ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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Chronic hemodialysis is associated with significant thrombophilia. Of interest, hemodialysis patients have increased carboxyhemoglobin (COHb) and exhaled carbon monoxide (CO), signs of upregulated heme oxygenase (Hmox) activity. Given that CO enhances plasmatic coagulation, we determined whether patients requiring chronic hemodialysis had an increase in endogenous CO, plasmatic hypercoagulability and decreased fibrinolytic vulnerability. ⋯ Furthermore, over half of COHF positive patients had a hypofibrinolytic state, evidenced by an abnormally prolonged time to maximum rate of lysis (53.3%, [37.9%-68.6%]) and clot lysis time (64.4%, [48.8%-78.1%]). Carbon monoxide enhanced coagulation and diminished fibrinolytic vulnerability in hemodialysis patients. Future investigation of hemodialysis, CO-related thrombophilia is warranted.
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Use of extracorporeal membrane oxygenation (ECMO) in adults has surged in recent years. Typical configurations are venovenous (VV), which provides respiratory support, or venoarterial (VA), which provides both respiratory and circulatory support. In patients supported with VV ECMO who develop hemodynamic compromise, an arterial limb can be added (venovenous-arterial ECMO) to provide additional circulatory support. ⋯ Eight patients (38.1%) died during ECMO support, four patients (19.0%) died after decannulation but before hospital discharge, and nine patients (42.9%) survived to hospital discharge. Our modest survival rate is likely related to the complexity and severity of illness of these patients, and this relative success suggests that hybrid configurations can be effective. It serves patients well to maintain a flexible and adaptable approach to ECMO configurations for their variable cardiopulmonary needs.
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Oxygenator thrombosis is a serious complication in extracorporeal membrane oxygenation (ECMO) and may necessitate a system exchange. Coagulation and fibrinolysis parameters, flow dynamics, and gas transfer performance are currently used to evaluate the degree of oxygenator thrombosis, but there is no technical approach for direct visualization and quantification of thrombotic deposits within the membrane oxygenator (MO). We used multidetector computed tomography (MDCT) with three-dimensional postprocessing to assess the incidence of oxygenator thrombosis, to quantify thrombus extent, and to localize clot distribution. ⋯ There was no correlation between clot volume and ECMO support time or aPTT. Clot formation within the MO is a common finding in ECMO despite adequate systemic anticoagulation. The clinical significance of thrombus formation and its influence on gas exchange capacity and hemostatic complications have to be addressed in further studies.
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During veno-venous extracorporeal membrane oxygenation (VV-ECMO) support, optimization of oxygenation can be achieved by therapeutic interventions on both patient physiological variables and adjustment of ECMO settings. Based on the physiology of oxygen delivery during VV-ECMO support, we established the mathematical relationship between the variables which define the oxygenation state: hemoglobin (Hb), extracorporeal blood flow (ECBF), cardiac output (Q), and systemic oxygen consumption (VO2). ⋯ Despite the same value of SaO2, the DO2 resulting from the different combinations of Hb and ECBF progressively decreases with decreasing Hb. By demonstrating the quantitative relationship between Hb and ECBF as determinants of oxygenation during VV-ECMO support, this mathematical model could provide a theoretical basis for a rational approach to strategies to optimize oxygenation in patients on VV-ECMO.
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Venoarterial extracorporeal life support (VA-ECLS) is a lifesaving circulatory support in hemodynamic collapse induced by miscellaneous etiologies. However, survival rates vary among etiologies. To investigate the therapeutic effectiveness of VA-ECLS in hemodynamic collapse induced by fulminant cardiomyopathy (CM), a retrospective chart review of 14 patients was conducted, among the 294 adults receiving VA-ECLS in a single institution from April 2006 to April 2013. ⋯ All of the 10 survivors, including the five experiencing dialysis-dependent acute renal failure, had their cardiac and renal function return to normal within 6 months after the episode. The VA-ECLS was a practical therapeutic option in fulminant CM. It could provide expeditious hemodynamic support and preserve organ viability essential to recovery.