This case report describes a 20-year-old female patient who underwent bilateral lung transplantation for cystic fibrosis and subsequently developed severe primary graft dysfunction (PGD). On post-operative day three, she developed respiratory failure and refractory hypoxemia. Extracorporeal membrane oxygenation (ECMO) was initiated as a rescue treatment. With ECMO support, her oxygenation and hemodynamics improved. She was successfully weaned from ECMO after 168 hours and mechanical ventilation after five days. The case report discusses ECMO as an effective rescue therapy for severe hypoxemia after lung transplantation.
Anesth considerations of pediatric patient with cardiac shunt for non cardiac...Bhavna Gupta
The large and growing population of patients who are living with CHD requires anaesthesia for non-cardiac surgeries and other procedures.
Knowledge of the pathophysiology of the common CHD lesions, as well as careful preoperative assessment and preparation, and communication with the patient’s cardiologist and surgeon, are essential to provide optimal care in the best setting for these patients.
Anesth considerations of pediatric patient with cardiac shunt for non cardiac...Bhavna Gupta
The large and growing population of patients who are living with CHD requires anaesthesia for non-cardiac surgeries and other procedures.
Knowledge of the pathophysiology of the common CHD lesions, as well as careful preoperative assessment and preparation, and communication with the patient’s cardiologist and surgeon, are essential to provide optimal care in the best setting for these patients.
Austin Journal of Anesthesia and Analgesia is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of anesthesiology and pain management.
The aim of the journal is to provide a forum for anesthesiologists, researchers, physicians, and other health professionals to find most recent advances in the areas of anesthesiology. Austin Journal of Anesthesia and Analgesia accepts original research articles, review articles, case reports and rapid communication on all the aspects of anesthesiology and pain management.
Austin Journal of Anesthesia and Analgesia strongly supports the scientific upgradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Mechanical Ventilation of Patient with COPD ExacerbationDr.Mahmoud Abbas
Mechanical Ventilation of Patient with COPD Exacerbation lecture presented by Dr Andres Esteban at the Egyptian Critical care Summit 2015 held at Cairo, egypt.
The Egyptian Critical Care Summit is the leading medical event and exhibition for Intensive Care Medicine in Egypt.
A study that has been conducted to assess incidence and risk factors of postintubation cardiovascular collapse and its impact on ICU length of stay and ICU mortality
Para que a Competência exista, é necessário que o homem esteja em um processo constante de aprendizado. As competências não existem apenas nas pessoas. As organizações também possuem competências e algumas destas as diferem das demais organizações trazendo vantagens competitivas. Este curso busca mostrar os novos requisitos em gestão de pessoas e ilustrar com o sistema de Recursos Humanos são impactados pela gestão por competências, que está presente em todas as fases das pessoas nas organizações.
Austin Journal of Anesthesia and Analgesia is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of anesthesiology and pain management.
The aim of the journal is to provide a forum for anesthesiologists, researchers, physicians, and other health professionals to find most recent advances in the areas of anesthesiology. Austin Journal of Anesthesia and Analgesia accepts original research articles, review articles, case reports and rapid communication on all the aspects of anesthesiology and pain management.
Austin Journal of Anesthesia and Analgesia strongly supports the scientific upgradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Mechanical Ventilation of Patient with COPD ExacerbationDr.Mahmoud Abbas
Mechanical Ventilation of Patient with COPD Exacerbation lecture presented by Dr Andres Esteban at the Egyptian Critical care Summit 2015 held at Cairo, egypt.
The Egyptian Critical Care Summit is the leading medical event and exhibition for Intensive Care Medicine in Egypt.
A study that has been conducted to assess incidence and risk factors of postintubation cardiovascular collapse and its impact on ICU length of stay and ICU mortality
Para que a Competência exista, é necessário que o homem esteja em um processo constante de aprendizado. As competências não existem apenas nas pessoas. As organizações também possuem competências e algumas destas as diferem das demais organizações trazendo vantagens competitivas. Este curso busca mostrar os novos requisitos em gestão de pessoas e ilustrar com o sistema de Recursos Humanos são impactados pela gestão por competências, que está presente em todas as fases das pessoas nas organizações.
Extracorporeal membrane oxygenation (ECMO) is a revolutionary life-saving technology for patients with severe but potentially reversible pulmonary or cardiac failure or for patients in need of a bridge to transplantation. In the Indian scenario, the facility of ECMO is limited to few specialized healthcare centers having the expertise personnel and the equipment for this technology. However, the critically unwell patients with respiratory and/or cardiac failure are managed by all the healthcare facilities throughout the country. This has led to the development of mobile ECMO team which carries necessary equipment for initiation of ECMO at referral center and also retrieval of the patient on ECMO. We present the case of a patient with H1N1 influenza associated severe ARDS who was retrieved via air-medical transport (fixed wing aircraft) on ECMO by the mobile ECMO team of our center. In the present case, the patient was cannulated and ECMO was initiated at the referral hospital. This allowed a safe transfer of this patient with severe refractory hypoxemia to ECMO centre. The long or short-distance inter-hospital transport of critical patients with respiratory and/or cardiac failure is feasible and safer on ECMO as compared to the conventional methods of transport. The mobile ECMO teams have made this technology available to all even when the admitting hospital doesn’t have this facility and expertise. To the author’s knowledge, this is the first case reported in India of air-medical retrieval of a patient on ECMO. Key-words- Acute respiratory distress syndrome (ARDS), Air ambulance, Extra corporeal membrane oxygenation (ECMO), H1N1 influenza (Swine flu), Hypoxia, Inter hospital transport
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
Assessment of the Implementation of Ventilator-associated Pneumonia Preventiv...IOSR Journals
Background: Pneumonia associated with mechanical ventilation (VAP) is one of the important
causes of nosocomial infections in pediatric intensive care units (PICU). VAP is the leading cause of morbidity
and mortality in PICUs. Aim: To assess the compliance to ventilator bundle components: elevation of the head
of bed >30, sedation interruption, spontaneous breathing trial, peptic ulcer prophylaxis and its effect on the
prevention of VAP. Subjects and Methods: A case control study at PICU of Abo EL Reish El Moneira Hospital,
including all mechanically ventilated patients admitted over a period of one year. The study tested the effect of
implementation of this bundle as regard the rate of VAP in both group, compliance to bundle and most affecting
component of it. Results: There was decrease incidence of VAP after implementation of the bundle, from (50%)
to (14%). Development of VAP was mostly affected by being in supine position, long duration of mechanical
ventilation and presence of pump failure. (p<0.05) The compliance to bundle components was statistically
significant, p= 0.001. Conclusion: VAP rate decreased after implementation of this bundle. Elevation of the
head of bed was the most compliant component of bundle in the PICU.
Here is a presentation about the double lung ventilation or independent lung ventilation
I hope it will be helpful
There are some videos in the presentation , here is the links :)
http://www.youtube.com/watch?v=w1cgx2AVC6k&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=JZkOiy4PXxg&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=mlS35eUUxqA&list=UUUIWCsRV3siWB-jzBmNg6pA
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Clinics pos tx
1. CASE REPORT
Respiratory failure after lung transplantation: extra-
corporeal membrane oxygenation as a rescue treat-
ment
Paulo Manuel Peˆgo-Fernandes,I
Ludhmila Abraha˜o Hajjar,II
Filomena Regina Barbosa Gomes Galas,II
Marcos Naoyuki Samano,I
Alexandre Kazantzi Fonseca Ribeiro,I
Marcelo Park,III
Rodolfo Soares,II
Eduardo
Osawa,II
Fabio Biscegli JateneI
I
Thoracic Surgery Division, Heart Institute (InCor) do Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo. II
Anesthesiology
Division, Heart Institute (InCor) do Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo. III
Intensive Care Unit, Instituto Central do
Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo.
Email: paulo.fernandes@incor.usp.br / paulopego@incor.usp.br
Tel.: 55 11 2661-5248
INTRODUCTION
Hypoxemia is a frequent finding after lung transplanta-
tion (LTx) (1-2). The underlying mechanisms include alveoli
collapse, diffuse alveolar damage, ventilation-perfusion
mismatch, and alveolar-capillary membrane damage (3-5).
Primary graft dysfunction (PGD) represents a multi-
factorial injury to the transplanted lung that develops in
15-25% of patients during the first days after transplanta-
tion; it is variously referred to as "ischemia-reperfusion
injury" and "early graft dysfunction" (6). PGD is character-
ized by severe hypoxemia, lung edema, and the radio-
graphic appearance of diffuse pulmonary opacities in the
absence of another identifiable cause (7). Despite significant
advances in organ preservation, surgical technique, and
perioperative care, PGD is responsible for significant
morbidity and mortality after lung transplantation (8-9).
Most patients recover with intensive care unit (ICU)
support that includes non-invasive and invasive ventilation,
negative fluid balance, and nitric oxide. However, some
patients with severe PGD develop refractory hypoxemia,
resulting in shock, multiorgan failure, and mortality in 60%
of cases (10-12). During the past few years, highlighted by
the influenza-A H1N1 epidemic, gas exchange support
using an extracorporeal membrane oxygenator (ECMO) has
been used as life-saving therapy in severe cases of
respiratory failure (13-15). We report the case of a patient
with a severe form of PGD after lung transplantation who
was successfully supported using veno-venous ECMO until
respiratory recovery.
CASE DESCRIPTION
A 20-year-old female patient with cystic fibrosis under-
went bilateral lung transplantation without cardiopulmon-
ary bypass at InCor of Hospital das Clı´nicas of the
University of Sa˜o Paulo. During the previous six months,
the patient was hospitalized four times due to worsening
dyspnea and hypoxemia. Just before lung transplantation,
the patient presented with pneumonia and right lung
atelectasis, with an increased need for oxygen and non-
invasive ventilation (Figure 1).
Bilateral lung transplantation (LTx) was performed with-
out complications. The ischemic time of the left graft was
660 minutes and that of the right graft was 415 minutes. The
patient was not exposed to allogeneic blood transfusion, and
fluid resuscitation was carried out with lactated Ringer’s
solution and albumin. At the end of the surgery, the patient
had a lactate level of 6 mmol/L and a mixed venous
saturation (ScVO2) of 75%, and the cardiac output was
4.8 L/min. After a 16-hour procedure, the patient was
brought to the ICU using mechanical ventilation (MV),
intubated and received norepinephrine (0.15 mg/Kg/min).
The patient presented no complications during the
immediate postoperative period and was weaned from
MV 18 hours after ICU arrival. However, on the third day
after surgery, the patient developed respiratory failure due
to severe hypoxemia (PO2/FiO2 of 130 mmHg), with normal
filling pressures (a central venous pressure of 7 mmHg and
a wedge pressure of 12 mmHg). A chest X-ray revealed
diffuse bilateral patchy opacities (Figure 2).
After approximately three hours of non-invasive mechan-
ical ventilation and forced diuresis, respiratory function and
gas exchange worsened (PO2/FiO2 of 100 mmHg and PaCO2
of 124 mmHg), and the hemodynamics of the patient
progressively deteriorated. She presented a mean blood
pressure of 50 mmHg, profuse sweating, and delayed
peripheral perfusion. The patient was then placed under
assisted pressure-controlled mechanical ventilation with an
inspired oxygen fraction (FiO2) of 1.0, a positive end-
expiratory pressure (PEEP) of 14 cmH2O, an inspiratory
pressure of 26 cmH2O (12 cmH2O driving pressure), an
inspiratory time of 0.80 seconds and a respiratory rate of 30.
Applying these parameters, the arterial blood gas presented a
PaO2 of 54 mmHg, a PaCO2 of 118 mmHg, a pH of 7.12 and
an oxygen saturation of 80%. Subsequent tests revealed a
progressive worsening of the physiological parameters, with
a ScVO2 of 48% and lactate of 8 mmol/L. Hypoxemia and
hypercapnia were persistent and refractory to recruitment
Copyright ß 2012 CLINICS – This is an Open Access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.
No potential conflict of interest was reported.
CLINICS 2012;67(12):1529-1532 DOI:10.6061/clinics/2012(12)32
1529
2. maneuvers, with PEEP values of 20-40 cmH2O. A transeso-
phageal echocardiogram was performed and showed no
abnormality at the pulmonary vein anastomoses.
Given the imminent risk of death from refractory
hypoxemia, six hours after invasive mechanical ventilation,
the ECMO team at our institution began veno-venous
ECMO support as a rescue procedure. Using the Seldinger
technique, 20-Fr draining cannulae were inserted into the
left common femoral vein, and a return cannula was placed
into the right jugular vein. The location was guided using
ultrasound. A centrifuge magnetic pump with a poly-
methylpentene oxygenation membrane (Rotaflow/Jostra
Quadrox, Maquet Cardiopulmonary AG, Hirrlinger,
Germany) was used. Initially, the blood flow was main-
tained at 500 mL per minute until the system was filled with
blood. The blood flow and sweeper (gas) flow were
subsequently increased to 2,000 mL per minute. The blood
flow and sweeper flow were then manipulated to target a
peripheral oxygen saturation of at least 90%.
Anticoagulation with heparin was started with 15 U/Kg
of heparin per hour, with the aim of reaching an activated
partial thromboplastin time ratio of 1.5–2.0. After two hours
of veno-venous ECMO support, gas analysis revealed
increasing of PO2/FiO2 to 220, decreased levels of PaCO2
to 45 mmHg, and improvement of the physiologic para-
meters (lactate 2.5 mmol/L, ScVO2 of 75%) and weaning of
norepinephrine.
Mechanical ventilation was adjusted to achieve a positive
end-expiratory pressure (PEEP) of 10 cmH2O, an inspired
fraction of oxygen (FiO2) of 0.4, a driving pressure lower
than 10 cmH2O, and a respiratory rate of 10 breaths per
minute (5). The parameters that were checked daily
included arterial blood gases, clots in the system that were
visible through transillumination, pump campanula auscul-
tation, and flowmeter lubrification to maintain a good signal
quality.
The ECMO blood flow was adjusted to maintain the PaO2
above 55 mmHg, and the sweeper flow was adjusted to
maintain the pH$7.3 (through PaCO2 modulation).
Fentanyl was used as an analgesic and sedative to reach a
Richmond agitation sedation scale (RASS) score of zero and
no pain. The body temperature was kept between 36 and 37
degrees Celsius using an external apparatus adapted to the
ECMO system (Figure 3).
A weaning (autonomy) test from ECMO support was
carried out daily. Five days after treatment, the patient
presented a PO2/FiO2 of 230 mmHg, and the FiO2 set was
adjusted to 0.6 in the ECMO. The sedation was interrupted,
and as patient maintained adequate arterial saturation and a
respiratory rate of 20 breaths per minute while in
spontaneous mode in mechanical ventilator with FiO2 of
0.30, she was successfully weaned from invasive ventilation.
The patient stayed in ECMO during the next two days in an
awake and cooperative state with no pain, at which point
she was considered able to have the ECMO support
removed. The decannulation was performed at the bedside
without complications. The patient was discharged from the
ICU after recovering lung function without complications.
Figure 1 - Chest X-ray showing a diffuse opacity of the right lung
that is compatible with atelectasis.
Figure 2 - Chest X-ray immediately after orotracheal intubation
showing diffuse bilateral opacities that are compatible with
primary graft dysfunction after lung transplantation
Figure 3 - A patient in intensive care receiving mechanical
ventilation and ECMO therapy.
ECMO for PDG after lung transplantation
Peˆgo-Fernandes PM et al.
CLINICS 2012;67(12):1529-1532
1530
3. DISCUSSION
Respiratory support with extracorporeal membrane oxyge-
nation (ECMO) has been used since 1971, with varied results
(16-19). In 2009, the influenza-A epidemic renewed the
interest in this therapy, which had shown efficacy in treating
refractory hypoxemia in many patients worldwide (20-21).
The CESAR trial revealed a reduction in mortality at six
months with ECMO compared with conventional protective
mechanical ventilation in severe ARDS patients (22).
In conjunction with lung transplantation, ECMO may be
useful as a temporary support for respiratory failure while
patients are waiting for the organ and after transplantation
in cases of refractory hypoxemia (23-25). Most cases of
severe hypoxemia after LTx are due to PGD and result in
high rates of mortality. A few single-center experiences have
been reported, with relatively few cases of ECMO after LTx
(26-27). The Extracorporeal Life Support Organization
(ELSO) registry, which was established to improve the
quality and outcome of extracorporeal life support (ECLS)
in patients treated with ECMO, currently includes 151 post-
LTx patients with PGD (28). The mean age is 35¡18 years.
Indications for LTx included acute respiratory distress
syndrome, (15%), cystic fibrosis (15%), idiopathic pulmon-
ary fibrosis (8%), primary pulmonary hypertension, (10%),
emphysema (15%), acute lung failure (11%), other (23%),
and unknown (3%). The ECMO run time was 140¡212
hours. Veno-venous ECMO was used in 25 patients, veno-
arterial in 89 patients, and other modes in 15 patients
(unknown in 22 patients). ECMO was discontinued in 93
patients because of lung recovery. It was also discontinued
in 29 patients with multiorgan failure, 22 patients who died
with no further specification, and seven patients for other
reasons. In total, 63 (42%) of the patients survived the
hospital stay. The major complications during ECMO
included hemorrhage (52%), hemodialysis (42%), neurologic
complications (12%), cardiac complications (28%), inotropic
support (77%), and sepsis (15%) (28).
In our patient, ECMO was placed on the third day after
LTx due to refractory hypoxemia and hypercapnic acidosis.
The patient presented no complications of the treatment,
and the duration spent in ECMO was 168 hours. The V-V
ECMO allowed adequate ventilatory support and resulted
in a reversion of the acidosis and shock. The choice of
ECMO modality (veno-venous or veno-arterial) depends on
the hemodynamic stability and need for cardiac support
(29). The veno-venous system is usually preferred in stable
patients because it involves an easier implant technique and
fewer bleeding and thrombotic complications. In our
patient, veno-venous ECMO was used once the patient
presented a normal ejection fraction without right ventricle
dysfunction, and the shock was interpreted as a conse-
quence of hypoxemia and acidosis. After a few hours of
treatment and the recovery of oxygenation, the shock
reversed, highlighting the right indication of the system.
Although the ELSO registry was not primarily established
to study ECMO in LTx, it provides valuable insights and
evidence that there is indeed an appreciable salvage rate
with the use of ECMO for PGD after LTx (28). Clearly, this is
a high-risk patient population, and no single center can
accumulate a large volume of ECMO experience for this
specific indication.
The case under discussion underscores the importance of
ECMO as a rescue therapy in patients undergoing lung
transplantation who develop severe hypoxemia. The main
challenges of this treatment are addressing the clear
indications, costs, system availability, and team training.
The Hospital das Clı´nicas ECMO team was innovative in
Brazil and has become a referral center with physicians,
nurses, and physiotherapists to assist patients and train
individuals to administer ECMO. In a recent paper from this
team, a 40% survival rate was described when using ECMO
as a respiratory and/or cardiovascular support (30).
The importance of this discussion is to call attention to the
need to develop experience and perform more studies in
patients treated with ECMO to better study the outcomes,
determine the optimum treatment strategies, and optimize
the patient and device selection, thus improving the
outcomes of patients who require this unique therapy.
AUTHOR CONTRIBUTIONS
Peˆgo-Fernandes PM, Hajjar LA, Galas FR, Samano MN and Park M took
part in the care of the patient and contributed equally in carrying out the
manuscript preparation and revision. Ribeiro AK, Soares R and Osawa E
were responsible for the medical literature search and preparation of the
manuscript. Jatene FB was responsible for the final revision of the
manuscript. All the authors have approved the final version of the
manuscript.
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