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Propofol, midazolam, vancomycin and cyclosporine therapeutic drug monitoring in extracorporeal membrane oxygenation circuits primed with whole human blood

Propofol, midazolam, vancomycin and cyclosporine therapeutic drug monitoring in extracorporeal membrane oxygenation circuits primed with whole human blood

This study was an experimental study and did not include any patients. Thus, it needed no ethical approval and no patient consent was needed. Whole ECMO circuits (Maquet®, Orleans, France) comprising a Quadrox® membrane oxygenator, a centrifugal pump, a heat exchanger and PVC tubing were used for ex vivo tests. All components of the circuit were treated with heparin (Bioline coating®, Maquet). Drug-free human whole blood (800 mL) was used to prime the circuit. In order to replicate the in vivo operating conditions, the temperature of the circulating blood was set at 37°C and circuit flow rate at 4.5 L/minute. Propofol (Dipri- van®10 mg/mL, Fresenius, France), midazolam (Hypnovel 1 mg/mL, Roche, France), vancomycin (Vancomycine® 50 mg/mL, Sandoz, France), and cyclosporine (Sandimmun® 50 mg/mL, Novartis, France) were introduced into the circuit to achieve final concentrations of 2 μg/mL, 30 μg/mL, 500 ng/mL and 1.2 μg/mL, respectively. Octanol/water parti- tion coefficients of the drugs are provided in Table 1. A high
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Extracorporeal membrane oxygenation support in pediatrics

Extracorporeal membrane oxygenation support in pediatrics

In the pediatric ECMO population, we face a wide range of weights and dimensions ranging from 4.25 to 60 kg. Therefore, different ECMO circuits and cannulas catering to these weight categories are used. As previously published (3), we use a Thoratec Centrimag ® or PediVas ® (Levitronix, Zurich, Switzerland) console with a back-up unit, heater unit, and a Sechrist Air-Oxygen-Mixer (Sechrist Industries, Anaheim, USA). For neonates and infants weighing up to 15 kg, the whole circuit contains approximately 250 mL priming volume with flow ranges up to 1.7 L/min; for children above 15 kg, the volume of priming solution is about 750 mL, with a capacity of achieving flow rates up to 7.0 L/min, which can also sufficiently cater to adult patients. Likewise, implantation sites differ. In adults, and in an emergency setting like cardiac arrest, femoral access is mainly used. In children, especially before the walking age, as a rule, the femoral vessels are not developed well enough to be suitable for ECMO cannulation and support. Cannulation for neonates, infants and small children focuses on either the neck vessels or large central vessels via median sternotomy. Neck cannulation has the advantage of being an expeditious procedure in an emergency situation, even during mechanical CPR, without causing major interruption to chest compressions. On the other hand, higher flow rates on ECMO might be able to be achieved when using the ascending aorta and the right atrium as cannulation sites. Theoretically, neck cannulation may carry the risk of blocking antegrade flow to the RCA, which in the setting of CPR, cerebral ischaemia or an incomplete circle of Willis, may increase the risk of ischaemic or haemorrhagic stroke. However, there is no clear evidence in the literature for this assumption (4). For VV ECMO
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Extracorporeal Membrane oxygenation in neonates and children

Extracorporeal Membrane oxygenation in neonates and children

Summary Extracorporeal membrane oxygenation (ECMO) is a general term that de- scribes the short- or long-term support of the heart and/or lungs in neonates, children and adults. It offers a treatment option for severe cardiac and/or respiratory failure from neonate to adult. Used as venoarterial extracorpor- eal membrane oxygenation (VA-ECMO), it remains the most commonly used modality for short- to mid-term mechanical support of the failing circu- lation in children. The aim of this article is to review the clinical indications, different circuits, technical options, patient management, and potential risks and benefits of this therapy for children. As ECMO therapy is an overwhelm- ing event for the whole family we also highlight the role of psychosocial counselling and support for the parents.
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Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Since lipophilic and highly protein bound drugs are more prone to sequestration in ECMO circuits, an understanding of the physicochemical properties of drugs can assist in determining the relationship between the dose administered and the anticipated blood concentration [5, 15]. The octanol‐water parti- tion coefficient or log P , is a common way to report the measure of a drug’s lipophilicity [16]. Drugs with high log P values (around 2.0) will have a propensity to be very soluble in organic materials such as the PVC tubing used in the ECMO circuit. However, to date, there has been no characterization of the drug‐ circuit interaction beyond 24 h and, as such, little is known regarding the adsorptive capacity of the circuit over longer periods of ECMO support. Table 1 sum- marizes the effects of critical illness and ECMO on pharmacokinetics of drugs based on degree of lipo- philicity of the drug.
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The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology

The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology

Although the complement response to CPB has been well-described [78–81], the role of complement activation during ECMO is, by contrast, poorly defined. The few avail- able studies date from the 1990s and were conducted using the much less advanced pump and circuit technology that was available to investigators at that time [19, 21–25]. This is important, as improvements in both circuitry and pump technology have likely had a beneficial effect on the levels of complement activation seen during ECMO. Studies on CPB have shown us that the use of centrifugal pumps, now ubiquitous in modern ECMO, reduces complement activa- tion [82, 83]. In addition, the use of contemporary heparin- bonded circuits has also been shown to reduce complement activation [84]. Studies have examined complement activa- tion in ex-vivo models of ECMO [20, 22, 24], neonatal ECMO [20, 23, 25] and in adult patients [21]. In keeping with CPB, all of these studies revealed rapid elevations in the levels of complement factors during ECMO, with peaks occurring within 1 to 2 hours.
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Imaging adults on extracorporeal membrane oxygenation (ECMO)

Imaging adults on extracorporeal membrane oxygenation (ECMO)

Abstract Extracorporeal membrane oxygenation (ECMO) is increasingly being used in adults following failure to wean from cardiopulmonary bypass, after cardiac surgery or in cases of severe respiratory failure. Knowledge of the different types of ECMO circuits, expected locations of cannulas and imaging appearance of complications is essential for accurate imaging interpretation and diagnosis. Commonly encountered complications are malposition of cannulas, adjacent or distal haemorrhage, stroke, stasis thrombus in access vessels, and distal emboli. This article will describe the imaging appear- ance of different ECMO circuits in adults as well as common- ly encountered complications. If a CT (computed tomogra- phy) angiogram is being performed on these patients to eval- uate for pulmonary embolism, the scan may be suboptimal from siphoning off of the contrast by the ECMO. In such cases, an optimal image can be obtained by lowering the flow rate of the ECMO circuit or by disabling the circuit for the duration of image acquisition.
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Heparin like effect in postcardiotomy extracorporeal membrane oxygenation patients

Heparin like effect in postcardiotomy extracorporeal membrane oxygenation patients

BP50 (Medtronic, Minneapolis, MN, USA) and an oxygen- ator Dideco Lilliput 2 ECMO (Sorin Group, Mirandola, Italy) with phosphorylcholine-biocompatible treatment. For patients weighing >10 kg different circuits have been used according to availability: the centrifugal pumps used were the Biomedicus BP 80 (Medtronic), the Stockert Revolu- tion (Sorin Group), the Levitronix (Waltham, MA, USA) equipped with the Dideco EOS ECMO (Sorin Group) oxy- genator with phosphorylcholine-biocompatible treatment (Phisio, Sorin Group). Starting in 2012, a pre-assembled ECMO system (Permanent Life Support, Maquet, Rastatt, Germany) with a Rotaflow centrifugal pump, and a Quadrox PLS oxygenator with Bioline® coating was used in adult patients. The ECMO was usually performed at full flow, under normothermic conditions guaranteed by the oxy- genator heat exchanger, a heater-cooler external group, and external heat-exchanging blankets.
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Extracorporeal Membrane Oxygenation in Cardiopulmonary Disease in Adults

Extracorporeal Membrane Oxygenation in Cardiopulmonary Disease in Adults

oxygenator, a gas exchange device that uses a semipermeable membrane to separate a blood compartment from a gas compartment. Deoxygenated blood is withdrawn through a drainage cannula by an external pump, passes through the oxygenator, and is returned to the patient through a rein- fusion cannula. When blood is drained from a central vein and returned to a central vein, a process known as venove- nous ECMO, the device is providing gas exchange only. When blood is drained from the venous system and pumped into an artery, a process known as venoarterial ECMO, the circuit provides both respiratory and circulatory support. The amount of blood flow through the circuit, the fraction of oxygen delivered through the oxygenator, and the contribution of the native lungs are the main determinants of blood oxygenation for a given device, whereas the rate of gas flow through the oxygenator, known as the sweep gas flow rate, and the blood flow rate are the major determinants of carbon dioxide removal (9) . Extracorporeal circuits are very efficient at removing carbon dioxide and can do so at blood flow rates much lower than what is needed to achieve adequate oxygenation (10,11) . Therefore, when the goal is extracorporeal carbon dioxide removal (ECCO 2 R), smaller cannulae can be used, which may be easier and safer to insert (12) . ECCO 2 R may be used to address hypercapnic respiratory failure or to eliminate carbon dioxide in pri- marily hypoxemic respiratory failure to permit reduced ventilation strategies. An alternative configuration used primarily for carbon dioxide removal is arteriovenous ECCO 2 R, in which the patient’s native cardiac output generates blood flow through the circuit, without the need for an external pump (13) .
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Clinical review: Extracorporeal membrane oxygenation

Clinical review: Extracorporeal membrane oxygenation

Long-term ECMO, as support for severe respiratory failure, was fi rst successfully used in 1972 in an adult patient with post-traumatic respiratory failure [2]. A few years later, at the University of California, Bartlett and colleagues successfully treated a newborn with ECMO [3]. Th e enthusiasm for this new technique led to a randomized trial sponsored by the National Institutes of Health that compared venous–arterial ECMO with conventional mechanical respiratory support in severe ARDS [4]. After randomization of 90 patients the trial was stopped for futility because the mortality in both groups was around 90%. However, one should note that the greatest concern for mechanical ventilation, at that time, was the high fraction of inspired oxygen and not the high ventilator pressure/volume; that is, nonphysio- logical stress and strain. In this ECMO trial, therefore, the only diff erence in mechanical ventilation settings between treatment and control patients was a lower FiO 2 in the group that received the extracorporeal support. Moreover, the ECMO technology at these times was very primitive, with consistent risks for the patients due to high priming volumes of the extracorporeal circuits and elevated bleed ing risks associated with systemic anti- coagulation. Th e limitations of this trial passed mostly unrecognized, however, and the discouraging results therefore led to the ECMO technique being abandoned worldwide.
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Extracorporeal Membrane Oxygenation in the Context of the 2009 H1N1 Influenza A Pandemic

Extracorporeal Membrane Oxygenation in the Context of the 2009 H1N1 Influenza A Pandemic

During cannulation, fatal vascular perforation can occur because of the size and stiffness of the cannulas. For this reason, if a surgeon is not personally performing the cannulation, one with vascular repair capabilities should be at hand. Hemolysis generally does not occur with modern ECMO circuits unless there is a problem in the circuit or the patient. The plasma free hemoglobin concentration should be monitored daily. Values > 10 mg/dL should prompt an investigation into the cause and correction thereof. Thromboembolic disease has been reported after decannulation after ECMO for H1N1- associated respiratory failure [71]. For this reason, consider- ation should be given to continuation of full anticoagulation after cannula removal. If the patient had a femoral venous cannula in place, consideration should be given to placement of an inferior vena cava filter at the time of cannula removal.
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Clinical review : Extracorporeal membrane oxygenation

Clinical review : Extracorporeal membrane oxygenation

Long-term ECMO, as support for severe respiratory failure, was fi rst successfully used in 1972 in an adult patient with post-traumatic respiratory failure [2]. A few years later, at the University of California, Bartlett and colleagues successfully treated a newborn with ECMO [3]. Th e enthusiasm for this new technique led to a randomized trial sponsored by the National Institutes of Health that compared venous–arterial ECMO with conventional mechanical respiratory support in severe ARDS [4]. After randomization of 90 patients the trial was stopped for futility because the mortality in both groups was around 90%. However, one should note that the greatest concern for mechanical ventilation, at that time, was the high fraction of inspired oxygen and not the high ventilator pressure/volume; that is, nonphysio- logical stress and strain. In this ECMO trial, therefore, the only diff erence in mechanical ventilation settings between treatment and control patients was a lower FiO 2 in the group that received the extracorporeal support. Moreover, the ECMO technology at these times was very primitive, with consistent risks for the patients due to high priming volumes of the extracorporeal circuits and elevated bleed ing risks associated with systemic anti- coagulation. Th e limitations of this trial passed mostly unrecognized, however, and the discouraging results therefore led to the ECMO technique being abandoned worldwide.
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Intracranial Hemorrhage During Extracorporeal Membrane Oxygenation in Neonates

Intracranial Hemorrhage During Extracorporeal Membrane Oxygenation in Neonates

The risk of intracranial hemorrhage with brain damage appears to be minimal in neonates of greater than 34 weeks’ gestational age treated with extracorpo- real membrane oxygenation and i[r]

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Venoarterial extracorporeal membrane oxygenation induces early immune alterations

Venoarterial extracorporeal membrane oxygenation induces early immune alterations

Background: Venoarterial extracorporeal membrane oxygenation (VA‑ECMO) provides heart mechanical support in critically ill patients with cardiogenic shock. Despite important progresses in the management of patients under VA‑ECMO, acquired infections remain extremely frequent and increase mortality rate. Since immune dysfunctions have been described in both critically ill patients and after surgery with cardiopulmonary bypass, VA‑ECMO initiation may be responsible for immune alterations that may expose patients to nosocomial infections (NI). Therefore, in this prospective study, we aimed to study immune alterations induced within the first days by VA‑ECMO initiation. Methods: We studied immune alterations induced by VA‑ECMO initiation using cytometry analysis to characterize immune cell changes and enzyme‑linked immunosorbent assay (ELISA) to explore plasma cytokine levels. To analyze specific changes induced by VA‑ECMO initiation, nine patients under VA‑ECMO (VA‑ECMO patients) were compared to nine patients with cardiogenic shock (control patients).
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Extracorporeal membrane oxygenation (ecmo) in the management of severe thoracic trauma

Extracorporeal membrane oxygenation (ecmo) in the management of severe thoracic trauma

intubation was inserted, without the gas exchange improvement. Emergency trauma CT scans showed showed a suspicious lower right bronchial tear with diffuse bilateral pulmonary contusion, with the mild left pneumothorax and a large quantity of abdominal fluid with splenic laceration. A chest tube was inserted on the left hemi thorax, but gas exchange remained stable with an O2saturation of 60%. A team of cardiothoracic surgeons, anaesthesiologistsand trauma leader, recommended a veno-venous ECMO, because the team were agreed that the patient would not survive without ECMO. The patient was placed on an extracorporeal circuit (Bio- Medicus; Medtronic Inc, Minneapolis, Minn) Fig-4 with venous access achieved through the right jugular vein and right femoral vein using a percutaneous Seldinger technique Fig-5,6 (VV-ECMO).
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Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation

Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation

RESULTS: Of 81 neonates studied, 46% demonstrated parenchymal injury; 6% showed infarction, mostly in vascular territories (5% anterior cerebral artery, 5% MCA, 1% posterior cerebral artery); and 20% had hemorrhagic lesions. The highest frequency of injury occurred in the frontal (right, 24%; left, 25%) and temporoparietal (right, 14%; left, 19%) white matter. Sonography had low sensitivity for these lesions. Other MR imaging findings included volume loss (35%), increased subarachnoid spaces (44%), and ventriculomegaly (17% mild, 5% moderate, 1% severe). There were more parenchymal injuries in neonates treated with venoarterial (49%) versus venovenous extracorporeal mem- brane oxygenation (29%, P ⫽ .13), but the pattern of injury was consistent between both modes.
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Common Pulmonary Vein Atresia: The Role of Extracorporeal Membrane Oxygenation

Common Pulmonary Vein Atresia: The Role of Extracorporeal Membrane Oxygenation

Surgical repair was attempted in three neonates; all three required continued extracorporeal membrane oxygenation support postoperatively because of pulmonary hypertension and severe pul[r]

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Neonatal Vocal Cord Paralysis Following Extracorporeal Membrane Oxygenation

Neonatal Vocal Cord Paralysis Following Extracorporeal Membrane Oxygenation

Infants with postextracorporeal membrane oxy- genation feeding difficulties have been observed and reported by several extracorporeal membrane oxygenation centers (National Neonatal Extr[r]

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Acute kidney injury in adults receiving extracorporeal membrane oxygenation

Acute kidney injury in adults receiving extracorporeal membrane oxygenation

Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. Introduction Critically ill patients frequently require mechanical venti- lation, circulatory support, and other assistant devices. Extracorporeal membrane oxygenation (ECMO) is recom- mended for patients with acute, potentially reversible, life-threatening respiratory failure that is unresponsive to conventional therapy. Treatment by ECMO may also be effective in patients with severe reversible myocardial dysfunction (e.g., myocarditis or postoperative cardiogenic Conflicts of interest: All authors declare no conflicts of interest.
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Extracorporeal Membrane Oxygenation Support for Post- Cardiotomy Cardiogenic Shock

Extracorporeal Membrane Oxygenation Support for Post- Cardiotomy Cardiogenic Shock

[14] Soleimani B, Pae WE. Management of left ventricular distension during peripheral extracorporeal membrane oxygenation for cardiogenic shock. Perfusion. 2012;27:326- 331. DOI: 10.1177/0267659112443722 [15] Seib PM, Faulkner SC, Erickson CC, Van Devanter SH, Harrell JE, Fasules JW, Frazier EA, Morrow WR. Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation. Catheterization and Cardiovascular Interventions 1999;46:179-186

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Use of Extracorporeal Membrane Oxygenation for Respiratory Failure in Term Infants

Use of Extracorporeal Membrane Oxygenation for Respiratory Failure in Term Infants

ECMO can be used to support respiratory failure due to a variety of clinical conditions in carefully selected term infants who have not improved after the utilization of standard intensi[r]

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