Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support

OBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions

Comparison of stress level; burnout; fatigue and satisfaction among family visitors and ICU staff in relation to single-bed or multibed room designs

INTRODUÇÃO: A estrutura física das unidades de terapia intensiva tem sido relacionada a um impacto significativo sobre o paciente, família e equipe. O modelo de arquitetura da UTI (quartos privativos versus unidades com múltiplos leitos) pode ser associado a níveis de estresse experimentados pela equipe e à vulnerabilidade das famílias e pacientes. OBJETIVO: verificar o impacto da arquitetura da UTI nos sintomas de estresse e burnout nos colaboradores da UTI (médicos, enfermeiros, fisioterapeutas e técnicos de enfermagem) e, estresse, fadiga e a satisfação dos familiares de pacientes internados na UTI. METODOS: Estudo transversal, realizado na UTI do AC Camargo Câncer Center, um hospital escola especializado no tratamento oncológico e localizado na cidade de São Paulo com 45 leitos de UTI adulto, divididas em duas UTIs com múltiplos leitos e duas com quartos individuais. Entre os colaboradores e familiares, o estresse foi avaliado com a Escala de Fatores Estressantes na UTI: Escala de LIPP - ISSL. Burnout nos funcionários da UTI foi avaliado com Escala da Maslach Burnout Inventory (MBI). A satisfação familiar foi avaliada com o Inventário de Necessidades de Familiares em Terapia Intensiva (INFTI), e a fadiga com Escala de Fadiga de Chalder. RESULTADOS: Entre os 156 funcionários entrevistados nas UTIs, foram encontrados níveis similares de burnout entre os funcionários que trabalharam em UTIs leitos individuais ou múltiplos leitos, com uma média de 17,3%. Entretanto, o estresse dos colaboradores em 24 horas foi mais elevado nas nos funcionários que trabalharam nas UTIs de leitos individuais (14.3% vs. 4.7%, p= .04). Foram entrevistados176 familiares de primeiro grau dos pacientes internados e foi observado um nível similar de estresse e fadiga nos familiares. Entretanto, a satisfação das famílias de pacientes alocados em UTIs de leitos individuais foi maior (96.0% vs. 84.6%, p=.02). CONCLUSÃO: A arquitetura da UTI tem influência nos funcionários e nos acompanhantes dos pacientes. UTIs com Leitos individuais são associadas com maior satisfação das famílias, porém um maior nível de estresse nos colaboradores. Apesar disto, observou-se níveis semelhantes de burnout nos funcionários nas UTIs de leitos individuais ou múltiplos leitosINTRODUTION: The design of the Intensive Care Units ICUs has been related with a significant impact over the patient, family and staff. The architectural variations among ICUs (single- bed or multibed rooms) can be related with diferent stress levels among staff, family and patients. OBJECTIVE: To compare the impact of single-bed versus multibed room intensive care units (ICU) architectural designs on the stress and burnout of ICU staff (doctors, nurses, and respiratory therapists) and on the stress and satisfaction of family visitors. METHODS: A cross-sectional study in ICUs of the A.C. Camargo Cancer Center, a teaching oncologic hospital with 45 ICU beds distributed among two ICUs with multibed rooms and two ICUs with single- bed rooms. Among ICU staff and family visitors, stress was evaluated with Lipp\'s Inventory of Stress Symptoms. ICU staff burnout was evaluated with the Maslach Burnout Inventory. Family visitor satisfaction was evaluated with Molter\'s Critical Care Family Needs Inventory and fatigue with Chalder Fatigue Scale. RESULTS: Among 156 ICU professionals who were interviewed, similar burnout rates were observed between ICU staff who worked single-bed versus multibed rooms, with an average of 17,3%. However, stress reported by ICU staff within the previous 24 hr was higher among the ICU staff who worked in single-bed rooms (14.3% vs. 4.7%, p= .04). 176 family visitors were interviewed and a similar level of stress and fatigue was reported by family members who visited patients in single-bed or multibed rooms. However, the satisfaction of family members visiting patients in single-bed rooms was higher (96.0% vs. 84.6%, p = .02). CONCLUSIONS: The architecture of the ICU has an influence on the staff and family visitors. Single-bed ICU design was associated with greater satisfaction of family visitors yet with higher levels of stress for ICU staff. Meanwhile, similar burnout levels were observed for ICU staff who worked in single-bed or multibed room

Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support

OBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions