Hemodynamic monitoring in patients with venoarterial extracorporeal membrane oxygenation
TL;DR: An overview of VA- ECMO pathophysiology, and the current state of the art in hemodynamic monitoring in patients with VA-ECMO is provided.
Abstract: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective mechanical circulatory support modality that rapidly restores systemic perfusion for circulatory failure in patients. Given the huge increase in VA-ECMO use, its optimal management depends on continuous and discrete hemodynamic monitoring. This article provides an overview of VA-ECMO pathophysiology, and the current state of the art in hemodynamic monitoring in patients with VA-ECMO.
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TL;DR: In this article, the authors highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients undergoing extracorporeal membrane oxygenation (ECMO).
Abstract: Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
8 citations
TL;DR: In this paper, the authors investigated whether changes in left ventricular outflow tract velocity-time integral (ΔVTI), induced by a Trendelenburg maneuver, could predict fluid responsiveness during VA-ECMO.
Abstract: Evaluation of fluid responsiveness during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is crucial. The aim of this study was to investigate whether changes in left ventricular outflow tract velocity–time integral (ΔVTI), induced by a Trendelenburg maneuver, could predict fluid responsiveness during VA-ECMO. This prospective study was conducted in patients with VA-ECMO support. The protocol included four sequential steps: (1) baseline-1, a supine position with a 15° upward bed angulation; (2) Trendelenburg maneuver, 15° downward bed angulation; (3) baseline-2, the same position as baseline-1, and (4) fluid challenge, administration of 500 mL gelatin over 15 min without postural change. Hemodynamic parameters were recorded at each step. Fluid responsiveness was defined as ΔVTI of 15% or more, after volume expansion. From June 2018 to December 2019, 22 patients with VA-ECMO were included, and a total of 39 measurements were performed. Of these, 22 measurements (56%) met fluid responsiveness. The R2 of the linear regression was 0.76, between ΔVTIs induced by Trendelenburg maneuver and the fluid challenge. The area under the receiver operating characteristic curve of ΔVTI induced by Trendelenburg maneuver to predict fluid responsiveness was 0.93 [95% confidence interval (CI) 0.81–0.98], with a sensitivity of 82% (95% CI 60–95%), and specificity of 88% (95% CI 64–99%), at a best threshold of 10% (95% CI 6–12%). Changes in VTI induced by the Trendelenburg maneuver could effectively predict fluid responsiveness in VA-ECMO patients. Trial registration ClinicalTrials.gov, NCT 03553459 (the TEMPLE study). Registered on May 30, 2018
7 citations
TL;DR: In this article, a documento de consenso pretende unificar conocimientos and aportar recomendations basadas tanto en la bibliografia reciente como en la experiencia de los principales centros nacionales implantadores de ECMO con el objetivo final de mejorar la atencion integral al paciente.
Abstract: Resumen La oxigenacion por membrana extracorporea (extracorporeal membrane oxygenation, ECMO) es un sistema extracorporeo de asistencia cardiorrespiratoria cuya utilizacion se ha visto incrementada en la ultima decada. La insuficiencia respiratoria, el shock postcardiotomia y el fallo primario del injerto cardiaco o pulmonar son complicaciones que pueden requerir la utilizacion de asistencia mecanica cardiorrespiratoria y, en este escenario, el conocimiento de las peculiaridades perioperatorias medicas y quirurgicas es fundamental. A pesar de la evolucion tecnologica en el area de la asistencia extracorporea, la morbimortalidad de estos pacientes continua siendo elevada, por lo tanto, la decision del implante de la ECMO como la de su retirada debe establecerse dentro de un equipo multidisciplinar experto en el area. El presente documento de consenso pretende unificar conocimientos y aportar recomendaciones basadas tanto en la bibliografia reciente como en la experiencia de los principales centros nacionales implantadores de ECMO con el objetivo final de mejorar la atencion integral al paciente.
6 citations
TL;DR: The use of extracorporeal membrane oxygenation (ECMO) is becoming commonplace worldwide in ICUs for the care of patients with respiratory and/or cardiac failure as mentioned in this paper.
5 citations
TL;DR: The use of extracorporeal membrane oxygenation (ECMO) is becoming commonplace worldwide in ICUs for the care of patients with respiratory and/or cardiac failure as discussed by the authors .
5 citations
References
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TL;DR: It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaP p is a more reliable indicator of fluid responsiveness than DeltaPs.
Abstract: In mechanically ventilated patients with acute circulatory failure related to sepsis, we investigated whether the respiratory changes in arterial pressure could be related to the effects of volume expansion (VE) on cardiac index (CI). Forty patients instrumented with indwelling systemic and pulmonary artery catheters were studied before and after VE. Maximal and minimal values of pulse pressure (Pp(max) and Pp(min)) and systolic pressure (Ps(max) and Ps(min)) were determined over one respiratory cycle. The respiratory changes in pulse pressure (DeltaPp) were calculated as the difference between Pp(max) and Pp(min) divided by the mean of the two values and were expressed as a percentage. The respiratory changes in systolic pressure (DeltaPs) were calculated using a similar formula. The VE-induced increase in CI was >/= 15% in 16 patients (responders) and < 15% in 24 patients (nonresponders). Before VE, DeltaPp (24 +/- 9 versus 7 +/- 3%, p < 0.001) and DeltaPs (15 +/- 5 versus 6 +/- 3%, p < 0.001) were higher in responders than in nonresponders. Receiver operating characteristic (ROC) curves analysis showed that DeltaPp was a more accurate indicator of fluid responsiveness than DeltaPs. Before VE, a DeltaPp value of 13% allowed discrimination between responders and nonresponders with a sensitivity of 94% and a specificity of 96%. VE-induced changes in CI closely correlated with DeltaPp before volume expansion (r(2) = 0. 85, p < 0.001). VE decreased DeltaPp from 14 +/- 10 to 7 +/- 5% (p < 0.001) and VE-induced changes in DeltaPp correlated with VE-induced changes in CI (r(2) = 0.72, p < 0.001). It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaPp is a more reliable indicator of fluid responsiveness than DeltaPs.
1,178 citations
"Hemodynamic monitoring in patients ..." refers background in this paper
...Dynamic markers exploring intra-tidal cyclic changes in hemodynamics, such as pulse pressure variations (PPV) and stroke volume variations (SVV) during mechanical ventilation, accurately predict fluid responsiveness (80-83)....
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TL;DR: Dynamic changes of arterial waveform-derived variables during mechanical ventilation are highly accurate in predicting volume responsiveness in critically ill patients with an accuracy greater than that of traditional static indices of volume responsiveness.
Abstract: Objectives:A systematic review of the literature to determine the ability of dynamic changes in arterial waveform-derived variables to predict fluid responsiveness and compare these with static indices of fluid responsiveness. The assessment of a patient's intravascular volume is one of the most dif
1,062 citations
"Hemodynamic monitoring in patients ..." refers background in this paper
...Dynamic markers exploring intra-tidal cyclic changes in hemodynamics, such as pulse pressure variations (PPV) and stroke volume variations (SVV) during mechanical ventilation, accurately predict fluid responsiveness (80-83)....
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TL;DR: Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock and identified responders with positive and negative predictive values of 93% and 92%, respectively.
Abstract: To investigate whether the respiratory variation in inferior vena cava diameter (ΔDIVC) could be related to fluid responsiveness in mechanically ventilated patients. Prospective clinical study. Medical ICU of a non-university hospital. Mechanically ventilated patients with septic shock (n=39). Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. Cardiac output and ΔDIVC were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7±2.0 to 6.4±1.9 L/min (P<0.001) and a decrease in ΔDIVC from 13.8±13.6 vs 5.2±5.8% (P<0.001). Sixteen patients responded to volume loading by an increase in cardiac output ≥15% (responders). Before volume loading, the ΔDIVC was greater in responders than in non-responders (25±15 vs 6±4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% ΔDIVC cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.
762 citations
"Hemodynamic monitoring in patients ..." refers background in this paper
...Variations in vena cava or internal jugular vein diameters also accurately reflect fluid responsiveness, and share many of the same limitations as PPV/SVV (88-91)....
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TL;DR: Testing whether increasing oxygen delivery immediately after cardiac surgery would shorten hospital and intensive care unit (ICU) stay found it to be shorter in the protocol group, which can shorten the length of hospital stay.
Abstract: Organ dysfunction and multiple organ failure are the main causes of prolonged hospital stay after cardiac surgery, which increases resource use and health care costs. Increased levels of oxygen delivery and consumption are associated with improved outcome in different groups of postoperative patients. Cardiac surgical patients are at risk of inadequate perioperative oxygen delivery caused by extracorporeal circulation and limited cardiovascular reserves. The purpose of our study was to test whether increasing oxygen delivery immediately after cardiac surgery would shorten hospital and intensive care unit (ICU) stay. Four hundred three elective cardiac surgical patients were enrolled in the study and randomly assigned to either the control or the protocol group. Goals of the protocol group were to maintain Svo 2 >70% and lactate concentration <=2.0 mmol/L from admission to the ICU and up to 8 h thereafter. Hemodynamics, oxygen transport data, and organ dysfunctions were recorded. The median hos-pital stay was shorter in the protocol group (6 vs 7 days, P < 0.05), and patients were discharged faster from the hospital than those in the control group (P < 0.05). Discharge from the ICU was similar between groups (P = 0.8). Morbidity was less frequent at the time of hospital discharge in the protocol group (1.1% vs 6.1%, P < 0.01). Increasing oxygen delivery to achieve normal Svo 2 values and lactate concentration during the immediate postoperative period after cardiac surgery can shorten the length of hospital stay. Implications: Health care economics has challenged clinicians to reduce costs and improve resource use in cardiac surgery and anesthesia in a patient population increasing in age and in severity of disease. Optimizing cardiovascular function to maintain adequate oxygen delivery during the immediate postoperative period after cardiac surgery can decrease morbidity and reduce length of hospital stay.
503 citations
"Hemodynamic monitoring in patients ..." refers background in this paper
...186 of tissue oxygenation, is an independent predictor of mortality in septic and cardiogenic shock (19-21)....
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TL;DR: The veins contain approximately 70% of total blood volume and are 30 times more compliant than arteries; therefore, changes in blood volume within the veins are associated with relatively small changes in venous pressure.
Abstract: The veins contain approximately 70% of total blood volume and are 30 times more compliant than arteries; therefore, changes in blood volume within the veins are associated with relatively small changes in venous pressure. The terms venous capacity, compliance, and stressed and unstressed volumes are defined. Decreases in flow into a vein are associated with decreases in intravenous pressure and volume, and vice versa. Changes in resistance in the small arteries and arterioles may affect venous return in opposite directions; this is explained by a two-compartment model: compliant (mainly splanchnic veins) and noncompliant (nonsplanchnic veins). Effects of intrathoracic and intraabdominal pressures on venous return and central venous pressure as well as the value of central venous pressure as a diagnostic variable are discussed.
466 citations
"Hemodynamic monitoring in patients ..." refers background in this paper
...It should be borne in mind that CVP can be impacted by several elements such as cardiac function, mechanical ventilation, position of the central catheter tip and vasoactive agents (67,68)....
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