Marinella Zanierato

Organ Allocation Waiting Time During Extracorporeal Bridge to Lung Transplant Affects Outcomes

BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (LTX) is still being debated. METHODS We performed a retrospective two-center analysis of the relationship between ECMO bridging duration and survival in 25 patients. Further survival analysis was obtained by dividing the patients according to waiting time on ECMO: up to 14 days (Early group) or longer (Late group). We also analyzed the impact of the ventilation strategy during ECMO bridging (ie, spontaneous breathing and noninvasive ventilation [NIV] or intubation and invasive mechanical ventilation [IMV]). RESULTS Seventeen of 25 patients underwent a transplant (with a 76% 1-year survival), whereas eight patients died during bridging. In the 17 patients who underwent a transplant, mortality was positively related to waiting days until LTX (hazard ratio [HR], 1.12 per day; 95% CI, 1.02-1.23; P = .02), and the Early group showed better Kaplan-Meier curves (P = .02), higher 1-year survival rates (100% vs 50%, P = .03), and lower morbidity (days on IMV and length of stay in ICU and hospital). During the bridge to transplant, mortality increased steadily with time. Considering the overall outcome of the bridging program (25 patients), bridge duration adversely affected survival (HR, 1.06 per day; 95% CI, 1.01-1.11; P = .015) and 1-year survival (Early, 82% vs Late, 29%; P = .015). Morbidity indexes were lower in patients treated with NIV during the bridge. CONCLUSIONS The duration of the ECMO bridge is a relevant cofactor in the mortality and morbidity of critically ill patients awaiting organ allocation. The NIV strategy was associated with a less complicated clinical course after LTX.

Are Neurogenic Stress Cardiomyopathy and Takotsubo Different Syndromes With Common Pathways?: Etiopathological Insights on Dysfunctional Hearts

The imbalance between the number of organ donors and the demand is currently a major health care problem, although improved technology and experience with long-term mechanical support are increasingly providing alternative solutions to end-stage heart disease. There are strict criteria to assess

Inhaled nitric oxide test in a pregnant patient with severe pulmonary hypertension

A reply We would like to thank you for the opportunity to reply and thank Dr Orme for his comments. It was reported that the patient underwent a percutaneous tracheostomy using an 8.0 mm Cook ‘Blue Rhino’ Kit and an 8.0 mm fenestrated Tracoe tracheostomy tube. After insertion, air leakage was detected and the Tracoe tracheostomy tube was replaced by a Portex 9.0 mm Blue Line Ultra fenestrated tracheostomy tube. Four hours after the procedure, the patient developed surgical emphysema affecting his face, neck and left anterior chest wall. The 9.0 mm Blue Line Ultra tube flange was found to be proud of the patient’s neck by approximately 1 cm and bubbling was noted between the inner and outer cannulae of the tracheostomy tube at the site of the fenestrations. Based on this statement, we have concluded that the surgical emphysema was caused by air passing through the fenestration hole(s) whilst positioned within the pretracheal tissue of the newly formed stoma. Smiths Medical does not recommend insertion of a cuffed, fenestrated tracheostomy tube in a newly formed stoma following percutaneous tracheostomy. Our ‘Instructions For Use’ supplied with these products, carry the following warning: ‘Do not insert a Portex Cuffed Fenestrated Tracheostomy Tube (100 ⁄ 802; 100 ⁄ 812; 100 ⁄ 832) using a percutaneous tracheostomy or open surgical technique because in a newly formed stoma the location of the fenestra may be in tissue, and could result in surgical emphysema during mechanical ventilation.’ Smiths Medical is committed to providing products which meet the needs of anaesthetic professionals worldwide and remains receptive to customer feedback.

Heart-Beating and Non-Heart-Beating Donors

Organ transplantation is limited by the shortage of viable donor organs. Non-heart-beating donors (NHBD), also frequently referred to as donor after cardiac death (DCD), represent a promising source of grafts. Nevertheless, the initial period of warm ischemia can compromise the graft viability. Modified preservation techniques are crucial in stopping or reversing cellular injury, through cytoprotective mechanisms, allowing the recovery of a great portion of these grafts. Selective normothermic extracorporeal membrane oxygenation (NECMO) minimizes ischemic injury, playing a protective role on organ function preservation and maintaining tissue perfusion under controlled condition and temperature to restore metabolic processes. NECMO is believed to shift warm ischemic time toward ischemic preconditioning, providing greater viability for DCD donors. In the clinical setting, NECMO has been demonstrated to offer the possibility to obtain good quality grafts for transplant both in controlled and in uncontrolled DCD. Furthermore, in some countries ECMO has been used to support brain death (BD) multiorgan donors in case in which it is not possible to complete death assessment for cardiac or respiratory failure.