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Myocarditis
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
Treatment of GCM, depending on the stage of progression, may require rapid initiation of biventricular mechanical cardiac support to maintain haemodynamic stability. Other indications for early biventricular support are persistent unstable ventricular arrhythmias or high-grade intranodal block. Extracorporeal life support is another well-established treatment option. Unlike its phenotypic cousin, fulminant lymphocytic myocarditis, GCM rarely results in spontaneous recovery after a period of mechanical support. This emphasizes the importance in making a tissue diagnosis. These two forms of FM often present in a similar fashion although they have widely varied prognoses. GCM responds to cyclosporine-based immunosuppressive therapy, indicating that most cases are autoimmune rather than the result of an active infection. Without immunosuppressive therapy and guideline-directed medical management of circulatory failure, the most frequent outcome is death or transplantation within the first year after diagnosis. More recently, use of tacrolimus/mycophenolate-based regimens relative to cyclosporine/azathioprine-based regimens have been advocated. Ongoing low-dose immunosuppression, possibly lifelong, may be necessary. Abrupt cessation of immunosuppressive therapy has been associated with fatal disease recurrence. After transplantation, GCM recurs in 20–25% of allografts.
Critical Care
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Jaimie Maines, Lauren A. Plante
The use of extracorporeal membrane oxygenation (ECMO) as an adjunct for refractory ARDS has been increasing in the past decade or two. Both the H1N1 and SARS-CoV-2 pandemics have been accompanied by a rise in demand for ECMO. Resorting to ECMO during pregnancy and the peripartum period has also increased, and mortality has decreased, over time. Analysis of the Extracorporeal Life Support Organization Registry from 1997 to 2017 (n = 280, most venovenous ECMO) showed that mortality dropped from about 54% to about 27% [126]. A significant risk of hemorrhagic complications, not all attributed to cannulation, is still associated with ECMO in these patients.
Mechanical Effects of Cardiovascular Drugs and Devices
Published in Michel R. Labrosse, Cardiovascular Mechanics, 2018
Extracorporeal membrane oxygenation, or extracorporeal life support (ECLS), as it is currently known, is essentially a long-term version of CPB that provides circulatory and respiratory support for hours to days. The standard CPB provides temporary cardiopulmonary support during various types of cardiac surgical procedures, while the purpose of ECMO is to allow time for intrinsic recovery of the lungs and heart. Extracorporeal life support is almost always “partial” bypass, as opposed to “total” bypass, which is required for cardiac operations. The amount of blood flow is based on the degree of support required, which is based on a series of physiological monitors in the circuit and on the patient. Many days may be required for the native heart or lungs to regain adequate function, and continuous anticoagulation is required. In general, ECLS is indicated in acute severe reversible cardiac or respiratory failure, when the risk of dying from the primary disease despite optimal conventional treatment is high (50%–100%). Usually, a patient on ECMO will also be on a ventilator, to give the lungs a chance to heal. The current survival rate is 80% for neonatal respiratory failure, 60% for pediatric respiratory failure, 50% for adult respiratory failure, 45% for pediatric cardiac failure, and 40% for adult cardiac failure.19
The ECMO Bridge and 5 Paths
Published in The American Journal of Bioethics, 2023
Issues inherent in ECMO discontinuation, where the intervention is “working,” in maintaining circulation are not readily resolved using futility policies focused on whether the intervention will restore or maintain vital function. The Extracorporeal Life Support Organization (ELSO) uses a broader definition of futility to encompass no hope for healthy survival with the triad of “severe brain damage, no heart or lung recovery, and no hope of organ replacement by VAD or transplant.” Kon and coauthors go even further: “ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting.” (Kon et al. 2016), and Kon supports that such a withdrawal from a conscious patient with procedural due process can be “consistent with good medical practice, ethical norms and the law” (Kon 2023).
ECMO as a Palliative Bridge to Death
Published in The American Journal of Bioethics, 2023
Rachel Rutz Voumard, Zied Ltaief, Lucas Liaudet, Ralf J. Jox
ECMO is a short-term measure providing temporary life support until resolution of the primary insult or transplantation. Thanks to technological advances in life support, its use has increased enormously over the past three decades, with less than 2,000 cases in the early 1990s to more than 20,000 in 2021 (www.elso.org; Extracorporeal Life Support Organization (ELSO) 2023). Although ECMO requires a minimum level of sedation and analgesia, there is a growing interest to maintain patients awake with spontaneous breathing. Recent studies support such a strategy pointing to a positive impact on post-ECMO recovery and survival (Crotti 2017). Arguments in favor of keeping patients awake on ECMO include a reduced incidence of delirium, early mobilization, improved rehabilitation, and the promotion of interactions with families and clinicians (Langer 2016). By contrast, awake patients may experience discomfort, are exposed to increased risks of device displacement, and may develop patient self-induced lung injury (P-SILI) in case of elevated respiratory drive.
Pharmacological management of adult patients with acute respiratory distress syndrome
Published in Expert Opinion on Pharmacotherapy, 2020
Maria Gabriella Matera, Paola Rogliani, Andrea Bianco, Mario Cazzola
Therapies for ARDS remain remarkably limited. An interesting review published in 2014 which examined 159 randomized trials and 29 meta-analyses concluded that there was no consistent evidence to support any specific intervention to reduce mortality in ARDS [11]. Mechanical ventilation with proper tidal volume and respiratory pressure, prone positioning, and neuromuscular blockade are still the mainstay in the treatment of ARDS [6,9], but injurious mechanical forces caused by ventilators induce lung injury and are major contributors to morbidity and mortality in ARDS [12]. Fluid management and extracorporeal membrane oxygenation (ECMO) are different strategies that can improve oxygenation and lung compliance. Recent data suggest that patients with more severe forms of ARDS exhibit better outcomes than those induced by conventional management when extracorporeal life support uses lower tidal volumes and airway pressures than the current standard of care, but it has also been highlighted that further studies are needed to improve strategies that may optimize invasive mechanical ventilation [13].