Mikael Broman - Academia.edu (original) (raw)

Papers by Mikael Broman

Efferent renal nerve activity and glomerular filtration rate during hypothermia

Pflügers Archiv: European Journal of Physiology, 1995

Critical Care, Jun 15, 2018

Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmona... more Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmonary and/or cardiac failure. Blood is drained from the venous system and pumped through a membrane oxygenator where it is oxygenated. For pulmonary support, the blood is returned to the patient via a vein (veno-venous ECMO) and for pulmonary/circulatory support it is returned via an artery (veno-arterial ECMO). Veno-venous ECMO can be performed either with a single dual-lumen cannula or with two separate single-lumen cannulas. If the latter is chosen, flow direction can either be from the inferior caval vein (IVC) to the right atrium or the opposite. Earlier research has shown that drainage from the IVC yields less recirculation and therefore the IVC to right atrium route has become the standard in most centers for veno-venous ECMO with two cannulas. However, recent research has shown that recirculation can be minimized using a multistage draining cannula in the optimal position inserted via the right internal jugular vein and with blood return to the femoral vein. The clinical results with this route are excellent. In veno-arterial ECMO the most common site for blood infusion is the femoral artery. If venous blood is drained from the IVC, the patient is at risk of developing a dual circulation (Harlequin syndrome, North-South syndrome, differential oxygenation) meaning a poor oxygenation of the upper part of the body, while the lower part has excellent oxygenation. By instead draining from the superior caval vein (SVC) via a multistage cannula inserted in the right internal jugular vein this risk is neutralized. In conclusion, the authors argue that draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein is equal or better than IVC drainage both in veno-venous two cannula ECMO and in veno-arterial ECMO with blood return to the femoral artery.

Perfusion, 2020

With ongoing progress of components of extracorporeal membrane oxygenation including improvements... more With ongoing progress of components of extracorporeal membrane oxygenation including improvements of oxygenators, pumps, and coating materials, extracorporeal membrane oxygenation became increasingly accepted in the clinical practice. A suitable testing in an adequate setup is essential for the development of new technical aspects. Relevant tests can be conducted in ex vivo models specifically designed to test certain aspects. Different setups have been used in the past for specific research questions. We conducted a systematic literature review of ex vivo models of extracorporeal membrane oxygenation components. MEDLINE and Embase were searched between January 1996 and October 2017. The inclusion criteria were ex vivo models including features of extracorporeal membrane oxygenation technology. The exclusion criteria were clinical studies, abstracts, studies in which the model of extracorporeal membrane oxygenation has been reported previously, and studies not reporting on extracorp...

Efferent renal nerve activity during hypothermia

Acta Physiologica Scandinavica, 1995

Pflügers Archiv - European Journal of Physiology, 2017

Hypothermia-induced reduction of metabolic rate is accompanied by depression of both glomerular p... more Hypothermia-induced reduction of metabolic rate is accompanied by depression of both glomerular perfusion and filtration. The present study investigated whether these changes are linked to changes in renal autoregulation and nitric oxide (NO) signalling. During hypothermia, renal blood flow (RBF) and glomerular filtration rate (GFR) were reduced and urine production was increased, and this was linked with reduced plasma cGMP levels and increased renal vascular resistance. Although stimulation of NO production decreased vascular resistance, blood pressure and urine flow, intravenous infusion of the NO precursor L-arginine or the NO donor sodium nitroprusside did not alter RBF or GFR. In contrast, inhibition of NO synthesis by N w-nitro-L-arginine led to a further decline in both parameters. Functional renal autoregulation was apparent at both temperatures. Below the autoregulatory range, RBF in both cases increased in proportion to the perfusion ±pressure, although, the slope of the first ascending limb of the pressure-flow relationship was lower during hypothermia. The main difference was rather that the curves obtained during hypothermia levelled off already at a RBF of 3.9 ± 0.3 mL/min then remained stable throughout the autoregulatory pressure range, compared to 7.6 ± 0.3 mL/min during normothermia. This was found to be due to a threefold increase in, primarily, the afferent arteriolar resistance from 2.6 to 7.5 mmHg min mL −1. Infusion of sodium nitroprusside did not significantly affect RBF during hypothermia, although a small increase at pressures below the autoregulatory range was observed. In conclusion, cold-induced rise in renal vascular resistance results from afferent arteriolar vasoconstriction by the autoregulatory mechanism, setting RBF and GFR in proportion to the metabolic rate, which cannot be explained by reduced NO production alone.

Critical Care, 2015

Introduction In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenatio... more Introduction In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenation (ECMO) may be a lifesaving procedure. Specialized departments provide ECMO, and these patients often have to be transferred for treatment. Conventional transportation is hazardous, and deaths have been described. Only a few centers have performed more than 100 ECMO transports. To date, our mobile ECMO teams have performed more than 700 transports with patients on ECMO since 1996. We describe 4 consecutive years (2010–2013) of 322 national and international ECMO transports and report adverse events. Methods Data were retrieved from our local databases. Neonatal, pediatric and adult patients were transported, predominantly with refractory severe respiratory failure. Results The patients were cannulated in 282 of the transports, and ECMO was started in these patients at the referring hospital and then they were transported to our ECMO intensive care unit. In 40 cases, the patient was alre...

ASAIO Journal, 2014

Extracorporeal membrane oxygenation (ECMO) is a salvage therapy in acute cardiac failure and/or s... more Extracorporeal membrane oxygenation (ECMO) is a salvage therapy in acute cardiac failure and/or severe respiratory failure. In this case report the importance of cannula positioning during veno-venous ECMO is exemplified. The use of echocardiography and its advantages compared to plain chest radiograph will be shown. This case reflects a 5-month-old boy who acquired a severe viral pneumonia leading to respiratory failure and ECMO treatment. Extracorporeal membrane oxygenation was performed via a dual lumen cannula correctly placed in the right atria according to a chest radiograph. During the first day of treatment the patient's arterial saturation was not satisfying. Assessment revealed that a part of the ECMO flow was recirculating. Echocardiography was used to optimize the cannula position, and thus, rapidly improving the patient's oxygenation. A persistent left superior vena cava and its effect on the central hemodynamics were also objectified. This case illustrates important considerations in daily ECMO treatment: the benefit of direct echocardiographic competence at all times during the day, the importance of understanding central blood flow dynamics, to adjust the cannula-position accordingly, and to address situations outside the ordinary with a physiologic approach.

Clinical Case Reports, 2016

We report a 17-year-old woman with bronchiolitis obliterans-organizing pneumonia (BOOP)-like gran... more We report a 17-year-old woman with bronchiolitis obliterans-organizing pneumonia (BOOP)-like granulomatosis with polyangiitis developing severe airway obliterations. Pending age, phase and grade of autoimmune treatment, and offering ECMO treatment may be crucial for survival but occasionally preface futility. ECMO-treated patient with BOOP-like GPA has never been described before.

Additional file 2: Table S1. of Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study

A compilation of the different forms of pre-admission antithrombotic therapy in ICH vs. non-ICH c... more A compilation of the different forms of pre-admission antithrombotic therapy in ICH vs. non-ICH cohorts. (DOCX 48 kb)

Additional file 1: of Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study

ECMO circuit. A description of the ECMO pumps, oxygenators, ventilators, cannulas and patients mo... more ECMO circuit. A description of the ECMO pumps, oxygenators, ventilators, cannulas and patients monitoring system used for the patients included in the study. (DOCX 84 kb)

Aspects of renal function during moderate hypothermia in the rat

Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure ... more Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquart...

Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey

ASAIO Journal, 2020

Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failur... more Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failure of invasive mechanical ventilation (IMV) and other adjuncts, including low tidal volume, prone positioning, adjusted positive end-expiratory pressure, and lung recruitment maneuvers, typically remain on IMV after VV ECMO commencement.1,2 Once both IMV and VV ECMO support are initiated, it is unclear which modality should be weaned first. Moreover, the optimal IMV settings, risk versus benefits of early spontaneous breathing, and optimal timing of VV ECMO weaning practices are yet to be defined. In addition, although the practice of liberation from IMV during ECMO3–8 has been increasing, the data concerning the weaning processes from ECMO and IMV are limited.9,10 Differences in weaning strategies for VV ECMO are based on the preferable approach is whether to wean ECMO or not when the patient is still mechanically ventilated.11 The approach to enable spontaneous breathing and early IMV weaning may prevent the complications of sedation allowing to avoid the risk of ventilationinduced lung injury and ventilator-associated pneumonia.5,6,12,13 A pragmatic way to “wean” as soon as the tidal volume start to recover has been proposed by clinicians at the Karolinska Institute ECMO Centre in Stockholm.11 Vasques et al. proposed a physiology-based assessment protocol, which combines an objective assessment of the native and artificial lung function. This method quantifies the patient’s response to a standardized weaning trial.9 However this strategy has not been tested in prospective trials and carries some challenges and risks in managing awake patients on ECMO. The aim of this survey was to understand current VV ECMO and IMV weaning practices globally.

Artificial Organs, 2021

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-... more This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Defining and understanding the “extra‐corporeal membrane oxygenation gap” in the veno‐venous configuration: Timing and causes of death

Artificial Organs, 2021

In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patient... more In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in-hospital death, either on-ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V-V ECMO, and to define the V-V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on-ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V-V ECMO-gap. Mortality rates on-ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V-V ECMO outcomes (on-ECMO mortality and discharge rate). Mortality on V-V ECMO support was 27.8% (95% confidence interval (CI) 22.5%-33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%-16.6%, defining the V-V ECMO gap). 72.2% of patients (95% CI 66.8%-77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%-63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V-V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V-V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V-V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.

Intensive Care Medicine, 2021

Full author information is available at the end of the article Members of the EuroECMO COVID-19 W... more Full author information is available at the end of the article Members of the EuroECMO COVID-19 Working Group and of the Euro-ELSO Steering Committee are listed in the Acknowledgements Section.

Scientific Reports, 2021

Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extraco... more Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excl...

Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation

Perfusion, 2020

Introduction: In the last decade, dual-lumen cannulae have been increasingly applied in patients ... more Introduction: In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure–flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. Methods: We performed a study evaluating pressure–flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer’s corresponding curves obtained from the public domain. Results: The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain s...

Journal of Intensive Care, 2020

In the original publication of this article [1], the first author’s name should be changed from A... more In the original publication of this article [1], the first author’s name should be changed from Alexander Fletcher Sandersjöö to Alexander Fletcher-Sandersjöö. The family name of the author is Fletcher-Sandersjöö.

SN Applied Sciences, 2020

Co-axial tubes have been used to produce a co-flowing confined jet similar to that found in an Ex... more Co-axial tubes have been used to produce a co-flowing confined jet similar to that found in an Extracorporeal Membrane Oxygenation return cannula flow configuration. Particle Image Velocimetry was used to investigate the flow rate ratio between jet and co-flow as well as changes in flow characteristics due to cannula position. The flow was found to be dominated by three main structures: lateral flow entrainment, shear layer induced vortices and backflow along the wall. An increase in cannula flow rate amplified entrainment and recirculation, resulting in a decrease in length required to reach a fully developed flow. Changing cannula position relative the outer cylinder induced a significant reduction in recirculation zone as well as vortex formation on the side to which the cannula was tilted towards, whereas on the other side, the recirculating flow region was enhanced. Proper Orthogonal Decomposition demonstrated that the dominating structure found in the flow is the backflow, com...

Efferent renal nerve activity and glomerular filtration rate during hypothermia

Pflügers Archiv: European Journal of Physiology, 1995

Critical Care, Jun 15, 2018

Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmona... more Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmonary and/or cardiac failure. Blood is drained from the venous system and pumped through a membrane oxygenator where it is oxygenated. For pulmonary support, the blood is returned to the patient via a vein (veno-venous ECMO) and for pulmonary/circulatory support it is returned via an artery (veno-arterial ECMO). Veno-venous ECMO can be performed either with a single dual-lumen cannula or with two separate single-lumen cannulas. If the latter is chosen, flow direction can either be from the inferior caval vein (IVC) to the right atrium or the opposite. Earlier research has shown that drainage from the IVC yields less recirculation and therefore the IVC to right atrium route has become the standard in most centers for veno-venous ECMO with two cannulas. However, recent research has shown that recirculation can be minimized using a multistage draining cannula in the optimal position inserted via the right internal jugular vein and with blood return to the femoral vein. The clinical results with this route are excellent. In veno-arterial ECMO the most common site for blood infusion is the femoral artery. If venous blood is drained from the IVC, the patient is at risk of developing a dual circulation (Harlequin syndrome, North-South syndrome, differential oxygenation) meaning a poor oxygenation of the upper part of the body, while the lower part has excellent oxygenation. By instead draining from the superior caval vein (SVC) via a multistage cannula inserted in the right internal jugular vein this risk is neutralized. In conclusion, the authors argue that draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein is equal or better than IVC drainage both in veno-venous two cannula ECMO and in veno-arterial ECMO with blood return to the femoral artery.

Perfusion, 2020

With ongoing progress of components of extracorporeal membrane oxygenation including improvements... more With ongoing progress of components of extracorporeal membrane oxygenation including improvements of oxygenators, pumps, and coating materials, extracorporeal membrane oxygenation became increasingly accepted in the clinical practice. A suitable testing in an adequate setup is essential for the development of new technical aspects. Relevant tests can be conducted in ex vivo models specifically designed to test certain aspects. Different setups have been used in the past for specific research questions. We conducted a systematic literature review of ex vivo models of extracorporeal membrane oxygenation components. MEDLINE and Embase were searched between January 1996 and October 2017. The inclusion criteria were ex vivo models including features of extracorporeal membrane oxygenation technology. The exclusion criteria were clinical studies, abstracts, studies in which the model of extracorporeal membrane oxygenation has been reported previously, and studies not reporting on extracorp...

Efferent renal nerve activity during hypothermia

Acta Physiologica Scandinavica, 1995

Pflügers Archiv - European Journal of Physiology, 2017

Hypothermia-induced reduction of metabolic rate is accompanied by depression of both glomerular p... more Hypothermia-induced reduction of metabolic rate is accompanied by depression of both glomerular perfusion and filtration. The present study investigated whether these changes are linked to changes in renal autoregulation and nitric oxide (NO) signalling. During hypothermia, renal blood flow (RBF) and glomerular filtration rate (GFR) were reduced and urine production was increased, and this was linked with reduced plasma cGMP levels and increased renal vascular resistance. Although stimulation of NO production decreased vascular resistance, blood pressure and urine flow, intravenous infusion of the NO precursor L-arginine or the NO donor sodium nitroprusside did not alter RBF or GFR. In contrast, inhibition of NO synthesis by N w-nitro-L-arginine led to a further decline in both parameters. Functional renal autoregulation was apparent at both temperatures. Below the autoregulatory range, RBF in both cases increased in proportion to the perfusion ±pressure, although, the slope of the first ascending limb of the pressure-flow relationship was lower during hypothermia. The main difference was rather that the curves obtained during hypothermia levelled off already at a RBF of 3.9 ± 0.3 mL/min then remained stable throughout the autoregulatory pressure range, compared to 7.6 ± 0.3 mL/min during normothermia. This was found to be due to a threefold increase in, primarily, the afferent arteriolar resistance from 2.6 to 7.5 mmHg min mL −1. Infusion of sodium nitroprusside did not significantly affect RBF during hypothermia, although a small increase at pressures below the autoregulatory range was observed. In conclusion, cold-induced rise in renal vascular resistance results from afferent arteriolar vasoconstriction by the autoregulatory mechanism, setting RBF and GFR in proportion to the metabolic rate, which cannot be explained by reduced NO production alone.

Critical Care, 2015

Introduction In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenatio... more Introduction In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenation (ECMO) may be a lifesaving procedure. Specialized departments provide ECMO, and these patients often have to be transferred for treatment. Conventional transportation is hazardous, and deaths have been described. Only a few centers have performed more than 100 ECMO transports. To date, our mobile ECMO teams have performed more than 700 transports with patients on ECMO since 1996. We describe 4 consecutive years (2010–2013) of 322 national and international ECMO transports and report adverse events. Methods Data were retrieved from our local databases. Neonatal, pediatric and adult patients were transported, predominantly with refractory severe respiratory failure. Results The patients were cannulated in 282 of the transports, and ECMO was started in these patients at the referring hospital and then they were transported to our ECMO intensive care unit. In 40 cases, the patient was alre...

ASAIO Journal, 2014

Extracorporeal membrane oxygenation (ECMO) is a salvage therapy in acute cardiac failure and/or s... more Extracorporeal membrane oxygenation (ECMO) is a salvage therapy in acute cardiac failure and/or severe respiratory failure. In this case report the importance of cannula positioning during veno-venous ECMO is exemplified. The use of echocardiography and its advantages compared to plain chest radiograph will be shown. This case reflects a 5-month-old boy who acquired a severe viral pneumonia leading to respiratory failure and ECMO treatment. Extracorporeal membrane oxygenation was performed via a dual lumen cannula correctly placed in the right atria according to a chest radiograph. During the first day of treatment the patient's arterial saturation was not satisfying. Assessment revealed that a part of the ECMO flow was recirculating. Echocardiography was used to optimize the cannula position, and thus, rapidly improving the patient's oxygenation. A persistent left superior vena cava and its effect on the central hemodynamics were also objectified. This case illustrates important considerations in daily ECMO treatment: the benefit of direct echocardiographic competence at all times during the day, the importance of understanding central blood flow dynamics, to adjust the cannula-position accordingly, and to address situations outside the ordinary with a physiologic approach.

Clinical Case Reports, 2016

We report a 17-year-old woman with bronchiolitis obliterans-organizing pneumonia (BOOP)-like gran... more We report a 17-year-old woman with bronchiolitis obliterans-organizing pneumonia (BOOP)-like granulomatosis with polyangiitis developing severe airway obliterations. Pending age, phase and grade of autoimmune treatment, and offering ECMO treatment may be crucial for survival but occasionally preface futility. ECMO-treated patient with BOOP-like GPA has never been described before.

Additional file 2: Table S1. of Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study

A compilation of the different forms of pre-admission antithrombotic therapy in ICH vs. non-ICH c... more A compilation of the different forms of pre-admission antithrombotic therapy in ICH vs. non-ICH cohorts. (DOCX 48 kb)

Additional file 1: of Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study

ECMO circuit. A description of the ECMO pumps, oxygenators, ventilators, cannulas and patients mo... more ECMO circuit. A description of the ECMO pumps, oxygenators, ventilators, cannulas and patients monitoring system used for the patients included in the study. (DOCX 84 kb)

Aspects of renal function during moderate hypothermia in the rat

Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure ... more Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquart...

Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey

ASAIO Journal, 2020

Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failur... more Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failure of invasive mechanical ventilation (IMV) and other adjuncts, including low tidal volume, prone positioning, adjusted positive end-expiratory pressure, and lung recruitment maneuvers, typically remain on IMV after VV ECMO commencement.1,2 Once both IMV and VV ECMO support are initiated, it is unclear which modality should be weaned first. Moreover, the optimal IMV settings, risk versus benefits of early spontaneous breathing, and optimal timing of VV ECMO weaning practices are yet to be defined. In addition, although the practice of liberation from IMV during ECMO3–8 has been increasing, the data concerning the weaning processes from ECMO and IMV are limited.9,10 Differences in weaning strategies for VV ECMO are based on the preferable approach is whether to wean ECMO or not when the patient is still mechanically ventilated.11 The approach to enable spontaneous breathing and early IMV weaning may prevent the complications of sedation allowing to avoid the risk of ventilationinduced lung injury and ventilator-associated pneumonia.5,6,12,13 A pragmatic way to “wean” as soon as the tidal volume start to recover has been proposed by clinicians at the Karolinska Institute ECMO Centre in Stockholm.11 Vasques et al. proposed a physiology-based assessment protocol, which combines an objective assessment of the native and artificial lung function. This method quantifies the patient’s response to a standardized weaning trial.9 However this strategy has not been tested in prospective trials and carries some challenges and risks in managing awake patients on ECMO. The aim of this survey was to understand current VV ECMO and IMV weaning practices globally.

Artificial Organs, 2021

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-... more This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Defining and understanding the “extra‐corporeal membrane oxygenation gap” in the veno‐venous configuration: Timing and causes of death

Artificial Organs, 2021

In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patient... more In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in-hospital death, either on-ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V-V ECMO, and to define the V-V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on-ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V-V ECMO-gap. Mortality rates on-ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V-V ECMO outcomes (on-ECMO mortality and discharge rate). Mortality on V-V ECMO support was 27.8% (95% confidence interval (CI) 22.5%-33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%-16.6%, defining the V-V ECMO gap). 72.2% of patients (95% CI 66.8%-77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%-63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V-V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V-V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V-V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.

Intensive Care Medicine, 2021

Full author information is available at the end of the article Members of the EuroECMO COVID-19 W... more Full author information is available at the end of the article Members of the EuroECMO COVID-19 Working Group and of the Euro-ELSO Steering Committee are listed in the Acknowledgements Section.

Scientific Reports, 2021

Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extraco... more Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excl...

Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation

Perfusion, 2020

Introduction: In the last decade, dual-lumen cannulae have been increasingly applied in patients ... more Introduction: In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure–flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. Methods: We performed a study evaluating pressure–flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer’s corresponding curves obtained from the public domain. Results: The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain s...

Journal of Intensive Care, 2020

In the original publication of this article [1], the first author’s name should be changed from A... more In the original publication of this article [1], the first author’s name should be changed from Alexander Fletcher Sandersjöö to Alexander Fletcher-Sandersjöö. The family name of the author is Fletcher-Sandersjöö.

SN Applied Sciences, 2020

Co-axial tubes have been used to produce a co-flowing confined jet similar to that found in an Ex... more Co-axial tubes have been used to produce a co-flowing confined jet similar to that found in an Extracorporeal Membrane Oxygenation return cannula flow configuration. Particle Image Velocimetry was used to investigate the flow rate ratio between jet and co-flow as well as changes in flow characteristics due to cannula position. The flow was found to be dominated by three main structures: lateral flow entrainment, shear layer induced vortices and backflow along the wall. An increase in cannula flow rate amplified entrainment and recirculation, resulting in a decrease in length required to reach a fully developed flow. Changing cannula position relative the outer cylinder induced a significant reduction in recirculation zone as well as vortex formation on the side to which the cannula was tilted towards, whereas on the other side, the recirculating flow region was enhanced. Proper Orthogonal Decomposition demonstrated that the dominating structure found in the flow is the backflow, com...