Stefano Isgrò

Extracorporeal membrane oxygenation for interhospital transfer of severe acute respiratory distress syndrome patients: 5-year experience.

Purpose Transfer of severely hypoxic patients is a high-risk procedure. Extracorporeal Membrane Oxygenation (ECMO) allows safe transport of these patients to tertiary care institutions. Our ECMO transportation program was instituted in 2004; here we report results after 5 years of activity. Methods This is a clinical observational study. Criteria for ECMO center activation were: potentially reversibile respiratory failure, PaO2 <50 mmHg with FiO2 >0.6 for >12 hours, PEEP >5 cmH20, Lung Injury Score (LIS) ≥3 or respiratory acidosis with pH <7.2, no intracranial bleeding, and no absolute contraindication to anticoagulation. If eligible, a skilled crew applied ECMO at the referral hospital. Transportation was performed with a specially equipped ambulance. Results Sixteen patients were possible candidates for ECMO transfer. Two patients were excluded while 14 (mean±SD, age 35.4±18.6, SOFA 8.4±3.7, Oxygenation Index 43.7±13.4) were transported to our institution (distance covered 102±114 km, global duration of transport 589±186 minutes). Two patients improved after iNO-trial and were transferred and subsequently managed without ECMO. The remaining 12 patients were transferred on veno-venous ECMO with extracorporeal blood flow 2.7±1 L·min−1, gas flow 3.8±1.8 L·min−1, and FiO2 1. Data were recorded 30 minutes before and 60 minutes after initiation of ECMO. ECMO improved PCO2 (75±23 vs. 53±9 mmHg, p<0.01) thus improving pH (7.28±0.13 vs. 7.39±0.05, p<0.01) and allowing a reduction in respiratory rate (35±14 vs. 10±4 breaths/min, p<0.01), minute ventilation (10.1±3.8 vs. 3.7±1.7 L·min−1, p<0.01), and mean airway pressure (26±6.5 vs. 22±5 cmH2O, p<0.01). No major clinical or technical complications were observed. Conclusions ECMO effectively enabled high-risk ground transfer of severely hypoxic patients.

Extra-corporeal life support for near-fatal multi-drug intoxication: a case report

IntroductionSevere mixed β-blocker and calcium channel blocker intoxication presents a significant risk for patient mortality. Although treatment is well-established, it sporadically fails to support the patient through massive overdoses, thus requiring non-conventional treatments. We report the use of extra-corporeal life support in a patient with refractory hemodynamic impairment due to multi-drug intoxication. Although sometimes used in clinical practice, extra-corporeal membrane oxygenation for intoxications has rarely been reported.Case presentationA 36-year-old Caucasian man presented to our hospital with refractory hypotension, severe cardiac insufficiency and multi-organ failure due to mixed intoxication with atenolol, nifedipine, Lacidipine and sertraline. Together with standard treatment, we performed extra-corporeal membrane oxygenation to overcome refractory cardiogenic shock and lead the patient to achieve a full recovery.ConclusionStandard of care for β-blocker and calcium channel blocker intoxication is well-defined and condensed into protocols of treatment. Although aimed at clearing the noxious agents from the patients system, standard measures may fail to provide adequate hemodynamic support to allow recovery. In selected cases, extra-corporeal membrane oxygenation could be considered a bridge to drug clearance while preventing multi-organ failure due to profound shock.

Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study☆☆☆★

PURPOSE Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF). MATERIAL AND METHODS We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST). RESULTS Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2 were utilized throughout the pronation cycle (n=18), PP improved oxygenation (Pao2/Fio2 124±50 mmHg, 187±72 mmHg, and 140±61 mmHg, during PRE, PRONE, and POST steps, respectively, P<.001), while pH and Paco2 were unchanged. CONCLUSIONS PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF.

Clinical management of severely hypoxemic patients.

Purpose of reviewTo describe a physiopathological-based approach to clinical management of severely hypoxemic patients that integrates the most recent findings on the use of rescue therapies. Recent findingsSeveral techniques are available to improve oxygenation in severely hypoxemic patients. Survival benefits have not been proved for most of these techniques. In a recent randomized trial, centralization of acute respiratory distress syndrome patients to a specialized center able to provide extracorporeal membrane oxygenation showed better survival as compared to conventional treatment. Randomized trials failed to prove survival benefits with the use of high levels of positive end-expiratory pressure (PEEP) or prone positioning. However, pooled data from two meta-analyses showed significant higher survival in the most severe patients both with the use of higher PEEP and prone positioning. SummaryTreatment of severely hypoxemic patients should aim to improve oxygenation while limiting ventilator-induced lung injury. A physiopathological approach that accounts for the underlying mechanisms of hypoxemia, and physiological and clinical effects of different treatments is likely the best guide we have to treat severely hypoxemic patients.

Bronchopleural Fistulae and Pulmonary Ossification in Posttraumatic Acute Respiratory Distress Syndrome: Successful Treatment With Extracorporeal Support

We report a case of severe posttraumatic acute respiratory distress syndrome (ARDS) complicated by bronchopleural fistulae (BPF). The stiff ARDS lung and huge air leaks from BPF resulted in the failure of different protective mechanical ventilation strategies to provide viable gas exchange. Lung rest, achieved by extracorporeal carbon dioxide removal (ECCO₂R), allowed weaning from mechanical ventilation, closure of BPF, and resumption of spontaneous breathing.

Helmet Continuous Positive Airway Pressure: Theory and Technology

Continuous positive airway pressure (CPAP) is administered to patients to maintain the airway at a selected pressure (usually named the positive end-expiratory pressure, PEEP) higher than that of the atmosphere one. PEEP application has several well-known effects on the respiratory system and hemodynamics, whose description is not among the aims of this chapter. The applied pressure is kept constant throughout the whole respiratory cycle so that intrapulmonary pressure swings around the set level. Patients can breath spontaneously at the selected pressure without any active support of inspiration; it follows that CPAP cannot be strictly considered a form of “ventilation.”

Partial or Total Extracorporeal Support

Extracorporeal membrane oxygenation (ECMO) is one of the terms used to describe a number of different techniques used for prolonged cardiac and/or respiratory support. During ECMO a fraction of the patient venous return is diverted through an artificial lung for gas exchange (oxygenation and CO2 removal) and then returned to the patient. Depending on the returning vessel (venous or arterial), ECMO can be used for cardiac (veno-arterial bypass (VA-ECMO)) or respiratory support. For respiratory support blood can be drained either from a venous vessel (veno-venous ECMO (VV-ECMO)) or from an arterial vessel (arteriovenous bypass (AV-ECMO)). During VV and VA-ECMO, the blood is withdrawn from the patient through the action of a pump, whereas during AV-ECMO, the blood flow is driven by the patient’s arterial pressure. For respiratory support in ARDS patients, VV-ECMO represents the simplest and more rational choice [1]. Depending on the extracorporeal blood flow (ECBF), VV-ECMO can be used to support both oxygenation and CO2 removal (ECBF 3–7 l/min, total extracorporeal support) or to provide mainly CO2 removal (ECBF 0.5–2.5 l/min, partial extracorporeal support). This chapter will focus mainly on the application of VV-ECMO in ARDS patient.

Ground Transport: Ambulance

Regionalization/centralization to tertiary care centre allows treatment of severe critically ill patients with full technology, staff and expertise resources but requires interhospital transportation of unstable severely ill patients. When patients already connected to ECMO systems or requiring ECMO assistance need transportation, special concerns ensue due to the high risk for adverse events (severity of illness, risk for technical failure during transportation). Transportation must be performed by a specialized skilled multidisciplinary team composed at least of two ECMO physicians, an ECMO specialist and a nurse. Ambulance ground, as compared to air transportation, may be considered when geographically advantageous, when weather does not allow flight transportation and for short distances. Enlarged fuel, electrical and oxygen supplies must be provided, and ECMO system must be protected against shocks, vibrations and sudden decelerations.

Interhospital ground transportation of severe acute respiratory distress syndrome patients on extracorporeal membrane oxygenation: Monza's experience

Severe acute respiratory distress syndrome (ARDS) patient transportation is an extremely high-risk procedure. We report our experience in transferring these patients to our centre while on extracorporeal membrane oxygenation (ECMO).