Venoarterial extracorporeal membrane oxygenation (VA-ECMO)—also referred to as extracorporeal life support—is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange. The initiation of VA-ECMO has emerged as a salvage intervention in patients with cardiogenic shock, even cardiac arrest refractory to standard therapies. Analogous to veno-venous ECMO for acute respiratory failure, VA-ECMO provides circulatory support and allows time for other treatments to promote recovery or may be a bridge to a more durable mechanical solution in the setting of acute or acute on chronic cardiopulmonary failure. In this review, we provide a brief overview of VA-ECMO, the attendant physiological considerations of peripheral VA-ECMO, and its complications, namely that of left ventricular distention, bleeding, heightened systemic inflammatory response syndrome, thrombosis and thromboembolism, and extremity ischemia or necrosis.

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Cardiogenic shock (CS) is a condition associated with high mortality rates in which prognostication is uncertain for a variety of reasons, including its myriad causes, its rapidly evolving clinical course and the plethora of established and emerging therapies for the condition. A number of validated risk scores are available for CS prognostication; however, many of these are tedious to use, are designed for application in a variety of populations and fail to incorporate contemporary hemodynamic parameters and contemporary mechanical circulatory support interventions that can affect outcomes. It is important to separate patients with CS who may recover with conservative pharmacological therapies from those in who may require advanced therapies to survive; it is equally important to identify quickly those who will succumb despite any therapy. An ideal risk-prediction model would balance incorporation of key hemodynamic parameters while still allowing dynamic use in multiple scenarios, from aiding with early decision making to device weaning. Herein, we discuss currently available CS risk scores, perform a detailed analysis of the variables in each of these scores that are most predictive of CS outcomes and explore a framework for the development of novel risk scores that consider emerging therapies and paradigms for this challenging clinical entity.

IntroductionEach year 7 million people die of stroke worldwide; most deaths are caused by chest infections. Patients with acute stroke have impaired voluntary cough flow, associated with increased risk of chest infections. Reduced functional residual capacity (FRC) could lead to impaired cough flow. We therefore compared FRC in acute hemiparetic stroke patients and controls and explored its relationship with volume inspired before cough and voluntary cough peak flow.Methods21 patients within 2 weeks of first-ever middle cerebral artery territory (MCA) infarct (mean (SD) age 68 (11) years, 10 females) and 30 controls (58 (11) years, 15 females) underwent FRC and voluntary cough testing (cough inspired volume and peak flow) while semirecumbent. FRC was expressed as % predicted; cough inspired volume was expressed as % predicted VC and cough peak flow as % predicted PEF. A clinician scored stroke severity using the National Institutes of Health Stroke Scale (NIHSS).ResultsPatients’ reclined FRC, voluntary cough peak flowand cough inspired volume were reduced compared with controls (p<0.01 for all): patients’ median (IQR) FRC 76 (67–90) % predicted, mean (SD) cough inspired volume 64 (20) % predicted and mean (SD) peak cough flow 61 (32) % predicted despite them having only mild stroke-related impairments: median NIHSS score 4 (IQR 2–6). Univariate linear regression analyses showed FRC predicted cough inspired volume (adjusted R2=0.45) and cough inspired volume predicted cough flow (adjusted R2=0.56); p<0.01 for both. Sitting patients upright increased their FRC by median 0.210 L.ConclusionsFRC and cough inspired volume in the reclined position are significantly reduced in acute hemiparetic stroke patients with mild impairments; both factors are associated with poor voluntary cough peak flow.

Background: Episiotomy is the surgical enlargement of the vaginal orifice by an incision on the perineum during the last part of the second stage of labour or delivery. Episiotomy, incision of the perineum at the time of vaginal childbirth, is a common surgical procedure experienced by women. This study is done to compare use of restrictive episiotomy and routine episiotomy in primigravidae undergoing vaginal birth.Methods: This is a prospective cohort study designed to analyse the outcome of the restrictive use of episiotomy in comparison to routine use of episiotomy. Total 100 primigravidae women reporting to labour room in spontaneous labour/induction of labour were included and two cohorts were formed. Both the cohorts were evaluated during labour, immediate postpartum period and first postnatal day and data was tabulated and analysed.Results: Vaginal and paraurethral tears were noted in 14% primigravidae in the routine episiotomy group and 22.22% in the restrictive episiotomy group with no statistically significant association. Number of cases sustaining perineal tear in restrictive group was 15.55% and extension of episiotomy in the routine group was 26% with no statistically significant association. Requirement of suturing was far less in restrictive group (20%) as compared to routine group (100%), as 64.45% of the patients in restrictive group delivered with an intact perineum. The restrictive use of episiotomy does not prolong the second stage of labour and has requirement of significantly less pain relief compared to the routine group. Complication rate was higher in the routine group and perineal laceration and pain severity, was less in restrictive episiotomy group. However, neonatal complications were similar in the two groups.Conclusions: This study identified fair to good evidence suggesting that immediate outcomes following routine use of episiotomy are no better than those of restrictive use. Indeed, routine use is harmful to the degree that some proportion of women who would have had lesser injury instead had a surgical incision.

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