Recombinant human activated protein C in acute lung injury: what is the role of bronchial circulation?

Impairment of the protein C pathway plays a central role in the pathogenesis of sepsis. Treatment with recombinant human activated protein C (rhAPC) has been reported to increase survival from severe sepsis. Protein C levels also decrease markedly in acute lung injury, of both septic and nonseptic origin. Low levels of protein C in acute lung injury are associated with poor clinical outcome. The present article discusses the beneficial effects of rhAPC in oleic acid-induced lung injury as well as the controversies between different animal models and the timing of drug administration. The unique bronchial circulation in ovine models seems to be responsible for the beneficial effects of rhAPC when given simultaneously to the injury

Extra-corporeal membrane oxygenation in aortic surgery and dissection : a systematic review

BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection. AIM To review the available literature to determine if there was any evidence. METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words. RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived. CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude

Argatroban anticoagulation for adult extracorporeal membrane oxygenation : a systematic review

Background: Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. Methods: A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. Results: The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). Conclusions: Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted

Children with burn injuries-assessment of trauma, neglect, violence and abuse

Burns are an important cause of injury to young children, being the third most frequent cause of injury resulting in death behind motor vehicle accidents and drowning. Burn injuries account for the greatest length of stay of all hospital admissions for injuries and costs associated with care are substantial

The ProtekDuo® Cannula for Acute Mechanical Circulatory Support

The ProtekDuo® is a dual lumen cannula that can be used in numerous configurations to treat cardiogenic shock and hypotension. Its default function is as a temporary percutaneous right ventricular assist device (RVAD) system, however, other configurations both alone and with other mechanical circulatory support (MCS) devices have evolved. In addition to its use as a component of a ventricular assist device (VAD), it can be used as a cannula for extracorporeal membrane oxygenation (ECMO) and may serve as double lumen drainage cannula on cardiopulmonary bypass (CPB). The role of the cannula in ECMO has been described in multiple configurations including traditional veno-pulmonary (V-P) or “oxygenated RVAD” (oxyRVAD), veno-venopulmonary (V-VP), or venopulmonary-arterial (VP-A). This book chapter summarizes various configurations and technical aspects of the ProtekDuo(R) cannula in the management of hypotension and cardiogenic shock

Recombinant human activated protein C attenuates cardiovascular and microcirculatory dysfunction in acute lung injury and septic shock

Introduction: This prospective, randomized, controlled, experimental animal study looks at the effects of recombinant human activated protein C (rhAPC) on global hemodynamics and microcirculation in ovine acute lung injury (ALI) and septic shock, resulting from smoke inhalation injury

Bridging the gap: safety and outcomes of intensivist-led ECMO retrievals

PurposeMost extracorporeal membrane oxygenation (ECMO) cannulations are performed by cardiothoracic surgeons (CTS). Due to an increase in utilization of ECMO and limited availability of CTS, there is a mismatch between ECMO demand and CTS accessibility for remote cannulations. We report our intensivist-led program’s experience in remote ECMO cannulations, retrievals, complications, and outcomes.Materials and methodsA prospective, single-center, observational study was performed on patients that required ECMO cannulation at the referring facilities and were transported to our institution between program initiation, on October 1, 2014 to September 30, 2022. Results were presented as mean ± SD, median (min – max) or number (%).ResultsSince program commencement, 305 patients were accepted for ECMO retrieval. Three hundred and three patients were placed on ECMO at the 47 referring hospitals among 5 states. In our study, 185 (61%) patients required veno-arterial ECMO and 115 (38%) were placed on veno-venous ECMO. Three patients (1%) were cannulated for veno-arteriovenous ECMO. Twenty patients were cannulated under cardio-pulmonary resuscitation. Most of the patients were transported by ambulance (79%), 14% by helicopter, and 7% by airplane. Six out of the 303 patients did not leave the referring facility. All patients that left the referring hospitals arrived safely to our institution. No major complications occurred in route.ConclusionOur study’s findings indicate that non-CTS physicians can successfully cannulate and retrieve patients with a low complication profile

A new frontier for an old drug? A word of caution for beta-blockers in sepsis!

Recent promising findings indicate a possible benefit of β-blockade in septic patients. Ongoing trials on esmolol in septic shock are investigating its hemodynamic effects, focusing on heart rate control and echocardiographic changes, as well as potential anti-inflammatory effects. However, given the complex physiology of sepsis and pharmacological effects on b-blockade, large multi-center trials are essential before such a therapy may be applied safely