Dissertations / Theses on the topic 'Extracorporeal Membrane Oxygenation (ECMO)'

Intensive care unit (ICU) staff are exposed to a broad range of professional, ethical and clinical practice issues such as when to offer and withdraw potentially life-saving care, which are most apparent when working with hyper-advanced technologies such as extracorporeal membrane oxygenation (ECMO). Despite the rapid increase in use of ECMO to support adults with critical heart and lung conditions, few studies have documented staff experiences of working with this technology. This study aimed to explore ICU doctors and nurses conceptualisations of key professional, ethical and clinical practice issues relating to ECMO, and the psychological impact of managing them. A qualitative design was utilised, in which semi-structured interviews were conducted with 10 ICU staff (five doctors and five nurses), working in a specialist ECMO centre in the United Kingdom (UK). Data were analysed using thematic analysis, underpinned by a critical realist epistemological stance. Three key themes were identified. 1) Embodying the ECMO Specialist: Staff experienced a sense of mastery when managing technical aspects of the work, but felt inept when dealing with abstract ethical issues. Specialists sought to drive forward clinical practice, and learning was considered important for developing clinical abilities. 2) Team dynamics: Staff came together as a team to address the technical, professional and ethical challenges associated with their work with ECMO, however ECMO was also described as a divisive force in the ICU. 3) Riding the Emotional Rollercoaster: Life or death outcomes were associated with intense emotions and staff reported various ways of managing them. These findings add a new dimension to the professional and ethical discussions in the academic literature and have several implications for clinical practice, which are discussed. Further research may wish to focus on more specific aspects of ECMO care, such as the processes involved in decision-making.

Objective: To investigate the feasibility of applying mild hypothermia in neonates receiving extracorporeal membrane oxygenation (ECMO).;Design: A prospective, non-randomised pilot study of twenty five neonates referred for ECMO. Whole body cooling was achieved by adjustment of the extracorporeal circuit water bath temperature. Five groups (N=5 per group) were each studied for the first five days of ECMO. The first group was maintained at 37°C throughout the study period. Subsequent groups were cooled to 36°C, 35°C and finally 34°C respectively for twenty four hours and the final group to 34°C for forty eight hours before being rewarmed to 37°C. Patients were carefully assessed clinically and biologically. In addition to routine laboratory tests, cytokines (IL-6 and IL-8) complement (C3a) and molecular markers of coagulation (thrombin-antithrombin III, antithrombin III and plasmin alpha 2 plasminogen) were measured.;Results: No major clinical or circuit problems were noted during cooling or rewarming. In particular there were no problems of bleeding or cardiac arrhythmias. No systematic difference was found between groups in terms of molecular markers of coagulation complement, cytokines and platelet transfusions. This could however not be tested statistically due to small group sizes.;Conclusions: This pilot study has demonstrated that the use of mild hypothermia in patients receiving ECMO is feasible and in the number of patients studied did not produce adverse effects, as indicated by the measurements undertaken.

Extracorporeal membrane oxygenation is a life support system for infants and children with intractable cardiorespiratory failure. The risk for developing neurological injuries in this group of patients is considerable. The causes are multifactorial and are not yet fully understood. Induction of ECMO involves ligation of the major neck vessels – common carotid artery and internal jugular vein – which may cause lateralised cerebrovascular injury. Physiologic changes such as hypoxia, hypotension and hypercarbia associated with ECMO can disrupt cerebral autoregulation. Near infrared spectroscopy (NIRS) offers the advantage of continuous non invasive means of monitoring cerebral oxygenation at the bedside. To date, NIRS systems used clinically are single or dual channel systems and do not allow evaluation of the status of cerebral circulation in the extended cerebral regions. This work involves the development of a multichannel NIRS system for use in paediatric cardiothoracic intensive care with specific application on patients supported on extracorporeal circulation. A novel flexible neonatal cap was designed and constructed to accommodate an array of sources and detectors that provide measurements of multisite cerebral oxygenation from 12 channels. Multimodal data collection (systemic and ECMO circuit parameters) simultaneous with multichannel NIRS was established to allow monitoring of multisite cerebral oxygenation and haemodynamics. A novel method of analysis, wavelet cross-correlation, was generated to study the concordance between multisite oxyhaemoglobin concentration (HbO2) and mean arterial pressure (MAP) as a means to investigate regional variations in cerebral circulation and assess cerebral autoregualtion. Group data of 6 patients showed statistically significant differences in WCC between right and left hemispheres during sequential changes in ECMO circuit blood flow. WCC between HbO2 and MAP provides a useful method to investigate the dynamics of cerebral autoregulation during ECMO. Modest manipulations of ECMO flows are associated with regional changes in cerebral autoregulation which may potentially have an important bearing on clinical outcome.

Over 26 million Americans suffer from pulmonary disease, resulting in more than 150,000 deaths annually. Lung transplantation remains the only definitive treatment for many patients, but has meager survival rates and only approximately 1,700 of the 2,200 patients added to the lung transplant wait list each year are transplanted. Extracorporeal gas exchangers have been used as an alternative to mechanical ventilation in acute respiratory failure and as a bridge to transplantation in chronic respiratory failure. Current gas exchangers are limited by their high resistance and low biocompatibility that lead to patient complications and device clot formation. Therefore, there exists a dire need for improved devices that can act as destination therapy. To accomplish the goal of destination therapy, this dissertation discusses three studies that were performed to pave the way. First, I examined clot formation and failure patterns of two common clinical devices (Maquet’s CardioHelp (CH) and Quadrox (Qx)) to further our understanding of their limitations with respect to long-term support. Overall, it was demonstrated that the Qx devices fail earlier and more frequently than CH devices and result in a significantly greater reduction in platelet count, and that a four-inlet approach is beneficial. Next, I determined the optimal sweep gas nitric oxide (NO) concentration that minimizes platelet binding and activation while ensuring that blood methemoglobin (metHb) concentrations increase less than 5%. Miniature artificial lungs were attached to rabbits in a pumped veno-venous configuration and run for 4 h with NO added to the sweep gases in concentrations of 0, 100, 250, and 500 ppm (n=8 ea.). 100 ppm significantly reduced the amount of platelet consumption (p < 0.05), reduced platelet activation as measured by soluble p-selectin (p < 0.05), and had negligible increases in metHb and will thus be used in future experiments. Last, I tested the Pulmonary Assist Device (PAD) which was designed for long term use as a bridge to transplantation and destination therapy. Benchtop experiments were performed that confirmed that it meets our design and performance goals. From here, we are equipped to commence with 30-day PAD testing in sheep.

Refractory cardiogenic shock (CS) is a condition that continues to have a very high mortality despite advances in medical therapy. Conventional treatment typically comprises inotrope infusions, vasopressors and intra-aortic-balloon-pump (IABP). When circulatory instability is refractory to these treatments, mechanical circulatory support represents the only hope for survival, as indicated by current guidelines. As most of these patients present with critical circulatory instability requiring urgent or emergent therapy, the chosen mechanical assistance should be rapidly and easily implanted. For this reason ExtraCorporeal Membrane Oxygenation (ECMO) represents the ideal “bridge-to-life” and increasingly it is used to keep the patient alive while the optimal therapeutic management is determined (bridge-to-decision). Management may then follow one of three courses: “bridge-to-recovery”: patient recovery, and weaning from ECMO; “bridge-to-transplant”: direct heart transplantation; “bridge-to-bridge”: placement of ventricular-assist-device or total artificial longer-term support. There have been several large reports on the use of ECMO as a mechanical support in post-cardiotomy patients but relatively few, mostly small case-series focusing on its role in primary acute cardiogenic shock outside of the post-cardiotomy setting. We present the results of our centre’s experience (Padova) in the treatment of primary acute cardiogenic shock with the PLS-Quadrox ECMO system (Maquet) as a bridge to decision. Furthermore, we evaluated the impact of etiology on patient outcomes by comparing acute primary refractory CS secondary to acute myocardial infarction (AMI), myocarditis, pulmonary embolism (PE) and post-partum cardiomyopathy (PPCM) with acute decompensation of a chronic cardiomyopathy, including dilated cardiomyopathy (DCM), ischemic cardiomyopathy (ICM) and grown-up-congenital-heart-diseases (GUCHD). We also analyzed whether duration and magnitude of support may predict weaning and survival. Materials and Methods. Between January 2009 and March 2013, we implanted a total of 249 ECMO; in this study we focused on 64 patients where peripheral ECMO was the treatment for primary cardiogenic shock. Thirty-seven cases (58%) were “acute” (Group A-PCS: mostly acute myocardial infarction, 39%), while twenty-seven (42%) had an exacerbation of “chronic” heart failure (Group C-PCS: dilated cardiomyopathy 30%, post-ischemic cardiomyopathy 9%, congenital 3%). Results. In group C-PCS, 23 patients were bridged to a LVAD (52%) or heart transplantation (33%). In group A-PCS, ECMO was used as bridge-to-transplantation in 3 patients (8%), bridge-to-bridge in 9 (24%), and bridge-to-recovery in 18 patients (49%). One patient in both groups was bridged to conventional surgery. Recovery of cardiac function was achieved only in group A-PCS (18 vs 0 pts, p=0.0001). Mean-flow during support ≤60% of the theoretical flow (BSA*2.4) was a predictor of successful weaning (p=0.02). Average duration of ECMO support was 8.9 ±9 days. Nine patients (14%) died during support; 30-day overall survival was 80% (51/64 pts); 59% of patients were discharged, in whom survival at 48 months was 90%. Better survival was observed in patients supported for 8 days or less (74% vs 36%, p=0.002). Conclusions. In “chronic” heart-failure ECMO represents a bridge to VAD or heart-transplantation, while in “acute” settings it offers a considerable chance of recovery, often representing the only required therapy.
Lo shock cardiogeno refrattario è una condizione gravata da alta mortalità nonostante i progressi nella terapia medica. Il trattamento convenzionale comprende infusione di inotropi, vasopressori, e contropulsazione aortica (intra-aortic-balloon-pump – IABP). Quando l’instabilità emodinamica è refrattaria a questi trattamenti, il supporto meccanico al circolo rappresenta la sola possibilità di sopravvivenza, come indicato dalle attuali linee guida. Tuttavia, poichè la maggior parte di questi pazienti si presenta con severa instabilità emodinamica che richiede un intervento urgente o emergente, l’assistenza meccanica scelta dovrebbe essere impiantabile in maniera rapida e semplice. Per questa ragione, l’ExtraCorporeal Membrane Oxygenation (ECMO) rappresenta l’ideale “bridge-to-life”, che sempre più viene usato per supportare le funzioni vitali in attesa che il programma terapeutico ottimale venga stabilito (bridge-to-decision). L’iter terapeutico può poi seguire tre diversi percorsi: “bridge-to-recovery”: il paziente recupera una funzione cardiocircolatoria tale da permettere lo svezzamento dall’ECMO; “bridge-to-transplant”: il paziente viene sottoposto a trapianto cardiaco; “bridge-to-bridge”: il paziente viene trattato con impianto di un’assistenza ventricolare o di un cuore artificiale totale. Sono state riportate diverse ampie casistiche sull’uso dell’ ECMO come supporto meccanico in pazienti con shock dopo intervento cardiochirurgico (“post-cardiotomy”), ma relativamente poche serie, e limitate a pochi casi, focalizzate sul ruolo dell’ECMO nello shock cardiogeno primario (non post-cardiotomico). In questo studio si presenta l’esperienza del centro di Padova nel trattamento dello shock cardiogeno primario con il sistema ECMO PLS-Quadrox (Maquet) come bridge-to-decision. In particolare, la ricerca proposta si prefigge di valutare l’impatto della differente eziologia sull'outcome dei pazienti, paragonando gli shock cardiogeni primari “acuti”, secondari ad infarto miocardico acuto, miocardite, embolia polmonare e cardiomiopatia post-partum, con scompensi acuti di cardiomiopatie “croniche”, includendo cardiomiopatie dilatative primitive, post-ischemiche, e cardiopatie congenite dell’adulto. Si è infine analizzato se la durata e l’entità del supporto possano predire la chance di sopravvivenza e di svezzamento. Materiali e metodi. Tra Gennaio 2009 e Marzo 2013, sono stati impiantati con ECMO un totale di 249 pazienti, di questi 64 erano affetti da shock cardiogeno "primario" (52 uomini e 12 donne, di 50±16 anni di età) e sono stati trattati con supporto ECMO periferico. Trentasette casi (58%) sono stati classificati come "acuti" (Gruppo A, Acuti, IMA 39%, miocardite 6%, embolia polmonare 8%, post-partum 2%), mentre i rimanenti 27 (42%) shock erano insorti in un quadro di scompenso cardiaco "cronico" (Gruppo B, Cronici, cardiomiopatia dilatativa primitiva 30%, cardiomiopatia dilatativa post-ischemica 9%, patologie congenite 3%). Risultati della ricerca. Nel gruppo con scompenso cardiaco cronico (Gruppo B), 23 pazienti sono stati trattati con impianto o di assistenza ventricolare sinistra (52%) o trapianto cardiaco ortotopico (33%). Nel gruppo con scompenso cardiaco acuto (Gruppo A), l' ECMO è stato usato come ponte a trapianto in 3 pazienti (8%), come ponte ad impianto di assistenza ventricolare sinistra in 9 pazienti (24%) e come ponte al recupero della propria funzionalità cardiaca in 18 pazienti (49%). Un solo paziente in ogni gruppo è stato trattato con chirurgia tradizionale. Il recupero della funzionalità cardiaca si è osservato solo all'interno del Gruppo A (18 vs. 0 pazienti, p=0,0001). E' stato visto che mantenere un flusso medio di supporto ≤60% del flusso teorico (BSA*2,4) costituisce un predittore positivo di svezzamento dal dispositivo (p=0,02). Globalmente, la durata media del supporto ECMO è stata di 8,9±9 giorni. Nove pazienti (14%) sono deceduti durante il supporto ECMO; la sopravvivenza globale a 30 giorni è stata dell' 80% (5/64 pazienti); il 59% dei pazienti è stato dimesso dall’ ospedale e, tra questi, la sopravvivenza a 48 mesi è stata del 90%, senza differenze significative nei due gruppi. La sopravvivenza migliore si è osservata in quei pazienti che hanno necessitato di supporto ECMO per un periodo inferiore o uguale ad 8 giorni (74% vs. 36%, P=0,002). In conclusione nei pazienti con shock cardiogeno refrattario nell'ambito di uno scompenso cardiaco cronico l'ECMO rappresenta un dispositivo-ponte verso l'impianto di assistenza ventricolare sinistra o verso trapianto cardiaco. Nei pazienti con shock refrattario dovuto ad eziologia acuta, invece, tale supporto offre sostanziali chance di recovery, costituendo spesso l'unica terapia necessaria.

UA Open Access Publishing Fund
Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.

ExtraCorporeal Membran Oxygenering (framgent ECMO) är en mycket användbar behandling i situationer där patientens tillstånd är kritiskt. ECMO kan potentiellt öka chanserna att överleva avsevärt för patienter som annars skulle avlida till följd av sina hjärt- eller lungproblem. Behandlingen är dock inte helt riskfri, utan komplikationer såsom tromboembolism och invärtes blödningar är vanliga. Dessa associeras båda med rapportens huvudsakliga ämne, nämligen blodplättsaktivering. Denna företeelse är en konsekvens av den icke fysiologiska miljö som slangsystemet utgör. Trombocyter (blodplättar) som utsätts för de höga skjuvspänningar och hastigheter i kombination med långa stillestånd i stagnationspunkter, löper ökad risk att aktiveras och därmed producera ansamlingar av koagulerat blod runtom i olika delar av systemet. I den här rapporten var kopplingarna, som utgör skarvar där olika delar av systemet kopplas samman, av intresse. Simuleringarna för att analysera kopplingarna i olika konfigurationer utfördes med hjälp av ANSYS Fluent på Parallelldatorcentrums (PDC) Beskow och Tegner. Det visade sig att flera kopplingar på rad ökade residenstiden för en individuell partikel mer än vad som vore väntat ifall resultaten från lika många enskilda koppling adderades. Från detta drogs slutsatsen att ett reducerat antal kopplingar är att föredra då det bidrar till att minska den totala blodplättsaktiveringen och därmed minska risken att patienten får komplikationer.

È stato dimostrato che la fisioterapia è indicata ed efficace sui pazienti ricoverati in ICU (Intensive Care Unit), ma ad oggi in letteratura non si è ancora arrivati ad un accordo sulla posologia del trattamento fisioterapico in tali pazienti in trattamento con ECMO (ExtraCorporeal Membrane Oxygenation). Questo sia perché l’utilizzo di questa procedura ha avuto solo ultimamente una grande crescita, sia perché praticare fisioterapia in una ICU presenta molti limiti, dalle condizioni psicofisiche dei pazienti alla presenza di numerosi device che creano ulteriori difficoltà. L’obiettivo di questa tesi è esporre una panoramica della letteratura riguardo l’utilizzo dell’ECMO nelle ICU, ponendo particolare attenzione alla fisioterapia e agli effetti nel trattamento tempestivo di pazienti sottoposti a ECMO. Questa Scoping Review include numerose evidenze scientifiche trovate in letteratura nelle principali banche dati (PubMed, CINAHL, EMBASE, Cochrane, PEDro), selezionando sia studi primari e secondari, che linee guida, capitoli di libri ecc pubblicati negli ultimi 10 anni. In letteratura si evince che la riabilitazione fisioterapica intensiva precoce è indicata e sicura, e può portare a una dimissione del paziente più rapida con migliori outcome. Gli studi selezionati concordano sul fatto che effettuare fisioterapia durante l’ECMO è sicuro ed efficace, se inserite all’interno di un team specializzato. Alcuni hanno evidenziato una minor durata della degenza in ICU, e un miglioramento di mobilità e forza muscolare. Pochi altri hanno rilevato un’associazione tra fisioterapia ed aumento della mortalità in ICU. Nonostante la scarsa letteratura disponibile, i benefici della fisioterapia su questo tipo di pazienti sono promettenti, anche se sono necessari ulteriori studi che valutino potenziali rischi e vantaggi riguardo l’uso di questa innovativa tecnica. Keywords: ExtraCorporeal Membrane Oxygenation (ECMO), Intensive Care Unit (ICU), Physical Therapy, Rehabilitation

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Introduction: Extracorporeal pulmonary assistance has been proposed as an invasive alternative to the conventional treatment when adequate oxygenation becomes impossible by mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) attained using assisted circulation may cause hemolysis, coagulation disorders, an inflammatory response and complications inherent to a high-risk high-cost procedure. The objective of this work was to evaluate the efficacy, both in vitro and ex vivo, of a low-resistance oxygenator in ECMO without assisted circulation. Material and Method: Initially, different prototypes of the low-resistance membrane oxygenator were developed to test the influence of the of inlet and outlet conditions of the blood, the area, the quantity and placement of the fibers in the oxygenation process and the removal of carbon dioxide gas (CO2). In the in vitro tests when bovine blood was utilized, the mean flow, volume of blood needed to fill the oxygenator and for priming, oxygen saturation, carbon dioxide gas exchange and the pressure gradient were measured. For the ex vivo experiments, five Santa Inês sheep, weighing between 5 and 33 kg, were used. In each animal, variations in respect to the oxygen saturation, the PO2 and the PCO2 were studied in the systemic blood at the outlet of the oxygenator and of the venous blood using oxygen flow rates of 0.5L/min, 1.0 L/min and 1.5 L/min. Results: The oxygenator had an excellent mechanical performance, which was seen by the PO2, PCO2 and oxygen saturation of the blood at the outlet of the oxygenator. From the clinical point of view, the improvement in the PO2 and oxygen saturation and the reduction in PCO2 of the systemic arterial blood (femoral artery of the sheep), were evident in the five sheep. A tendency of better results was seen when the weight was less than 10kg. Translating these relationships in terms of blood flow and total volume, the best results appeared when the blood flow in the oxygenator/volume proportion was 20% or greater, establishing this cutoff point as the ideal flow necessary for the best performance of the oxygenator. Conclusion: The in vitro and ex vivo performance tests achieved with the low-resistance membrane oxygenator used in arteriovenous extracorporeal circulation without the assistance of a propulsion pump, proved that this device is capable of providing oxygen and removing carbon dioxide from the blood in sufficient quantities to maintain the tested parameters at acceptable limits when ventilation is prejudiced.
Introdução: A assistência pulmonar extracorpórea tem sido proposta como uma alternativa invasiva ao tratamento convencional, quando a oxigenação adequada torna-se impossível pelo uso de ventilação mecânica. A oxigenação extracorpórea por membrana (ECMO) realizada com auxílio circulatório pode produzir hemólise, distúrbios da coagulação, resposta inflamatória e complicações inerentes a um procedimento de alto risco e elevado custo. O objetivo deste trabalho foi avaliar a eficácia in vitro e ex vivo de um oxigenador de baixa resistência em ECMO sem auxílio circulatório. Material e Método: Inicialmente foram desenvolvidos diferentes protótipos do oxigenador de membrana de baixa resistência para testar a influência das condições de entrada e saída do sangue, área, quantidade e disposição das fibras no processo de oxigenação e remoção de gás carbônico (CO2). Nos testes in vitro, utilizando-se sangue bovino, foram avaliados fluxo médio, volume de sangue necessário para preencher o oxigenador ou priming, saturação de oxigênio e transferência de gás carbônico e o gradiente de pressão. Nos experimentos ex vivo foram utilizados cinco carneiros da raça Santa Inês, pesando entre 5 a 33 Kg. Em cada animal foram estudadas as variações com relação à saturação de O2, PO2 e PCO2, no sangue sistêmico, na saída do oxigenador e no sangue venoso com fluxos de oxigênio no oxigenador 0,5 L/min, 1,0 e 1,5 L/min. Resultados: O oxigenador demonstrou excelente desempenho mecânico, o que pode ser verificado pelos valores de PO2, PCO2 e SatO2 do sangue na saída do oxigenador. Do ponto de vista clínico, a melhora de PO2 e SO2 e a redução de PCO2 no sangue arterial sistêmico (artéria femoral do carneiro) foram evidentes nos cinco experimentos. Foi possível observar uma tendência para melhores resultados com pesos inferiores a 10,0 kg. Traduzindo-se essas relações em termos de fluxo sanguíneo e volemia total, os melhores resultados apareceram com proporção fluxo sangüíneo no oxigenador/volemia, de 20% ou maior, podendo-se estabelecer esse limite de corte, como fluxo ideal necessário para bom desempenho do oxigenador. Conclusão: Os testes de performance in vitro e desempenho ex vivo, realizados com o oxigenador de membrana de baixa resistência ao fluxo, para uso em circulação extracopórea arteriovenosa, sem o auxílio de bomba propulsora, mostraram resultados suficientes para concluir que tais dispositivos são capazes de fornecer Oxigênio e retirar gás Carbônico do sangue em quantidades suficientes para manter tais parâmetros em níveis aceitáveis, quando a ventilação está prejudicada.

Introduction : L’arrêt cardiaque réfractaire est défini par l’absence du retour à l’activité circulatoire spontané (RACS) après 30 minutes de réanimation cardiopulmonaire médicalisé. ExtraCorporeal Membrane Oxygenation (ECMO) représente une thérapie alternative urgente dans cette population. L’hémodynamique post la réanimation cardiopulmonaire extracorporel (E-CRP) est un entité complexe et le pris en charge dans les premières heures suivant l’implantation d’ECMO n’est pas bien décrit. L’objectif de cette étude est d’évaluer l’effet de deux stratégie de débit d’ECMO dans un modèle porcin d’arrêt cardiaque réfractaire sur les conséquences métaboliques, microcirculatoires et inflammatoires.Matériels et Méthodes : l’arrêt cardiaque a été induit par la ligature l’artère intraventriculaire antérieure (IVA) chez 18 cochons. E-RCP a été initié après 40 minutes de low-flow avec un débit d’ECMO bas de 30-35 ml.kg-1.min-1 ou un débit d’ECMO standard de 65-70 ml.kg-1.min-1, avec la même pression artérielle moyenne (PAM) au niveau de 65 mmHg. Les paramètres hémodynamiques et métaboliques ont été évalués avec la clairance de lactate et le débit sanguin carotidien. Les paramètres microcirculatoires ont été évalués par la microcirculation sublinguale avec l’imagerie de SDF et NIRS. Cytokines inflammatoires ont été mesurés avec un plateforme de ELISA multiplexe. Résultats : Pas de différence entre les deux groups à H basale et à l’initiation d’ECMO (H0). La clairance de lactate était plus faible dans le groupe débit bas comparé au groupe débit standard (6.67[-10.43-18.78] vs. 47.41[19.54, 70.69] %, p=0.04). Le débit carotidien était plus bas significativement (p<0.005) dans le groupe débit bas pendant les dernières quatre heures malgré le même niveau de la pression artérielle moyenne. Pour les paramètres microcirculatoires, le flux microcirculatoire sublingual évalué par SDF et le StO2 par NIRS ont été altéré transitoirement à H3 dans le groupe débit bas. Le niveau de cytokine IL-6 était plus élevé significativement dans le groupe débit bas à la fin d’expérimentation. Conclusions : Une réanimation à objectif de débit d’ECMO bas 35 ml.kg-1.min-1 versus standard 70ml.kg-1.min-1dans les six premières heures d’un ACR réfractaire n’est pas associé à une meilleure réversion des conséquences métaboliques, microcirculatoire et inflammatoire avec un objectif de PAM à 65 mmHg dans un modèle porcin
Introduction : Refractory cardiac arrest is defined by the absence of the return of spontaneous circulation (ROCS) within 30 minutes of cardiopulmonary resuscitation (CRP) under medical supervision. ExtraCorporeal membrane oxygenation (ECMO) is an emerging alternative therapy in this population. The post extracorporeal cardiopulmonary resuscitation (ECPR) hemodynamic state is a complex entity and the critical care management in the first hours following ECMO implantation is not well defined. This study was designed to assess the effect of two veno-arterial Extracorporeal Membrane Oxygenation (ECMO) blood-flow strategies in an experimental model of ECPR (extracorporeal cardio-pulmonary resuscitation) on macrocirculatory, metabolic and microcirculatory parameters in the first six hours of ECMO initiation. Material and methods : Cardiac arrest was induced in 18 pigs by surgical ligature of the left descending coronary artery. ECPR was initiated after 40 minutes of low-flow with an ECMO blood-flow of 30-35 ml.kg-1.min-1 (low-blood-flow group, LBF) or 65-70 ml.kg-1.min-1 (standard-blood-flow group, SBF), with the same mean arterial pressure target (65 mmHg). Macrocirculatory and metabolic parameters were assessed by lactate clearance and carotid blood-flow. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field (SDF) imaging and peripheral Near-InfraRed Spectrometry (NIRS). Inflammatory cytokine levels were measured with a multiplexed ELISA-based array platform. Results : There was no between-group difference at baseline and at ECMO initiation (H0). Lactate clearance at H6 was lower in LBF compared to SBF (6.67[-10.43-18.78] vs. 47.41[19.54, 70.69] %, p=0.04). carotid blood flow was significantly lower (p<0.005) during the last four hours despite similar mean arterial pressure levels. For microcirculatory parameters, SDF and NIRS parameters were transitorily impaired at H3 in LBF. IL-6 cytokine level was significantly higher in LBF at the end of the experiment. Conclusion: In an experimental porcine model of refractory cardiac arrest treated by ECMO, a low-blood-flow strategy during the first six hours of resuscitation was associated with lower lactate clearance and lower cerebral blood-flow with no benefits on ischemia-reperfusion parameters

Background and objectives Research suggests that parents of children supported on Extracorporeal Membrane Oxygenation (ECMO) may be at risk of posttraumatic stress symptoms (PTSS), although no specific investigations have been carried out. The current study explored PTSS in this group. Associations with family functioning and parenting self-esteem were also investigated. Method Parents were identified from the hospital database and recruited in a cross-sectional, single group design by postal invite. Participants (n = 52) completed questionnaires measuring PTSS, family functioning, parenting self- esteem, depression and anxiety. Results Participants reported levels of intrusion and hyperarousal symptoms which were not statistically different to those found in parents from a comparison paediatric population. Avoidance symptoms were significantly higher in the current sample. Participants reported significantly more effective family functioning than parents from a comparison paediatric population. Family functioning and parenting self-esteem were also greater than that reported in community samples. Family functioning was not independently 3 I DClinPsy project: PARENT EXPERIENCE OF ECMO associated with PTSS and PTSS were not independently associated with parenting self-esteem. Conclusions PTSS appear to be a problem for some parents of children supported on ECMO. While associations exist between family functioning, PTSS and parenting self-esteem, it seems likely that these are indirect relationships. 4

Hypothesis: ECMO is an acceptable supportive therapy for patients with severe SIRS despite triggering haematic response.;Objectives: To develop a reliable and reproducible animal model of SIRS to investigate strategies for reducing the haematic response.;Materials and Methods: Literature review: (I) The Systemic Thrombo-inflammatory Pathway (STIP). (II) The haematic response. Clinical studies: (I) Institutional review of ECMO for severe SIRS. (II) Comparative review of oxygenators performance. In-vivo studies: Animal experiments, (I) Development of a rabbit model of graded SIRS. (II) Dose response relationship between administered intravenous endotoxin and fatal Multi-organ Dysfunction Syndrome (MODS). (III) Inter-individual variation amongst rabbits receiving a lethal dose of endotoxin. In-vitro studies: Evaluation of the cellular and biochemical components of STIP in rabbits. (I) Development of rabbit ELISA. (II) Determination of the normal range, dose response and inter-individual variation. (III) Immunohistochemical evaluation of endotoxin induced lung injury. (IV) Dose related oxidative stress and DNA damage and (V) apoptosis in rabbit lung.;Results: There is a reciprocal relationship between graded SIRS and the outcome of ECMO. There is a linear relationship between the dose of endotoxin and the development of graded SIRS in rabbits. Significant DNA homology and cross-reactivity exists between humans and rabbits making this a useful model for immune experimentation.;Conclusions: ECMO is superior to conventional ICU management in selected groups of patients. New oxygenator technology has significantly reduced the haematic response to ECMO, however it has failed to influence survival. Cellular components such as neutrophils play a central role in SIRS activation, however thrombin appears to be the common biochemical component for feedback escalation and progression of severe SIRS to MODS.

Extracorporeal membrane oxygenation (ECMO) has been used as life-saving support for children with varying causes of respiratory and/or cardiac failure. However, few studies have assessed the utility of ECMO as a viable treatment option in the setting of pediatric burn injury. We aim to examine the outcomes of pediatric burn patients requiring ECMO support by utilizing the Extracorporeal Life Support Organization (ELSO) registry in order to elucidate whether or not ECMO should be considered in this population. A retrospective cohort study was conducted by querying the ELSO database for all pediatric patients (birth to less than 18 years) who were supported on ECMO with burn-associated cardiopulmonary failure between 1990 and 2016. ICD-9 codes 940–949.5 were utilized to identify patients with an associated burn injury. Venovenous ECMO was defined as any patient with only venous cannulas, including double-lumen venous cannulas. Venoarterial ECMO was defined as any patient with a venous and an arterial cannula, any patient originally supported on VA ECMO that was converted to venovenous, or any patient originally supported on venovenous that was converted to venoarterial ECMO. Oxygenation indices (OI) and complication rates were compared among survivors and non-survivors for both venovenous (VV) and venoarterial (VA) groups. Primary outcome variables were survival and non-survival to hospital discharge. Demographic and clinical data, along with pre-ECMO variables and ECMO complications, were analyzed for predictive mortality. A total of 113 patients met inclusion criteria for the study. Overall survival to discharge was 52.2% (n=59) for the entire cohort. 73 patients were supported on VA ECMO, while 37 patients required VV ECMO support with a survival to discharge of 47.9% (n=35) and 62.2% (n=23), respectively. There was no statistical difference for median age (p=0.765), median weight (p=0.932), or median hours on ECMO (p=0.963) between survivors and non-survivors. Three patients did not have the type of cannulation identified but were listed as “other” in the ELSO registry. Patients requiring ECMO support for respiratory failure had a higher over-all survival (55.7%, n=97) compared to those requiring ECMO for cardiac failure (33.3%, n=6) or ECPR (30%, n=10). Patients who were supported on VV ECMO for respiratory failure had the best overall survival at 62.2% (n=37) and those cannulated to VA ECMO for respiratory failure had a survival of 51.7% (n=58). Patients supported on VA ECMO for cardiac failure or ECPR support had the same survival at 33.3% (n=6 and 9 respectively). Several factors were found to be significantly associated with mortality. Cardiac arrest prior to cannulation was associated with increased mortality with an odds ratio of 3.41 (95% CI 1.29-9.06, p=0.011). There was a trend for the use of nitric oxide prior to cannulation to be associated with a decrease in mortality with an odds ratio of 0.40 (95% CI 0.16-1.01, p=0.048)Following cannulation, complications including the need for inotropes (OR 2.64, 95% CI 1.24-5.65, p=0.011), presence of gastrointestinal hemorrhage (p=0.049), and hyperglycemia (glucose > 240mg/dL) (OR 3.42, 95% CI 1.13-10.38, p=0.024) were associated with increased mortality.

Given that pandemic swine flu outbreak led to substantial admission in intensive care unit, extracorporeal membrane oxygenation has been increasingly applied to those who suffered from H1N1 infection induced acute respiratory distress syndrome. This review is going to evaluate the effectiveness of using ECMO based on five related observational studies. The result, discussion and policy implication in Hong Kong are discussed. Since the ECMO system has been technological improved in recent years, there are less complications when applying ECMO. In view of evidence of reviewed studies, application of ECMO in Hong Kong can be considered as cost effective. And since only a few hospitals in Hong Kong can offer ECMO application, retrieval teams are needed to ensure safety transfer between hospitals.
published_or_final_version
Public Health
Master
Master of Public Health

Extracorporeal Membrane Oxygenation (ECMO) is a life-saving therapy usedfor support in critical heart and/or lung failure. Patient’s blood is pumped viaan artificial lung for oxygenation outside of the body. The circuit is composedof a blood pump, cannulae for drainage and reinfusion, a membrane lung,tubing and connectors. Its use is associated with thromboembolic complicationsand hemolytic damage. Detailed numerical studies of two blood pumps anda lighthouse tip drainage cannula were undertaken to characterize the flowstructures in different scenarios and their link to platelet activation. The pumpsimulations were modelled according to manufacturer’s proclaimed use but alsoin off-design conditions with flow rates used in adult and neonatal patients.Lagrangian Particle Tracking (LPT) was used to simulate the injection ofparticles similar in size to platelets to compute platelet activation state (PAS).The results indicated that low flow rates impacted PAS similarly to high flowrates due to increased residence time leading to prolonged exposure to shearstress despite the fact that shear per se was lower at low flow rate. Regardingthe cannula, the results showed that a flow pattern similar to a jet in crossflowdeveloped at the side holes. A parameter study was conducted to quantifydrainage characteristics in terms of flow rate distribution across the holes wheninput variables of flow rate, modelled fluid, and hematocrit were altered. Thefindings showed, across all the cases, that the most proximal hole row drainedthe largest fraction of fluid. The effects due to the non-Newtonian nature ofblood were confined to regions far from the cannula holes and the flow structuresshowed very limited dependence on the hematocrit. A scaling law was found tobridge the global drainage performance of fluid between water and blood.

QC 210906

Introduction: Despite an undeniable improvement in knowledge and care over time, resuscitation in cardiac patients remains one of the most relevant challenges for cardiologists and intensivists. Objectives: We aimed to provide insight into resuscitation and outcomes of critically ill pediatric cardiac patients, exploring different knowledge opportunities - from big data, to bench, to bedside. We performed 6 individual projects, aiming to define, predict, and treat resuscitation events and ultimately improve the associated outcome. Methods: We performed: 1. a systematic review and meta-analysis on the incidence, risk factors, and outcome of CA in pediatric cardiac critically ill patients; 2. a big data analysis to determine whether novel mathematically computed variables as shock index (SI), coronary perfusion pressure (CPP), and rate pressure product (RPP) may predict resuscitation events; 3. a retrospective analysis of ELSO Registry data on patients resuscitated with ECMO after failure to wean (FTW) from cardiopulmonary bypass (CPB); 4. a review of extracorporeal CPR (ECPR) events and their outcomes at our center (BCH), modeling prediction of severe functional impairment or death; 5. a propensity-weighted analysis to define the benefits of left atrial (LA) decompression in patients supported with ECMO; 6. a prospective Phase1 study for the safety evaluation of a new FDA-approved drug, the inhaled hydrogen (H2), which has shown potential in prevention/treatment of ischemia-reperfusion injury in animal models. Results: We have shown: 1. Among 126,087 critically ill cardiac patients, 5% (CI 4-7%) experienced CA, and21% (CI 15-28%) underwent ECPR. Overall, 35% of patients (CI 27-44%) did not reach ROSC, and 54% died before discharge (CI 47-62%); 2. 7% (296/4,161) of patients who underwent cardiac surgery had CPR/ECPR, need for ECMO/VAD, unplanned surgery, heart transplant, or death within 7 postoperative days. In a multivariable regression model adjusted for age, surgical complexity, inotropic and respiratory support, and organ dysfunction, SI>1.83 was significantly associated with the adverse outcome (OR 6.6 [CI 4.4-10.0]), and CPP>35mmHg was protective against the outcome (OR 0.5 [0.4-0.7]); 3. 55% of the 2,322 patients who FTW from CPB died before discharge. Non-cardiac congenital anomalies, comorbidities, pre-operative CA, pre-operative mechanical ventilation>24h, pre-operative bicarbonate administration, longer CPB time, complex surgical procedures, longer ECMO duration, and ECMO complications were all independently associated with in-hospital mortality. Age>26 days (OR 0.56 [CI 0.42-0.75]) reduced the odds of mortality; 4. 52% of the 182 patients who underwent ECPR at BCH died before discharge. The median Functional Status Scale (FSS) among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. Predictive models identified FSS at admission, single ventricle physiology, ECMO duration, mean PELOD-2, and worst mASPECTS as independent predictors of severe functional outcome at discharge (AUC=0.931) and at 6 months (AUC=0.924); 5. 18% of the 1,508 cardiac patients with biventricular physiology supported with ECMO underwent LA decompression (LA+). Covariates were well-balanced after propensity-weighting. In-hospital adverse outcome rate was 47% in LA+ vs 51% in LA-. Propensity-weighted multivariable logistic regression showed LA decompression to be protective for in-hospital adverse outcome (OR 0.77 [CI 0.64-0.93]); 6. H2 inhalation is safe in adult healthy volunteers, with no significant adverse events. This lays the foundation of a future trial for the use of H2 for the prevention/treatment of ischemia-reperfusion injury. Conclusion: We have provided new insight into resuscitation and outcomes of critically ill cardiac patients, from big data, to bench, to bedside. Future steps will include a randomized trial on the use of H2 to improve neurologic outcomes in cardiac ECPR patients.
Introduction: Despite an undeniable improvement in knowledge and care over time, resuscitation in cardiac patients remains one of the most relevant challenges for cardiologists and intensivists. Objectives: We aimed to provide insight into resuscitation and outcomes of critically ill pediatric cardiac patients, exploring different knowledge opportunities - from big data, to bench, to bedside. We performed 6 individual projects, aiming to define, predict, and treat resuscitation events and ultimately improve the associated outcome. Methods: We performed: 1. a systematic review and meta-analysis on the incidence, risk factors, and outcome of CA in pediatric cardiac critically ill patients; 2. a big data analysis to determine whether novel mathematically computed variables as shock index (SI), coronary perfusion pressure (CPP), and rate pressure product (RPP) may predict resuscitation events; 3. a retrospective analysis of ELSO Registry data on patients resuscitated with ECMO after failure to wean (FTW) from cardiopulmonary bypass (CPB); 4. a review of extracorporeal CPR (ECPR) events and their outcomes at our center (BCH), modeling prediction of severe functional impairment or death; 5. a propensity-weighted analysis to define the benefits of left atrial (LA) decompression in patients supported with ECMO; 6. a prospective Phase1 study for the safety evaluation of a new FDA-approved drug, the inhaled hydrogen (H2), which has shown potential in prevention/treatment of ischemia-reperfusion injury in animal models. Results: We have shown: 1. Among 126,087 critically ill cardiac patients, 5% (CI 4-7%) experienced CA, and21% (CI 15-28%) underwent ECPR. Overall, 35% of patients (CI 27-44%) did not reach ROSC, and 54% died before discharge (CI 47-62%); 2. 7% (296/4,161) of patients who underwent cardiac surgery had CPR/ECPR, need for ECMO/VAD, unplanned surgery, heart transplant, or death within 7 postoperative days. In a multivariable regression model adjusted for age, surgical complexity, inotropic and respiratory support, and organ dysfunction, SI>1.83 was significantly associated with the adverse outcome (OR 6.6 [CI 4.4-10.0]), and CPP>35mmHg was protective against the outcome (OR 0.5 [0.4-0.7]); 3. 55% of the 2,322 patients who FTW from CPB died before discharge. Non-cardiac congenital anomalies, comorbidities, pre-operative CA, pre-operative mechanical ventilation>24h, pre-operative bicarbonate administration, longer CPB time, complex surgical procedures, longer ECMO duration, and ECMO complications were all independently associated with in-hospital mortality. Age>26 days (OR 0.56 [CI 0.42-0.75]) reduced the odds of mortality; 4. 52% of the 182 patients who underwent ECPR at BCH died before discharge. The median Functional Status Scale (FSS) among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. Predictive models identified FSS at admission, single ventricle physiology, ECMO duration, mean PELOD-2, and worst mASPECTS as independent predictors of severe functional outcome at discharge (AUC=0.931) and at 6 months (AUC=0.924); 5. 18% of the 1,508 cardiac patients with biventricular physiology supported with ECMO underwent LA decompression (LA+). Covariates were well-balanced after propensity-weighting. In-hospital adverse outcome rate was 47% in LA+ vs 51% in LA-. Propensity-weighted multivariable logistic regression showed LA decompression to be protective for in-hospital adverse outcome (OR 0.77 [CI 0.64-0.93]); 6. H2 inhalation is safe in adult healthy volunteers, with no significant adverse events. This lays the foundation of a future trial for the use of H2 for the prevention/treatment of ischemia-reperfusion injury. Conclusion: We have provided new insight into resuscitation and outcomes of critically ill cardiac patients, from big data, to bench, to bedside. Future steps will include a randomized trial on the use of H2 to improve neurologic outcomes in cardiac ECPR patients.

L’insuffisance cardiaque aigue est une émergence médicale qui nécessite une prise en charge multidisciplinaire. L’Extracorporeal Life Support (ECLS) peut être envisagé comme option thérapeutique pour les formes d’insuffisance cardiaque aigue réfractaire au traitement conventionnel. L’objectif de ce projet de recherche clinique est de fournir une vue d’ensemble de l’ECLS dans la prise en charge du choc cardiogénique et de l’arrêt cardiaque réfractaire. L’intoxication médicamenteuse et la myocardite sont les meilleures indications à l’implantation de l’ECLS en considération de leur potentiel de récupération myocardique très élevé. La défaillance primaire du greffon après transplantation cardiaque et l’infarctus du myocarde présentent des résultats plus mitigés avec l’ECLS en raison d’une physiopathologie plus complexe. Le choc cardiogénique postcardiotomie après une intervention de chirurgie cardiaque montre des résultats décevants en raison du profile préopératoire des patients. L’arrêt cardiaque aussi exige une prise en charge immédiate et l’ECLS peut être considéré comme une solution thérapeutique de sauvetage. Une meilleure sélection des patients s’impose afin d’améliorer les résultats de l’ECLS pour l’arrêt cardiaque réfractaire intrahospitalier. Les résultats de l’ECLS pour l’arrêt cardiaque réfractaire extrahospitalier sont dictés principalement par le temps de réanimation cardio-pulmonaire et le rythme cardiaque. Les rythmes non choquables pourraient être considérés comme une contre-indication formelle à l’utilisation de l’ECLS autorisant une concentration de nos efforts sur les rythmes choquables où les chances de survie sont plus importantes
Acute heart failure is a clinical situation requiring a prompt multidisciplinary approach. Extracorporeal Life Support (ECLS) could represent a therapeutic option for acute heart failure refractory to standard maximal treatment. The aim of this report is to offer an overview of ECLS in the management of refractory cardiogenic shock and cardiac arrest. Drug intoxication and myocarditis are the best indications of ECLS in consideration of their high potential of myocardial recovery. Primary graft dysfunction after heart transplantation and acute myocardial infarction show reduced survival rates owing to their more complex pathophysiology. Postcardiotomy cardiogenic shock after cardiac surgery operations displays poor outcomes due to the preoperative profile of the patients. ECLS could be also considered as a rescue solution for refractory cardiac arrest. A better selection of in-hospital cardiac arrest patients is mandatory to improve ECLS outcomes. In-hospital cardiac arrest patients with a reversible cause like drug intoxication and acute coronary syndrome should benefit from ECLS whereas end-stage cardiomyopathy and postcardiotomy patients with an unclear cause of cardiac arrest should be contraindicated to avoid futile support. ECLS for refractory out-ofhospital cardiac arrest should be limited in consideration of its poor, especially neurological, outcome and the results are mainly limited by the low-flow duration and cardiac rhythm. Nonshockable rhythms could be considered as a formal contraindication to ECLS for refractory out-of-hospital cardiac arrest allowing a concentration of our efforts on the shockable rhythms, where the chances of success are substantial

Le poumon est un organe vital dont les pathologies au stade terminal peuvent induire une insuffisance circulatoire avec une défaillance cardiaque droite secondaire. Concernant les options thérapeutiques disponibles, des oxygénateurs sanguins macroscopiques basés sur la technologie des membranes extracorporelles (ECMO) sont actuellement utilisés au sein d'une unité de soins intensifs. Ces oxygénateurs doivent être remplacés en quelques semaines en raison de la coagulation dans le système.Dans ce contexte, le but de mon doctorat était de développer un dispositif microfluidique pour l'oxygénation du sang, qui présente une grande surface d'échange gazeux et capable de soutenir une endothélialisation durable à long terme des microcapillaires sanguins améliorant son hémocompatibilité pour les applications cliniques.Des calculs numériques basés sur le modèle d’échange gazeux de Potkay et coll. ont permis de comprendre le rôle de chaque paramètre géométrique sur l’échange gazeux et, donc, de dimensionner au mieux le système tri-couches « microcapillaire de sang / membrane / microcanal de gaz ».J’ai ensuite mis au point un protocole de microfabrication qui permet d’intégrer une membrane fine de polymère de très grande surface, et de fabriquer des oxygénateurs robustes et étanches sous pression.Les performances d’échange gazeux mesurées avec du sang veineux de cochon sont remarquables, tant pour les tri-couches unitaires que pour les structures empilées, avec un faible volume d’injection et une oxygénation élevée (379 ml O2/min/m²) à débit élevé (15ml/min). Ces résultats expérimentaux ont pu être comparés aux calculs numériques. Enfin, avec une géométrie optimisée pour minimiser la contrainte de cisaillement, un protocole d’endothélialisation durable dans les capillaires sanguins a été proposé
End-stage lung diseases may result in death either by oxygenation and carbon dioxide exchange insufficiency or by right heart failure. Concerning the therapeutic options currently available, macroscopic blood oxygenators based on extracorporeal membrane (ECMO) technology are currently used. However, the environment of an intensive care unit is still required. Modern oxygenators need to be exchanged within a couple of weeks because of clotting.In this context, the goal of my PhD was the development of a novel microfluidic device for blood oxygenation, which exhibits a large surface area of gas exchange and can support long-term sustainable endothelialization of blood microcapillaries enhancing its hemo-compatibility for clinical applications. Numerical calculations based on the gas exchange model of Potkay et al. helped to best size the three-layer "blood microcapillary / membrane / gas microchannel" system.I then developed a microfabrication protocol that allows the integration of a thin polymer membrane with a very large surface area, producing robust sealed oxygenators.The gas exchange performances achieved with venous pig blood are remarkable both for unit trilayers, and for stacked structures with a low reduced injection volume, high oxygenation (379 ml O2 / min / m²) at a flow rate high (15 ml/min). These experimental results could be compared to numerical calculations. Finally, with an optimized geometry minimizing shear stress, a sustainable endothelialization protocol in blood capillaries has been proposed

博士
國立臺灣大學
臨床醫學研究所
100
Extracorporeal membrane oxygenation (ECMO) had been quite successfully utilized in neonatal respiratory failure, but cardiac ECMO was used more and more in recent years. In National Taiwan University Hospital, we had successful experience in adult ECMO for mechanical circulatory support, however, there were no published paper in our pediatric group. The purpose of this study was to apply ECMO for pediatric mechanical circulatory support, and try to identify the prognostic factors. The first part of this study is ECMO for post-operative circulatory failure in pediatric patients. Between January 1999 and December 2004, 2107 children had cardiac surgery in our institute. There were sixty-eight pediatric patients (3.2%), who received ECMO within 7 days after cardiac surgery in our hospital. The overall survival rate of this cohort was 32.4%. The age and gender did not affect the survival. Patients with separate biventricular physiology had a higher probability of survival than those with systemic-pulmonary shunt or cavo-pulmonary anastomosis (41.3% vs 13.6%, p<0.05). Acute renal failure during ECMO were significantly associated with mortality (83% vs 33.5%, p<0.001). After ECMO initiation, the lowest lactate levels on the 2nd-4th day were lower in the survivors than in the non-survivors (2.4 vs 3.3 mmole/L, p<0.05). There was a trend toward a better survival in recent two years in comparison to the previous 4 years (47.6% vs 25.5%, p=0.07), although it did not reach statistical significance. In this study, non bi-ventricular physiology, acute renal failure, and high blood lactate levels after ECMO increased the risk of mortality for pediatric patients requiring ECMO for post-operative cardiac support. In this part of study, we found some patients could be separate from ECMO but died in the ICU, we try to study if B-type natriuretic peptide (BNP) could be served as a marker during pediatric ECMO support. In adult patients with heart failure, decreased BNP levels after implantation of ventricular assist devices might be indicative of recovery. However, BNP levels among pediatric patients receiving mechanical support are unknown. We included fifteen pediatric patients with cardiogenic shock who were supported by extracorporeal membrane oxygenation (ECMO). The BNP levels were determined before ECMO initiation, during ECMO support, and after ECMO removal. All patients had elevated BNP levels before initiation of ECMO (median, 1430 pg/mL; range, 361–5000 pg/mL). Among the 15 patients, one received heart transplantation. ECMO was withdrawn in two patients, and the other 12 patients were weaned from ECMO. Four patients died after initial successful weaning from ECMO. The BNP levels of the non-survivors (median, 3685 pg/mL; range, 2494–5000 pg/mL) were higher than that of the survivors (median, 1127pg/mL; range, 108–3030 pg/mL) on the next few days after ECMO removal (p = 0.018). The BNP levels on the 4th day after removal of ECMO among the survivors (median, 498 pg/mL; range, 108–890 pg/mL) were lower than that among the non-survivors (median, 3900 pg/mL; range, 3230–5000 pg/mL; P < 0.01). While the differences in BNP levels at these time points reached statistical significance, the other clinical parameters, such as blood pressure, central venous pressure, lactate level, and urine amount did not. In this art, we concluded that among pediatric patients supported with ECMO, the survivors had lower BNP levels than those who did not survive. We suggest that serial blood BNP levels could be potential markers for monitoring pediatric patients on mechanical circulatory support, and the concept merits further study. The third part of this study was to apply ECMO in pediatric cardiopulmonary resuscitation (CPR), this technique now was called as ECPR. Between 1999 and 2009, we performed 54 ECPR in pediatric in-hospital cardiac arrest. The survival rate to hospital discharge was 46% (25/54), and 21 (84%) of the survivors had favorable neurological outcomes. The duration of cardiopulmonary resuscitation (CPR) was 39+/-17 minutes in the survivors and 52+/- 45 minutes in the non-survivors (p=N.S). The patients with pure cardiac causes of cardiac arrest had a similar survival rate to those with non-cardiac causes(47%[18/38] vs 44%[7/16], p=NS) The non-survivors had higher serum lactate levels prior to ECPR (13.4+/-6.4 vs 8.8+/-5.1 mmol/L , p < 0.01) and more renal failure after ECPR (66% [19/29] vs 20% [5/25], p < 0.01). The patients resuscitated between 2006-2009 had shorter a shorter duration of CPR (34+/- 13min vs 78+/- 76 min, p=0.032), and higher rates of survival (55% (16/29) vs 0% (0/8), p=0.017) than those resuscitated between 1999-2002. In summary, during the 11-year experience with ECPR for pediatric in-hospital cardiac arrest, the duration of CPR has shortened and outcomes have improved in recent years. Higher pre-ECPR lactate levels and the presence of post-ECPR renal failure were associated with increased mortality. The presence of non-cardiac causes of cardiac arrest did not preclude successful ECPR outcomes.

碩士
國立中興大學
生命科學院碩士在職專班
106
Background and Objective: Previous reports have indicated that less than 10% of out-of-hospital cardiac arrest (OHCA) patients who have undergone cardiopulmonary resuscitation (CPR) survived for hospital discharge. When the heart is unable to recover, doctors choose to implant extracorporeal membrane oxygenation (ECMO) to rescue patients. Although we have had plenty of successful experience in ECMO, the mortality rates of OHCA are still very high. So far there is still no standard procedure for how to treat OHCA patients with ECMO. The purpose of this study is to investigate the differences between survivors and non-survivors of OHCA patients treated with ECMO and to analyze the factors that are related to the success rate for ECMO weaning. Methods: This retrospective observational study included 75 OHCA patients treated with ECMO between January 2012 and December 2017 in China Medical University Hospital. The survivor group included 36 patients with successful ECMO weaning, whereas the non-survivor group included 39 patients failed ECMO weaning. Statistical analyses were performed using chi-square test and t-test for the univariate analysis and logistic regression model for multivariate analysis. We further used receiver operating characteristic (ROC) curve to evaluate the performance. Results: Fifty-one (68%) of the 75 OHCA patients were caused by acute myocardial infarction (AMI). The significant differences between survivors and non-survivors were detected in the duration of mechanical ventilation (p＜0.001), duration of intensive care unit (ICU) (P＜0.001), and duration of ECMO (P=0.001). Survivors had lower lactate concentration during initial to 48h (p＜ 0.05) and higher blood lactate clearance rate during 24h to 48h (p＜ 0.05) in comparison to the non-survivors. Lactate clearance was significantly higher in survivors than in non-survivors for the T1-T24 period (0.48±0.31 vs. 0.07±0.73, p=0.003) and remained significantly higher at each studied interval in T1-T36 and T1-T48. Multivariate logistic regression analysis using significant univariate variables showed significant correlation of ECMO weaning with both lactate clearance (T1-T24) and lactate clearance (T1-T48). In the ROC curve analysis, the area under ROC curve (AUC) of lactate clearance (T1-T24) was 0.672 (p＜ 0.05), lactate clearance (T1-T36) was 0.681 (p＜ 0.05) and lactate clearance (T1-48) was 0.771 (p＜ 0.05), respectively. After removal of the confounding factor, the AUC of lactate clearance (T1-T24) was 0.725 (p＜ 0.05), lactate clearance (T1-T36) was 0.764 (p＜ 0.05) and lactate clearance (T1-T48) was 0.845 (p＜ 0.05) respectively, indicating three factors predict the accuracy of ECMO weaning. Conclusions: In this study, survivors who succeed ECMO weaning showed lower lactate concentration and higher lactate clearance rate. Lactate clearance (T1-T24), lactate clearance (T1-T36) and lactate clearance (T1-T48) in the early period are associated with successful ECMO weaning. The survival patients with higher lactate clearance have improved outcome compared to those with lower lactate clearance.

The 2009 Influenza A (H1N1) virus quickly became a pandemic and a threat to the health of many across the globe. H1N1 was able to preferentially bind to pneumocytes in the lower lung, resulting in atelectasis, surfactant disruption, and eventual acute respiratory distress syndrome (ARDS). Management of ARDS during this time included non-ventilatory and ventilatory techniques such as conservative fluid management, prone positioning, differing PEEP levels, and Extracorporeal Membrane Oxygenation (ECMO). High cost, unequal global access to ECMO centers, and complication rates present challenges to future ECMO expansion. Despite this, the available information supports the use of ECMO for H1N1-associated ARDS. Future studies and simulations should be conducted to expand the knowledge base on using ECMO as a treatment for pandemic influenza-associated ARDS, with particular attention on bridging gaps in access for the most vulnerable and affected populations.

Extracorporeal membrane oxygenation (ECMO) is a method that allows extracorporeal life support in potentially reversible life-threatening conditions affecting the heart or lungs which are refractory to conventional treatment. Depending on the parameters of its setting, this method affects the haemodynamics of the cardiovascular system and the perfusion of the target organ. From the point of view of its character, the necessity for invasive application, and the function thereof in the conditions of the cardiovascular system, ECMO is regarded as a risky method accompanied by a number of complications. Among the critical complications are thromboembolic complications affecting the central nervous system (CNS) and haemorrhagic complications. The goal of this paper is to present and verify the prerequisites for the formation of periprocedural embolisms affecting the CNS and to evaluate the regional haemodynamics of the CNS. This is done by analysing the presence of embolisms and by analysing the parameters of blood flow rates in the right common carotid artery (arteria carotis communis-ACC) and the corresponding oxygenation of the brain tissue during various flow rate parameters generated by the ECMO support on induced heart failure in a biological porcine model. In the first section of the paper, 8...

Introduction: Left-ventricular (LV) distension and consequent pulmonary congestion are complications frequently discussed in patients with severe LV dysfunction treated with veno- arterial extracorporeal membrane oxygenation (VA ECMO). The goal of this study was to describe the influence of high VA ECMO flows to LV distension, lung hemodynamics, and lung fluid accumulation. Methods of LV decompression were studied to prevent lung edema. Methods: In all experiments porcine models under general anesthesia were used. The effects of high extracorporeal blood flow (EBF) on LV heart work were assessed in a chronic heart failure model. The effects of LV afterload on lung fluid accumulation were evaluated by electrical impedance tomography (EIT) on acute heart failure models. Phase and frequency filtration and mathematical analysis were applied to the raw EIT data. Subsequently, mini- invasive techniques of LV decompression were evaluated for LV work. Results: The stepwise increases of VA ECMO flow improved both hemodynamic and oxygenation parameters. Nevertheless, it also caused distension and increased work of LV. The rise in EBF led to increased pulmonary capillary wedge pressure and lung fluid accumulation assessed by EIT in heart failure. The methods for LV decompression (Impella pump, atrial...

博士
國立臺灣大學
臨床醫學研究所
90
Introduction John Gibbon built the first mechanical heart-lung machine to permit operations on the still heart in 1953. With the rapid progress in the development of cardiac surgery, people considered to modify the heart-lung machine for prolonged heart and lung support. The first successful use of prolonged extracorporeal support was reported in 1972 by Hill et al. The patient suffered acute post-traumatic respiratory failure, and was managed on venoarterial extracorporeal support for 3 days. From then on, extracorporeal membrane oxygenation (ECMO) is a term used to describe prolonged but temporary (< 30 days) support of heart/lung function using mechanical devices. Heart-lung machine, also called cardiopulmonary bypass (CPB), was used in the operating room to permit operations on the still heart; and ECMO was used in the intensive care units to support patients with profound cardiopulmonary failure until recovery of heart-lung function or bridge to transplantation. Both CPB and ECMO shared the same purpose of replacing cardiopulmonary function, but they had a significant difference between them. In CPB, it is always possible to aspirate large amounts of air into the venous catheters, and it is common to have rapid change of blood volume of the patient during cardiac operations. Therefore, a large venous reservoir is included in the venous drainage line, both to trap aspirated air and to allow frequent variations in extracorporeal versus intracorporeal blood volume. Because of blood stagnation in the venous reservoir, total anticoagulation is required to prevent blood clot formation in the venous reservoir. In addition, there is total stagnation in the pulmonary circulation and some chambers of the heart during total CPB for cardiac surgery. This requires total anticoagulation, too. Total anticoagulation is achieved by giving a huge dose of heparin to make whole blood clotting time indefinitely long. This total anticoagulation and uncontrolled bleeding into the operative field from the coronary sinus, bronchial veins, Thebesian veins, and surgical wounds, result in continuous bleeding. To minimize this bleeding and decrease any risks associated with high blood flow, it is common to keep low blood flow (2 ~ 2.4 L/min/m2) and low hematocrit (typically 20%). This combination of low blood flow and low hematocit leads to low systemic oxygen delivery. This is why hypothermia is required to decrease oxygen requirement to meet low systemic oxygen delivery. In contrast, ECMO only provides partial cardiopulmonary support. The patient’s heart and lungs still work. The ECMO has a closed circuit without a venous reservoir in it. Since there is no blood stagnation in the patient’s body and ECMO circuits, only light anticoagulation is required. The difference of anticoagulation requirement explains the major distinction between CPB and ECMO; and lower anticoagulation requirement makes possible the prolonged ECMO support up to several weeks with acceptable bleeding complications. There are two types of ECMO support: VA-ECMO, and VV-ECMO. VA-ECMO drains the patient’s venous blood, and returns oxygenated blood to the patient’s artery. It can support both heart and lung. VV-ECMO drains the patient’s venous blood, and returns oxygenated blood to the patient’s vein. It replaces only the lung function, and does not provide support to the heart. Therefore, VV-ECMO is used for respiratory failure only. At the National Taiwan University Hospital (NTUH), the ECMO system consists of the new microporous membrane oxygenator, centrifugal pump, and heparin-bound Carmeda Bioactive surface on all blood-contact surface of the ECMO. In fact, the NTUH had its own customer-made ECMO from the Medtronic Inc. in USA.The customer-made ECMO had no unnecessary connectors and bridges for prevention of clot formation, and the design allowed rapid priming within 10 minutes. We had a “ECMO cart”, which had all equipments and consumables needed for ECMO set-up operation. When ECMO support was needed anywhere in the hospital, ECMO cart could be sent to that place to allow ECMO set-up on the spot. By this method, we could provide ECMO support anywhere in the hospital, including catheterization room, emergency service, intensive care units, etc., within 30 minutes. In this study, we first extended clinical applications of ECMO treatment beyond conventional indications for acute cardiopulmonary failure. Then we tried to find out the prognosis predictors in ECMO treatment for adult post-cardiotomy cardiogenic shock or for all acute cardiopulmonary failure. After we knew more about prognosis predictors in ECMO treatment, we hoped to improve the outcome of ECMO treatment if we could better select patients for ECMO treatment and prevented factors that adversely affected ECMO outcome. New clinical application of ECMO: I. lung transplantation: Cardiopulmonary bypass is required in some lung transplantation (LTx) operations. However, it increases risks of bleeding and early graft dysfunction. We replaced CPB with heparin bound ECMO in LTx operations. If extracorporeal circulation was anticipated for the LTx operations, ECMO support was set up through the femoral venoarterial route after induction of anesthesia; then, LTx was done as usual. Five thousand units of heparin was injected intravenously during the femoral vessels cannulation, but no more was used during the first 24 h of ECMO support. Twelve single LTxs and 3 bilateral sequential single LTxs were done under ECMO support. The advantages of using femoral ECMO rather than conventional CPB in LTx operations were that the operative field was not disturbed by the bypass cannula, stable cardiopulmonary function and normothermia were maintained throughout the operations, there were less blood loss and transfusion requirements, and the left LTx was as easily performed as the right LTx. Red blood cell transfusion requirements during the operation and the first postoperative day were 4.4±2.8 and 2.4±2.0 units, respectively, in 10 adult patients undergoing uncomplicated single LTx with ECMO support, and 4.3±1.3 and 1.5 ± 1.5 U in 8 adult patients undergoing single LTx without any extracorporeal circulatory support. The difference was not significant between the 2 groups (p=0.53 and 0.32 by Mann —Whitney U test). The ECMO did not increase blood transfusion requirements. In comparison, 13 U of red blood cell transfusion was required in 2 patients receiving single LTx under CPB support. If necessary, as in patients undergoing single LTx for end-stage pulmonary hypertension, the ECMO support was directly extended into the postoperative period until reperfusion edema of the graft lung subsided.The ECMO support made the postoperative critical care easier in recipients with graft lung edema. Except for 2 cases of primary graft failure, the ECMO could be weaned off and removed at bedside within a short period (27.9±24.6 h, n=13) with no major complications. In conclusion, the heparin-bound femoral ECMO rather than CPB should be used for LTx operations unless concomitant cardiac repair is planned. II. non-heart-beating donors under ECMO support: Bottleneck of organ transplantation is scarcity of donor organs. One solution to this problem is non-heart-beating donors (NHBD). NHBD could provide up to 22% of renal grafts in some renal transplant programs. Taiwan is the first Asian country having a law of organ transplantation and brain death to allow organ donation from brain-dead heart-beating donors. However, we never tried organ procurement from NHBD before because of some practical difficulties. In the recent years, we developed a method of using ECMO to support NHBD for a longer time, and made feasible renal transplantation from NHBD in our situation. If a patient was accepted as a NHBD and family consent was obtained, we disconnected the ventilator and injected 25,000 units of heparin and 10 mg of phentolamine intravenously. The ECMO was primed with normal saline alone and a temperature controller was connected to the ECMO to cool down the recirculating priming solution to 4°C. After the heart stopped, the right femoral vessels were dissected and cannulated, and the cannulas were connected to the ECMO circuit. Initial ECMO blood flow was set around 2 L/min, and sweep gas flow through the oxygenator was 2 L/min with a FiO2 of 0.6. The left femoral artery was dissected, and an occlusion balloon catheter was pushed into the left femoral artery through a guide wire until the balloon was above the xyphoid process. The balloon was inflated to occlude the thoracic aorta, and bilateral femoral artery was ligated around the ECMO arterial cannula and the balloon catheter. The whole abdominal organs were well perfused by recirculating ECMO blood flow, cold and oxygenated. Bilateral femoral wounds were closed primarily. A district attorney came to the beside to confirm the donor’s asystole, interviewed the family to confirm their consent for organ donation, and completed some necessary legal documents before a legal consent was finally insued. After that, we sent the donor under the ECMO support to the operation room for the organ procurement. Laporotomy and kidney procurement were done as usual. From 1998 to 2000, there were 89 cadaveric kidney transplantations at the National Taiwan University Hospital. Seventy-one of them were from brain-dead heart-beating donors, and 18 (20%) were from 9 NHBDs. The sex was male in 7 NHBDs, and female in 2. Their ages were 37 ± 9 years old. The etiologies of brain lesions included stroke (n = 4), and head injury (n = 5). Except in one NHBD due to failed resuscitation, it was 10-20 min from ventilator disconnection to the donor’s asystole. Because of our experienced ECMO team, ECMO support could begin within 10-15 min after the donor’s asystole. The duration of ECMO support ranged from 45 min to 70 min with a median of 60 min. The cold storage duration of renal grafts was 6.3 ± 3.1 hours. (range: 4 - 12.5 hr, median: 5 hr). The sex of the kidney recipients was male in 9 recipients, and female in 9. Their ages were 41.3 ± 8.9 years. Twelve recipients (66%) had immediate graft function postoperatively, and no more needed dialysis. Six patients had delayed graft function, and postoperative hemodialysis was needed one time in 3 recipients, 3 times in 1 recipient, 4 times in 1 recipient, and 6 times in 1 recipient. Only 2 recipients needed dialysis more than one week after the kidney transplantation. The serum creatine levels were 1.6 ± 0.4 mg/dL at one month, and 1.5 ± 0.6 mg/dL at 6 month. The lowest serum creatine levels were 1.2 ± 0.3 mg/dL. During the median follow-up period of 16 months (range: 7 — 41 months), only one graft was lost due to chronic rejection at 27 month. Renal grafts from NHBD had a high incidence of delayed graft function (50-82.5%) or primary graft non-function (4-14%) in the past. The determining factor was warm ischemic injury before organ procurement from NHBD. The most common method used to decrease warm ischemic injury in renal grafts from NHBD was in situ cooling technique. The technique included abdominal aorta cannulation with a double-balloon catheter through the femoral artery, infusion of large amount of cold lactated Ringer solution through the catheter, and blood drainage through a femoral vein cannula. In comparison, our ECMO technique has several advantages. In situ cooling technique needed 6 L or more of cold solution to cool down the abdominal organs of NHBD, this required a lot of nursing work to prepare the cold solution and replace it during the perfusion. Collection of a large amount of venous drainage was another problem. In comparison, our ECMO technique was simple and labor-saving, because no extra solution was needed to run the ECMO after its priming with normal saline. Because a temperature controller was used to cool down the recirculating ECMO blood flow, the abdominal organs of NHBD could be maintained at a steady lower temperature. In addition, the ECMO oxygenator allowed gas exchange in recirculating ECMO blood flow. The thoracic aorta occlusion by a balloon catheter and bilateral femoral artery ligation directed all ECMO blood flow to perfuse the abdominal organs. Because ECMO provided cold oxygenated blood flow to the abdominal organs, their warm ischemic injury was prevented. This could explain a lower incidence of delayed graft function and no primary graft non-function by our ECMO method. There were several advantages of early graft function, including improving detection of acute rejection, permitting early therapeutic cyclosporine dose, simplifying fluid and electrolyte management, saving cost of postoperative dialysis and prolonged hospitalization. The only disadvantage of our ECMO technique was its cost. But advantages of early renal graft function could justify the cost. In conclusion, the ECMO technique made possible the kidney transplantation from NHBD in our situation. It could better prevent warm ischemic injury, and decreased risk of delayed renal graft function. III. ECMO rescue after heart transplantation: The mortality of heart transplantation (HTx) had the highest incidence in the first month after the transplantation and sharply declined afterwards.Cardiac pump dysfunction from primary graft failure or acute rejection was the most important mechanism for the early mortality. Since the primary graft failure and acute rejection were potentially reversible, if there were some mechanical circulatory devices to temporarily support the circulation until recovery of the graft function, some patients could be rescued. From Jul. 1987 to Mar. 1999, there were 113 patients undergoing 115 heart transplantations at the National Taiwan University Hospital. Two patients underwent cardiac retransplantation for primary graft failure and chronic rejection, respectively. Mechanical circulatory support was needed in the early post-transplant period in 19 of our 115 HTx operations. The MCS used in these situations included IABP alone (n = 7), IABP followed by ECMO (n = 8); and ECMO alone (n = 5). IABP could not be used in 3 girls with body weight less than 25 kg. One patient had bilateral femoral thromboembolism from dilated cardiomyopathy. One patient had the right ventricular failure alone. In these 5 patients, ECMO was directly applied without the previous IABP use. In another 8 HTx, IABP was first tried but failed to support the circulation, then the ECMO support was added. In summary, 13 ECMO supports with or without IABP were used. Nine patients needed the ECMO support for primary cardiac graft failure. Four of these patients could not be weaned from the cardiopulmonary bypass, and directly received the ECMO support in the operation rooms. One patient was fortunate enough to get another donor heart and underwent a successful retransplantation after 8 hours of ECMO and IABP support. One patient was put on the ECMO support for 161 hour and successfully weaned from it, but still died of multiple organ failure one week later. Two patients had high central venous pressure (> 12 cm-H2O) under ECMO support and could not be weaned from the ECMO support, cardiac catheterization was done to search the underlying problems. Anatomic defects of the right atrial twist and stenosis at pulmonary artery anastomosis were found, respectively. Reoperations to correct the anatomic defects were done, and both patients could be weaned off the ECMO support after the reoperations. However, due to complications from the prolonged ECMO support (168 and 216 hours), both patients died of sepsis and multiple organ failure. Five patients received the ECMO support for primary graft failure after they had been transferred to the intensive care units for the postoperative care. These five patients were successfully rescued by the ECMO support. Four patients needed the ECMO support for graft dysfunction from acute rejection. But only one of them survived. The most common complication of the ECMO support was mediastinal bleeding and cardiac tamponade. The bleeding complication was related to the ECMO route. Reexploration for hemostasis and blood colt removal was needed in 1 of 8 patients receiving the ECMO support through the femoral venoarterial route and in 4 of 5 patients receiving the ECMO support through the open sternotomy wound. If possible, ECMO support was better though the femoral veno-arterial route than through the open sternotomy wound. The femoral route had fewer complications of bleeding, infection, and sepsis, especially when the ECMO support had to extend beyond several days. Acute renal failure occurred in 6 patients before initiation of the ECMO support. Continuous hemofiltration was set up on the ECMO circuit for dialysis. Only two patients of them were long-term survivors, but they had complete renal recovery. In comparison, 5 of 7 patients without complications of acute renal failure survived. In conclusion, ECMO could provide temporary mechanical circulatory support and rescued some HTx recipients with profound heart failure in their early post-transplant periods. ECMO support for adult postcardiotomy cardiogenic shock: In order to find out factors that affected outcomes of ECMO treatment, we chose adult patients with postcardiotomy cardiogenic shock (PCS) as a study population. Because number of the patients in our series were larger and there were less interfering factors to explain post-cardiotomy cardiogenic shock, it was much easier to get a statistically significant conclusion. We performed a retrospective study to review medical records of adult patients receiving ECMO support for postcardiotomy cardiogenic shock. From Aug. 1994 to May 2000, 76 adult patients (48 male, 28 female; mean age:56.8±15.9 years) received ECMO support for PCS at the National Taiwan University Hospital. The mean ECMO blood flow was 2.53±0.84 L/min. The cardiac operations included coronary artery bypass grafting (n=37), coronary artery bypass grafting and valvular surgery (n=6), valvular surgery alone (n=14), heart transplantation (n=12), correction of congenital heart defects (n=3), implantation of a left ventricular assist device (n=2), and aortic operations (n=2). Fifty-four patients received ECMO support after intra-aortic balloon pumping, but 22 patients directly received ECMO support. Two patients were bridged to heart transplantation and two bridged to ventricular assist devices (VAD). Thirty patients died on ECMO support. The mortality etiologies included brain death (n=3), refractory arrhythmia (n=2), near motionless heart (n=2), acute graft rejection (n=1), primary graft failure (n=1), uncontrolled bleeding (n=5), and multiple organ failure (n=16). Twenty-two patients were weaned off ECMO support but presented intrahospital mortality. The mortality etiologies included brain death (n=1), sudden death (n=4), and multiple organ failure (n=17). Twenty patients were weaned off ECMO support and survived to hospital discharge. During the follow-up of 33±22 months, all were in NYHA functional status I or II except two cases of late deaths. One patient died suddenly at 11 months, and the other died of pneumonia at 12 months. Among the ECMO-weaned patients, “dialysis for acute renal failure” was a significant factor in reducing the chance of survival. When MCS was indicated, IABP was the first consideration because of its relative non-invasiveness. IABP decreases the left ventricular afterload and augments the coronary arterial perfusion. IABP is particularly beneficial for heart failure from ischemic heart diseases. However, IABP cannot remarkably increase cardiac output. Its effect is limited or infeasible in patients with profound heart failure, tachyarrhythmia, small body weight, or the right heart failure alone. When IABP support is not enough or infeasible, the next choice is VAD or ECMO. In comparison to VAD, ECMO is a better MCS choice for PCS not amenable to IABP support alone. ECMO support has several advantages. ECMO composed of microporous membrane oxygenator and centrifugal pump allows rapid priming. ECMO support via the femoral route can be emergently set up at bedside under local anesthesia. ECMO support can be easily applied through the cannula also used for CPB. ECMO support can support both the right and left heart failure, and substitute the lung function. All these advantages make ECMO support an ideal means of cardiopulmonary rescue for critical patients with an uncertain diagnosis. ECMO is much cheaper than the currently available pulsatile VAD, and can provide a temporary support giving clinicians time to decide whether patients can benefit from further aggressive treatment. Four patients suffered brain death from intraoperative stroke or resuscitation, and one patient suffered hypoxic encephalopathy from preoperative resuscitation. Applying expensive VAD in these patients would be a waste. Myocardial stunning from ischemic-reperfusion injury is the most important etiology of PCS. In theory, patients can recover from myocardial stunning regardless of the severity of cardiac dysfunction. However, no feasible methods distinguish irreversible infarction from reversible stunning in the immediate postoperative period. Seventeen patients were weaned off ECMO support, but later died of multiple organ failure. Multiple organ failure was attributed to severe secondary organs damage that had occurred before initiation of ECMO support. However, the severity of secondary organ damage was always unknown, when MCS was used for PCS. ECMO support allowed time for medical decision. Then, if necessary, the patients could be bridged to heart transplantation or other more permanent VAD. The indication of ECMO support could be less strict, because of its relative simplicity and a lower cost. More patients could be evaluated and the next step decided upon. Patients could recover rapidly from myocardial stunning caused by ischemia reperfusion injury. Therefore, VAD, which could provide long-term MCS, was usually unnecessary for most PCS. Mean durations of ECMO support for post-cardiotomy survivors were 99 ± 33 hours in this report. This study well demonstrated the concept of myocardial stunning. Under ECMO support, PCS from myocardial stunning usually could recover within 4 to 6 days. However, due to severe shock damage before ECMO set-up, some ECMO-weaned patients still died of multiple organ failure later. Prognostic predictors in ECMO treatment The outcome of ECMO treatment is always unpredictable. We conducted a prospective study to collect clinical, biochemical, immunological parameters at variable times during an ECMO course to determine which factors influenced ECMO outcome. The patients’ demography, pre-ECMO conditions, biochemistry, hematology, and arterial blood gas analysis during ECMO treatment, were recorded along with the duration, outcome and complications of the treatment. Blood was collected on the 3rd and 6th days after initiation of ECMO for cytokines study. Fifty patients, who received ECMO for acute cardio/pulmonary failure at NTUH during the period from Oct. 2000 to Sep. 2001, were included in this study; 32 were male, and 18 were female. Their ages ranged from 20 days to 84 years; their body weights ranged from 2.4 kg to 95 kg. ECMO was set up in operation rooms (n=20), intensive care units (n=18), cardiac catheterization rooms (n=3), emergency rooms (n=3), and outside hospitals (n=6). The indications of ECMO treatment included postcardiotomy cardiogenic shock (n=27), acute myocarditis (n=5), myocardial infarction that required resuscitation (n=7), cardiomyopathy with cardiogenic shock (n=2), acute respiratory distress syndrome (n=5), and others (n=4). Eleven patients (22%) died within 48 hours following initiation of ECMO. The etiologies of mortality included extremely poor heart function (n=5), severe shock damage (n=5), and uncontrollable bleeding (n=1). These three situations should be recognized as contraindications to ECMO treatment. Three patients died of brain death due to ECMO mechanical failure (n=1) or intracranial hemorrhage while on the ECMO (n=2). Sixteen patients underwent a successful ECMO treatment, but three of them died suddenly months later. However, the mortality was unrelated to the ECMO event. Only 2 of 16 successful ECMO patients needed ECMO support for more than five days. The ECMO treatment in 20 patients failed and the patients died of multiple organs failure whether or not they were weaned off ECMO. An attempt was made to identify the indicators of shock damage that predicted the outcome of ECMO treatment. However, pre-ECMO IE, pre-ECMO blood lactate levels, CPR, peak CK, CK-MB, and AST levels in the first 3 days, and peak Bil, maximum WBC count, minimum platelet count in the first week, were not different between the successful ECMO patients and failed ECMO patients. Only the variable “acute renal failure at the time of ECMO set-up” showed a significant difference between the two groups, and is a good indicator of shock damage to predict late MOF and mortality. Variables CK, CK-MB, blood lactate levels on the 3rd day, and CK, CK-MB, AST levels on the 6th day, differed between the two groups. These variables indicated persistent damage during ECMO treatment and higher values were associated with ECMO treatment failure. The failed ECMO patients had significantly higher serum levels of IL-18, IL-17, IL-6, IL-8, MCP-1 on the 3rd day, and significantly higher serum levels of IL-17, Il-6, IL-8, TNF-α on the 6th day than their successful ECMO counterparts. Persistent elevation of proinflammatory cytokines levels, including IL-18, IL-17, IL-6, IL-8, TNF-α, and MCP-1, contributed to multiple organ failure and subsequent mortality. Notably, the failed ECMO patients had significantly lower IL-12 serum levels on the 3rd day than the successful ECMO patients, but higher IL-12 serum level on the 6th day. This “early-low, late-high” pattern in the IL-12 blood level was associated with mortality in ECMO patients. To build a model to predict ECMO outcome, we combined all clinical, biochemical, immunological variables to perform a logistic regression analysis. Significant predictors (p<0.2) from simple logistic regression analyses were selected. With colinearity eliminated, multiple logistic regression was conducted by backward stepwise selection method. The significant predictors in the final model were acute renal failure at the time of ECMO set-up (odds ratio=28, 95% confidence interval: 4.43~176.8, p<0.001), sepsis from ECMO set-up to one week following ECMO removal (odds ratio=5.30, 1.14~24.54, p=0.033), and IL-12 serum level on the 3rd day (odds ratio=0.95, 0.896~0.999, p=0.049). These results imply that the presence of acute renal failure at ECMO set-up, sepsis during ECMO, and lower IL-12 serum levels on the 3rd day were positive predictors of failed ECMO treatment. Conclusion: ECMO is an ideal rescue treatment for acute cardio/pulmonary failure, but a successful ECMO treatment requires the following: 1. Acute cardiopulmonary failure treated by ECMO must be rapidly reversible. ECMO is not intended for prolonged treatment. 2. No severe shock damage must have occurred due to underlying diseases before ECMO support is begun. 3. No complications can occur during ECMO.

博士
國防醫學院
生命科學研究所
106
Background: Extracorporeal membrane oxygenation (ECMO) is most frequently used in patients experiencing cardiopulmonary failure. It uses extracorporeal circulation and gas exchange to provide relief to patients suffering from short-term reversible cardiopulmonary failure, giving the patient's cardiopulmonary system a chance to recover its gas exchange function. ECMO is thus the last resort for treating patients with cardiopulmonary failure. Currently, several studies worked on the survival to hospital discharge and prognostic factors of patients receiving ECMO, but comorbidities, severity scoring systems, and age still need more investigation. Methods: The study was divided into two parts. (1) Claimed data of ECMO patients (age ≧18 years) from the National Health Insurance Research Database (NHIRD) were used to analyze the impact of age and comorbidities on hospital mortality of ECMO patients. (2) Retrospective analyses were extended to assess patient records for VA-ECMO patients (age ≧18 years) at a medical center between 2009 and 2012. Data were collected and evaluated for each patient’s pre-ECMO conditions, duration of ECMO therapy, associated comorbidity and survival to hospital discharge. Results: (1) Claimed data: A total of 5,834 adult patients were included in the study, and 2,270 patients (38.9%) were discharged from the hospital between 2004 and 2012. The most common comorbidities in ECMO patients were coronary artery disease (35.7%), hypertension (32.0%), and acute myocardial infarction (28.4%). Interstitial lung disease (OR=4.010; p=0.010), rheumatologic disease (OR=2.201; p=0.001) and lymphoma (OR=4.416; p=0.006) were the major predictors for hospital mortality in ECMO patients. Age was also a significant predictor of mortality. On the contrary, acute myocarditis was found to be a favorable factor (OR=0.687; p=0.003). (2) A total of 187 patients (mean age: 63.5±16.4 years) were included and with a hospital survival rate of 19.8%. We found that age (OR=1.029; p=0.011), cardiogenic shock (OR=2.273, p=0.038), renal failure (OR=4.172, p<0.001), APACHE II (OR=1.131, p<0.001), MOD score (OR=1.65 1, p=0.009), and SAPS II score (OR=1.043, p<0.001) were associated risk factors of hospital mortality. APACHE II, and SAPS II score showed acceptable discrimination of hospital mortality prediction for ECMO patients (AUC=0.737 and 0.717, respectively). Conclusions: These findings can assist ECMO specialists to improve evaluations of mortality risk and provide valuable prognostic information for medical decision-making.

博士
國立臺灣大學
臨床醫學研究所
105
Extracorporeal membrane oxygenation (ECMO) provides effective respiratory and circulatory support for cardiopulmonary arrest, and has been increasingly used for patients with cardiogenic shock and acute respiratory distress syndrome (ARDS) refractory to conventional therapies. However, the overall prognosis of these patients, despite significant advances in quality of the devices and in the management of intensive care unit, remains grave. Therefore, understanding the underlying mechanisms which contribute to poor clinical outcomes is a pivotal issue to improve patient selection as well as further refine this therapeutic intervention. An ischemia/reperfusion injury testified during ECMO is systemic inflammatory response syndrome (SIRS) which is associated with the widespread activation of the innate immunity, which, if unconstrained, would result in multiple organ failure and eventual mortality. To understand the underlying mechanisms which contribute to SIRS and identify potential biomarker of predicting value for appropriate use of ECMO, plasma damage associated molecular pattern (DAMP) molecule peroxiredoxin 1 (Prdx1), inflammatory cytokines, immune cell populations, and signaling receptors of DAMP (TLR4 and CD14) were examined during the early and subsequent disease courses of adult patients who received ECMO support. In patients with cardiogenic shock, Prdx1 not only peaks earlier than all the other cytokines we study during the initial course of ECMO installation, but also predicts a worse outcome in patients who had higher initial Prdx1 plasma levels. The Prdx1 levels in patients positively correlate with hypoxic markers carbonic anhydrase IX and lactate, and inflammatory cytokines. An in vitro study demonstrates that hypoxia/re-oxygenation induced Prdx1 release from human monocytes and enhances the responsiveness of the monocytes in Prdx1-induced cytokine secretions. Furthermore, functional inhibition by Prdx1 antibody implicates a crucial role of Prdx1 in hypoxia/re-oxygenation-induced IL-6 secretion. These findings indicate that Prdx1 release during the early phase of ECMO support in cardiogenic shock patients is associated with the development of SIRS and poor clinical outcomes. For ARDS patients, high IL-10 level at the time of ECMO installation and during the first 6 hours after ECMO support stands as a promising biomarker associated with grave prognosis. The initial IL-10 level is correlated to other conventional risk evaluation scores as a predictive factor for survival, and furthermore, elevated IL-10 levels are also related to a delayed recovery of certain immune cell populations such as CD14+CD16+, CD14+TLR4+ monocytes, and T regulatory cells. Genetically, high interleukin-10 is associated to two polymorphic nucleotides (–592C and –819C) at the interleukin-10 gene promoter area. Our finding provides prognostic and mechanistic information on the outcomes of cardiogenic shock and severely respiratory distressed patients, and potentially paves the strategy to develop new therapeutic modality based on the principles of precision medicine.

碩士
國立成功大學
航空太空工程學系
104
SUMMARY Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a life support treatment for saving severe acute respiratory failure by machine-assisted extracorporeal blood oxygenation and carbon dioxide removal. The VV-ECMO drains de-oxygenated blood from patient’s large vein to the oxygenator and pumps the oxygenated blood back to the vena cava near the right atrium. Often some of the reinfused oxygenated blood would be sucked back into the drainage cannula rather than entering the desired systemic circulation, resulting in the so-called “recirculation” phenomenon. This phenomenon is the major issue in VV-ECMO cannulation that limits the support efficacy. In this study, we set up various VV-ECMO cannulation scenarios on a specially designed Mock Circulation Loop (MCL) and measured the recirculation rate in-vitro. The fluid used on the present MCL was a mixture of water, glycerol and photochromic slurry with bulk density and viscosity similar to those of the human blood. This blended photochromic slurry, which can change color under the irradiation of ultraviolet light, has been used as the media to quantify the level of oxygenation. The color of the slurry mixture can be detected and characterized using spectrometric analysis. An empirical scaling rule relating color chromaticity and recirculation rate was established on the calibration loop prior to formal recirculation assessment. VV-ECMO support efficacy pertaining to double- and single-site cannulations was evaluated in relation to ECMO pump flow rate and the deployment positioning. For double-site cannulation, we studied the ECMO circuit flow direction effect, namely, atrio-femoral flow (AF flow) and femoro-atrial flow (FA flow), and confirm that femoral drainage may lead to better support efficacy for pump flow greater than 2 L/min. In general, for both double- and single-site cannulations, VV-ECMO recirculation deteriorates as pump flow increases. The recirculation rate can be as high as 20% and 40% respectively for single-site and double-side cannulations when pump flow reaches 2.5 L/min and the trend is nearly linearly increasing as the support flow goes further higher.

碩士
臺北醫學大學
醫務管理學研究所
98
Objectives: With the continuous improvement of first-aid equipment and technologies, one of the general first-aid methods except Endotracheal Intubation and other treatments, Extracorporeal Membrane Oxygenator (ECMO), has become a rapidly developing and frequently used instrument for first-aid in recent years. However, ECMO can only maintain the vital signs of patients rather than for the utilization of effective treatments. According to the documents from the ECMO manual and other reports, the patients who received ECMO for first-aid has a greater chance of survival than other patients who receive other first-aid treatments. The main factors that may affect the mortality of patients after the operations are the physicians (sex, age, and department) or the characteristics of patients (sex, age, principal diagnosis, and Charlson Comorbidity Index). Therefore, the study attempts to use ECMO as an example; meanwhile, it is the first research on the relationship between the volume of physician service and in-hospital mortality as well. Methods: The information for the study are obtained from National Health Insurance Research Database of Taiwan from the years 2005 to 2008 that includes Registry for Contracted Medical Facililities (HOSB), Registry for Board-certified Specialists (DOC), Registry for Medical Personnel (PER), and Inpatient Expenditures by Admissions (DD). The subjects of the study are patients over the age of eighteen who received ECMO (ICD-9-CM code 39.65) treatment for first-aid. The volume of physician service was separately divided into three groups (medium, high and very high). The outcome of taking care of patients is the in-hospital mortality. The information was analyzed by Chi-square Test (χ2 Test) and Conditional Generalized Estimating Equation Model (GEE) in order to observe the relationship between the volume of the physician service and in-hospital mortality. Results: In Chi-square Test (χ2 Test), the unadjusted rates of mortality among the groups of the physician service divided into medium, high and very high were separately presented the percentage of 60.77%, 53.70% and 50.21% (p &lt;0.01). After controlling and removing all other variables through Conditional Generalized Estimating Equations (GEE), it shows that the ratio of in-hospital mortality in the high and very high volume of physician service groups were 0.73(95% C.I.= 0.54-0.98) and 0.63(95% C.I. = 0.46-0.87) compared to the medium volume of physician service group. Conclusion: After obtaining the result from the adjustment, it is concluded that the ratio of in-hospital mortality among the high volume and the very high volume of physician service groups have significant discrepancy (p&lt;0.05; p&lt;0.01). All in all, the in-hospital mortality can be reduced by increasing the volume of the physician service. Recommended: (1) The Central of Health Authorized Association in Taiwan may establish medical quality control standard indexes and specified obligation systems. (2) All of the hospitals may develop the benchmark of team learning and clinical education training. (3) The researchers may institute a physician interviews system for the future study.

碩士
國立陽明大學
醫務管理研究所
103
Background: Extracorporeal membrane oxygenation (ECMO) is an important life support for respiratory failure which provides patients cardiac and respiratory support. ECMO was first used in adult with life-threatening respiratory failure in 1971 and was widely used for cardiac and respiratory support. ECMO is recommended in use for severe respiratory failure and circulatory failure patients. Further analysis of the way of organ and system failure, sepsis was life threatening and a common cause of respiratory and circulatory failure. Due to limited data on the outcomes of adults with septic shock undergoing ECMO existed, it is important to figure out the relationships between ECMO use patient and septic stasis and provide better management for ECMO. Methods: Data for this study was derived from the Taiwan National Health Insurance (NHI) program was launched in 1995. The National Health Insurance Research Database (NHIRD) is a nationwide database extracted from the claim data of the NHI program for research purposes. In this study, we used a longitudinal cohort database (Longitudinal Health Insurance Database, LHID2005) that contains claim data of one million randomly sampled individuals who were insured in 2005. This dataset has been confirmed as having no significant differences in either age, gender or health care costs from its whole population composed of all beneficiaries under the NHI program. This anonymous database contains information regarding inpatient and outpatient medical claims, including prescription records. The claim data comprise administrative information including admission month, year, admission type, and various demographic information such as age, gender and medical costs, as well as medical information such as diagnosis, prescription and intervention. In this database, the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9 CM) codes are used for diagnosis and NHI codes are used for reimbursement including prescription and intervention.   Results: In this study, the ECMO patients were collected from 2005 to 2010. The numbers of ECMO use increased every year from 2005 to 2010. The survival rate decreased in 2005 to 2006 but increased since 2007 due to invalid use. The risk factors of mortality in using ECMO included age, dyslipidemia and sepsis status.(Odds ratio: 2.399, 2.923, and 5.416 respectively) Sepsis group and non-sepsis group had no difference in 30 days survival rate but different in survival to discharge. (Sepsis vs non-sepsis: 21.88% vs 53.45%, P=0.002). Conclusion: The risk factors of mortality in using ECMO included age, dyslipidemia and sepsis status. Sepsis in ECMO use did not affect 30 days survival rate but did affect survival to discharge. Key words: Extracorporeal Membrane Oxygenation, ECMO, Extracorporeal Life support, ELS, ECLS, Risk factor, Medical Expenditure, Sepsis

碩士
臺北醫學大學
傷害防治學研究所
104
Objective: Application of extracorporeal membrane oxygenation (ECMO) for life support has been widely used in various fields of resuscitation. When the common femoral artery (CFA) is used during cannulation for ECMO support in adults is often complicated by limb ischemia. Placement of distal perfusion catheter (DPC) can reduce the incidence of limb ischemia and increases the likelihood of limb preservation, but selection criteria is uncertain. Methods: This is a retrospective study. Data was reviewed of patients in one medical center who were supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) via CFA cannulation percutaneously between January 2008 and June 2014. Two groups were divided as no-ischemia and ischemic limb. Age, sex, height, weight, body surface area (BSA), cannula size, femoral artery diameter, co-morbidity, acute physiology and chronic health evaluation (APACHE) II score, vasoactive-inotropic score (VIS) and mortality rate were analysed. Doppler was used by measuring the distal pulsation in the dorsalis pedis and posterior tibial artery to select the patients. A DPC was prophylactic inserted percutaneously into the superficial femoral artery for antegrade flow to the extremity in the patient with selection criteria. Result: 139 (43.6%) patients were included in the study and limb ischemia occurred in 46 (33%) of 139. There was a significant difference between the no-ischemia group and the ischemia group in age (55.5±14.2 vs 63.2±13.2 ; P < .001 ), Common femoral artery diameter (0.82±0.14 vs 0.63±0.17 ; P < .001 ), known peripheral artery occlusive disease (9% vs 24% ; P < .001) and VIS (12.1±8.1 vs 15.8±10.1 ; P < .001). Mortality rate was higher in the ischemia group (46% vs 26% ; P < .001). 11 patients are used DPC prophylactic inserted with selection criteria and they were no ischemia limb occurred. Conculsion: Smaller common femoral artery diameter (<= 6.3 cm) or known peripheral arterial occlusive disease or higher VIS (>=15.8) or absence of distal pulsation pre-cannulation or post-cannulation immediately or 4 hrs later have higher risk of limb ischemia when CFA cannulation for VA ECMO. Due to the mortality and morbidity rate were increased when limb ischemia occurred. A DPC should be prophylactic inserted in the high risk patients with selection criteria.

碩士
嘉南藥理大學
醫務管理系
104
Today the medical disputes in Taiwan have occurred frequently. For most people, ECMO is regarded at a severe medical help symbol. However, there are many restrictions of using ECMO and the investment medical personnel and costs are huge. Therefore, this study tries to take ECMO as an example to explore the role of health communication in a medical environment and on critical care decision-making. This study uses theoretical sampling and selected twelve critical care team professionals as samples and conducted in-depth interviews using qualitative research. Grounded theory analysis was used for data analysis. Studies have shown that factors affecting the health of communication can be divided into the cognitive aspects of medical, demographic variables respect, health communication content and external factors. The models of today's critical care clinical decision-making are shared medical decisions, informed decision-making and professional mentor-based decision-making. Health communication will directly affect the critical care decision-making, such as trust , medical information asymmetry and other factors. The study suggests that cognitive aspects of health care can enhance the popularization of medical knowledge and understand the characteristics of health care can reduce the gap between expectation and clinical; Health communication process in view to complete and time permit to fulfill our obligations to communicate, By linking relevant team resources to ensure the quality of communication when necessary. Finally, we should establish a friendly medical treatment culture gradually improve today's health care environment and the relative collapse of the doctor-patient relationship, Reach patients, families and medical end-win situation.

Introduction: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is widely used in the treatment of circulatory failure, but repeatedly, its negative effects on the left ventricle (LV) have been observed. The purpose of this study is to assess the influence of ex- tracorporeal blood flow (EBF) on systemic hemodynamic changes and LV performance parameters during VA ECMO therapy of decompensated heart failure. Methods: Porcine models of low-output chronic and acute heart failure were developed by long-term fast cardiac pacing and coronary hypoxemia, respectively. Profound signs of circulatory decompensation were defined by reduced cardiac output and tissue hypoperfusion. Sub- sequently, under total anesthesia and artificial ventilation, VA ECMO was introduced. LV performance and organ specific parameters were recorded at different levels of EBF using an LV pressure-volume loop analysis, arterial flow probes on carotid and subclavian arteries, and transcutaneous probes positioned to measure cerebral and forelimb regional tissue oxygen saturations. Results: Conditions of severely decompensated heart failure led to systemic hypotension, low tissue and mixed venous oxygen saturations, and increase in LV end-diastolic pressure. By increasing the EBF from minimal flow to 5 L/min, we observed a...

Current Possibilities in Use of a Centrifugal Pump in the Cardiac Sugery Abstract Currently, the most commonly used technical solution for pumping blood during extracorporeal circulation during cardiac surgery, as well as for some types of ECMO (extracorporeal membrane oxygenation) are either a roller pump or centrifugal pump. Due to its advantages the centrifugal pump is mainly used for prolonged extracorporeal circulation in cardiac surgery and as a heart and / or lung support system. In current literature there is a lack of compelling scientific evidence that would clearly support its use in a routine cardiac surgery. The aim of our study was to compare both types of currently used blood pumps in longer cardiac procedures with deep hypothermic circulation arrest. In a randomized clinical study we had selected a group of patients that underwent a pulmonary endarterectomy (PEA) in order to demonstrate the positive effects of the centrifugal pump on the postoperative inflammatory reactions. There were no statistically significant differences between these two pumps when other clinical and laboratory parameters were observed. Based on the hypothesis that significant temperature changes during cardiac procedure with a deep hypothermia can affect sealing pressure of the endotracheal tube cuff, we performed a...