Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events. (ClinicalTrials.gov number, NCT00314704.)

Recently diagnosed immunodeficiency is associated with a much better prognosis in ECMO-treated severe ARDS. However, low 6-month survival of our large cohort of immunocompromised patients supports restricting ECMO to patients with realistic oncological/therapeutic prognoses, acceptable functional status and few pre-ECMO mortality-risk factors.

BackgroundThe potential benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional CPR (CCPR) for patients with refractory cardiac arrest (CA) remains unclear.MethodsThis study is a retrospective analysis of a prospective database of CA patients, which includes all consecutive adult patients admitted to the Department of Intensive Care after CA between January 2012 and December 2017. The decision to initiate ECPR was made by the attending physician and ECPR performed by the ECPR team, which is composed of ICU physicians. A propensity score was derived using a logistic regression model, including characteristics that varied between groups with a p <  0.10 and were potentially related to outcome. Primary outcomes were survival to ICU discharge and favorable 3-month neurologic outcome, assessed by a Cerebral Performance Category (CPC) score of 1–2.ResultsFrom a total of 635 patients with CA during the study period (ECPR, n = 112), 80 ECPR patients were matched to 80 CCPR patients. The time from arrest to termination of CPR (i.e., return of spontaneous circulation [ROSC], extracorporeal membrane oxygenation [ECMO] initiation, or death) was 54 ± 22 and 54 ± 19 min in the ECPR and CCPR groups, respectively. ROSC rates were 77/80 (96%) for ECPR and 30/80 (38%) for CCPR (p <  0.001). Survival to ICU discharge was 18/80 (23%) vs. 14/80 (18%) in the ECPR and CCPR groups, respectively (p = 0.42). At 3 months, 17/80 (21%) ECPR patients and 9/80 (11%) CCPR patients had a favorable outcome (p = 0.11). Cox regression analysis stratified by matched pairs showed a significantly higher neurologic outcome rate in the ECPR group than in the CCPR group (log-rank test p = 0.003).ConclusionsECPR after CA may be associated with improved long-term neurological outcome.

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Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.

Monitoring of rSO could be considered as an interesting tool to monitor the brain of patients on VA-ECMO.

IntroductionFluid administration is a first-line therapy for acute kidney injury associated with circulatory failure. Although aimed at increasing renal perfusion in these patients, this intervention may improve systemic hemodynamics without necessarily ameliorating intrarenal flow distribution or urine output. We used Doppler techniques to investigate the effects of fluid administration on intrarenal hemodynamics and the relationship between changes in renal hemodynamics and urine output. We hypothesized that, compared to systemic hemodynamic variables, changes in renal hemodynamics would better predict increase in urine output after fluid therapy.MethodsWe measured systemic hemodynamic variables and performed renal interlobar artery Doppler on both kidneys before and after volume expansion in 49 adult patients with acute circulatory failure. We measured systolic and diastolic velocities and computed the resistivity index (RI). We recorded urine output for 3 h before and after the fluid challenge.ResultsFluid administration resulted in a small but consistent decrease in RI (from 0.73 ± 0.09 to 0.71 ± 0.09, p < 0.01). There was a concomitant increase in mean arterial pressure (from 75 ± 15 to 80 ± 14 mmHg, p < 0.01), pulse pressure (49 ± 19 to 55 ± 19 mmHg, p < 0.01) and urine output (55 ± 76 to 81 ± 87 ml/hour, p < 0.01). Changes in RI were negatively correlated with changes in urine output and mean arterial pressure but not in pulse pressure. The increase in urine output was predicted by changes in RI but not by changes in systemic hemodynamics.ConclusionsChanges in renal hemodynamics during a fluid challenge can be observed by Doppler ultrasonography before urine output increases. Moreover, these changes are better predictors of an increase in urine output than are mean arterial pressure and pulse pressure.