Refractory Vasodilatory Shock Secondary to Metformin Overdose Supported with VA ECMO

Abstract:: Despite the technological improvements of the last 40 years conditions such as refractory cardiogenic shock and cardiac arrest still present a very high mortality rate in the real-world clinical practice. In this light we have performed a review of the techniques, indications, contraindications and results of the so-called Veno-Arterial Extracorporeal Circulatory Membrane Oxygenation (VA-ECMO) in the adult population to evaluate the current results of this temporary cardio-pulmonary support as salvage and/or bridge therapy in patient suffering from refractory cardiogenic shock or cardio-circulatory arrest. The results are encouraging, especially in the setting of refractory cardiogenic shock and in-hospital cardiac arrest. Among a selected population the prompt institution of a VA-ECMO may radically change the prognosis by sustaining vital functions while looking for the leading cause or waiting for the reversal of the temporary cardio-respiratory negative condition. The future directions aim to standardized and shared protocols, miniaturization of the machines and possibly the institution of specialized “ECMO teams” for in and out-of-hospital institution of the tool.

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Update – Intoxikationen in der Intensivmedizin

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/a-0965-3203 ◽

2020 ◽

Vol 145 (03) ◽

pp. 161-165

Author(s):

Christoph Hüser ◽

Gerald Hackl ◽

Matthias Baumgärtel

Keyword(s):

Va Ecmo

Was ist neu? Intoxikationen mit Betablockern und Kalziumantagonisten Es gibt eine Experten-Konsensus-Empfehlung für die Intoxikation mit Kalziumantagonisten. Diese kann zum Teil auch auf Betablocker-Intoxikationen übertragen werden. Die Verwendung von hochdosiertem Insulin sowie von Lipidemulsionen wird empfohlen. Des Weiteren soll der Einsatz einer VA-ECMO bei diesen Intoxikationen erwogen werden. Paracetamol-Intoxikationen Bei Einnahme einer größeren Menge Paracetamol sollte die Gabe einer höheren Acetylcystein-Dosis als im ursprünglichen von Prescott vorgeschlagenen Schema überlegt werden. Ab einer Einnahme von etwa 30–40 g ist die Aktivkohlegabe bis 4 Stunden nach der Einnahme sinnvoll. Physostigmin Wird Physostigmin als Antidot bei Patienten mit anticholinergem Syndrom verabreicht, ist die Rate an unerwünschten Ereignissen gering. Betablocker bei Kokainintoxikation Entgegen der jahrelangen Meinung, dass Betablocker bei Kokain-assoziiertem ACS kontraindiziert sind, konnte inzwischen durch mehrere Studien ein sicherer und sinnvoller Einsatz von Betablockern in dieser Indikation gezeigt werden. Reanimation Intoxikierter Die Intoxikation ist eine reversible Ursache eines kardiopulmonalen Arrests. Daher ist in vielen Fällen die prolongierte Reanimation bis zum Abklingen der Giftwirkung sinnvoll. Der Einsatz von ECLS-Verfahren wird zunehmend in der Literatur mit gutem Outcome beschrieben.

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Anticoagulation after VA-ECMO decannulation, providing new insights

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.168 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

A Maestro-Benedicto ◽

A Duran-Cambra ◽

M Vila-Perales ◽

J Sans-Rosello ◽

J Carreras-Mora ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Anticoagulation Therapy ◽

Thromboembolic Events ◽

Bleeding Events ◽

Membrane Oxygenation ◽

Funding Sources ◽

Va Ecmo ◽

A Prospective Study

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential tool for the management of refractory cardiogenic shock. Little is known about the incidence of thromboembolic events after V-A ECMO decannulation, although some studies report a high incidence of cannula-related venous thrombosis after venovenous extracorporeal membrane oxygenation (VV-ECMO). Due to this fact, in our institution anticoagulation therapy is systematically prescribed for at least 3 months after VA-ECMO per protocol. AIM The main objective of this study was to explore the feasibility of 3-month anticoagulation therapy after VA-ECMO decannulation. METHODS We performed a prospective study that included 27 consecutive patients who were successfully treated with VA-ECMO in a medical ICU between 2016 and 2019 and were prescribed 3-month anticoagulation therapy per protocol after decannulation. Exclusion criteria was dying on ECMO or while on the ICU. Data analysis included demographics, mean days on ECMO, 3-month survival, and thromboembolic and bleeding events (excluding immediate post-decannulation bleeding, since anticoagulation was prescribed 24h after). RESULTS Our cohort consisted mainly of men (N = 21, 78%), with a mean age of 60 ± 11 years and a mean time on VA-ECMO of 8 ± 3 days, who primarily suffered from post-cardiotomy cardiogenic shock (N = 9, 34%) or acute myocardial infarction (N = 6, 23%). 5 patients (18%) received a heart transplant. Regarding anticoagulation, 15 patients (60%) had other indications apart from the protocol, like incidental thrombus diagnosis (N = 7, 26%) or valve surgery (N = 5, 18%). Anticoagulation therapy was not feasible in 1 patient (4%) with severe thrombopenia. No patients had severe or life-threatening bleeding events in the follow-up, although 8 patients (30%) had bleeding events, mainly gastrointestinal bleeding (N = 4, 15%), requiring withdrawal of anticoagulation in 1 patient. The incidence of thromboembolic events was 7%; two patients with low-risk pulmonary embolisms. During the 3-month follow-up survival rate was 95%. CONCLUSIONS This is the only study to date addressing the strategy of 3-month anticoagulation therapy after VAECMO, showing it is feasible and safe and may be helpful in reducing or ameliorate thromboembolic complications in the follow-up, although it is not exempt of complications. Abstract Figure. Kaplan-Meier survival analysis

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Interventional and Surgical Treatments for Pulmonary Arterial Hypertension

Journal of Clinical Medicine ◽

10.3390/jcm10153326 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3326

Author(s):

Tomasz Stącel ◽

Magdalena Latos ◽

Maciej Urlik ◽

Mirosław Nęcki ◽

Remigiusz Antończyk ◽

...

Keyword(s):

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Interdisciplinary Approach ◽

Left Ventricular ◽

Free Survival ◽

Atrial Septostomy ◽

Surgical Options ◽

Pulmonary Arterial ◽

Va Ecmo ◽

Surgical Treatments

Despite significant advancements in pharmacological treatment, interventional and surgical options are still viable treatments for patients with pulmonary arterial hypertension (PAH), particularly idiopathic PAH. Herein, we review the interventional and surgical treatments for PAH. Atrial septostomy and the Potts shunt can be useful bridging tools for lung transplantation (Ltx), which remains the final surgical treatment among patients who are refractory to any other kind of therapy. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) remains the ultimate bridging therapy for patients with severe PAH. More importantly, VA-ECMO plays a crucial role during Ltx and provides necessary left ventricular conditioning during the initial postoperative period. Pulmonary denervation may potentially be a new way to ensure better transplant-free survival among patients with the aforementioned disease. However, high-quality randomized controlled trials are needed. As established, obtaining the Eisenmenger physiology among patients with severe pulmonary hypertension by creating artificial defects is associated with improved survival. However, right-to-left shunting may be harmful after Ltx. Closure of the artificially created defects may carry some risk associated with cardiac surgery, especially among patients with Potts shunts. In conclusion, PAH requires an interdisciplinary approach using pharmacological, interventional, and surgical modalities.

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Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽

10.1177/02676591211033947 ◽

2021 ◽

pp. 026765912110339

Author(s):

Shek-yin Au ◽

Ka-man Fong ◽

Chun-Fung Sunny Tsang ◽

Ka-Chun Alan Chan ◽

Chi Yuen Wong ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Primary Outcome ◽

Left Ventricular ◽

Circulatory Support ◽

Queen Elizabeth Hospital ◽

Intra Aortic Balloon Pump ◽

Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

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Urgent coronary artery bypass graft surgery supported by veno-arterial extracorporeal membrane oxygenation: a report of two cases

Perfusion ◽

10.1177/02676591211008139 ◽

2021 ◽

pp. 026765912110081

Author(s):

Tamer Abdalghafoor ◽

Bassam Shoman ◽

Amr Salah Omar ◽

Yasser Shouman ◽

Abdulwahid Almulla

Keyword(s):

Coronary Artery ◽

Extracorporeal Membrane Oxygenation ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Bypass Graft ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Cardiac Procedures ◽

Risk Patients ◽

Va Ecmo

Mechanical circulatory support (MCS) devices, especially veno-arterial extracorporeal membrane oxygenation (VA-ECMO) devices, are increasingly used to shore complex cardiac procedures in high-risk patients. We are reporting two cases where patients underwent coronary artery bypass grafting (CABG) under support of VA-ECMO in the setting of cardiogenic shock complicating acute myocardial infarction. The patients had different courses, but both survived the initial insult and were weaned successively from VA-ECMO. Our report indicates that VA-ECMO can be used instead of the cardiopulmonary bypass machine (CPB) to support the circulation during CABG surgery in patients with complex coronary anatomy and unstable haemodynamics. Future studies focusing on the long-term outcomes of such patients will probably help to establish the optimal management of this type of patients.

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