Drs. Maurovich-Horvat, Bosserdt, and Kofoed contributed equally to this article. This article was published on March 4, 2022, at NEJM.org.
Objectives: Extracorporeal membrane oxygenation is used to stabilize severe cardiocirculatory and/or respiratory failure. However, extracorporeal membrane oxygenation is associated with a coagulopathy characterized by thromboembolic and hemorrhagic complications. This study aimed to characterize the pathomechanism of the extracorporeal membrane oxygenation-associated coagulopathy and identify options to optimize its monitoring and therapy. Design: Prospective observational clinical trial. Setting: ICU of a university hospital. Patients: Patients treated with venovenous extracorporeal membrane oxygenation (n = 10) due to acute respiratory distress syndrome and patients treated with venoarterial extracorporeal membrane oxygenation (n = 8) due to cardiocirculatory failure. One patient per group (venovenous extracorporeal membrane oxygenation or venoarterial extracorporeal membrane oxygenation) had surgery before extracorporeal membrane oxygenation. Interventions: Blood was sampled before, and 1, 24, and 48 hours after extracorporeal membrane oxygenation implantation. Point-of-care tests (thrombelastometry/platelet aggregometry), conventional coagulation tests, whole blood counts, and platelet flow cytometry were performed. Measurements and Main Results: Even before extracorporeal membrane oxygenation, plasmatic coagulation and platelet aggregation were impaired due to systemic inflammation, liver failure, anticoagulants (heparins, phenprocoumon, apixaban), and antiplatelet medication. During extracorporeal membrane oxygenation, hemodilution and contact of blood components with artificial surfaces and shear stress inside extracorporeal membrane oxygenation additionally contributed to coagulation and platelet defects. Fibrinogen levels, fibrin polymerization, platelet activation, and microparticle release were increased in venovenous extracorporeal membrane oxygenation compared to venoarterial extracorporeal membrane oxygenation patients. Point-of-care results were available faster than conventional analyses. Bleeding requiring blood product application occurred in three of 10 venovenous extracorporeal membrane oxygenation patients and in four of eight venoarterial extracorporeal membrane oxygenation patients. No thrombotic events were observed. In-hospital mortality was 30% for venovenous extracorporeal membrane oxygenation and 37.5% for venoarterial extracorporeal membrane oxygenation patients. Conclusions: The extracorporeal membrane oxygenation-associated coagulopathy is a multifactorial and quickly developing syndrome. It is characterized by individual changes of coagulation parameters and platelets and is aggravated by anticoagulants. The underlying factors of the extracorporeal membrane oxygenation-associated coagulopathy differ between venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation patients and are best diagnosed by a combination of point-of-care and conventional coagulation and platelet analyses. Therapy protocols for treating extracorporeal membrane oxygenation-associated coagulopathy should be further validated in large-scale prospective clinical investigations.
Background: Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and causes acute and chronic morbidity as hypertension and chronic kidney disease. Objectives: To describe the demographic characteristics, infectious agent, antibiotic resistance patterns and empiric therapy response of UTI in pediatric population. Methods: This is a descriptive, retrospective study. Results: Were included 144 patients, 1:2.06 male to female ratio. The most common symptom was fever (79.9%) and 31.3% had history of previous UTI. 72.0% of the patients had positive urine leukocyte count (>5 per field), urine gram was positive in 85.0% of samples and gram negative bacilli accounted for 77.8% for the total pathogens isolated. The most frequent uropathogens isolated were Escherichia coli and Klebsiella pneumoniae. Our E.coli isolates had a susceptibility rate higher than 90% to most of the antibiotics used, but a resistance rate of 42.6% to TMP SMX and 45.5% to ampicillin sulbactam. 6.3% of E. coli was extended-spectrum beta-lactamases producer strains. The most frequent empirical antibiotic used was amikacin, used in 66.0% of the patients. 17 of 90 patients who undergone voiding cistouretrography (VCUG) had vesicoureteral reflux. Conclusion: This study revealed that E. coli was the most frequent pathogen of community acquired UTI. We found that E. coli and other uropathogens had a high resistance rate against TMP SMX and ampicillin sulbactam. In order to ensure a successful empirical treatment, protocols should be based on local epidemiology and susceptibility rates. ResumenAntecedentes: La infección del tracto urinario (ITU) es una de las infecciones bacterianas más frecuentes en la infancia, se asocia con alta morbilidad aguda y de enfermedades a largo plazo como hipertensión arterial e insuficiencia renal crónica. Objetivo: Describir las características demográficas, agente etiológico, perfil de sensibilidad y respuesta al tratamiento empírico de una población pediátrica. Métodos: Estudio descriptivo, retrospectivo realizado en el Hospital Pablo Tobón Uribe (HPTU), Medellín (Colombia), entre enero de 2010 y diciembre de 2011. Resultados: Se incluyeron 144 pacientes, con una relación hombre: mujer de 1:2.06. El 79.9% consultó por fiebre objetiva y el 31.3% había tenido un episodio de ITU previa. El 72.0% presentó leucocituria y el gram de gota de orina sin centrifugar fue positivo en el 86.0% (77.8% de bacilos con tinción de gram negativos). Los uropatógenos más frecuentes fueron Escherichia coli y Klebsiella pneumoniae. Escherichia coli tuvo una sensibilidad mayor al 90% para la mayoría de antibióticos, excepto en el de trimetropín sulfametoxazol, con una resistencia del 42.6% y del 45.5% a la ampicilina sulbactam. Se usó la amikacina como tratamiento empírico en el 66.0%. En 17 de 90 pacientes se encontró algún grado de reflujo vesicoureteral (RVU). Conclusión: La elección del tratamiento empírico precoz debe basarse en el conocimiento de la epidemiología y el perfil de sensibilidad y resistencia...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.