Extracorporeal resuscitation (ECPR) has been shown to improve outcomes in out-of-hospital cardiac arrest (OHCA). It is, however, not the standard of care. The establishment of new ECPR centers is challenging, even though valuable lessons can be learned from more experienced centers. The primary objective of this study was to assess survival rates and neurological outcomes after ECPR. The secondary objective is to evaluate peri-ECPR parameters in relation to neurological outcomes, and to describe the long-term quality of life six months after ECPR. This monocentric study involves patients with refractory OHCA transported to the hospital with ongoing mechanical cardiopulmonary resuscitation (CPR) for ECPR implementation at the extracorporeal membrane oxygenation (ECMO) Center of the University Hospital Ostrava, Czech Republic, from 1 January 2022 until the end of 2024. Outcome was assessed through analysis of data from the Ostrava ECMO Centre registry and long-term outcomes were evaluated using the SF36, EQ-5D-5L, and HADS questionnaires as retrospective study. The indication criteria and care standards were followed according to a local protocol. Over three years, 74 patients met the inclusion criteria for ECPR, with a cannulation success rate exceeding 93

Massive bleeding causes approximately 50% of deaths in patients with major trauma. Most patients die within 6 h of injury, which is preventable in at least 10% of cases. For these patients, early activation of the massive transfusion protocol (MTP) is a critical survival factor. With severe trauma, high-mobility group box 1 (HMGB-1, i.e., amphoterin) is released into the blood, and its levels correlate with the development of a systemic inflammatory response, traumatic coagulopathy, and fibrinolysis. Previous work has shown that higher levels of HMGB-1 are associated with a higher use of red blood cell transfusions. We conducted a retrospective analysis of previous prospective single-center study to assess the value of admission HMGB-1 levels in predicting activation of MTP in the emergency department. From July 11, 2019, to April 23, 2022, a total of 104 consecutive adult patients with severe trauma (injury severity score > 16) were enrolled. A blood sample was taken at admission, and HMGB-1 was measured. MTP activation in the emergency department was recorded in the study documentation. The total amount of blood products and fibrinogen administered to patients within 6 h of admission was monitored. Among those patients with massive bleeding requiring MTP activation, we found significantly higher levels of HMGB-1 compared to patients without MTP activation (median [interquartile range]: 84.3 µg/L [34.2-145.9] vs. 21.1 µg/L [15.7-30.4]; p < 0.001). HMGB-1 level showed good performance in predicting MTP activation, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.75-0.93) and a cut-off value of 30.55 µg/L. HMGB-1 levels correlated significantly with the number of red blood cell units (rs [95% CI] 0.46 [0.28-0.61]; p < 0.001), units of fresh frozen plasma (rs 0.46 [0.27-0.61]; p < 0.001), platelets (rs 0.48 [0.30-0.62]; p < 0.001), and fibrinogen (rs 0.48 [0.32-0.62]; p < 0.001) administered in the first 6 h after hospital admission. Admission HMGB-1 levels reliably predict severe bleeding requiring MTP activation in the emergency department and correlate with the amount of blood products and fibrinogen administered during the first 6 h of hemorrhagic shock resuscitation.Trial registration: NCT03986736. Registration date: June 4, 2019.

Despite the substantial advancements in mechanical ventilation (MV), mortality remains high. Mechanical power (MP), MV forces are associated with outcomes. Real-time monitoring of MP and the adjustment of MV according to MP may result in ventilation with lower MP. Randomized controled trial conducted at the ECMO Centre Ostrava, Czech Republic, from March 2023 to March 2024 enrolled adult patients on MV (with or without extracorporeal membrane oxygenation, ECMO) with acute respiratory failure. A system for real-time MP monitoring (geometric method and simplified Becher´s formula) has been developed. In the intervention arm, the physician was able to observe the MP in real time and adjust the MV parameters accordingly. In the control group, the MP was concealed. A total of 494 subjects were screened and 33 patients were randomized (further 7 ECMO patients). There was no significant difference between the control and intervention groups. Median MPGeom was 3.22 J/min (maximum 15.2 J/min) and MPBecher of 5.94 J/min (maximum 18.4 J/min). Only a weak (but significant, p = 0.0001) correlation between MPGeom and MPBecher was observed. A highly significant difference was observed in MP between day and night (6 a.m. − 6 p.m.) with higher MP at night. Although real-time MP measurement is feasible, there was no significant difference in MP between the control and intervention groups with low MP in both groups. Experience physicians was capable of safe MV, even if they do not know the exact MP value. The night shift was a high-risk period for developing lung damage due to elevated MP. ClinicalTrials NCT06035146.

Postoperative nausea and vomiting (PONV) are among the most common postoperative complications affecting children. In adult patients, cigarette smoking significantly reduces the incidence of PONV, although the mechanism underlying this effect is unclear. Here we aimed to investigate whether environmental tobacco smoke exposure influenced the PONV incidence among children. This monocentric retrospective study included 1348 children (1–15 years of age), who underwent endoscopic adenoidectomy under general anaesthesia, between 22 March 2017 and 26 June 2023. Data for this study were obtained from the patient’s medical records and from a telephone conversation with their parent. Our analysis revealed that the PONV incidence was significantly lower in children exposed to environmental tobacco smoke (ETS), compared to in children who were not passive smokers (13.9

During the COVID-19 pandemic, specific COVID-19-related conditions renewed interest in the full-awake venovenous extracorporeal membrane oxygenation ( fa V-V ECMO) approach, in which ECMO is applied to awake, cooperative, and non-intubated patients. This scoping review aims to provide a descriptive overview of fa V-V ECMO in patients with COVID-19-related acute respiratory distress syndrome (CARDS). We searched the PubMed, Web of Science, and Scopus databases using the keywords "awake ECMO" or "spontaneous breathing AND ECMO", combined with "COVID-19", "SARS-CoV-2" or "coronavirus", utilizing the Boolean operator "AND". The search included papers published from November 1, 2019, to December 31, 2024. Sixty-four papers were assessed for eligibility at the abstract level, and fourteen articles (seven small-sample cohort studies and seven case reports) comprising 95 patients were included in the final analysis. The most frequent reasons for preferring fa V-V ECMO over mechanical ventilation were barotrauma and patient refusal of intubation and mechanical ventilation. The fa V-V ECMO strategy was successful (ie, patients not intubated, disconnected from ECMO, and discharged from the hospital) in 36.4% of cases (cohort studies only). The incidence of defined severe adverse events (bleeding, thrombosis, cannula malposition, delirium, and progression of barotrauma) was considered low. The mortality rate for CARDS patients treated with fa V-V ECMO (including only patients from cohort studies) reached 33.0%, notably lower than the 48% reported for CARDS patients treated with V-V ECMO in the ELSO registry. Patients who were intubated due to worsening respiratory failure during fa V-V ECMO had significantly higher mortality. Infectious complications, sepsis, and multiorgan failure were the most frequent causes of death. However, significant heterogeneity in the definitions and reporting of management, ECMO-related complications, and outcomes was observed across the papers. Despite the heterogeneity of the data, fa V-V ECMO in CARDS patients can be considered a safe approach associated with a lower mortality rate than that reported in the overall V-V ECMO CARDS population.

Unfractionated heparin has long been considered the standard anticoagulation in ECMO, despite some pitfalls such as heparin resistance, heparin induced thrombocytopenia (HIT), etc Recently, some centres started to increasingly use argatroban for this purpose, typically using activated partial thromboplastin time (aPTT) for its monitoring. Direct monitoring of the efficacy of argatroban using Anti-IIa is not yet an established method, although it might be more appropriate as it targets the same pathway.An observational study was performed in adult veno-venous ECMO patients hospitalized with SARS-CoV-2 infection anticoagulated with argatroban to an aPTT target of 40-60 s and Anti-IIa target of 0.4–0.6 µg/mL. Bleeding and thrombotic complications were monitored.Forty-four VV ECMO patients were included, with an overall hospital mortality of approx. 50%. No life-threatening thrombotic events were recorded. The risk of bleeding complications significantly increased with aPTT above 52.7 s and with Anti-IIa values over 0.78 µg/mL. Using the above cut-offs for both the aPTT and Anti-IIa and their combination, the negative predictive value for bleeding was approximately 90%.It seems that the generally recommended limits for Anti-IIa of 1.5 µg/mL may be high. However, further data are needed to confirm lower limits. Trial Registration: retrospectively registered in ClinicalTrials.gov, NCT06038682.

Here, we report the first case of successful extracorporeal cardiopulmonary resuscitation (eCPR) in a patient with an out-of-hospital cardiac arrest following the ingestion of a lethal dose of ethylene glycol (EG). A 49-year-old man was found unconscious for an unknown period of time after suspected ethylene glycol ingestion. Upon arrival of the Emergency Medical Service (EMS), the patient was found to have a Glasgow Coma Score of 3, bilateral non-reactive mydriasis, and hypoventilation. Despite the urgent orotracheal intubation, the patient developed cardiac arrest immediately thereafter. After 8 minutes of conventional CPR, the regional ECMO (extracorporeal membrane oxygenation) center was contacted. The patient was transferred under mechanical CPR to an ECMO center where veno-arterial extracorporeal membrane oxygenation (VAECMO) was initiated 59 minutes after the cardiac arrest. Laboratory tests confirmed EG intoxication with a plasmatic EG level of 1474 mg/L, greatly exceeding reported lethal values. A left stellate ganglion blockade was performed because of refractory ventricular fibrillation, and the return of spontaneous circulation was achieved 149 minutes after the cardiac arrest. As a result of direct organ toxicity, the patient developed anuric acute kidney injury and multifocal brain lesions revealed by nuclear magnetic resonance imaging. In addition to the VA-ECMO, the therapeutic protocol included hemodialysis, intravenous ethanol and fomepizole. This multimodal treatment eventually led to the patient's survival with near complete recovery.

Aim. The main objective of this study was to determine whether urinary trauma increases the risk of acute kidney injury (AKI) in patients with severe trauma. As a secondary objective, we assessed the reliability of neutrophil gelatinase-associated lipocalin (NGAL) in the early prediction of AKI in this patient population. Methods. Retrospective analysis of two prospective observational studies involving 179 adult patients with severe trauma (Injury Severity Score >16). NGAL levels were measured by taking a blood sample 24 h after admission. AKI was diagnosed according to the Kidney Disease Improving Global Outcomes (KDIGO) classification. Results. The overall incidence of AKI was 29%. Kidney or vascular injury was an independent risk factor for AKI (risk ratio [RR] = 3.1, 95% confidence interval [CI] 1.93-4.90). Trauma to urinary passages was also associated with an increased risk of AKI (RR = 4.2, 95% CI 2.70-6.46). Among patients without urinary tract injury, serum NGAL levels were significantly higher in trauma patients who developed AKI during the first 5 days in the intensive care unit (ICU) compared to patients without this organ dysfunction (214.6 µg/L [IQR 167.3] vs. 90.6 µg/L [IQR 58.4]; P<0.001). In patients with urinary tract trauma, there was no difference in the NGAL levels between the two groups (184.6 µg/L [IQR 139.9] vs. 118.3 µg/L [IQR 118.1]; P=0.216). NGAL was not a reliable predictor of AKI in patients with urinary trauma (AUC 0.660). Conclusion. Urinary tract injury is associated with a significant increase in AKI in patients with severe trauma during the first 5 days of hospitalization in the intensive care unit. In these patients, NGAL is not a reliable predictor of the development of AKI.

Background Massive bleeding causes approximately 50% of deaths in patients with major trauma. Most patients die within 6 hours of injury, which is preventable in at least 10% of cases. For these patients, early activation of the massive transfusion protocol (MTP) is a critical survival factor. With severe trauma, high-mobility group box 1 (HMGB-1, i.e., amphoterin) is released into the blood, and its levels correlate with the development of a systemic inflammatory response, traumatic coagulopathy, and fibrinolysis. Previous work has shown that higher levels of HMGB-1 are associated with a higher use of red blood cell transfusions. We conducted a single-center, prospective, observational study to assess the value of admission HMGB-1 levels in predicting activation of MTP in the emergency department. Methods From July 11, 2019, to April 23, 2022, a total of 104 consecutive adult patients with severe trauma (injury severity score > 16) were enrolled. A blood sample was taken at admission, and HMGB-1 was measured. MTP activation in the emergency department was recorded in the study documentation. The total amount of blood products and fibrinogen administered to patients within 6 hours of admission was monitored. Results Among those patients with massive bleeding requiring MTP activation, we found significantly higher levels of HMGB-1 compared to patients without MTP activation (median [interquartile range]: 84.3 µg/L [34.2–145.9] vs. 21.1 µg/L [15.7–30.4]; p < 0.001). HMGB-1 level showed good performance in predicting MTP activation, with an area under the curve of 0.84 (95% CI 0.75–0.93) and a cut-off value of 30.55 µg/L. HMGB-1 levels correlated significantly with the number of red blood cell units (rs [95% CI] 0.46 [0.28–0.61]; p < 0.001), units of fresh frozen plasma (rs 0.46 [0.27–0.61]; p < 0.001), platelets (rs 0.48 [0.30–0.62]; p < 0.001), and fibrinogen (rs 0.48 [0.32–0.62]; p < 0.001) administered in the first 6 hours after hospital admission. Conclusions Admission HMGB-1 levels reliably predict MTP activation in the emergency department and correlate with the amount of blood products and fibrinogen administered during the first 6 hours of hemorrhagic shock resuscitation. Trial registration NCT03986736 Registration date: June 4, 2019

As in the previous year, very few original prospective clinical papers concerning respiratory failure and pulmonary lung support, including artificial lung ventilation and veno-venous form of extracorporeal membrane oxygenation, have been published so far over this year, 2024. In the first part, the manuscript focuses on selected pathophysiological aspects of acute hypoxemic respiratory failure. In the second part, the text continues with a description of several publications that deal with the issue of the use of invasive ventilation support in the form of artificial lung ventilation. The third part deals with a non-invasive form of ventilation support. In the final part, two papers concerning the prone position in conscious patients (awake proning) and one that deals with the length of pronation in patients on artificial lung ventilation are described.

Abstract Background Postoperative nausea and vomiting (PONV) is a significant problem following paediatric surgery, and volatile anaesthetics are an important cause of this phenomenon. BIS-guided anaesthesia, by reducing the consumption of anaesthetics, leads to a decrease in PONV in adult patients. Study objective Evaluate the role of BIS-guided anaesthesia in reducing the incidence of paediatric PONV. Design Prospective, randomized, double-blind study. Setting A single center study in university hospital in Czech republic, from June 2021 to November 2022. Patients A total of 163 children, aged 3–8 years with ASA I-II who underwent endoscopic adenoidectomy under general anaesthesia were included. Interventions In the intervention group, the depth of anaesthesia was maintained to values between 40 and 60 of BIS. Main outcome measure The primary outcome was the incidence of postoperative nausea and vomiting during 24 h after surgery. Results The use of BIS-guided anaesthesia led to a significant decrease in the incidence of nausea and vomiting compared to the control group [17% vs. 53%; RR (95%CI) 0.48 (0.27–0.86); p < 0.001and 16% vs. 34%; RR (95%CI) 0.33 (0.20–0.54); p = 0.01, respectively]. Conclusions BIS-guided anaesthesia decreases the incidence of postoperative nausea and vomiting in children undergoing adenoidectomy. Trial registration Clinicaltrials.gov identifier: NCT04466579.

Background: Maintaining the patient awake and not intubated during the venovenous extracorporeal membrane oxygenation (VV ECMO) reduces the risk of ventilation-induced lung injury in patients with ARDS. Currently, there is a lack of data on outcomes and complications associated with the awake ECMO approach. Objectives: To evaluate outcomes and the occurrence of complications of awake ECMO approach guided by local safety protocol comprising ultrasound-guided cannulation, argatroban-based anticoagulation, respiratory support, and routine sedation targeted to reduce respiratory effort and keeping nurse-to-patient ratio of 1:1. Design: A single-center retrospective case series analysis. Methods: Consecutive patients with COVID-19-related acute respiratory distress syndrome (ARDS) (CARDS) treated by full awake VV ECMO approach from April 2019 to December 2023 were eligible. Results: Our center treated 10 patients (mean age 54.7 ± 11.6 years) with CARDS with an awake ECMO approach. The reasons for awake ECMO included the presence of barotrauma in six patients, a team consensus to prefer awake ECMO instead of mechanical ventilation in three patients, and the patient’s refusal to be intubated in one case. Before ECMO, patients were severely hypoxemic, with a mean value of Horowitz index of 48.9 ± 9.1 mmHg and a mean respiratory rate of 28.8 ± 7.3 breaths per minute on high-flow nasal cannula or noninvasive ventilation support. The mean duration of awake VV ECMO was 558.0 ± 173.6 h. Seven patients (70%) were successfully disconnected from ECMO and fully recovered. Intubation from respiratory causes was needed in three patients (30%), all of whom died eventually. In total, three episodes of delirium, two episodes of significant bleeding, one pneumothorax requiring chest tube insertion, and one oxygenator acute exchange occurred throughout the 5580 h of awake ECMO. No complications related to cannula displacement or malposition occurred. Conclusion: The awake ECMO strategy guided by safety protocol appears to be a safe approach in conscious, severely hypoxemic, non-intubated patients with COVID-19-related ARDS.

BackgroundAnticoagulation during extracorporeal membrane oxygenation (ECMO) might still lead to severe bleeding complications. Heparin is the most frequently used anticoagulant, but novel drugs could be promising. Argatroban is a new alternative to heparin. To date, no robust studies have confirmed the clear superiority of argatroban (AG) over heparin, although it has some advantages and may be safer.Study Design and MethodsAn observational study was conducted in all adult veno-venous ECMO patients with COVID-19-associated acute respiratory distress syndrome admitted to the University Hospital Ostrava (n = 63). They were anticoagulated with heparin in the first period and with AG in the second period, targeting the same activated partial thromboplastin time (aPTT; 45-60 s). Bleeding complications requiring transfusion and life-threatening bleeding events were evaluated. The primary objective was to compare heparin and AG in terms of bleeding, transfusion requirements and mortality-related bleeding.ResultsThe total time on ECMO per patient was 16 days with an in-hospital mortality of 55.6%. The red blood cell consumption in the AG group (median 2.7 transfusions/week) was significantly lower than in the heparin group (median 4.2 transfusions/week, p = 0.011). Life-threatening bleeding complications were higher in the heparin group compared to the AG group (35.7% vs. 10.2%, p = 0.035), and mortality-related bleeding complications were also higher in the heparin group (21.4% vs. 2.0%, p = 0.032).DiscussionArgatroban is an interesting alternative to heparin with less bleeding, less need for red blood cell transfusions and improved safety of ECMO with less mortality-related bleeding.

Background: Acute kidney injury (AKI) is a common cause of organ failure in patients after major trauma and is associated with increased morbidity and mortality. Early identification of patients at risk enables the implementation of a bundle of supportive care, which reduces the incidence of AKI. The primary objective of our study was to in-vestigate whether the levels of biomarkers on admission predicted the onset of early AKI in patients with se-rious injuries. Material/Methods: This prospective observational study included 98 adult patients of both sexes with a serious injury (injury se-verity score >16). At admission, blood samples were taken, and creatinine, neutrophil gelatinase-associated li-pocalin (NGAL), high mobility group box 1 (HMGB-1), and markers of rhabdomyolysis (creatine kinase, myo-globin) were evaluated. The patients were provided with standard resuscitation care, and the occurrence of AKI was monitored during the first 7 days after admission to the Intensive Care Unit, according to the Kidney Disease Improving Global Outcomes diagnostic criteria. Results: AKI occurred in 25 (25.5%) patients, in whom the admission levels of HMGB-1, NGAL, creatinine, and myoglo-bin were significantly higher than in non-AKI patients (48.3 +/- 98.4 vs 113.0 +/- 209.4 mu g/L, P=0.006; 150.2 +/- 349.9 vs 181.4 +/- 152.2 mu g/L, P=0.004; 83.1 +/- 20.8 vs 118.8 +/- 32.2 mu mol/L, P<0.005; 2734.4 +/- 2214.5 vs 4182.3 +/- 2477.1 mu g/L, P=0.008, respectively). Creatine kinase was 14.5 +/- 9.2 mu kat/L in non-AKI patients and 13.7 +/- 7.9 mu kat/L in AKI pa-tients (P=0.916). Conclusions: Admission levels of HMGB-1, NGAL, creatinine, and myoglobin predicted the risk of AKI in severely injured patients.

Purpose:Anticoagulation therapy aims to improve the outcome of critically ill patients with severe COVID-19-associated pneumonia. Activated partial thromboplastin time (aPTT) is commonly used to maintain the target therapeutic range of continuous infusion of unfractionated heparin (UFH). The UFH infusion efficacy can be evaluated by determining the time in therapeutic range (TTR) using a modified Rosendaal method. The present study's primary aim was to evaluate TTR based on the aPTT in critically ill patients with severe forms of COVID-19 pneumonia and its influence on survival. The secondary aim was to evaluate the time spent above (TATR) and below the therapeutic range (TBTR). Patients and Methods:We performed a retrospective analysis of critically ill patients with COVID-19-associated pneumonia. All patients received a continuous infusion of UFH from the 2nd to 8th day since admission to the ICU. TTR, TATR, and TBTR were calculated using the modified Rosendaal method, and survival days were analyzed by regression (censored after 60 days). Results:Of 103 patients, the median TTR was 49% (IQR 38-63%), TATR 11% (IQR 5-20%), and TBTR 33% (IQR 22-51%). The regression analysis indicated a positive impact of higher TTR and TATR on the number of survival days [β=0.598 (p=0.0367) and β=1.032 (p=0.0208), respectively] and a negative impact of higher TBTR [β=-0.681 (p=0.0033)] on the number of survival days. Conclusion:Higher TTR and TATR were associated with better survival of critically ill patients with a severe course of COVID-19-associated pneumonia. Higher TBTR was associated with worse survival in these patients.

Only a few original papers on respiratory issues have been published so far in 2023. The vast majority are systematic reviews and meta-analyses of already published studies. In March 2023, the European Society for Intensive Care Medicine (ESICM) issued recommendations for the management of acute respiratory distress syndrome (ARDS). In the first part of this text, a very basic summary of recommendations according to individual domains is described. Extracorporeal membrane oxygenation (ECMO) is an intervention that has received much attention in recent years, mainly due to the COVID-19 pandemic. The last randomized trial (EOLIA trial) did not confirm a mortality benefit [1]. However, the subsequent Bayesian analysis of the data of this study brought a posterior probability of a mortality benefit of ECMO support compared to conventional therapy in a selected subgroup of patients with early use of ECMO in patients with severe ARDS [2]. In the second part of the article, we summarize publications related to the effect of ECMO support on several specific groups of diseases. These are patients with polytrauma, life-threatening bronchial asthma, burn trauma, and kidney transplant patients. The third part of the article deals with various aspects of anticoagulant therapy used in ECMO support, including its monitoring and comparison of the effect of heparin and bivalirudin. The fourth part describes a publication evaluating the effectiveness of extracorporeal CO2 removal (ECCO2R) from the point of view of enabling ultraprotective mechanical ventilation in patients with moderate to severe ARDS. The fifth part deals with the relationship of selected pathophysiological aspects to clinical practice and results. It is an investigation of exhaled air analysis for determining the clinical outcome of patients with ventilator-associated pneumonia (VAP). Furthermore, there is also a description of the relationship between dead space ventilation and the prognosis of patients with ARDS. The sixth part deals with the optimization of artificial lung ventilation settings based on the use of transpulmonary pressure measurement. The next part of the article, the seventh, deals with a meta-analysis of the comparison of the effectiveness of non-invasive forms of mechanical ventilation and other methods, such as high-flow oxygen therapy and conventional oxygen therapy. The penultimate section relates to the effect of various forms of nebulization therapy, such as the use of heparin in patients with COVID-19 pneumonia, and in the general population of patients on mechanical ventilation, and the use of volatile anesthetics in patients with refractory bronchospasm. In the last section, the text deals with various aspects of interventions in patients with severe respiratory failure who remain conscious. This invloves the effect of the so-called awake prone position and awake extracorporeal oxygenation support.