The use of ECLS in the treatment of poisoned patients has been recently reviewed by de Lange et al. [1], but a case of aluminum phosphide poising supported by ECLS has not been described yet.
We want to report a successful support with ECLS in a 6 year old child with severe cardiovascular failure due to aluminum phosphide poising
Extracorporeal membrane oxygenation (ECMO) is considered a rescue therapy in severe cases of acute cardiac and or respiratory failure.
We describe our initial experience at the first ECMO center in Egypt.
Our adult ECMO program started in January 2014. Since then we supported eleven respiratory failure patients on ECMO indicated according to ELSO guidelines and one case of ECMO CPR. Respiratory failure patients were subjected to VV ECMO when lung injury score (LIS) was above 3 and PaO2/FiO2 <100 on protective lung strategy mechanical ventilation according to ARDS net protocol and or severe hypercapnia with pH < 7.2 with trial of prone positioning in the indicated cases. Percutaneous cannulation was done in all patients using single lumen cannulae, additional cannula was added when needed. Cardiohelp (Maquet, Germany) and Rotaflow (Maquet, Germany) ECMO consoles were used with centrifugal pump. ECMO circuits PLS for Rotaflow and HLS for Cardiohelp were changed when indicated. The ECMO CPR patient was a primary PCI for acute inferior STEMI complicated by left main occlusion, VA ECMO instituted in the cath-lab after 20 min of CPR. Percutaneous (and or surgical) tracheostomy was done after 14 days of mechanical ventilation.
A total of twelve patients received ECMO between January 2014 and June 2015. The mean age was 35.9 years. (range 13–65 years), 8 males, with VV ECMO in 10 patients, and VA ECMO in 2 patients. Out of ten patients of VV ECMO, one had H1N1 pneumonia, one had advanced vasculitic lung, four had bacterial pneumonia, two traumatic lung contusions and one with organophosphorus poisoning, and one undiagnosed etiology leading to severe ARDS. Lung injury score range was 3–3.8, PaO2/FiO2 (20–76) mechanical ventilation duration before ECMO 1–14 days, Femoro-jugular cannulation in 7 patients and femoro-femoral in 2 patients and femoro-subclavian in 1 patient; all patients were initially sedated and paralyzed for (2–4 days) and ventilated on pressure controlled ventilation with Pmax of 25 cm H2O and PEEP of 10 cm H2O. In VA ECMO patients were cannulated percutaneously using femoro-femoral approach. One patient showed no neurologic recovery and died after 24 h, the other had CABG on ECMO however the heart didn’t recover and died after 9 days. Heparin intravenous infusion was used initially in all patients and changed to Bivalirudin in 2 patients due to possible HIT. Pump flow ranged from 2.6 to 6.5 L/min. Average support time was 12 days (range 2–24 days). Seven patients (63.3%) were successfully separated from ECMO and survived to hospital discharge. Hospital length of stay
The indication and usage for Extracorporeal Life Support (ECLS) has increased significantly over the last 10 years, and more and more hospitals are now offering this service. Despite this trend, ECLS is a mature “daily business” in only a few centers.
In this context, the importance of simulation in the field of ECLS must be strongly emphasized for the following reasons:
Infrequent use of the technology requires practicing of routine actions on ECLS, as necessary preparation for the moment that it will be actually used,
Emergencies on ECLS are fortunately even rarer than its practice, but are potentially fatal and call for repetitive and frequent training targeting at identifying, interacting and solving these problems.
ECPR is defined as the rapidly-deployed application of venoarterial extracorporeal membrane oxygenation, in patients with cardiac arrest, during cardiopulmonary resuscitation before the return of ROSC. ECPR is one of the most rapidly growing segments of ECLS, and is becoming more widespread. Consideration for institution of ECPR is given to patients with witnessed arrest, good quality CPR instituted within 5 min of arrest, in whom ROSC does not occur within 15 min, and who can complete cannulation within 30–60 min. Patients from both inpatient and out-of-hospital settings are candidates if they meet these criteria. Deep hypothermic cardiac arrest, such as cold-water drowning, should receive consideration for ECPR even after considerable duration of arrest. Available outcome data are based on retrospective observation studies, some with propensity matching, and suggests a higher chance for survival with ECPR. Published outcomes from ECPR, however, are difficult to interpret, since many centers classify their use of ECLS after ROSC, in addition to ECLS before ROSC, as ECPR. Both children and adults are candidates for ECPR, but the experience in children is weighted heavily toward those with a diagnosis of cardiac disease and arrest occurring within closely monitored units.
To compare the prognostic value of the SIPF (shock index and hypoxemia) score as the combination of shock index (heart rate/systolic blood pressure) >0.7 (1 point) plus PaO2/FiO2 < 250 (1 point), and the severity score for community-acquired pneumonia (CAP) (CURB-65) and pneumonia severity index (PSI) in predicting the need for ICU admission and mortality of patients with community-acquired pneumonia.
This retrospective study was conducted on patients with CAP admitted to AL-Hussein University hospital (Egypt), Muhayl general hospital and King Khalid hospital at Hail, (KSA). The information required for calculating SIPF, PSI and CURB-65 was extracted from the medical records.
We studied 100 patients with community-acquired pneumonia (64 men, 36 women). Thirty-four patients needed ICU admission (while 66 did not need ICU admission and admitted in observation room or general ward) and among the ICU patients 21 cases needed mechanical ventilation. Ten cases died; 9 cases in ICU and one case in observation room (ward). The ability to predict ICU admission was higher for SIPF score compared to CURB-65 (AUC SIPF 0.88 vs. 0.83; p < 0.001) and PSI (AUC SIPF 0.88 vs. 0.79; p < 0.001). The ability to predict mortality was higher for SIPF score compared to CURB-65(AUC SIPF 0.80 vs. 0.84; p < 0.001) and PSI (AUC SIPF 0.80 vs. 0.83; p < 0.001).
The ability of SIPF score to predict ICU admission in CAP is higher than that of CURB-65 and PSI. Simple SIPF score could be a useful tool to predict mortality in CAP.
C-reactive protein (CRP) value can identify the risk level for acute coronary syndrome (ACS). Ivabradine, a selective inhibitor of the funny current channel, reduces resting and exercise HR without affecting cardiac contractility or blood pressure.
Evaluate the influence of Ivabradine on long term prevention of major adverse cardiac events (MACE) using high sensitivity crp (hs CRP).
60 pts were admitted with ACS over the period of 6 months. Cardiac enzymes were withdrawn on admission and every 6 h thereafter for 24 h then followed up daily for five days and when indicated. High sensitivity C-reactive protein (hs-CRP) (quantitative value) which was done on day of admission and repeated for follow up at day 4 and at day 30 patients divided into two groups each 30 pts: group (A) who received conventional therapy & ivabradine, group (B) who received conventional therapy only. Ivabradine given within 48 h of admission 5 mg twice daily upgraded to 7.5 mg twice daily after one week if tolerable Myocardial perfusion imaging (MPI): Patients were subjected to Technetium99 sesta MIBI Myocardial perfusion imaging (MPI) within 6–8 h after admission and were followed up on day 30 with the same dose of injection using multi-spect Siemens dual head gamma Camera.
There were significant variances in Hs-CRP value at day 30 in both groups (P value < 0.001). Patients of group A showed statistically significant lower level of hs-CRP at day 30 compared to group B (0.7 ± 0.3 mg/dl versus 1.66 ± 0.9 mg/dl; P value < 0.001) but there was no statistically significant difference between both groups regarding 30 days follow up MACE (P value 0.552).
Administration of ivabradine within 48 h of CCU admission decreased hs-CRP level in patients with acute coronary syndrome (unstable angina) but did not decrease the occurrence of major cardiac events in ACS patients.
Our objective was to assess the global longitudinal peak systolic strain (GLPSS) by speckle tracking echocardiography (STE) in patients with STEMI in the first 24 h after primary percutaneous coronary intervention (PCI) and its correlation with LV infarction size and ejection fraction.
A total of 30 patients with STEMI (mean age: 58 ± 8 years, 25 men) were studied. All patients underwent 1ry PCI. Conventional 2D echocardiography was performed to assess left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and end systolic volume index (ESVI), while STE was performed within 24 h of 1ry PCI to assess LV GLPSS. Infarction size was estimated by myocardial perfusion imaging before hospital discharges. All patients with STEMI had low LV GLPSS (mean: −10.57 ± 2.67%). Significant inverse correlation was observed between LV GLPSS and IS (p = 0.03, r = 0.39) with the cut-off point for GLPSS, which defined large myocardial infarction size (⩾30% of LV mass), was −11.5% with 93% sensitivity and 67% specificity (AUC = 0.8). Also LV GLPSS proportionally correlated with EF (p = 0.01, r = 0.35) and inversely correlated with WMSI (p = 0.04, r = 0.5). WMSI showed the most significant correlation to IS (p = 0.0, r = 0.64). Significant correlation was observed between IS and EF (p = 0.04, r = 0.37). No significant correlation was found neither between ESVI and IS (p = 0.4, r = 0.2) nor GLPSS (p = 0.08, r = 0.33).
Assessment of IS by echocardiography after PCI in patients with STEMI was superior with GLS and WMSI when compared with LVEF and ESVI. Since global strain is an inexpensive test, these data may be of health economic interest.
Acute coronary syndrome (ACS), one of the commonest causes of ICU admission, casts a large burden of cost on the health care system, with a huge mortality in the elderly, in Egypt and worldwide.
Comparative study between elderly and younger patients with acute coronary syndrome in the last 4 years in the Critical Care department, Cairo University.
The population of the study included 570 patients who were admitted to the Critical Care department, Cairo University with ACS (between January 2011 and February 2015). Patients were divided into two groups: (1) Elderly ⩾ 60 year. (2) Younger < 60 year.
Data collection focused on patients’ demographics; risk factors for CAD, PCI indications; baseline cardiac status & associated medical conditions; angiographic & PCI procedure and clinical success of PCI.
Dyslipidemia, hypertension and diabetes were the most significant risk factors for ACS in elderly (p < 0.001), while smoking was the most significant risk factor in younger patients (p < 0.001). Predictors of heart failure were age and TIMI score. Being elderly increases odds ratio of heart failure by 3.154 times, (P value .035), also increases in TIMI score increase the incidence of heart failure by 0.825 times, (P value <.001). Mortality was frequent in elderly than younger, (P value = 0.002).
Dyslipidemia, hypertension and diabetes were the most frequent risk factors for CAD in elderly, while smoking was the most frequent risk factor in younger patients. Mortality was more frequent in elderly than younger. Complications were more frequent in elderly than younger. A predictor of Heart failure was an increase in both age and TIMI score.
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