Objective: To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pump (IABP) on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock (AMICS). Methods: This was a prospective cohort study, patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled. According to combination with IABP and time point, patients were divided into VA-ECMO alone group, VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group. Data from 3 groups of patients were collected, including the demographic characteristics, risk factors, ECG and echocardiographic examination results, critical illness characteristics, coronary intervention results, VA-ECMO related parameters and complications were compared among the three groups. The primary clinical endpoint was all-cause death, and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L, gastrointestinal bleeding, bacteremia, lower extremity ischemia, lower extremity thrombosis, acute kidney injury, pulmonary edema and stroke. Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up. Using VA-ECMO+IABP concurrent group as reference, multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days. Results: The study included 68 AMICS patients who were supported by VA-ECMO, average age was (59.8±10.8) years, there were 12 female patients (17.6%), 19 cases were in VA-ECMO alone group, 34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group. The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group (all P<0.05). Compared with the ECMO+IABP non-concurrent group, the other two groups had shorter ECMO support time, lower rates of acute kidney injury complications (all P<0.05), and lower rates of pulmonary edema complications in the ECMO alone group (P<0.05). In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group (28 patients (82.4%)) than in the VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (7 patients) (all P<0.05). The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group (26 cases) than in VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (4 patients) (all P<0.05). Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP, the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients (HR=2.801, P=0.036; HR=2.985, P=0.033, respectively). Conclusions: When VA-ECMO is indicated for AMICS patients, combined use with IABP at the same time can improve the ECMO weaning rate, in-hospital survival and survival at 30 days post discharge, and which does not increase additional complications.
Humans ; Female ; Middle Aged ; Aged ; Shock, Cardiogenic/complications* ; Extracorporeal Membrane Oxygenation/methods* ; Pulmonary Edema/complications* ; Aftercare ; Prospective Studies ; Patient Discharge ; Myocardial Infarction/therapy* ; Intra-Aortic Balloon Pumping/methods* ; Treatment Outcome ; Retrospective Studies

Objective: To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pump (IABP) on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock (AMICS). Methods: This was a prospective cohort study, patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled. According to combination with IABP and time point, patients were divided into VA-ECMO alone group, VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group. Data from 3 groups of patients were collected, including the demographic characteristics, risk factors, ECG and echocardiographic examination results, critical illness characteristics, coronary intervention results, VA-ECMO related parameters and complications were compared among the three groups. The primary clinical endpoint was all-cause death, and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L, gastrointestinal bleeding, bacteremia, lower extremity ischemia, lower extremity thrombosis, acute kidney injury, pulmonary edema and stroke. Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up. Using VA-ECMO+IABP concurrent group as reference, multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days. Results: The study included 68 AMICS patients who were supported by VA-ECMO, average age was (59.8±10.8) years, there were 12 female patients (17.6%), 19 cases were in VA-ECMO alone group, 34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group. The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group (all P<0.05). Compared with the ECMO+IABP non-concurrent group, the other two groups had shorter ECMO support time, lower rates of acute kidney injury complications (all P<0.05), and lower rates of pulmonary edema complications in the ECMO alone group (P<0.05). In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group (28 patients (82.4%)) than in the VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (7 patients) (all P<0.05). The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group (26 cases) than in VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (4 patients) (all P<0.05). Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP, the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients (HR=2.801, P=0.036; HR=2.985, P=0.033, respectively). Conclusions: When VA-ECMO is indicated for AMICS patients, combined use with IABP at the same time can improve the ECMO weaning rate, in-hospital survival and survival at 30 days post discharge, and which does not increase additional complications.
Humans ; Female ; Middle Aged ; Aged ; Shock, Cardiogenic/complications* ; Extracorporeal Membrane Oxygenation/methods* ; Pulmonary Edema/complications* ; Aftercare ; Prospective Studies ; Patient Discharge ; Myocardial Infarction/therapy* ; Intra-Aortic Balloon Pumping/methods* ; Treatment Outcome ; Retrospective Studies

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.
Humans ; Inferior Wall Myocardial Infarction/complications* ; Papillary Muscles/surgery* ; Pulmonary Edema ; Myocardial Infarction/surgery* ; Shock, Cardiogenic

Extracorporeal membrane oxygenation (ECMO) is a technique that uses a pump to drain blood from a body, circulate blood through a membrane lung, and return the oxygenated blood back into the body. Venoarterial (VA) ECMO is a simplified version of the heart-lung machine that assists native pulmonary and/or cardiac function. VA ECMO is composed of a drainage cannula in the venous system and a return cannula in the arterial system. Because VA ECMO can increase tissue perfusion by increasing the arterial blood flow, it is used to treat medically refractory cardiogenic shock or cardiac arrest. VA ECMO has a distinct physiology that is referred to as differential flows. It can cause several complications such as left ventricular distension with pulmonary edema, distal limb ischemia, bleeding, and thromboembolism. Physicians who are using this technology should be knowledgeable on the prevention and management of these complications. We review the basic physiology of VA ECMO, the mechanism of complications, and the simple management of VA ECMO.
Catheters ; Drainage ; Extracorporeal Membrane Oxygenation ; Extremities ; Heart Arrest ; Heart-Lung Machine ; Hemorrhage ; Ischemia ; Lung ; Membranes ; Oxygen ; Perfusion ; Physiology ; Postoperative Complications ; Pulmonary Edema ; Shock ; Shock, Cardiogenic ; Thromboembolism

OBJECTIVETo appraise the significance of extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), and intrathoracic blood volume index (ITBVI) in the differential diagnosis of the type of burn-induced pulmonary edema.

METHODSThe clinical data of 38 patients, with severe burn hospitalized in our burn ICU from December 2011 to September 2014 suffering from the complication of pulmonary edema within one week post burn and treated with mechanical ventilation accompanied by pulse contour cardiac output monitoring, were retrospectively analyzed. The patients were divided into lung injury group ( L, n = 17) and hydrostatic group (H, n = 21) according to the diagnosis of pulmonary edema. EVLWI, PVPI, ITBVI, oxygenation index, and lung injury score ( LIS) were compared between two groups, and the correlations among the former four indexes and the correlations between each of the former three indexes and types of pulmonary edema were analyzed. Data were processed with t test, chi-square test, Mann-Whitney U test, Pearson correlation test, and accuracy test [receiver operating characteristic (ROC) curve].

RESULTSThere was no statistically significant difference in EVLWI between group L and group H, respectively (12.9 ± 3.1) and (12.1 ± 2.1) mL/kg, U = 159.5, P > 0.05. The PVPI and LIS of patients in group L were respectively 2.6 ± 0.5 and (2.1 ± 0.6) points, and they were significantly higher than those in group H [1.4 ± 0.3 and (1.0 ± 0.6) points, with U values respectively 4.5 and 36.5, P values below 0.01]. The ITBVI and oxygenation index of patients in group L were respectively (911 197) mL/m2 and (136 ± 69) mmHg (1 mmHg = 0.133 kPa), which were significantly lower than those in group H [(1,305 ± 168) mL/m2 and (212 ± 60) mmHg, with U values respectively 21.5 and 70.5, P values below 0.01]. In group L, there was obviously positive correlation between EVLWI and PVPI, or EVLWI and ITBVI (with r values respectively 0.553 and 0.807, P < 0.05 or P < 0.01), and there was obviously negative correlation between oxygenation index and EVLWI, or oxygenation index and PVPI (with r values respectively -0.674 and -0.817, P values below 0.01). In group H, there was obviously positive correlation between EVLWI and ITBVI (r = 0.751, P < 0.01) but no obvious correlation between EVLWI and PVPI, oxygenation index and EVLWI, or oxygenation index and PVPI (with r values respectively -0.275, 0.197, and 0:062, P values above 0.05). The total area under ROC curve of PVPI value for differentiating the type of pulmonary edema was 0.987 [with 95% confidence interval (CI) 0.962-1.013, P < 0.01], and 1.9 was the cutoff value with sensitivity of 94.1% and specificity of 95.2% . The total area under ROC curve of ITBVI value for differentiating the type of pulmonary edema was 0.940 (with 95% CI 0.860-1.020, P < 0.01), and 1,077. 5 mL/m2 was the cutoff value with sensitivity of 95.2% and specificity of 88.2%.

CONCLUSIONSEVLWI, PVPI, and ITBVI have an important significance in the differential diagnosis of the type of burn-induced pulmonary edema, and they may be helpful in the early diagnosis and management of burn-induced pulmonary edema.

Blood Gas Analysis ; Blood Volume ; Burns ; complications ; Capillary Permeability ; Diagnosis, Differential ; Extravascular Lung Water ; Humans ; Lung ; blood supply ; Lung Injury ; physiopathology ; therapy ; Monitoring, Physiologic ; Pulmonary Edema ; diagnosis ; etiology ; ROC Curve ; Respiration, Artificial ; Retrospective Studies

Pulmonary edema frequently occurs after severe burn. It not only impairs pulmonary function directly, but also can induce or exacerbate other pulmonary complications such as lung infection, acute lung injury ( ALI), and ARDS. Extravascular lung water (EVLW) is closely related to the pulmonary edema. Dynamical monitor of EVLW has been used to predict and quantify the degree of pulmonary edema clinically. This review focuses on the recent progresses at home and abroad on the formation mechanism, monitoring approach, and prevention and treatment of EVLW after severe burn injury.
Acute Lung Injury ; etiology ; physiopathology ; Burns ; Extravascular Lung Water ; Humans ; Pulmonary Edema ; diagnosis ; etiology ; Severity of Illness Index ; Shock, Septic ; complications ; physiopathology ; Thermodilution ; Trauma Severity Indices

A male patient undergoing extracorporeal ultrasound lithotripsy developed the symptoms of dyspnea, low blood pressure, palpitations, chest tightness, and sweating, and a clinical diagnosis of pulmonary capillary leak and hypovolemic shock was made. Pulse indicator continuous cardiac output (PiCCO) technique was used for resuscitation according to the measurements of extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI). The patient showed low levels of cardiac output (CO) and GEDI with a peak EVLWI of 32 ml/kg and profuse pink and thin sputum overflow from the trachea. The high ventilator support parameters failed to correct low oxygen saturation. Restricted fluid infusion was used to reduce pulmonary edema. Colloidal solution was given when GEDI was below 500 ml/m(2), and the volume and fluid infusion rate were reduced for a GEDI higher than 500 ml/m(2). Pulmonary edema was gradually reduced after the treatments with improvement of lactic acid level and liver and kidney functions. Vasopressors were withdrawn 6 days later, mechanical ventilation was discontinued 10 days later, and tracheal intubation was removed 25 days later, after which the patient was discharged. In the treatment of the patient, PiCCO monitoring played an important role.
Adult ; Capillary Leak Syndrome ; complications ; therapy ; Fluid Therapy ; Humans ; Lithotripsy ; adverse effects ; Male ; Pulmonary Edema ; complications ; therapy ; Shock ; complications ; therapy

OBJECTIVETo evaluate the clinical value of the pulse indicator continuous cardiac output (PiCCO) system in patients with severe acute pancreatitis (SAP) complicated with acute respiratory distress syndrome (ARDS).

METHODTwo cases of SAP with ARDS were monitored using PiCCO during comprehensive management in the Pediatric Intensive Care Unit (PICU) of Shengjing Hospital, China Medical University. To guide fluid management, the cardiac index (CI) was measured to assess cardiac function, the global end-diastolic volume index (GEDVI) was used to evaluate cardiac preload, and the extravascular lung water index (EVLWI) was used to evaluate the pulmonary edema.

RESULTCase 1 was diagnosed with type L2 acute lymphoblastic leukemia (intermediate risk) and received the sixth maintenance phases of chemotherapy this time. After a 1-week dosage of chemotherapeutic drugs (pegaspargase and mitoxantrone), he suffered SAP combined with ARDS. Except comprehensive treatment (life supporting, antibiotic, etc.) and applying continuous veno-venous hemodiafiltration (CVVHDF) to remove inflammatory mediators. PiCCO monitor was utilized to guide fluid management. During the early stage of PiCCO monitoring, the patient showed no significant manifestations of pulmonary edema in the bedside chest X-ray (bedside ultrasound showed left pleural effusion), and had an oxygenation index 223 mmHg (1 mmHg = 0.133 kPa), GEDVI 450 ml/m², and ELVWI 7 ml/kg. We increased cardiac output to increase tissue perfusion and dehydration speed of CVVHDF was set at 70 ml/h. Two hours later, GEDVI significantly increased to 600 ml/m² and ELVWI significantly increased to 10 ml/kg, the oxygenation index declined to 155 mmHg, the bedside chest X-ray showed a significant decrease of permeability (right lung) and PEEP was adjusted to 5 cmH₂O (1 cmH₂O = 0.098 kPa), indicating circulating overload. ARDS subsequently occurred, upon which the fluid infusion was halted, the dehydration rate of CVVHDF raised (adjusted to 100-200 ml/h). On day 3 in the PICU, EVLWI dropped to 6 ml/kg, GEDVI dropped to 370 ml/m², and the oxygenation index increased to 180 mmHg. On day 8, the patient was successfully weaned from the ventilator. However, on day 9, the patient reverted to mechanical ventilation due to secondary infection. On day 30, the patient was discharged for voluntarily giving up treatment. Late follow-up results showed that the patient was dead one day after giving up treatment. Case 2 was admitted due to SAP induced by overeating one day before admission. On day 2, the patient showed dyspnea and oxygen saturation decreased to 80%. We applied mechanical ventilation, CVVHDF to remove inflammatory mediators and PiCCO to guide fluid management. According to the initial data of PiCCO, EVLWI was 9 ml/kg, GEDVI was 519 ml/m², the oxygenation index was 298 mmHg, the bedside chest X-ray showed decreased permeability and PEEP was adjusted to 5 cmH₂O, suggesting the existence of ARDS. During treatment, the dehydration speed of CVVHDF was set at 50 ml/h to maintain the balance of fluid input and output. Two hours after PiCCO monitoring, the oxygenation index decreased to 140 mmHg, GEDVI 481 ml/m², EVLWI 9 ml/kg, thus the dehydration speed of CVVHDF was increased (up to 100 ml/h). On day 4 in the PICU, EVLWI was 9 ml/kg, GEDVI was 430 ml/m², oxygenation index was 394 mmHg, and the bedside chest X-ray showed that permeability was higher. On day 5, the patient was transferred from PiCCO. On day 30, the patient recovered and was discharged.

CONCLUSIONPiCCO monitoring can provide real-time surveillance of cardiac function, cardiac preload and afterload, and extravascular lung water in pediatric patients with SAP combined with ARDS. These results are clinically significant for the rescue of critically ill patients with ARDS or shock.

Acute Disease ; Cardiac Output ; physiology ; Child ; China ; Critical Illness ; Extravascular Lung Water ; Fluid Therapy ; Heart ; physiology ; Heart Rate ; Humans ; Lung ; physiology ; Monitoring, Physiologic ; methods ; Pancreatitis ; complications ; physiopathology ; therapy ; Pulmonary Edema ; Respiration, Artificial ; Respiratory Distress Syndrome, Adult ; complications ; physiopathology ; Severity of Illness Index ; Treatment Outcome

OBJECTIVETo investigate the clinical characteristics and treatment of negative pressure pulmonary edema (NPPE) with upper airway obstruction (UAO) in children.

METHODData of 3 cases with NPPE and UAO in pediatric intensive care unit (PICU) from Mar, 2007 to May, 2013 were analyzed.

RESULT(1) Two cases were male and 1 was female with age respectively 6, 16 and 30 months.One had airway foreign body , 1 laryngitis , and 1 retropharyngeal abscess. The onset of NPPE varied from 5 to 40 minutes following relief of obstruction. (2) NPPE presented with acute respiratory distress with signs of tachypnea, tachycardia, 2 of the 3 with pink frothy pulmonary secretions, progressively decreased oxygen saturation, rales on chest auscultation and wheezing. (3) NPPE chest radiograph showed diffuse interstitial and alveolar infiltrates, images confirmed pulmonary edema. (4) All these patients received these therapeutic measures including mechanical ventilation, retaining high PEEP, diuretics, limiting the fluid input volume to 80-90 ml/ (kg×d) on the basis of circulation stability. The rales on chest auscultation disappeared after 10, 6, 12 hours. The ventilators of 2 patients were removed within 24 hours, in another case it was removed 50 hours later because of secondary infection. All patients were cured and discharged without complication.

CONCLUSIONNPPE progresses very fast, characterized by rapid onset of symptoms of respiratory distress after UAO, with pulmonary edema on chest radiograph. The symptoms resolve rapidly if early support of breath and diuretics are applied properly.

Acute Disease ; Airway Obstruction ; complications ; Child, Preschool ; Diuretics ; therapeutic use ; Female ; Foreign Bodies ; complications ; Humans ; Infant ; Laryngismus ; complications ; Male ; Positive-Pressure Respiration ; Postoperative Complications ; etiology ; physiopathology ; therapy ; Pulmonary Edema ; diagnosis ; etiology ; physiopathology ; therapy ; Radiography, Thoracic ; Retrospective Studies

A 59-year-old man with a history of major depression was found by his wife to be unconscious and foaming at the mouth. On arrival at the emergency department, the patient was noted to be unresponsive. Computed tomography of the brain showed symmetrical ill-defined areas of hypoattenuation involving the medial aspects of both lentiform nuclei, while magnetic resonance images of the brain showed symmetrical increased signal in the bilateral globi pallidi on diffusion weighted, T2-weighted and fluid attenuated inversion recovery sequences. These findings were those of acute carbon monoxide poisoning. Despite aggressive treatment, the patient's condition continued to deteriorate and he eventually passed away. The various imaging findings of carbon monoxide poisoning in the brain and the differential diagnoses are discussed.
Brain ; diagnostic imaging ; Carbon Monoxide Poisoning ; diagnosis ; diagnostic imaging ; Depressive Disorder, Major ; complications ; Diagnostic Imaging ; Fatal Outcome ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Pulmonary Edema ; pathology ; Radiography, Thoracic ; Suicide, Attempted ; Tomography, X-Ray Computed