatively associated with the outcome (aSHR: 0.15, 95% CI: 0.05–0.43). Conclusions: This study confirms that the incidence of candidemia was significantly higher in critically ill COVID-19 patients supported with VV-ECMO than in critically ill COVID patients who did not meet criteria for VV-ECMO. [ABSTRACT FROM AUTHOR]

Background: Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. Methods: This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1–2 mL/kg of predicted body weight), low respiratory rate (5–10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). Results: The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). Conclusions: Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www.clinicaltrials.gov (NCT03918603). Registered 17 April 2019. [ABSTRACT FROM AUTHOR]

Background: Patients supported with extracorporeal membrane oxygenation (ECMO) may develop elevated carboxyhemoglobin (CO-Hb), a finding described in the context of hemolysis. Clinical relevance of elevated CO-Hb in ECMO is unclear. We therefore investigated the prognostic relevance of CO-Hb during ECMO support. Methods: Data derives from a retrospective single-center registry study. All ECMO patients in a medical ICU from October 2010 through December 2019 were considered. Peak arterial CO-Hb value during ECMO support and median CO-Hb values determined by point-of-care testing for distinct time intervals were determined. Groups were divided by CO-Hb (<2% or ≥2%). The primary endpoint was hospital survival. Results: A total of 729 patients with 59,694 CO-Hb values met the inclusion criteria. Median age (IQR) was 59 (48–68) years, 221/729 (30.3%) were female, and 278/729 (38.1%) survived until hospital discharge. Initial ECMO configuration was veno-arterial in 431/729 (59.1%) patients and veno-venous in 298/729 (40.9%) patients. Markers for hemolysis (lactate dehydrogenase, bilirubin, hemolysis index, and haptoglobin) all correlated significantly with higher CO-Hb (p < 0.001, respectively). Hospital survival was significantly higher in patients with CO-Hb < 2% compared to CO-Hb ≥ 2%, evaluating time periods 24–48 h (48.6% vs. 35.2%, p = 0.003), 48–72 h (51.5% vs. 36.8%, p = 0.003), or >72 h (56.9% vs. 31.1%, p < 0.001) after ECMO cannulation. Peak CO-Hb was independently associated with lower hospital survival after adjustment for confounders. Conclusions: In ECMO, CO-Hb correlates with hemolysis and hospital survival. If high CO-Hb measured should trigger a therapeutic intervention in order to reduce hemolysis has to be investigated in prospective trials. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) provides pulmonary and/or cardiac support for critically ill patients. Due to their diseases, they are at high risk of developing acute kidney injury. In that case, continuous renal replacement therapy (CRRT) is applied to provide renal support and fluid management. The ECMO and CRRT circuits can be combined by an integrated or parallel approach. So far, all methods used for combined extracorporeal lung and kidney support present serious drawbacks. This includes not only high risks of circuit related complications such as bleeding, thrombus formation, and hemolysis, but also increase in technical workload and health care costs. In this sense, the development of a novel optimized artificial lung device with integrated renal support could offer important treatment benefits. Therefore, we conducted a review to provide technical background on existing techniques for extracorporeal lung and kidney support and give insight on important aspects to be addressed in the development of this novel highly integrated artificial lung device.

Objective: The COVID-19 pandemic requires thinking about alternatives to establish ECMO when often-limited hardware resources are exhausted. Heart-lung-machines may potentially be used for ECMO but contain roller pumps as compared to centrifugal pumps in ECMO-circuits. We here tested roller pumps as rescue pump for ECMO-establishment. Methods: We set up in vitro circuits on roller pumps from C5 heart-lung-machine with 5 l/minutes flow. In two series, we placed either PVC or silicon tubing for an ECMO circuit into the roller pump. We assessed the mechanical stress on the tubing (aiming to run the pump for at least 1 week), measured the temperature increase generated by the friction and assessed flow characteristics and its measurement in simulated situations resembling tube kinking and suction. Results: The roller pumps led to expected and unexpected adverse events. PVC tubing burst between 36 and 78 hours, while silicon tubing lasted for at least 7 days. At 7 days, the silicone tubing showed significant signs of roller pump wear visible on the outside. The inside, however, was free of surface irregularities. Using these tubings in a roller pump led to a remarkable increase in circuit temperature (PVC: +12.0°C, silicone +2.9°C). Kinking or suction on the device caused the expected dramatic flow reduction (as assessed by direct measurement) while the roller pump display continued to show the preset flow. The roller pump is therefore not able to reliably determine the true flow rate. Conclusion: Roller pumps with silicone tubing but not PVC tubing may be used for running ECMO circuits. Silicone tubing may endure the roller pump shear forces for up to 1 week. Thus, repeated tubing repositioning may be a solution. Circuit heating and substantial limitations in flow detection should increase attention if clinical use in situations of crisis is considered. [ABSTRACT FROM AUTHOR]

Background: There are inconclusive data of Ven venous extracorporeal membrane oxygenation (VV‐ECMO) VV‐ECMO for a therapeutic strategy for acute respiratory distress syndrome (ARDS). Methods: Totally 28 critically ill patients were included into the study between 23 September 2013 and 20 january 2020. Critically ill adult patients who were refractory to conventional therapeutic modalities were eligible for veno-venous ECMO and study inclusion. Results: Of a total of 28 patients, 15 patients (53.6%) survived and 13 (46.42%) died. Gender frequency had no significant difference between survivors and non-survivors (P=0.07). Mean of age and BMI had no significant differences between the mentioned groups also (P>0.05). It was the same for BSA and the two groups were in the same situation (1.82±0.37 vs. 1.79±0.29; P=0.81). There were no significant differences between survivors and non-survivors regarding ECMO time (114.49±91.05 vs. 162.62±100.17 minutes; P=0.20) and ICU stays (9.65±5.11 vs. 8.93±4.96; P=0.10). The average time of ICU stay was 9.29±5.16 days. The ejection fraction in survives was significantly higher than non-survivors (52.14±6.42 vs. 57.31±4.39; P=0.02). Those patients who were in the non-survivors group had lower blood pressure (MAP

Persistent sinus tachycardia (pST) has been associated with adverse cardiovascular events in critically ill patients. Pharmacological control of heart rate with negative inotropic agents has proven to be safe but could be potentially dangerous in patients with concomitant right ventricular (RV) dysfunction. Ivabradine, a medication devoid of negative inotropy, could be a potentially safe solution for this patient population when adequate heart rate control is desired. A 17-year-old male with a history of vaping developed acute respiratory distress syndrome (ARDS) and RV dysfunction, requiring extra corporal life support (ECLS). He suffered from pST. Given his RV dysfunction, a beta-blocker was avoided, and ivabradine was used safely with improvement of his pST. This case demonstrates the efficacy of ivabradine to reduce heart rate and avoid the use of beta-blockers for patients with RV dysfunction, which could be detrimental. Ivabradine was shown to lower the heart rate without altering hemodynamic parameters., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Akopyan et al.)

Abstract Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmonary and/or cardiac failure. Blood is drained from the venous system and pumped through a membrane oxygenator where it is oxygenated. For pulmonary support, the blood is returned to the patient via a vein (veno-venous ECMO) and for pulmonary/circulatory support it is returned via an artery (veno-arterial ECMO). Veno-venous ECMO can be performed either with a single dual-lumen cannula or with two separate single-lumen cannulas. If the latter is chosen, flow direction can either be from the inferior caval vein (IVC) to the right atrium or the opposite. Earlier research has shown that drainage from the IVC yields less recirculation and therefore the IVC to right atrium route has become the standard in most centers for veno-venous ECMO with two cannulas. However, recent research has shown that recirculation can be minimized using a multistage draining cannula in the optimal position inserted via the right internal jugular vein and with blood return to the femoral vein. The clinical results with this route are excellent. In veno-arterial ECMO the most common site for blood infusion is the femoral artery. If venous blood is drained from the IVC, the patient is at risk of developing a dual circulation (Harlequin syndrome, North-South syndrome, differential oxygenation) meaning a poor oxygenation of the upper part of the body, while the lower part has excellent oxygenation. By instead draining from the superior caval vein (SVC) via a multistage cannula inserted in the right internal jugular vein this risk is neutralized. In conclusion, the authors argue that draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein is equal or better than IVC drainage both in veno-venous two cannula ECMO and in veno-arterial ECMO with blood return to the femoral artery.

The indications for extracorporeal membrane oxygenation (ECMO) are expanding. Postobstructive pulmonary edema, also known as negative pressure pulmonary edema, can result in severe respiratory compromise and acute respiratory distress syndrome. We present a case of a 26-year-old female with laryngeal papillomatosis and laryngospasm after direct laryngoscopy, who developed severe NPPE refractory to mechanical ventilator support, which was successfully treated with veno-venous ECMO. [ABSTRACT FROM AUTHOR]

Abstract Background We report two cases of acute respiratory distress syndrome in burn patients who were successfully managed with good outcomes with extra corporeal membrane oxygenation (ECMO) after failing multiple conventional modes of ventilation, and review the relevant literature. Case presentation The two patients were a 39-year-old male and 53-year-old male with modified Baux Scores of 79 and 78, respectively, with no known inhalation injury. After the initial modified Parkland-based fluid resuscitation and partial escharotomy, both patients developed worsening hypoxemia and acute respiratory distress syndrome. The hypoxemia continued to worsen on multiple modes of ventilation including volume control, pressure regulated volume control, pressure control, airway pressure release ventilation and volumetric diffusive ventilation. In both cases, the PaO2 ≤ 50 mm Hg on a FiO2 100% during the trial of mechanical ventilation. The deterioration was rapid (

Objective: Extracorporeal membrane oxygenation is used to bypass the cardiopulmonary system in a severe heart or/and lung failure, mainly in intractable conditions where all other therapy options fail or are unfeasible. Extracorporeal membrane oxygenation (ECMO) is a well-established therapeutic option in such circumstances for neonatal, pediatric, and adult patients. Managing a patient with ECMO requires dedicated and specific management. The importance and necessity of this essential technology in life-threatening cardio-respiratory rescue prompted Rambam Health Care Campus to implement it and make it available as a service to the population in northern Israel. This article includes a brief review of extracorporeal life support and a report of our single-center experience since the establishment of the service. Methods: The ECMO unit was established in 2014 under the responsibility of the Cardiac Surgery Department. The ECMO service was initiated by a well-planned program with consideration of all aspects including economics, education and training, the specialist team and equipment needed, strategies for medication, and ethical challenges. Results: Between February 2014 and May 2018, 65 patients were treated with ECMO; 43 patients received veno-arterial ECMO for cardiac support (66%), while 22 received veno-venous ECMO for respiratory support (34%). The in-hospital mortality was 56%. Conclusions: Extracorporeal membrane oxygenation is an effective therapy that is constantly growing in use and provides a therapy that can replace previous options. To establish such a service requires a planned program and concerted effort. Our single-center experience presented a good learning curve and showed the feasibility as well as the efficacy of the ECMO procedure in life-threatening conditions.

COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory failure calling for an extracorporeal approach (veno-venous ECMO). In this scenario, most of these patients need an early tracheostomy procedure to be carried out, which creates the risk of distribution of aerosol particles, possibly leading to personnel infection. The use of apneic tracheostomy has been proposed for COVID-19 patients, but in case of ECMO it may produce lung derecruitment, severe hypoxemia, and sudden worsening of respiratory mechanics. We developed an apneic tracheostomy technique and applied it in over 32 patients supported by veno-venous ECMO. We present data showing the safety and feasibility of this technique in terms of patient care and personnel protection. Gas exchange and pH did not show statistically significant changes after the tracheostomy, nor did respiratory mechanics data or the need for inspiratory pressure and FiO2. The use of apneic tracheostomy was a safe option for patient care during ECMO and reduced the possibility of virus spreading.

Objective: Extracorporeal membrane oxygenation is used to bypass the cardiopulmonary system in a severe heart or/and lung failure, mainly in intractable conditions where all other therapy options fail or are unfeasible. Extracorporeal membrane oxygenation (ECMO) is a well-established therapeutic option in such circumstances for neonatal, pediatric, and adult patients. Managing a patient with ECMO requires dedicated and specific management. The importance and necessity of this essential technology in lifethreatening cardio-respiratory rescue prompted Rambam Health Care Campus to implement it and make it available as a service to the population in northern Israel. This article includes a brief review of extracorporeal life support and a report of our single-center experience since the establishment of the service. Methods: The ECMO unit was established in 2014 under the responsibility of the Cardiac Surgery Department. The ECMO service was initiated by a well-planned program with consideration of all aspects including economics, education and training, the specialist team and equipment needed, strategies for medication, and ethical challenges. Results: Between February 2014 and May 2018, 65 patients were treated with ECMO; 43 patients received veno-arterial ECMO for cardiac support (66%), while 22 received veno-venous ECMO for respiratory support (34%). The in-hospital mortality was 56%. Conclusions: Extracorporeal membrane oxygenation is an effective therapy that is constantly growing in use and provides a therapy that can replace previous options. To establish such a service requires a planned program and concerted effort. Our single-center experience presented a good learning curve and showed the feasibility as well as the efficacy of the ECMO procedure in life-threatening conditions. [ABSTRACT FROM AUTHOR]

Extracorporeal Life Support (ECLS) merupakan suatu tindakan medis yang dilakukan untuk mempertahankan oksigenasi dan eliminasi dari karbon dioksida yang adekuat untuk mengembalikan fungsi pernapasan yang sudah terganggu. ECLS terdiri dari beberapa jenis, yaitu Extracorporeal lung assist (ECLA), Extracorporeal membrane oxygenation (ECMO), Extracorporeal carbon dioxide removal (ECOO2R), and Extracorporeal cardiopulmonary resuscitation (ECPR). Wabah virus H1N1 (flu babi) yang terjadi pada tahun 2009 dan 2010 menjadikan penggunaan ECMO menjadi popular. ECMO menggunakan teknologi yang diturunkan dari penggunaan cardiopulmonary bypass (CPB) yang memungkinkan terjadinya pertukaran gas di luar tubuh, penggunaannya lebih praktis dan dapat digunakan dalam jangka waktu yang lama. Indikasi penggunaan ECMO pada pasien dengan permasalahan jantung dan paru yang berat yang tidak respon terhadap terapi konvensional, permasalahan seperti acute respiratory distress syndrome, shock kardiogenik yang berulang atau henti jantung. Circuit ECMO terdiiri dari 3 pengaturan yang memiliki fitur masing-masing, yaitu veno-arterial ECMO, Veno-venous ECMO dan arterio-venous ECM). Survival rate penggunaan ECMO pada gagal napas akut berkisar antara 50-70 persen, tetapi belum cukup untuk menjadikan ECMO sebagai rekomendasi umum penatalaksanaan gagal napas akut, tetapi penggunaan ECMO dapat dipertimbangkan jika terapi lainnya gagal. Pemahaman tentang ECMO yang semakin meningkat menjanjikan luaran yang lebih .

The COVID-19 pandemic has increased the need for an accessible, point-of-care and accurate imaging modality for pulmonary assessment. COVID-19 pneumonia is mainly monitored with chest X-ray, however, lung ultrasound (LUS) is an emerging tool for pulmonary evaluation. In this study, patients with verified COVID-19 disease hospitalized at the intensive care unit and treated with ventilator and extracorporal membrane oxygenation (ECMO) were evaluated with LUS for pulmonary changes. LUS findings were compared to C-reactive protein (CRP) and ventilator settings. Ten patients were included and scanned the day after initiation of ECMO and thereafter every second day until, if possible, weaned from ECMO. In total 38 scans adding up to 228 cineloops were recorded and analyzed off-line with the use of a constructed LUS score. The study indicated that patients with a trend of lower LUS scores over time were capable of being weaned from ECMO. LUS score was associated to CRP (R = 0.34; p < 0.03) and compliance (R = 0.60; p < 0.0001), with the strongest correlation to compliance. LUS may be used as a primary imaging modality for pulmonary assessment reducing the use of chest X-ray in COVID-19 patients treated with ventilator and ECMO.

A 33-year-old male with severe COVID-19 required prolonged veno-venous extracorporeal membrane oxygenation (ECMO) support. Following decannulation, he developed an Enterococcus faecium empyema. Tube thoracostomy and broad-spectrum antibiotics were initiated, followed by an unsuccessful attempt at pleural irrigation with saline, given the patient had an increased risk of bleeding due to the concomitant requirement for systemic anticoagulation. Subsequently, intrapleural tissue plasminogen activator (tPA) and recombinant human Dornase alfa (DNase) were safely administered with the resolution of empyema. Enterococcus faecium is an uncommon cause of pleural empyema and, to our knowledge, has not previously been reported to be associated with COVID-19 or ECMO., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Brown et al.)

We report a patient with chest trauma who was admitted to the ICU after surgery. As he fulfilled protocol-based criteria, he was extubated 7 days after admission. However, despite intermittent non-invasive ventilation, the patient had to be re-intubated on day 10 owing to progressive hypercapnia. We decided to support the patient with a mid-flow veno-venous extracorporeal carbon dioxide removal (ECCO2‑R) system instead of a tracheotomy. Sufficient CO2 removal was established with a blood flow of 1.5 l/min and the patient was successfully extubated within a few hours. After 5 days of ECCO2‑R the patient could be weaned and transferred to a general ward in a stable condition. [ABSTRACT FROM AUTHOR]

BACKGROUND: Previous studies have demonstrated the safety of flexible bronchoscopy (FB) in mechanically ventilated subjects. However, the safety of FB in adult subjects receiving extracorporeal membrane oxygenation (ECMO) has not been described previously. METHODS: A retrospective review was conducted of all adult subjects who underwent FB while receiving ECMO support at the University of Alabama at Birmingham Hospital from January 1, 2013, to December 31, 2014. Physiologic variables, pre- and post-FB ECMO, and ventilator settings were recorded. RESULTS: 79 adult subjects underwent FB receiving ECMO with a total of 223 bronchoscopies. The most common indications for bronchoscopy included diagnostic evaluation of infection in subjects with pneumonia (29%) and clearance of excessive secretions (22%). In 70% of subjects, moderate or greater amounts of secretions were noted. FB yielded positive culture data in 37 subjects (47%), which resulted in a change to the antibiotic regimen in 14 subjects (38%) with positive culture data. No significant differences in mean PaO/Fio,' mean ECMO flow, mean sweep gas, ventilator settings, or hemodynamic parameters (heart rate, oxygen saturation, and mean blood pressure) were noted before and after FB. Complications were mild and transient: blood-tinged secretions after FB in 21% cases, which resolved spontaneously, intraprocedural hypoxemia in 2.2% of cases, and dysrhythmia in <1% of cases. There were no episodes of ECMO cannula dislodgement or inadvertent extubation. CONCLUSIONS: FB can be used safely in adult subjects supported with ECMO and is not associated with significant hemodynamics changes, bleeding, or mechanical complications during ECMO support. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) has become the standard of care for potentially reversible cardiopulmonary conditions intractable to conventional medical management. Single site, dual-lumen veno-venous ECMO has proven to be safe and advantageous with respect to mobilization of the patient. Nevertheless, adequate respiratory support demands optimal cannula positioning and catastrophic cannulation complications have been reported. We describe herein the utilization of an angulated guiding catheter to obtain trans-caval access for the successful placement of a single site dual-lumen cannula for veno-venous ECMO in a patient with unfavorable trans-caval anatomy. [ABSTRACT FROM AUTHOR]

Introduction We report a case of an adult patient with human immunodeficiency virus (HIV), acute respiratory distress syndrome (ARDS) and ventilator associated pneumonia (VAP) caused by multidrug resistant (MDR) bacteria that was successfully managed with veno-venous extracorporeal membrane oxygenation (ECMO). Case report A 25 year old male with no significant past medical history had been admitted to a local hospital due to dyspnea and fever. His pulmonary function subsequently failed necessitating mechanical ventilation (MV) and introduction of ECMO support. The patient was transported for 300 km by road on ECMO to a tertiary medical center. The diagnosis of ARDS, HIV infection and MDR bacterial and fungal VAP was made. Patient was successfully treated with antiretroviral therapy (ART), anti-infective agents and 58 days of veno-venous ECMO support, with complete resolution of the respiratory symptoms. Conclusion HIV infected patients with ARDS and MDR bacterial VAP whose HIV replication is controlled by ART could be successfully managed with ECMO. [ABSTRACT FROM AUTHOR]

The use of extracorporeal membrane oxygenation (ECMO) is becoming a popular tool in the treatment of cardiogenic shock. We present two case reports where classical veno-arterial peripherally cannulated ECMO therapy proved insufficient with profuse cerebral hypoxemia. After augmenting the setting into veno-veno-arterial ECMO, we achieved a remarkable improvement of all oxygenation parameters. The simultaneous use of veno-venous and veno-arterial ECMO might display as a novel strategy to counteract the coronary and cerebral hypoxemia in veno-arterial ECMO therapy in patients with therapy-refractory cardiogenic shock or in combined cardiopulmonary failure. In this manuscript, the veno-veno-arterial ECMO setup is described in full detail and different venous cannulas are discussed. [ABSTRACT FROM PUBLISHER]

Extracorporeal membrane oxygenation (ECMO) is a form of circulatory support used in patients with refractory cardiac and/or respiratory failure. The main role of such support is to allow the lungs and heart to rest and heal while providing adequate oxygenation to vital organs. During extracorporeal support, the venous blood removed is decarboxylated, oxygenated, warmed, and infused back into the circulation. Physicians and nursing staff should be familiar with ECMO in order to provide the best care for critically ill patients. The aim of this paper is to review the technical aspects, indications, contraindications, complications, and management of both veno-venous (VV) and veno-arterial (VA) ECMO., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Rabah et al.)

COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory failure calling for an extracorporeal approach (veno-venous ECMO). In this scenario, most of these patients need an early tracheostomy procedure to be carried out, which creates the risk of distribution of aerosol particles, possibly leading to personnel infection. The use of apneic tracheostomy has been proposed for COVID-19 patients, but in case of ECMO it may produce lung derecruitment, severe hypoxemia, and sudden worsening of respiratory mechanics. We developed an apneic tracheostomy technique and applied it in over 32 patients supported by veno-venous ECMO. We present data showing the safety and feasibility of this technique in terms of patient care and personnel protection. Gas exchange and pH did not show statistically significant changes after the tracheostomy, nor did respiratory mechanics data or the need for inspiratory pressure and FiO2. The use of apneic tracheostomy was a safe option for patient care during ECMO and reduced the possibility of virus spreading. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Purpose: Beta-blockers (BB) may improve oxygenation in patients on veno-venous extracorporeal membrane oxygenation (V-V ECMO). This study analyzed safety and efficacy of BB in hypoxemic patients on V-V ECMO., Materials and Methods: Retrospective analysis of patients who were treated with BB during V-V ECMO in two centers. The primary safety outcome was a composite of occurrence of bradycardia or hypotension with need for intervention, resuscitation, unexplained rise in serum lactate, and discontinuation of beta-blockers for other reasons than inefficacy or resolution on hypoxemia during the first 5 days of therapy. The main efficacy outcome was increase in oxygen saturation (SaO 2 ) within 12 h after start of BB., Results: 33 patients received BB for 4 [3-7] days while on V-V ECMO. Fifteen episodes of adverse events occurred in 13 patients (39%); BB had to be discontinued in only one patient for sustained hypotension. In two other patients, doses were reduced or temporarily withheld due to bradycardia. There was an increase in SaO 2 from 92 [90-96]% to 96 [94-97]% at 12 h, with unchanged mean arterial pressure and norepinephrine doses., Conclusions: In this study, use of BB in hypoxemic patients on V-V ECMO was safe and associated with a moderate increase in SaO 2 ., (Copyright © 2019 Elsevier Inc. All rights reserved.)