Journal of thoracic disease
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Data evaluating pharmacokinetic/pharmacodynamic (PK/PD) aspect in the pediatric population are scarce especially regarding the pediatric intensive care unit. Dosing of frequently used drugs (sedatives, analgesics, antibiotics and cardiovascular drugs) are mainly based on non "pediatric intensive care unit (PICU)" patients, and sometimes are translated from adult patients. ⋯ The use of extracorporeal membrane oxygenation is associated with major PK and PD changes, especially in neonates and children. The objective of this review is to assess the current literature for pediatric PK data in patients receiving extracorporeal membrane oxygenation (ECMO).
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Veno-venous extracorporeal membrane oxygenation (VV ECMO) has started to be applied in awake spontaneously breathing patients as an alternative to invasive mechanical ventilation. As the physiologic cardiorespiratory variability is increased in this condition, the dynamic interaction between patient respiratory activity and extracorporeal system function affects the clinical management. The effect of extracorporeal CO2 removal on patient respiratory drive is variable and not always predictable, with some patients responding to CO2 removal with a decrease in respiratory rate and effort and other patients demonstrating a persistently high work of breathing independent on CO2 unload. ⋯ Assessment of native lung function and of its evolution over time is challenging while respiratory gas exchanges are provided by the extracorporeal system, since both oxygenation and decarboxylation capabilities can be fully evaluated only when alveolar ventilation is restored reducing extracorporeal CO2 removal. The rationale for using "awake ECMO" varies across different types of acute respiratory failure: the pathophysiological mechanisms of the underlying disease affect the patient-ECMO interaction and the goal of support. In this review we discuss the pathophysiology, technical challenges and monitoring issues of the use of ECMO in awake spontaneously breathing patients with acute respiratory failure of different etiologies.
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Extracorporeal membrane oxygenation (ECMO) is described as a modified, smaller cardiopulmonary bypass circuit. The veno-venous (VV) ECMO circuit drains venous blood, oxygenate the blood, and pump the blood back into the same venous compartment. Draining and reinfusing in the same compartment means there are a risk of recirculation. ⋯ Efficiency can be reasonable in either strategy if the cannulas are carefully positioned and monitored during the dynamic procedure of pulmonary disease. The disadvantage draining from IVC only occurs when there is a need for converting from VV to veno-arterial (VA) ECMO, reinfusing in the femoral artery. Then draining from SVC is the most efficient strategy, draining low saturated venous blood, and also means low risk of dual circulation.
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Veno-venous extracorporeal membrane oxygenation (VV ECMO) restores gas exchanges in severely hypoxemic patients. The need for adjunctive therapies usually originates either from refractory hypoxemia during ECMO (defined as the persistence of low blood oxygen levels despite extracorporeal support) or from the attempt to give a specific therapy for acute respiratory distress syndrome (ARDS). ⋯ The therapies currently available often allow for an effective treatment of hypoxemia during ECMO. ARDS is still lacking a specific therapy, with low-grade evidence sustaining the majority of currently used drugs.
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Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). ⋯ In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.