Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.
- MeSH
- antikoagulancia škodlivé účinky MeSH
- dospělí MeSH
- hemokoagulace MeSH
- heparin * škodlivé účinky MeSH
- krvácení chemicky indukované terapie MeSH
- lidé MeSH
- mimotělní membránová oxygenace * škodlivé účinky MeSH
- retrospektivní studie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
BACKGROUND: The impact of serial imaging on the outcome of ICU patients has not been studied specifically in patients with high illness severity. METHODS: The authors sought a relationship between the numbers of antero-posterior supine chest X-rays (CXR), computed tomography (CT) examinations, and outcome in a cohort of 292 patients with severe COVID-19 ARDS collected over 24 months in a high-volume ECMO center with established ultrasound and echocardiographic diagnostics. Of the patients, 172 (59%) were obese or morbidly obese, and 119 (41%) were treated with ECMO. RESULTS: The median number of CXRs was eight per 14 days of the length of stay in the ICU. The CXR rate was not related to ICU survival (p = 0.37). Patients required CT scanning in 26.5% of cases, with no relationship to the outcome except for the better ICU survival of the ECMO patients without a need for a CT scan (p = 0.01). The odds ratio for survival associated with ordering a CT scan in an ECMO patient was 0.48, p = 0.01. The calculated savings for not routinely requesting a whole-body CT scan in every patient were 98.685 EUR/24 months. CONCLUSIONS: Serial imaging does not impact the survival rates of patients with severe ARDS. Extracorporeal membrane oxygenation patients who did not need CT scanning had significantly better ICU outcomes.
- Publikační typ
- časopisecké články MeSH
The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient's critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
PURPOSE: Acute onset supraventricular arrhythmias can contribute to haemodynamic compromise in septic shock. Both amiodarone and propafenone are available interventions, but their clinical effects have not yet been directly compared. METHODS: In this two-centre, prospective controlled parallel group double blind trial we recruited 209 septic shock patients with new-onset arrhythmia and a left ventricular ejection fraction above 35%. The patients were randomised in a 1:1 ratio to receive either intravenous propafenone (70 mg bolus followed by 400-840 mg/24 h) or amiodarone (300 mg bolus followed by 600-1800 mg/24 h). The primary outcomes were the proportion of patients who had sinus rhythm 24 h after the start of the infusion, time to restoration of the first sinus rhythm and the proportion of patients with arrhythmia recurrence. RESULTS: Out of 209 randomized patients, 200 (96%) received the study drug. After 24 h, 77 (72.8%) and 71 (67.3%) were in sinus rhythm (p = 0.4), restored after a median of 3.7 h (95% CI 2.3-6.8) and 7.3 h (95% CI 5-11), p = 0.02, with propafenone and amiodarone, respectively. The arrhythmia recurred in 54 (52%) patients treated with propafenone and in 80 (76%) with amiodarone, p < 0.001. Patients with a dilated left atrium had better rhythm control with amiodarone (6.4 h (95% CI 3.5; 14.1) until cardioversion vs 18 h (95% CI 2.8; 24.7) in propafenone, p = 0.05). CONCLUSION: Propafenone does not provide better rhythm control at 24 h yet offers faster cardioversion with fewer arrhythmia recurrences than with amiodarone, especially in patients with a non-dilated left atrium. No differences between propafenone and amiodarone on the prespecified short- and long-term outcomes were observed.
- MeSH
- amiodaron * terapeutické užití MeSH
- antiarytmika terapeutické užití MeSH
- fibrilace síní * terapie MeSH
- funkce levé komory srdeční MeSH
- lidé MeSH
- propafenon terapeutické užití MeSH
- prospektivní studie MeSH
- septický šok * komplikace farmakoterapie MeSH
- tepový objem MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
- MeSH
- kongresy jako téma MeSH
- péče o pacienty v kritickém stavu * MeSH
- Publikační typ
- zprávy MeSH
Zobrazovací metody dostupné u lůžka pacienta se staly nezastupitelnou částí diagnostického procesu u těžkých forem covid-19 v intenzivní péči. Hrudní ultrasonografie se etablovala jako unikátní zobrazovací modalita umožňující záchyt spektra plicních patologií, pleurálního prostoru a funkce bránice, což umožňuje bez prodlení volit adekvátní terapeutické intervence. Vitální informace je možné získat o funkci srdce a hemodynamice, pokud se hrudní ultrazvuk kombinuje s echokardiografií a ultrazvukovým vyšetřením cévního systému. Hrudní rtg u lůžka pacienta má svoje technická omezení, není senzitivní v časných fázích onemocnění a exponuje pacienty radiaci. Computerová tomografie má vynikající prostorové rozlišení s možností vizualizace všech struktur hrudníku a mediastina, nevýhodou je zátěž pacienta a personálu transportem, společně s radiací a vedlejšími efekty podávané kontrastní látky. Hrudní ultrasonografie se ukázala být výhodná během pandemie v diagnostice covid-19 pneumonie a jejích komplikací. Jedním z důvodů je redukce potenciální infekční kontaminace personálu a pacientů při transportu na radiologii a zpět. V tomto review autoři srovnávají tři nejčastější modality zobrazení hrudníku v diagnostice covid-19 v intenzivní péči a diskutují benefity a limitace hrudního ultrazvuku.
Imaging methods available at the bedside have become an indispensable part of the diagnostic process of COVID-19 in the intensive care setting. Chest ultrasound has been established as an exquisite bedside imaging tool to assess and diagnose a myriad of lung pathologies, assess the pleural space and diaphragm, and ultimately gauge therapeutic interventions. Furthermore, vital information can be attained on the haemodynamic status of a patient when chest ultrasound is combined with echocardiography and Doppler vascular assessment. Bedside chest x‐ray has its technical limitations, is not sensitive in early stages of the disease, and exposes patients to radiation. Computed tomography has great spatial resolution and all the structures in the chest can be assessed, but on the other hand, it requires patient transport and exposes them to radiation and the potential side effects of contrast administration. Recently, chest ultrasound has proved to be extremely useful during the COVID-19 pandemic in assessing COVID-19 pneumonia and its complications with a resultant reduction in potential infectious cross‐ contamination of staff and patients due to transport to and from the radiology department. In this review, the authors compare the three most frequent modalities of chest imaging in the diagnosis of COVID-19 in critical care, with a focus on the benefits of chest ultrasound.
PURPOSE: The objective of our study was to evaluate the diagnostic accuracy of internal jugular vein (IJV) collapsibility as a predictor of fluid responsiveness in spontaneously breathing patients after cardiac surgery. METHODS: In this prospective observational study, spontaneously breathing patients were enrolled on the first postoperative day after coronary artery bypass grafting. Hemodynamic data coupled with simultaneous ultrasound assessment of the IJV were collected at baseline and after passive leg raising test (PLR). Continuous cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV) were assessed with FloTracTM/EV1000TM. Fluid responsiveness was defined as an increase in CI ≥ 10% after PLR. We compared the differences in measured variables between fluid responders and non-responders and tested the ability of ultrasonographic IJV indices to predict fluid responsiveness. RESULTS: Fifty-four patients were included in the study. Seventeen (31.5%) were fluid responders. The responders demonstrated significantly lower inspiratory and expiratory diameters of the IJV at baseline, but IJV collapsibility was comparable (P = 0.7). Using the cut-off point of 20%, IJV collapsibility predicted fluid responsiveness with a sensitivity of 76.5% and specificity of 38.9%, ROC AUC 0.55. CONCLUSION: In spontaneously breathing patients after surgical coronary revascularisation, collapsibility of the internal jugular vein did not predict fluid responsiveness.
- MeSH
- dýchání MeSH
- hemodynamika MeSH
- kardiochirurgické výkony * MeSH
- lidé MeSH
- tekutinová terapie MeSH
- tepový objem MeSH
- venae jugulares * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
Dokument shrnuje stanovisko expertního diskusního panelu I. odborné konference Point-of-Care ultrasonografie, která se konala dne 14. listopadu 2022 v Praze a na které došlo k založení Mezioborové pracovní skupiny pro doporučené postupy, vzdělávání a výzkum v oblasti Point-of-Care ultrasonografii (Czech POCUS group).
The document summarizes the statement of the expert discussion panel of the 1st Point- of-Care Ultrasonography, which took place on 14 November 2022 in Prague and which led to the foundation of the Czech Multidisciplinary Task Force Group for standards,education and research in Point-of-Care ultrasound (Czech POCUS group).
