Myocarditis
Mary N. Sheppard in 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.
Mechanical Effects of Cardiovascular Drugs and Devices
Michel R. Labrosse in 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
Pediatric ICU management
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Guidelines from the American College of Critical Care Medicine and, more recently, the Surviving Sepsis Campaign recommend goal-directed resuscitation with infusion of crystalloids and initiation of pressors and appropriate antibiotic therapy within the first hour of presentation, as well as source control, when appropriate, within 12 hours [19, 21]. Each hour delay in antibiotic administration has been shown to decrease survival by 8% [22]. Goals of therapy include reversal of hypotension, increasing urine output, normal capillary refill, full peripheral pulses, and adequate level of consciousness without inducing hepatomegaly or rales. For ScvO2 < 70%, Hb levels of 10 g/dL should be targeted, although a lower target of >7 g/dL is appropriate after stabilization. Hydrocortisone therapy should be given to children with fluid-refractory, catecholamine -resistant shock and/or absolute adrenal insufficiency. Extracorporeal membrane oxygenation (ECMO) should be considered for refractory septic shock and/or data suggest improved survival (up to 74%) in patients treated with veno-arterial (VA) ECMO [23].
Research progress of portable extracorporeal membrane oxygenation
Published in Expert Review of Medical Devices, 2023
Yuansen Chen, Duo Li, Ziquan Liu, Yanqing Liu, Haojun Fan, Shike Hou
Some patients may require ECMO support for a prolonged time, such as sepsis, ARDS and other medical conditions, neuromuscular dysfunction should be a problem to consider in these patients [36]. Traditional ECMO systems require patients to be bedridden, which lead to muscle atrophy and affect prognosis [37,38]. Early mobilization may improve the patient’s prognosis, recent studies have shown that ECMO can provide adequate hemodynamic and gas exchange support for patients with cardiac and respiratory insufficiency to perform early mobilization [39,40]. Another report demonstrates that for patients with heart and respiratory failure receiving extracorporeal life support, awake and mobile ECMO support is feasible and associated with improved long-term and short-term patient outcomes [41]. To meet the requirement for early mobilization and physical training for patients supported by ECMO, further portable, wearable ECMO is also being developed.
From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients
Published in The American Journal of Bioethics, 2023
Andrew Childress, Trevor Bibler, Bryanna Moore, Ryan H. Nelson, Joelle Robertson-Preidler, Olivia Schuman, Janet Malek
The clinical and bioethics literature is somewhat equivocal on how clinicians and ethicists should navigate capacitated patients’ requests for continued long-term ECMO support. The Extracorporeal Life Support Organization (ELSO) sets several conditions for when ECMO support is considered “futile.” In their 2017 guidelines, they recommend that ECMO support “should be discontinued promptly if there is no hope for healthy survival (severe brain damage, no heart or lung recovery, and no hope of organ replacement by VAD or transplant).” While it’s unlikely that Mr. J would be considered or consider himself “healthy,” there is ambiguity about whether he meets these criteria, as he does not have severe brain damage, does have minimal lung recovery, and is not a lung transplant candidate. More importantly for our purposes, even if these guidelines recommend discontinuation of ECMO support in Mr. J’s case, ELSO provides no arguments for this conclusion and no recommendations for how to address a capacitated patient or surrogate decision maker’s objections.
Bail-out extracorporeal membrane oxygenation for hydroxychloroquine intoxication: a warning for COVID-19 health-care givers
Published in Acta Cardiologica, 2021
Wouter Holvoet, Kaja van Soest, Thomas Havenith, Roberto Lorusso, Walther N. K. A. van Mook, Thijs Delnoij
Hydroxychloroquine (HCQ), e.g. sold under the brand name Plaquenil, is used in malaria prevention and treatment, as well as certain inflammatory diseases such as rheumatoid arthritis and lupus. HCQ also appears to be a promising treatment for coronavirus disease 2019 (COVID-19) and is considered to be safer than chloroquine based on clinical studies. As HCQ is currently increasingly used in the treatment of Severe Acute Respiratory Syndrome caused by Coronavirus 2 (SARS-CoV-2), it is important to be aware of its possible side effects, particularly in case of severe intoxication [1,2]. Intoxications can be lethal and the clinical picture is dominated by cardiovascular collapse, ventricular dysrhythmias and unconsciousness. Quick and decisive action is needed regarding the initiation of circulatory support to improve prognosis. Cardio-circulatory support by means of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) can provide a bridge to recovery in case of life-threatening intoxications. An illustrative case with a substantial HCQ intoxication treated with V-A ECMO is described underlining its usefulness as bail-out procedure in such circumstances.
Related Knowledge Centers
- Extracorporeal
- Perfusion
- Pneumonia
- Cardiopulmonary Bypass
- Lung
- Heart
- Respiratory System
- Red Blood Cell
- Membrane Oxygenator
- Covid-19