Objective To investigate the indications, procedures, risks and efficacy of extracorporeal membrane oxygenation (ECMO) in bronchoscopic interventional surgery for patients with severe airway stenosis. Methods Retrospective analysis was performed on 6 patients with severe airway stenosis treated by bronchoscopic surgery under ECMO in West China Hospital from January 2018 to July 2021, and the experience of application was summarized in combination with 23 relevant literatures retrieved. Results Six patients on ECMO successfully completed bronchoscopic interventional surgery with satisfactory intraoperative oxygenation and no obvious hemostasis difficulties were observed. ECMO placement was as an emergency medical countermeasure in 3 patients while the other 3 patients were as preventive purpose. Following treatment, the shortness of breath index and mMRC score decreased and the patients were cured and discharged. During hospitalization, 3 patients had lower extremity deep vein thrombosis, and 1 patient with lower extremity swelling and pain, which was relieved after treatment with low molecular weight heparin. During discharge follow-up, 1 patient died due to airway stenosis, pulmonary infection, and subarachnoid hemorrhage secondary to cardiopulmonary resuscitation, while the other 5 patients did not show any worsening of dyspnea. Combined with the retrieval of 46 similar cases reported in the literature before 2020, it was concluded that these patients who met the application indications of ECMO and followed the shutdown procedure had a good prognosis and controllable risk. Conclusions ECMO can ensure the safety of patients with severe airway stenosis who need undergoing bronchoscopic interventional surgery for patients, improve the success rate of the operation and do not significantly increase the risk of bleeding. However, ECMO is difficult to operate and requires professional team management. Therefore, it is essential to master the indications of application, implement strict withdrawal procedures and necessary monitoring to improve the patient's cure rate and reduce the occurrence of adverse events.
Objective We aimed to evaluate the comparative efficacy and cost-effectiveness of the ECMO versus mechanical ventilation through a rapid health technology assessment. Methods PubMed, EMbase, The Cochrane Library, CNKI, WanFang Data, and CBM databases were electronically searched to collect randomized controlled trials (RCTs), systematic reviews, meta-analyses, complete economic evaluations, and CRD database for HTA reports from inception to December 2020. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of the included studies. Descriptive analysis and summary were then performed. Results A total of 21 references were involved, including 2 HTA reports, 5 RCTs, 11 systematic reviews or meta-analyses, and 3 economic evaluations. The quality of the literature evidence was heterogenous, and only 2 RCTs of high quality were included for meta-analysis. The results showed that the difference of 60-day mortality between ECMO and mechanical ventilation was statistically significant (RR=0.73, 95%CI 0.57 to 0.92, P=0.007). The majority of recent meta-analysis literature showed that short-term mortality of ECMO treatment was lower than that of mechanically ventilated patients. The cost-effective literature from different countries all showed that it was cost-effective in their respective health system, however, the quality of the literature varied. Conclusions Current evidence shows that ECMO has better safety, effectiveness and cost-effectiveness for ARDS compared with mechanical ventilation. However, it still required to be verified by high-quality studies with a long-term follow-up. Validate conclusions are needed through rigorous health technology assessments.
[Abstract]Acute cardiac tamponade after thoracoscopic lobectomy is extremely rare and highly lethal once it occurs. This paper reports a case of a 64-year-old male with preoperative hypertension and coronary heart disease who underwent video-assisted thoracoscopic right upper lung wedge resection for early-stage lung adenocarcinoma. Three hours postoperatively, he suddenly developed hypotension and loss of consciousness. Ultrasound indicated a large amount of pericardial effusion, suggesting cardiac tamponade. Despite emergency pericardiocentesis, his hemodynamics did not improve, and the patient went into cardiac arrest. Subsequent veno-arterial extracorporeal membrane oxygenation was performed to support systemic circulation, and emergency thoracotomy was carried out. During the surgery, a needle-like tear in the anterior wall of the ascending aorta was found, corresponding exactly to a prominent staple at the lung resection margin, suggesting a stapler malfunction. After vascular repair, the patient recovered smoothly and was discharged. This case suggests that during lung resection, great attention should be paid to the integrity of staples and anatomical variations of large vessels, and vigilance is needed for rare but potentially fatal stapler-related complications.
Objective To analyze the risk factors for death in children with interruption of aortic arch (IAA) and ventricular septal defect (VSD) after one-stage radical surgery. Methods A retrospective analysis was performed on patients with IAA and VSD who underwent one-stage radical treatment in the First Hospital of Hebei Medical University from January 2006 to January 2017. Cox proportional hazards regression model was used to analyze the risk factors for death after the surgery. Results A total of 152 children were enrolled, including 70 males and 82 females. Twenty-two patients died with a mean age of 30.73±9.21 d, and the other 130 patients survived with a mean age of 37.62±11.06 d. The Cox analysis showed that younger age (OR=0.551, 95%CI 0.320-0.984, P=0.004), low body weight (OR=0.632, 95%CI 0.313-0.966, P=0.003), large ratio of VSD diameter/aortic root diameter (VSD/AO, OR=2.547, 95%CI 1.095-7.517, P=0.044), long cardiopulmonary bypass time (OR=1.374, 95%CI 1.000-3.227, P=0.038), left ventricular outflow tract obstruction (LVOTO, OR=3.959, 95%CI 1.123-9.268, P=0.015) were independent risk factors for postoperative death. Conclusion For children with IAA and VSD, younger age, low body weight, large ratio of VSD/AO, long cardiopulmonary bypass time and LVOTO are risk factors for death after one-stage radical surgery.
Cardiogenic shock (CS) describes a physiological state of end-organ hypoperfusion characterized by reduced cardiac output in the presence of adequate intravascular volume. Mortality still remains exceptionally high. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has become the preferred device for short-term hemodynamic support in patients with CS. ECMO provides the highest cardiac output, complete cardiopulmonary support. In addition, the device has portable characteristics, more familiar to medical personnel. VA ECMO provides cardiopulmonary support for patients in profound CS as a bridge to myocardial recovery. This review provides an overview of VA ECMO in salvage of CS, emphasizing the indications, management and further direction.
ObjectiveTo analyze the risk factors for pediatric heart transplantation at a single center and its impact on short-term prognosis, providing experience and reference for pediatric heart transplantation. MethodsThe children who underwent heart transplantation from May 2022 to May 2024 at the Seventh Medical Center of Chinese PLA General Hospital were included in this study. We conducted a retrospective analysis of the clinical data of donors and recipients, perioperative conditions, and postoperative complications. The double-lumen venoplasty technique was used for all surgeries. Basiliximab was applied for immune induction during and after the operation (on the 4th day). Tacrolimus+mycophenolate mofetil+prednisolone acetate was used for postoperative immunosuppressive maintenance treatment. According to whether patients had a history of extracorporeal membrane oxygenation (ECMO) installation before surgery, they were divided into an ECMO group and a non-ECMO group. The postoperative ICU stay time, postoperative ventilator assistance time, aortic clamping time, cardiopulmonary bypass time, recipient body surface area, left ventricular ejection fraction, X-ray cardiothoracic ratio, donor heart cold ischemia time, and the weight ratio between donor and recipient were compared between the two groups, and correlation analysis was performed. ResultsA total of 17 children were included, with 10 (58.8%) males and 7 (41.2%) females. Their ages ranged from 7 months to 16 years, with a median age of 11.0 (10.0, 13.0) years. Their weights ranged from 7.0 to 67.5 kg, with an average weight of (41.6±16.7) kg. Of the 17 children, 16 survived post-operation, and 1 died 5 days after the operation. Five patients were ABO incompatible heart transplantations, and 11 patients had a history of ECMO installation before surgery. The left ventricular ejection fraction of the non-ECMO group was higher than that of the ECMO group (t=2.188, P=0.045). The postoperative ICU stay time and postoperative ventilator assistance time (r=0.599, P=0.011), and cardiopulmonary bypass time (r=0.667, P=0.003) were positively correlated. The cardiothoracic ratio was negatively correlated with the postoperative ventilator assistance time (r=−0.527, P=0.030). ConclusionPediatric heart transplantation is an effective treatment method for children with end-stage heart failure. The left ventricular ejection fraction of the recipient may be a predictive factor indicating that the child needs ECMO assistance. Longer extracorporeal circulation time and larger recipient body surface area may affect the surgical process and perioperative prognosis.
During the new coronavirus disease 2019 (COVID-19) pandemic, there has been controversy over whether emergency surgical management should be performed or not in the patients with COVID-19. Stanford type A aortic dissection is a very urgent life-threatening disease, and guidelines recommend surgical treatment for patients with type A aortic dissection in the first instance. However, intraoperative extracorporeal circulation can be fatal to patients recovering from COVID-19. During the pandemic, extracorporeal membrane oxygenation (ECMO) has played an important role in supporting COVID-19 patients with acute respiratory failure. This article reports a successful V-V ECMO treatment for a Stanford type A aortic dissection patient, who suffered respiratory failure caused by COVID-19 after emergency surgery.
ObjectiveTo explore the clinical value of fibrinogen-albumin-ratio (FAR) in adult extracorporeal membrane oxygenation (ECMO) hemorrhage. MethodsThe clinical data of adult patients receiving ECMO in the West China Hospital from 2018 to 2020 were analyzed retrospectively. Patients were divided into a bleeding group and a non-bleeding group based on whether they experienced bleeding after ECMO. Logistic regression analysis was used to study the relationship between FAR and bleeding, as well as risk factors for death. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive ability of FAR. According to the optimal cut-off value of FAR for predicting hemorrhage, patients were divided into a high-risk group and a low-risk group, and the occurrence of bleeding was compared between the two groups. ResultsA total of 125 patients were enrolled in this study, including 85 males and 40 females, aged 46.00 (31.50, 55.50) years. Among them, 58 patients received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 67 patients received veno-venous extracorporeal membrane oxygenation (VV-ECMO). There were 49 patients having bleeding, and the lactate level was higher (P=0.026), the platelet count before ECMO initiation and 24 h after ECMO initiation was lower (P=0.031, 0.020), the fibrinogen level 24 h after ECMO initiation was lower (P=0.049), and the proportion of myocarditis patients was higher (P=0.017) in the bleeding group than those of the non-bleeding group. In the subgroup analysis of ECMO mode, the higher D-Dimer, lactate level and lower FAR before and 24 h after ECMO initiation were associated with bleeding in the VA-ECMO group (P=0.017, 0.011, 0.033, 0.005). The 24 h FAR was independently correlated with bleeding (P=0.048), and AUC was 0.714. The cut-off value was 55.73. According to this optimal cut-off value, 25 patients were divided into the high-risk group (≤55.73) and 33 into the low-risk group (>55.73). There was a higher incidence of bleeding in the high-risk group compared to the low-risk group (unadjusted P=0.002; P=0.013 for multivariable adjustment). In the VV-ECMO group, the relationship between FAR and bleeding events was not significant (P>0.05). ConclusionLow 24 h FAR is an independent risk factor for bleeding in VA-ECMO patients, and the diagnostic cut-off value is 55.73.
ObjectiveTo explore the diagnosis and treatment of severe adenovirus pneumonia patients with severe acute respiratory distress syndrome (ARDS) in a short time and reduce the complications after rehabilitation. MethodsThe clinical data, laboratory results, treatment process and imaging outcomes of three severe community-acquired adenovirus pneumonia patients with normal immune function were analyzed. ResultsAll the three patients developed ARDS in a very short time. In the early stage, alveolar lavage fluid obtained by fiberoptic bronchoscopy was taken for macrogenomic second-generation sequencing (mNGS), adenovirus was detected and antiviral drugs were immediately used. The first two patients received cidofovir antiviral therapy and the third patient received ribavirin antiviral therapy. All three patients received very high respiratory support, of which the first two received extracorporeal membrane oxygenation treatment. The lungs of all three patients recovered well after treatment. ConclusionsThe diagnosis and treatment of severe adenovirus pneumonia is still based on individualized symptomatic support, immune regulation and treatment of complications. mNGS can help diagnose and direct treatment of adenovirus pneumonia as early as possible, which is beneficial to reduce complications and improve survival rate.
目的 分析股动静脉插管在体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）抢救治疗中的临床应用。方法 回顾性分析笔者所在医院2002 年6 月至2010年7 月期间因重症心肺功能衰竭而施行股动静脉插管并进行静脉-动脉转流体外膜肺氧合（VA-ECMO）抢救的47例患者的临床资料。结果 本组47例患者均顺利施行ECMO支持，37例患者经过治疗后治愈出院，10例死亡。插管并发症有出血、肢体缺血等，均经相应处理后治愈。结论 ECMO对急性心肺衰竭是理想的支持方法，股动静脉为急救插管的首选通道。