Publications by authors named "Mirko Belliato"

64 Publications

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study.

Int J Cardiol 2022 Jan 5. Epub 2022 Jan 5.

Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, Paris, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France. Electronic address:

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results.

Results: Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts.

Conclusion: Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.
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http://dx.doi.org/10.1016/j.ijcard.2021.12.053DOI Listing
January 2022

Prediction of Insufficient Beta-Lactam Concentrations in Extracorporeal Membranous Oxygenation Patients.

Microorganisms 2021 Oct 25;9(11). Epub 2021 Oct 25.

Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium.

Background: The aim of this study was to identify predictors of insufficient beta-lactam concentrations in patients undergoing extracorporeal membrane oxygenation (ECMO).

Methods: Retrospective analysis of all patients receiving ECMO support and treated with ceftazidime or cefepime (CEF), piperacillin/tazobactam (TZP), or meropenem (MEM). Trough drug concentrations (C) were measured before the subsequent dose, according to the decision of the attending physician. Insufficient drug concentrations were identified if C was below the clinical breakpoint of Pseudomonas aeruginosa.

Results: A total of 222 C (CEF, n = 41; TZP, n = 85; MEM, n = 96) from 110 patients were included; insufficient concentrations were observed in 26 (12%) antibiotic assessments; 21 (81%) of those occurred during MEM therapy. Insufficient C were associated with a shorter time from initiation of antibiotics to measurement, a lower single dose of antibiotic, a higher creatinine clearance (CrCL), lower sequential organ failure assessment (SOFA) scores, and less use of continuous renal replacement therapy (CRRT) when compared to others.

Conclusions: Insufficient broad-spectrum beta-lactam concentrations were observed in 12% of drug measurement during ECMO therapy. Higher than recommended drug regimens could be considered in the very early phase of therapy and in those patients with augmented renal clearance and with less severe organ dysfunction.
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http://dx.doi.org/10.3390/microorganisms9112219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8625763PMC
October 2021

Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database.

Resuscitation 2021 Nov 22;170:71-78. Epub 2021 Nov 22.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. Electronic address:

Background: The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR).

Methods: A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5).

Results: A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n = 250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n = 333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p < 0.01) and higher ECMO blood flow (OR 1.99, p = 0.01) were associated with UO while initial shockable rhythm (OR 0.04, p < 0.01), previous heart disease (OR 0.20, p < 0.01) and pre-hospital hypothermia (OR 0.08, p < 0.01) had a protective role. In IHCA, prolonged time from arrest to ECMO implantation (OR 1.02, p = 0.03), high lactate level on admission (OR 1.15, p < 0.01) and higher body weight (OR 1.03, p < 0.01) were independently associated with UO.

Conclusions: IHCA and OHCA patients receiving ECPR have different predictors of UO at presentation, suggesting that selection criteria for ECPR should be decided according to the location of CA. After ECMO initiation, ECMO blood flow management and mean arterial pressure targets might also impact neurological recovery.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.015DOI Listing
November 2021

Respiratory Monitoring at Bedside in COVID-19 Patients.

J Clin Med 2021 Oct 26;10(21). Epub 2021 Oct 26.

U.O.C. Anestesia e Rianimazione 2 Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy.

The SARS-CoV-2 (COVID-19) pandemic has forced some reflections to be had surrounding the ventilatory support to be applied to certain types of patients. The model of two phenotypes, set out by Professor Gattinoni and colleagues, suggests that adequate monitoring of respiratory effort may play a key role in the treatment of respiratory failure due to COVID-19. An insufficient control of the patient's respiratory efforts could lead to an aggravation of lung damage, mainly due to the possibility of generating Patient Self-Inflicted Lung Injury (PSILI) with a consequent aggravation of the pathological picture. Nevertheless, effectively monitoring the patient's respiratory work, especially in nonintensive settings, is not easy. This article briefly describes some methods that allow the assessment of respiratory effort, such as the use of ultrasound and respiratory tests, which can be performed in nonintensive settings.
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http://dx.doi.org/10.3390/jcm10214943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8585054PMC
October 2021

International survey of neuromonitoring and neurodevelopmental outcome in children and adults supported on extracorporeal membrane oxygenation in Europe.

Perfusion 2021 Sep 22:2676591211042563. Epub 2021 Sep 22.

Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK.

Background: Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children.

Objective: To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines.

Methods: The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe.

Results: Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS ( = 88, 66.2%), electroencephalography ( = 52, 39.1%), transcranial Doppler ( = 38, 28.5%) and brain injury biomarkers ( = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority ( = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors.

Conclusions: This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.
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http://dx.doi.org/10.1177/02676591211042563DOI Listing
September 2021

Defining and understanding the "extra-corporeal membrane oxygenation gap" in the veno-venous configuration: Timing and causes of death.

Artif Organs 2021 Sep 7. Epub 2021 Sep 7.

Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.

In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in-hospital death, either on-ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V-V ECMO, and to define the V-V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on-ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V-V ECMO-gap. Mortality rates on-ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V-V ECMO outcomes (on-ECMO mortality and discharge rate). Mortality on V-V ECMO support was 27.8% (95% confidence interval (CI) 22.5%-33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%-16.6%, defining the V-V ECMO gap). 72.2% of patients (95% CI 66.8%-77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%-63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V-V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V-V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V-V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.
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http://dx.doi.org/10.1111/aor.14058DOI Listing
September 2021

Major Trauma in Elderly Patients: Worse Mortality and Outcomes in an Italian Trauma Center.

J Emerg Trauma Shock 2021 Apr-Jun;14(2):98-103. Epub 2021 Jun 25.

Emergency Department, IRCCS Policlinico San Matteo, Pavia, Italy.

Introduction: Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes.

Methods: We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018-January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75).

Results: We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients ( = 0.01).

Conclusions: The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.
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http://dx.doi.org/10.4103/JETS.JETS_55_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312913PMC
June 2021

Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death.

Artif Organs 2021 Oct 6;45(10):1155-1167. Epub 2021 Jul 6.

Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.

Timing and causes of hospital mortality in adult patients undergoing veno-arterial extracorporeal membrane oxygenation (V-A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V-A ECMO and subsequently define the "V-A ECMO gap," which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V-A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%-41.9%) during V-A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%-19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8-52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one-third of V-A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the "V-A ECMO gap." Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V-A ECMO patients to better understand the effectiveness and complications of this support.
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http://dx.doi.org/10.1111/aor.14006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8518076PMC
October 2021

Is it time for a paradigm shift: Should double-lung transplant be considered the treatment of choice for idiopathic pulmonary arterial hypertension and giant pulmonary aneurysm?

J Card Surg 2021 Aug 16;36(8):2996-2999. Epub 2021 May 16.

Division of Cardiac Surgery, IRCCS Fondazione Policlinico "San Matteo", Pavia, Italy.

Idiopathic pulmonary arterial hypertension is a rare condition, frequently complicated by pulmonary arteries' aneurysm. Aggressive medical therapy is often unsatisfactory and lung transplantation remains the only option. We report a unique case of severe idiopathic pulmonary arterial hypertension complicated by a giant pulmonary aneurism, massive pulmonary valve regurgitation, and right ventricle dysfunction. The patient was, as our first choice, listed for heart-lung transplantation and remained in emergency list for more than 7 months. Unfortunately, due to further clinical deterioration and the unavailability of a heart-lung bloc, plan B was mandatory. The patient underwent a combined procedure including: double lung transplant, pulmonary artery plasty, and sutureless pulmonary valve prosthesis with open deployment (first-in-man use in such scenario). Postoperative outcome was uneventful. Our thought is that double lung transplantation and conventional combined pulmonary artery/valve surgery should be considered as the first option avoiding excessive waiting times and potential further clinical deterioration.
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http://dx.doi.org/10.1111/jocs.15655DOI Listing
August 2021

Early caloric deficit is associated with a higher risk of death in invasive ventilated COVID-19 patients.

Clin Nutr 2021 Mar 2. Epub 2021 Mar 2.

Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. Electronic address:

Background & Aims: The aim of this study was to evaluate the nutritional support management in mechanically ventilated coronavirus disease 2019 (COVID-19) patients and explore the association between early caloric deficit and mortality, taking possible confounders (i.e. obesity) into consideration.

Methods: This was a prospective study carried out during the first pandemic wave in the intensive care units (ICUs) of two referral University Hospitals in Lombardy, Italy. Two hundred twenty-two consecutive mechanically ventilated COVID-19 patients were evaluated during the ICU stay. In addition to major demographic and clinical data, we recorded information on the route and amount of nutritional support provided on a daily basis.

Results: Among patients still in the ICUs and alive on day 4 (N = 198), 129 (65.2%) and 72 (36.4%) reached a satisfactory caloric and protein intake, respectively, mainly by enteral route. In multivariable analysis, a satisfactory caloric intake on day 4 was associated with lower mortality (HR = 0.46 [95%CI, 0.42-0.50], P < 0.001). Mild obesity (body mass index [BMI] ≥30 and < 35 kg/m) was associated with higher mortality (HR = 1.99 [95%CI, 1.07-3.68], P = 0.029), while patients with moderate-severe obesity (BMI≥35 kg/m) were less likely to be weaned from invasive mechanical ventilation (HR = 0.71 [95%CI, 0.62-0.82], P < 0.001).

Conclusions: This study confirmed the negative prognostic and clinical role of obesity in mechanically ventilated COVID-19 patients and suggested that early caloric deficit may independently contribute to worsen survival in this patients' population. Therefore, any effort should be made to implement an adequate timely nutritional support in all COVID-19 patients during the ICU stay.
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http://dx.doi.org/10.1016/j.clnu.2021.02.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921717PMC
March 2021

Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database.

Crit Care 2021 03 17;25(1):107. Epub 2021 Mar 17.

Departments of Surgery, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA.

Background: Single- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications.

Methods: A retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas.

Results: From a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91-1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI - 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups.

Conclusions: In this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO.
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http://dx.doi.org/10.1186/s13054-021-03533-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968168PMC
March 2021

Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience.

Membranes (Basel) 2021 Jan 22;11(2). Epub 2021 Jan 22.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, B-1070 Brussels, Belgium.

Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting.

Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation.

Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31-59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1-5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO and SaO significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3-7.1) to 2.8 (1.4-4.4) mmol/L ( = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8-5.0) to 4.9 (4.3-5.9) L/min; < 0.01) was observed, with 3.0 (2.5-3.2) L/min for the arterial and 2.8 (2.1-3.6) L/min for the venous return flows.

Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.
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http://dx.doi.org/10.3390/membranes11020081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912524PMC
January 2021

Validation of Prognostic Scores in Extracorporeal Life Support: A Multi-Centric Retrospective Study.

Membranes (Basel) 2021 Jan 24;11(2). Epub 2021 Jan 24.

Department of Internal Medicine II, University Hospital Regensburg, 93053 Regensburg, Germany.

Multiple prognostic scores have been developed for both veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO), mostly in single-center cohorts. The aim of this study was to compare and validate different prediction scores in a large multicenter ECMO-population.

Methods: Data from five ECMO centers included 300 patients on VA and 329 on VV ECMO support (March 2008 to November 2016). Different prognostic scores were compared between survivors and non-survivors: APACHE II, SOFA, SAPS II in all patients; SAVE, modified SAVE and MELD-XI in VA ECMO; RESP, PRESET, ROCH and PRESERVE in VV ECMO. Model performance was compared using receiver-operating-curve analysis and assessment of model calibration. Survival was assessed at intensive care unit discharge.

Results: The main indication for VA ECMO was cardiogenic shock; overall survival was 51%. ICU survivors had higher Glasgow Coma Scale scores and pH, required cardiopulmonary resuscitation (CPR) less frequently, had lower lactate levels and shorter ventilation time pre-ECMO at baseline. The best discrimination between survivors and non-survivors was observed with the SAPS II score (area under the curve [AUC] of 0.73 (95% CI 0.67-0.78)). The main indication for VV ECMO was pneumonia; overall survival was 60%. Lower PaCO, higher pH, lower lactate and lesser need for CPR were observed among survivors. The best discrimination between survivors and non-survivors was observed with the PRESET score (AUC 0.66 (95% CI 0.60-0.72)).

Conclusion: The prognostic performance of most scores was moderate in ECMO patients. The use of such scores to decide about ECMO implementation in potential candidates should be discouraged.
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http://dx.doi.org/10.3390/membranes11020084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912316PMC
January 2021

Anxiety among front-line health-care workers supporting patients with COVID-19: A global survey.

Gen Hosp Psychiatry 2021 Jan-Feb;68:90-96. Epub 2020 Dec 20.

Department of Anaesthesia Critical Care Emergency and Pain Medicine, University Hospital of Nimes, Montpellier University, Nimes, France; Clinical Research and Epidemiology in Pneumonia and Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.

Objective: We aimed to explore anxiety status across a broad range of HCWs supporting patients with COVID-19 in different global regions.

Method: This was an international online survey in which participation was on voluntary basis and data were submitted via Google Drive, across a two-week period starting from March 18, 2020. The Beck Anxiety Inventory was used to quantify the level of anxiety.

Results: 1416 HCWs (70.8% medical doctors, 26.2% nurses) responded to the survey from 75 countries. The distribution of anxiety levels was: normal/minimal (n = 503, 35.5%), low (n = 390, 27.5%); moderate (n = 287, 20.3%), and severe (n = 236, 16.7%). According to multiple generalized linear model, female gender (p = 0.001), occupation (ie, being a nurse dealing directly with patients with COVID-19 [p = 0.017]), being younger (p = 0.001), reporting inadequate knowledge on COVID-19 (p = 0.005), having insufficient personal protective equipment (p = 0.001) and poor access to hand sanitizers or liquid soaps (p = 0.008), coexisting chronic disorders (p = 0.001) and existing mental health problems (p = 0.001), and higher income of countries where HCWs lived (p = 0.048) were significantly associated with increased anxiety.

Conclusions: Front-line HCWs, regardless of the levels of COVID-19 transmission in their country, are anxious when they do not feel protected. Our findings suggest that anxiety could be mitigated ensuring sufficient levels of protective personal equipment alongside greater education and information.
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http://dx.doi.org/10.1016/j.genhosppsych.2020.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749993PMC
February 2021

Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study.

Membranes (Basel) 2021 Jan 2;11(1). Epub 2021 Jan 2.

Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands.

Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, < 0.001), plateau pressure (27 vs. 21 cmHO, = 0.012), driving pressure (11 vs. 8 cmHO, = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, < 0.001), and tidal volume adjusted to patient ideal body weight (V/IBW, 5.5 vs. 4.0 mL/kg, = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmHO, = 0.048) and V/IBW (3.0 vs. 4.0 mL/kg, = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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http://dx.doi.org/10.3390/membranes11010030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824596PMC
January 2021

Evaluation of a New Extracorporeal CO Removal Device in an Experimental Setting.

Membranes (Basel) 2020 Dec 23;11(1). Epub 2020 Dec 23.

Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium.

Background: Ultra-protective lung ventilation in acute respiratory distress syndrome or early weaning and/or avoidance of mechanical ventilation in decompensated chronic obstructive pulmonary disease may be facilitated by the use of extracorporeal CO removal (ECCOR). We tested the CO removal performance of a new ECCOR (CORESET) device in an experimental animal model.

Methods: Three healthy pigs were mechanically ventilated and connected to the CORESET device (surface area = 1.8 m, EUROSETS S.r.l., Medolla, Italy). Respiratory settings were adjusted to induce respiratory acidosis with the adjunct of an external source of pure CO (target pre membrane lung venous PCO (PCO): 80-120 mmHg). The amount of CO removed (VCO, mL/min) by the membrane lung was assessed directly by the ECCOR device.

Results: Before the initiation of ECCOR, the median PCO was 102.50 (95.30-118.20) mmHg. Using fixed incremental steps of the sweep gas flow and maintaining a fixed blood flow of 600 mL/min, VCO progressively increased from 0 mL/min (gas flow of 0 mL/min) to 170.00 (160.00-200.00) mL/min at a gas flow of 10 L/min. In particular, a high increase of VCO was observed increasing the gas flow from 0 to 2 L/min, then, VCO tended to progressively achieve a steady-state for higher gas flows. No animal or pump complications were observed.

Conclusions: Medium-flow ECCOR devices with a blood flow of 600 mL/min and a high surface membrane lung (1.8 m) provided a high VCO using moderate sweep gas flows (i.e., >2 L/min) in an experimental swine models with healthy lungs.
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http://dx.doi.org/10.3390/membranes11010008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7823796PMC
December 2020

Mortality reduction in 46 severe Covid-19 patients treated with hyperimmune plasma. A proof of concept single arm multicenter trial.

Haematologica 2020 12 1;105(12):2834-2840. Epub 2020 Dec 1.

Carlo Poma Hospital, ASST Mantova.

Hyperimmune plasma from Covid-19 convalescent is a potential treatment for severe Covid-19. We conducted a multicenter one arm proof of concept interventional study. Patients with Covid-19 disease with moderate-to-severe Acute Respiratory Distress Syndrome, elevated C-reactive Protein and need for mechanical ventilation and/or CPAP were enrolled. One to three 250-300 ml unit of hyperimmune plasma (neutralizing antibodies titer ≥1:160) were administered. Primary outcome was 7-days hospital mortality. Secondary outcomes were PaO2/FiO2, laboratory and radiologic changes, as well as weaning from mechanical ventilation and safety. The study observed 46 patients from March, 25 to April, 21 2020. Patients were aged 63, 61% male, of them, 30 were on CPAP and 7 intubated. PaO2/FiO2 was 128 (SD 47). Bilateral infiltrates on chest X-ray was present in 36 patients (84%). Symptoms and ARDS duration were 14 (SD 7) and 6 days (SD 3). Three patients (6.5%) died within 7 days as compared to an expected 15% from the National Statistics and 30% from a small concurrent cohort of 23 patients. The upper one-sided 90%CI was 13.9%, allowing to reject the null hypothesis of a 15% mortality. PaO2/FiO2 increased by 112 units (95%CI 82 to142) in survivors, the chest radiogram severity decreased in 23% (95%CI 5% to 42%); CRP, Ferritin and LDH decreased by 60, 36 and 20% respectively. Weaning from CPAP was obtained in 26/30 patients and 3/7 were extubated. Five serious adverse events occurred in 4 patients (2 likely, 2 possible treatment related). In conclusion, Hyperimmune plasma in Covid-19 shows promising benefits, to be confirmed in a randomized controlled trial. This proof of concept study could open to future developments including hyperimmune plasma banking, development of standardized pharmaceutical products and monoclonal antibodies.
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http://dx.doi.org/10.3324/haematol.2020.261784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716363PMC
December 2020

Hemoperfusion with CytoSorb as Adjuvant Therapy in Critically Ill Patients with SARS-CoV2 Pneumonia.

Blood Purif 2021;50(4-5):566-571. Epub 2020 Nov 12.

Department of Anaesthesia and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.

We report a preliminary experience of adjuvant therapy with Hemoperfusion (HP) in patients with Severe Acute Respiratory Syndrome-CoronaVirus 2 (SARS-CoV2) pneumonia. Currently, there are no approved treatments for CoronaVirus Disease 19 (COVID-19); however, therapeutic strategies based on the preclinical evidence include supportive measures, such as oxygen supplementation, antiviral, and anticoagulant agents. Despite these treatments, 10% of patients worsen and develop severe acute respiratory distress syndrome (ARDS). Since the pathogenic mechanism of ARDS is an uncontrolled inflammatory state, we speculate that removing inflammation effectors from blood may contrast tissue injury and improve clinical outcome. In a scenario of dramatic medical emergency, we conducted an observational study on 9 consecutive patients hospitalized in COVID Intensive Care Unit, where 5 of 9 consecutive patients were treated with HP, due to the emergency overload made it impossible to deliver blood purification in the other 4 patients. COVID-19 was diagnosed through the identification of virus sequences by reverse transcription-PCR on respiratory specimens. All patients had severe pneumonia requiring continuous positive airway pressure. HP was started in all patients 6-7 days after hospital admission. The treated patients (T) received 2 consecutive sessions of HP using CytoSorb cartridge. Our results show a better clinical course of T compared to control patients (C), in fact all T except 1 survived, and only 2 of them were intubated, while all C required intubation and died. Lymphocytopenia worsened in C but not in T. C-reactive protein decreased in both patients, but to a greater extent in T. IL-6, IL-8, and TNF-α decreased after HP, IL-10 did not change. Respiratory function remained stable and did not worsen in T compared to C. The limited sample size and observational study design preclude a sound statement about the potential effectiveness of HP in COVID-19 patients, but our experience suggests a potential therapeutic role of adjuvant CytoSorb HP in the early course of CO-VID-19 pneumonia. A randomized clinical trial is ongoing.
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http://dx.doi.org/10.1159/000511725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705939PMC
July 2021

Update in COVID-19 in the intensive care unit from the 2020 HELLENIC Athens International symposium.

Anaesth Crit Care Pain Med 2020 Dec 22;39(6):723-730. Epub 2020 Oct 22.

Department of Critical Care Medicine, National and Kapodistrian University of Athens, Medical School, Greece.

The 2020 International Web Scientific Event in COVID-19 pandemic in critically ill patients aimed at updating the information and knowledge on the COVID-19 pandemic in the intensive care unit. Experts reviewed the latest literature relating to the COVID-19 pandemic in critically ill patients, such as epidemiology, pathophysiology, phenotypes of infection, COVID-19 as a systematic infection, molecular diagnosis, mechanical ventilation, thromboprophylaxis, COVID-19 associated co-infections, immunotherapy, plasma treatment, catheter-related bloodstream infections, artificial intelligence for COVID-19, and vaccination. Antiviral therapy and co-infections are out of the scope of this review. In this review, each of these issues is discussed with key messages regarding management and further research being presented after a brief review of available evidence.
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http://dx.doi.org/10.1016/j.accpm.2020.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580531PMC
December 2020

Carbon Dioxide Elimination During Veno-Venous Extracorporeal Membrane Oxygenation Weaning: A Pilot Study.

ASAIO J 2021 06;67(6):700-708

Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands.

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.
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http://dx.doi.org/10.1097/MAT.0000000000001282DOI Listing
June 2021

Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020).

Eur Respir Rev 2020 Sep 5;29(157). Epub 2020 Oct 5.

Dept of Medicine, Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven CT, USA.

Background: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research.

Methods: An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion.

Results: The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder.

Conclusions: The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.
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http://dx.doi.org/10.1183/16000617.0287-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537943PMC
September 2020

Prone Positioning during Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Multicenter Cohort Study and Propensity-matched Analysis.

Ann Am Thorac Soc 2021 03;18(3):495-501

Dipartimento di Anestesia, Terapia Intensive, e Emergenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.

Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS). To date, no evidence supports the use of prone positioning (PP) during venovenous extracorporeal oxygenation (ECMO). The aim of the study was to assess the feasibility, safety, and effect on oxygenation and lung mechanics of PP during ECMO. As a secondary exploratory aim, we assessed the association between PP and hospital mortality. We performed a multicenter retrospective cohort study in six Italian ECMO centers, including patients managed with PP during ECMO support (prone group; four centers) and patients managed in the supine position (control group; two centers). Physiological variables were analyzed at four time points (supine before PP, start of PP, end of PP, and supine after PP). The association between PP and hospital mortality was assessed by multivariate analysis and propensity score-matching. A total of 240 patients were included, with 107 in the prone group and 133 in the supine group. The median duration of the 326 pronation cycles was 15 (12-18) hours. Minor reversible complications were reported in 6% of PP maneuvers. PP improved oxygenation and reduced intrapulmonary shunt. Unadjusted hospital mortality was lower in the prone group (34 vs. 50%;  = 0.017). After adjusting for covariates, PP remained significantly associated with a reduction of hospital mortality (odds ratio, 0.50; 95% confidence interval, 0.29-0.87). Sixty-six propensity score-matched patients were identified in each group. In this matched sample, patients who underwent pronation had higher ECMO duration (16 vs. 10 d;  = 0.0344) but lower hospital mortality (30% vs. 53%;  = 0.0241). PP during ECMO improved oxygenation and was associated with a reduction of hospital mortality.
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http://dx.doi.org/10.1513/AnnalsATS.202006-625OCDOI Listing
March 2021

Antibiotic use in patients with COVID-19: a 'snapshot' Infectious Diseases International Research Initiative (ID-IRI) survey.

J Antimicrob Chemother 2020 Nov;75(11):3386-3390

ID-IRI, Ankara, Turkey.

Background: Antibiotics may be indicated in patients with COVID-19 due to suspected or confirmed bacterial superinfection.

Objectives: To investigate antibiotic prescribing practices in patients with COVID-19.

Methods: We performed an international web-based survey and investigated the pattern of antibiotic use as reported by physicians involved in treatment of COVID-19. SPSS Statistics version 25 was used for data analysis.

Results: The survey was completed by 166 participants from 23 countries and 82 different hospitals. Local guidelines for antibiotic use in COVID-19 patients were reported by 61.8% (n = 102) of participants and for 82.9% (n = 136) they did not differ from local community-acquired pneumonia guidelines. Clinical presentation was recognized as the most important reason for the start of antibiotics (mean score = 4.07 and SD = 1.095 on grading scale from 1 to 5). When antibiotics were started, most respondents rated as the highest the need for coverage of atypical pathogens (mean score = 2.8 and SD = 0.99), followed by Staphylococcus aureus (mean score = 2.67 and SD = 1.05 on bi-modal scale, with values 1 and 2 for disagreement and values 3 and 4 for agreement). In the patients on the ward, 29.1% of respondents chose not to prescribe any antibiotic. Combination of β-lactams and macrolides or fluoroquinolones was reported by 52.4% (n = 87) of respondents. In patients in the ICU, piperacillin/tazobactam was the most commonly prescribed antibiotic. The mean reported duration of antibiotic treatment was 7.12 (SD = 2.44) days.

Conclusions: The study revealed widespread broad-spectrum antibiotic use in patients with COVID-19. Implementation of antimicrobial stewardship principles is warranted to mitigate the negative consequences of antibiotic therapy.
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http://dx.doi.org/10.1093/jac/dkaa326DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454563PMC
November 2020

Coronavirus disease 2019 in critically ill patients: can we re-program the immune system? A primer for Intensivists.

Minerva Anestesiol 2020 11 4;86(11):1214-1233. Epub 2020 Aug 4.

Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.

In December 2019, Coronavirus disease 2019 (COVID-19) emerged in Wuhan and rapidly spread around the word. The immune response is essential to control and eliminate CoV infections, however, multiorgan damage might be due to direct SARS-CoV2 action against the infected organ cells, as well as an imbalanced host immune response. In effect, a "cytokines storm" and an impaired innate immunity were found in the COVID-19 critically ill patients. In this review, we summarized the virus immune response steps, underlying the relevance of introducing the measurement of plasma cytokine levels and of circulating lymphocyte subsets in clinical practice for the follow-up of critically ill COVID-19 patients and support new therapy.
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http://dx.doi.org/10.23736/S0375-9393.20.14663-7DOI Listing
November 2020

Mild head trauma in elderly patients: experience of an emergency department.

Heliyon 2020 Jul 7;6(7):e04226. Epub 2020 Jul 7.

Emergency Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Introduction: We evaluated the risk profile of elderly patients who came to the emergency department for mild head trauma. The primary goal was to determine the difference in the incidence of posttraumatic intracranial hemorrhage (ICH) after minor head injury (MHI). The secondary objective was to assess worse outcome, such as: hospitalization rate, rate of re-admission, need of neurosurgery. We also assess the admission process times and length of hospital stay. The ultimate goal was to optimize the diagnostic-observational management of minor head trauma in elderly patients.

Material And Methods: We evaluated all patients with MHI who came to our emergency department during 2017 and 2018. All patients underwent computed tomography.

Results: We enrolled 2325 patients, of whom 1094 were 75 years of age or older. The population was divided into two categories according to age: The "elderly population" was 75 or older, and the younger patients were younger than 75. The elderly population, in comparison with the younger patients, had a higher rate of ICH (12.1% versus 5.1%), a higher hospitalization rate (11.7% versus 5.5%), and a higher rate of readmission within 30 days (6.8% versus 3.2%). The elderly population also had longer admission process times (8 h, 25 min, versus 4 h, 09 min) and longer lengths of hospital stay (9 h, 41 min, versus 5 h, 29 min). Of the younger patients, 92% (versus 41% of the elderly population) did not take any drugs, 6% (versus 39%) were receiving antiplatelet therapy, 1% (versus 13%) took vitamin K antagonists, and 1% (versus 7%) took oral direct-acting anticoagulants. Logistic regression models revealed that a 1-year increase in age raised the risk of bleeding by 2% on average; this finding was statistically significant (odds ratio [OR], 1023/year, < 0.001). The rate of ICH increased significantly after the age of 75, by 180% (OR, 2.82; < 0.001).

Conclusions: These data suggest that age is an independent risk factor for ICH, whereby the age of 75 entails a 180% increase in the risk of bleeding.
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http://dx.doi.org/10.1016/j.heliyon.2020.e04226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347629PMC
July 2020

Has Venoarterial ECMO Been Underutilized in COVID-19 Patients?

Innovations (Phila) 2020 Jul/Aug;15(4):317-321. Epub 2020 Jul 7.

199236 Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital, The Netherlands.

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http://dx.doi.org/10.1177/1556984520939076DOI Listing
September 2020

Monitoring and Management of Home-Quarantined Patients With COVID-19 Using a WeChat-Based Telemedicine System: Retrospective Cohort Study.

J Med Internet Res 2020 07 2;22(7):e19514. Epub 2020 Jul 2.

Department of Emergency Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

Background: Most patients with coronavirus disease (COVID-19) who show mild symptoms are sent home by physicians to recover. However, the condition of some of these patients becomes severe or critical as the disease progresses.

Objective: The aim of this study was to evaluate a telemedicine model that was developed to address the challenges of treating patients with progressive COVID-19 who are home-quarantined and shortages in the medical workforce.

Methods: A telemedicine system was developed to continuously monitor the progression of home-quarantined patients with COVID-19. The system was built based on a popular social media smartphone app called WeChat; the app was used to establish two-way communication between a multidisciplinary team consisting of 7 medical workers and 188 home-quarantined individuals (including 74 confirmed patients with COVID-19). The system helped patients self-assess their conditions and update the multidisciplinary team through a telemedicine form stored on a cloud service, based on which the multidisciplinary team made treatment decisions. We evaluated this telemedicine system via a single-center retrospective study conducted at Tongji Hospital in Wuhan, China, in January 2020.

Results: Among 188 individuals using the telemedicine system, 114 (60.6%) were not infected with COVID-19 and were dismissed. Of the 74 confirmed patients with COVID-19, 26 (35%) recovered during the study period and voluntarily stopped using the system. The remaining 48/76 confirmed patients with COVID-19 (63%) used the system until the end of the study, including 6 patients whose conditions progressed to severe or critical. These 6 patients were admitted to hospital and were stabilized (one received extracorporeal membrane oxygenation support for 17 days). All 74 patients with COVID-19 eventually recovered. Through a comparison of the monitored symptoms between hospitalized and nonhospitalized patients, we found prolonged persistence and deterioration of fever, dyspnea, lack of strength, and muscle soreness to be diagnostic of need for hospitalization.

Conclusions: By continuously monitoring the changes in several key symptoms, the telemedicine system reduces the risks of delayed hospitalization due to disease progression for patients with COVID-19 quarantined at home. The system uses a set of scales for quarantine management assessment that enables patients to self-assess their conditions. The results are useful for medical staff to identify disease progression and, hence, make appropriate and timely treatment decisions. The system requires few staff to manage a large cohort of patients. In addition, the system can solicit help from recovered but self-quarantined medical workers to alleviate shortages in the medical workforce and free healthy medical workers to fight COVID-19 on the front line. Thus, it optimizes the usage of local medical resources and prevents cross-infections among medical workers and patients.
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http://dx.doi.org/10.2196/19514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333794PMC
July 2020

Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation.

Perfusion 2020 11 5;35(8):736-744. Epub 2020 Jun 5.

Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK.

Introduction: In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure-flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water.

Methods: We performed a study evaluating pressure-flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer's corresponding curves obtained from the public domain.

Results: The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain same drainage flow (hematocrit of 26%) compared with manufacturer's water charts in 13-31 Fr bi-caval dual-lumen cannulae. The same net difference was found in cavo-atrial cannulae (16-32 Fr), where a lower drainage pressure was required (Hct of 26%) compared with the manufacturer's test using blood with an Hct of 33%. Return pressure-flow data were similar, independent whether pumping blood or water, to the data reported by manufacturers.

Conclusion: Non-standardized testing of pressure-flow properties of extracorporeal membrane oxygenation dual-lumen cannulae prevents an adequate prediction of pressure-flow results when these cannulae are used in patients. Properties of dual-lumen cannulae may vary between sizes within same cannula family, in particular concerning the drainage flow.
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http://dx.doi.org/10.1177/0267659120926009DOI Listing
November 2020

Perception of prolonged extracorporeal membrane oxygenation in Europe: an EuroELSO survey.

Perfusion 2020 05;35(1_suppl):81-85

ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.

The substantial increase in the number of patients receiving extracorporeal membrane oxygenation over the last decade has led to an evolution of indications and an expansion into wider patient groups. One of the unanticipated benefits of the increase in extracorporeal membrane oxygenation has been a change in the understanding of the natural history of many respiratory diseases. Development in technology and materials, reduced extracorporeal membrane oxygenation-specific complications, and improvement of critical care, in general, have facilitated longer extracorporeal membrane oxygenation runs, and the definition of prolonged extracorporeal membrane oxygenation was recently expanded to continuous support for more than 28 days. This survey aimed to describe European ECMO centers' perception and arbitrary definition of prolonged extracorporeal membrane oxygenation, patient management, and futility. Of 94 center responses, 37% regarded 14-21 days, 30% 21-28 days, and 28% >28 days as prolonged treatment. Bridge to recovery (64%) or to transplantation (20%) was the most common causes. Awake, and ambulation while on extracorporeal membrane oxygenation was reported from 34% of the centers. In case of perceived futility, decision to withdraw was taken in 65% of the centers in agreement between profession and family and in 30% by profession only. One-fourth of the centers did not discontinue support. Large differences prevail among European ECMO centers concerning local perception and patient management in prolonged extracorporeal membrane oxygenation.
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http://dx.doi.org/10.1177/0267659120909740DOI Listing
May 2020
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