In this study the use of extracorporeal carbon dioxide removal allowed avoiding intubation and invasive mechanical ventilation in the majority of patients with acute on chronic respiratory failure not responding to NIV. Compared to conventional invasive ventilation, short- and long-term survivals were similar.

Bleeding is still the most common complication during extracorporeal membrane oxygenation (ECMO) for temporary cardio-circulatory support. We present a case of a young man suffering from intractable hemorrhage during ECMO support, who was pre-treated with glycoprotein IIb/IIIa receptor antagonist Tirofiban due to a suspicion of myocardial ischemia. After failure of conventional hemostatic means, hemostasis was achieved by the donation of recombinant Factor VIIa (rFVIIa). Aspects of bleeding control during extracorporeal circulatory support, the use of Tirofiban and rFVIIa are discussed.

BackgroundTo evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO2R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV).MethodsRetrospective ancillary cost analysis of data extracted from a recently published multicentre case–control-study (n = 42) on the use of arterio-venous ECCO2R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO2R system.ResultsIn the group treated with ECCO2R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO2R group (19.610 vs. 46.552 €, p = 0.01).ConclusionsAdditional costs for the use of arterio-venous ECCO2R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.

Objective In amyotrophic lateral sclerosis (ALS), respiratory muscle involvement and sleep-disordered breathing relate to worse prognosis. The present study investigated whether respiratory outcomes on first-ever sleep studies predict survival in patients with ALS, specifically taking into account subsequent initiation of non-invasive ventilation (NIV). Methods From patients with ALS, baseline sleep study records, transcutaneous capnometry, early morning blood gas analysis, survival data and clinical disease characteristics were retrospectively analyzed. Patients were stratified according to whether enduring NIV was consecutively established (“NIV(+)”) or not (“NIV(–)”). Results Among the study cohort (n = 158, 72 female, 51 with bulbar onset ALS, 105 deceased) sleep-disordered breathing was present at baseline evaluation in 97 patients. Early morning base excess (EMBE) > 2 mmol/l predicted nocturnal hypercapnia. Ninety-five patients were NIV(+) and 63 were NIV(–). Survival from baseline sleep studies was significantly reduced in NIV(–) but not in NIV(+) patients with nocturnal CO2 tension ≥ 50 mmHg, apnea hypopnea index ≥ 5/h, and EMBE > 2 mmol/l. Hazard ratio for EMBE > 2 mmol/l was increased in NIV(–) patients only, and EMBE independently predicted survival in both NIV(–) and NIV(+) patients. Furthermore, EMBE on baseline sleep studies was the only predictor for survival from symptom onset, and hazard ratio for shorter survival was markedly higher in the NIV(–) than the NIV(+) group (2.85, p = 0.005, vs. 1.71, p = 0.042). Interpretation: In patients with ALS, EMBE > 2 mmol/l predicts nocturnal hypercapnia and shorter survival. Negative effects of sleep-disordered breathing on survival are statistically abolished by sustained NIV.

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A case of phlebothrombosis with recurrent pulmonary and cerebral embolism is presented which occurred in a 42 year old patient two weeks after treatment of a traumatic crural fracture despite of prophylaxis with low molecular heparin. By means of transthoracic echocardiography a large intracardiac thrombus was detected, entrapped in an patent foramen ovale (PFO) and prolapsing through both atrioventricular valves into both ventricles. This was found after systemic thrombolysis with rtPA had been performed because of fulminant pulmonary embolism. Subsequently the intracardiac thrombus was surgically removed and the PFO closed. The importance of an PFO for paradoxical embolism is discussed as well as the various therapeutical paths to treat an "embolus-in-transit" (cardiac surgery, thrombolytic therapy or anti-coagulation).