Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support

 

by Quentin de Roux, Yekcan Disli, Wulfran Bougouin, Marie Renaudier, Ali Jendoubi, Jean-Claude Merle, Mathilde Delage, Lucile Picard, Faiza Sayagh, Chamsedine Cherait, Thierry Folliguet, Christophe Quesnel, Aymeric Becq and Nicolas Mongardon 

 

Annals of Intensive Care volume 14, Article number: 104, Published: 03 July 2024

 

Introduction

Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients.

Materials and methods

A retrospective single-center study (2013–2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation.

Results

A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7–17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07–50.01], p = 0.042).

Conclusion

UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

 

 

Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications

 

By Sasa Rajsic, Benedikt Treml, Dragana Jadzic, Robert Breitkopf, Christoph Oberleitner, Marina Popovic Krneta and Zoran Bukumiric 

 

Annals of Intensive Care volume 12, Article number: 93 (2022) 

 

Background

Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock.

Methods

We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size.

Results

Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality.

Conclusions

Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.

 

How to improve intubation in the intensive care unit. Update on knowledge and devices

 

De Jong, A., Myatra, S.N., Roca, O. et al.

Intensive Care Med 48, 1287–1298 (2022).

Tracheal intubation in the critically ill is associated with serious complications, mainly cardiovascular collapse and severe hypoxemia. In this narrative review, we present an update of interventions aiming to decrease these complications. MACOCHA is a simple score that helps to identify patients at risk of difficult intubation in the intensive care unit (ICU). Preoxygenation combining the use of inspiratory support and positive end-expiratory pressure should remain the standard method for preoxygenation of hypoxemic patients. Apneic oxygenation using high-flow nasal oxygen may be supplemented, to prevent further hypoxemia during tracheal intubation. Face mask ventilation after rapid sequence induction may also be used to prevent hypoxemia, in selected patients without high-risk of aspiration. Hemodynamic optimization and management are essential before, during and after the intubation procedure. All these elements can be integrated in a bundle. An airway management algorithm should be adopted in each ICU and adapted to the needs, situation and expertise of each operator. Videolaryngoscopes should be used by experienced operators.

SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications?

link to article: SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications?

by Pierre Tissières and Jean-Louis Teboul 

Annals of Intensive Care volume 10, Article number: 98 (2020) 23 July 2020

Recent paediatric cases of acute myocarditis following a SARS-CoV-2 infection have raised the possibility of post-infective complications of COVID-19. This short editorial is reviewing current understanding of this new complication, its pathophysiology, diagnosis and therapeutic strategy.

COVID-19 post-infective acute myocarditis, an unrecognized complication?

Recent descriptions of a short outbreak of acute myocarditis in otherwise healthy children raise the hypothesis of additional critical complications of SARS-CoV-2 infection [1,2,3,4,5,6]. Grimaud et al. just reported in Annals of Intensive Care, a series of 20 critically ill children with shock admitted, during a 12-day period, in four pediatric intensive care units in the Paris urban area [1]. This outbreak occurred after 4–6 weeks of strict lockdown. All children had acute myocardial dysfunction requiring cardiovascular support. This study confirmed similar observations from United Kingdom, France and Switzerland [2,3,4,5,6]. In the Grimaud et al. study, 19 out of 20 children had either positive SARS-CoV-2 detection by quantitative PCR or positive serology. The remaining child had a typical SARS-CoV-2 chest tomography scan. Note that all children had abdominal symptoms [1].

Acute heart failure is clearly a dissonant clinical feature of COVID-19 infection in children that is known to be less frequent and less severe than in adults and with very low mortality [7, 8]. Besides its unusual nature, the main characteristic of COVID-19 acute myocarditis is its association with major multisystem inflammatory syndrome, mimicking a well-known pediatric entity, the Kawasaki disease. Currently three case definitions issued from the World Health Organization, the Centers for Disease Control and Prevention and the Royal College of Paediatrics and Child Health related to this emerging inflammatory condition during COVID-19 pandemic exist. Those definitions identify the multisystem inflammatory syndrome in children (MIS-C) or the Pediatric Inflammatory Multisystem Syndrome (PIMS) [4]. All three case definitions include either partial or full criteria for Kawasaki disease and evidence of COVID-19 diagnosis (clinical and/or biological—serology/PCR). Kawasaki disease’s, which affect mostly young children of less than 5 years of age, has typical clinical features including: (1) prolonged fever, (2) conjunctivitis, (3) dry cracked lips, ((4) cervical adenopathy (5) diffuse skin rash involving the trunk and extremities, subsequent desquamation of the tips of the toes and fingers, and 6) edema. In addition to classical manifestations of Kawasaki disease, MIS-C patients, who are much older, display digestive symptoms, shock and myocardial involvement more frequently [9]. Kawasaki disease pathophysiology refers to a systemic arteritis with the most severe complication being coronary aneurysm. Kawasaki disease can follow by a few days or weeks a wide range of infection involving numerous viruses such as EBV, MERS- and SARS-CoV-1, H1N1 influenza and other respiratory illnesses [10]… cont

Acute complications and mortality in hospitalized patients with coronavirus disease 2019: a systematic review and meta-analysis

Acute complications and mortality in hospitalized patients with coronavirus disease 2019: a systematic review and meta-analysis

by Nicola Potere, Emanuele Valeriani, Matteo Candeloro, Marco Tana, Ettore Porreca, Antonio Abbate, Silvia Spoto, Anne W. S. Rutjes and Marcello Di Nisio

Critical Care volume 24, Article number: 389 (2020) 

Background

The incidence of acute complications and mortality associated with COVID-19 remains poorly characterized. The aims of this systematic review and meta-analysis were to summarize the evidence on clinically relevant outcomes in hospitalized patients with COVID-19.

Methods

MEDLINE, EMBASE, PubMed, and medRxiv were searched up to April 20, 2020, for studies including hospitalized symptomatic adult patients with laboratory-confirmed COVID-19. The primary outcomes were all-cause mortality and acute respiratory distress syndrome (ARDS). The secondary outcomes included acute cardiac or kidney injury, shock, coagulopathy, and venous thromboembolism. The main analysis was based on data from peer-reviewed studies. Summary estimates and the corresponding 95% prediction intervals (PIs) were obtained through meta-analyses.

Results

A total of 44 peer-reviewed studies with 14,866 COVID-19 patients were included. In general, risk of bias was high. All-cause mortality was 10% overall (95% PI, 2 to 39%; 1687/14203 patients; 43 studies), 34% in patients admitted to intensive care units (95% PI, 8 to 76%; 659/2368 patients; 10 studies), 83% in patients requiring invasive ventilation (95% PI, 1 to 100%; 180/220 patients; 6 studies), and 75% in patients who developed ARDS (95% PI, 35 to 94%; 339/455 patients; 11 studies). On average, ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies), acute cardiac injury in 15% (95% PI, 5 to 38%; 452/2389 patients; 10 studies), venous thromboembolism in 15% (95% PI, 0 to 100%; patients; 3 studies), acute kidney injury in 6% (95% PI, 1 to 41%; 318/4682 patients; 15 studies), coagulopathy in 6% (95% PI, 1 to 39%; 223/3370 patients; 9 studies), and shock in 3% (95% PI, 0 to 61%; 203/4309 patients; 13 studies).

Conclusions

Mortality was very high in critically ill patients based on very low-quality evidence due to striking heterogeneity and risk of bias. The incidence of clinically relevant outcomes was substantial, although reported by only one third of the studies suggesting considerable underreporting.

Acute Systemic Complications of Convulsive Status Epilepticus—A Systematic Review

Acute Systemic Complications of Convulsive Status Epilepticus—A Systematic Review

Sutter, R et al
Critical Care Medicine: January 2018 - Volume 46 - Issue 1 - p 138–145

Objectives: Status epilepticus is a neurologic emergency with high morbidity and mortality requiring neurointensive care and treatment of systemic complications. This systematic review compiles the current literature on acute systemic complications of generalized convulsive status epilepticus in adults and their immediate clinical impact along with recommendations for optimal neurointensive care. 
Data Sources: We searched PubMed, Medline, Embase, and the Cochrane library for articles published between 1960 and 2016 and reporting on systemic complications of convulsive status epilepticus. Study Selection: All identified studies were screened for eligibility by two independent reviewers. Data Extraction: Key data were extracted using standardized data collection forms. Data Synthesis: Thirty-two of 3,046 screened articles were included. Acute manifestations and complications reported in association with generalized convulsive status epilepticus can affect all organ systems fueling complex cascades and multiple organ interactions. Most reported complications result from generalized excessive muscle contractions that increase body temperature and serum potassium levels and may interfere with proper and coordinated function of respiratory muscles followed by hypoxia and respiratory acidosis. Increased plasma catecholamines can cause a decay of skeletal muscle cells and cardiac function, including stress cardiomyopathy. Systemic complications are often underestimated or misinterpreted as they may mimic underlying causes of generalized convulsive status epilepticus or treatment-related adverse events. 
Conclusions: Management of generalized convulsive status epilepticus should center on the administration of antiseizure drugs, treatment of the underlying causes, and the attendant systemic consequences to prevent secondary seizure-related injuries. Heightened awareness, systematic clinical assessment, and diagnostic workup and management based on the proposed algorithm are advocated as they are keys to optimal outcome.