key: cord-0031211-nn9z2dgw
authors: nan
title: Abstracts der 53. Gemeinsamen Jahrestagung der ÖGIAIN und DGIIN
date: 2022-05-11
journal: Med Klin Intensivmed Notfmed
DOI: 10.1007/s00063-022-00924-6
sha: d3f8871469a354cf79effbb560bad52e0b944f65
doc_id: 31211
cord_uid: nn9z2dgw

nan

The Impella device (Impella, Abiomed, Danvers, MA, USA) is a percutaneous transvalvular microaxial flow pump that is currently used for: (1) cardiogenic shock, (2) left ventricular unloading ( ECMELLA concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion and coronary blood flow in observational studies and some randomized trials. However, due to need for large bore femoral access (14 Fr for the commonly used Impella CP device) and anticoagulation the incidence of bleeding and ischemic complications are up to 44 % and 18 %, respectively. Hemolysis is reported in up to 32 % of patients and stroke in up to 13 %. Despite the rapidly growing use of the Impella device, there are still insufficient data on its impact on outcome and complications based on large, adequately powered randomized controlled trials (RCTs). The only two, small and also underpowered RCTs in cardiogenic shock comparing Impella vs. intra-aortic balloon pump did not show improved mortality. Several larger RCTs are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock Outcomes of patients with initial acute respiratory failure on veno-venous extracorporeal membrane oxygenation ( ECMO) requiring additional circulatory support by VVA ECMO Erlebach R. 1 , Wild LC., Seeliger B., David S., Bode C., Stahl K., for the BonHanZA (Bonn-Hannover-Zurich-ARDS) study group 1 Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland Goal of the Study: Veno-venous ( VV) extracorporeal membrane oxygenation ( ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome ( ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the VV-ECMO with an additional arterial backflow cannula (termed VVA-ECMO). Data about survival in these patients is scarce1. The aim of the study was to analyze both short and longterm outcomes of a homogenous cohort of ARDS patients on VV-ECMO that suffered from a clinical deterioration that triggered an upgrade to VVA-ECMO. Methods: Retrospective analysis of outcome in VV-ECMO patients with ARDS that received VVA upgrade due to acute cardio-circulatory deterioration from 2008-2021 at three ECMO referral centers. Results and Discussion: We identified 73 VVA-ECMO patients that had either required an upgrade from VV to VVA (n = 53) or were directly triple cannulated (n = 20). Median (Interquartile Range) age was 49 (28-57) years and SOFA score was 13 (11-16) at VV implantation. ECMO support was required over 12 (6-22) and ICU length of stay was 32 (16-46) days. Overall ICU mortality was 48 % and hospital mortality 51 %. Eight patients were lost to follow-up at two years, only two patients died after hospital discharge. A SOFA score > 14 at the day of VVA upgrade and higher lactate level were independent predictors of mortality in the multivariate regression analysis. The Survival plot is presented in . Fig. 1 Markers for hemolysis were significantly higher in patients with peak CO-Hb ≥2 % compared to those below (bilirubin p = 0.003 and hemolysis index p = 0.042). Peak CO-Hb was independently associated with lower hospital survival after adjustment for predictors of survival (. Fig. 1 

Goal of the Study: Herpes simplex virus ( HSV)-2 is a rare cause of hepatitis that can lead to acute liver failure ( ALF) (1) . The only specific therapeutic option against HSV-2 that showed a reduction of mortality is acyclovir. With regard to ALF, controlled randomized data support the use of therapeutic plasma exchange ( TPE) both as bridge to recovery or transplantation (2) . Seraph® 100 Microbind® Affinity Blood Filter (Seraph), a novel extracorporeal adsorption device, removes living pathogens by binding to a heparin-coated surface was shown to efficiently clear HSV-2 particles in vitro (3) . The combination of Seraph with TPE consequently seems reasonable to reduce HSV-2 load and to bridge ALF to recovery or transplantation. Methods: We report Seraph clearance ( CL) data of HSV-2 and of Epstein-Barr virus ( EBV) in vivo as well as total viral elimination by TPE. Genome copies/mL of HSV-2 and EBV in EDTA plasma were measured by polymerase chain reaction ( PCR) every 60 min over 6 h after starting Seraph both systemically and post-adsorber. HSV-2 and EBV was quantified before and after TPE and in the removed apheresis plasma. Results and Discussion: We found a total elimination of 1.81 × e 11 HSV-2 copies and 2.11 × e 6 EBV copies with a single TPE (1.5 × calculated plasma volume exchanged). Whole blood CLHSV-2 in the first 6 h of Seraph treatment was 6.64 [4.98-12.92] mL/min. CLEBV was higher (i. e. 36.62 [22.67-53.48] mL/min). In contrast to the promising in vitro data we observed a low CLHSV-2 with Seraph, whereas CLEBV was much better. One possible explanation of this findings could be a structural difference of the two Herpesviridae. TPE, as a standard of care in many transplant-centers, lead to a rather impressive reduction of the viral load. Conclusion: TPE was able to remove circulating HSV-2 copies by 25 % and EBV copies by 40 % from the blood. On the other hand, CLHSV-2 by Seraph was clinically irrelevant but CLEBV showed promising clinical response, implicating a possible use in EBV-associated pathologies.

Goal of the study: Coronavirus disease 2019 ( COVID-19) is a systemic disease associated with disruption of the endothelial glycocalyx (eGC), a protective layer on the vascular endothelium. The aim of this study was to investigate the role of the eGC-degrading enzyme heparanase ( HPSE), which is known to play a central role in the destruction of the eGC in bacterial sepsis. Methods: Sublingual intravital microscopy of the microcirculation, analysis of blood samples and corresponding in vitro experiments using atomic force and immunofluorescence microscopy were performed to investigate eGC properties. Results and Discussion: Analysis of serum samples revealed distinctive increases in HPSE and heparan sulfate compared to apparently healthy controls. Further experiments show that changes in eGC thickness of cultured cells exposed to COVID-19 serum correlated closely with HPSE activity in concordant plasma samples (R = 0.82, P = 0.003). Loss of eGC in response to COVID-19 serum could be abolished by inhibition of HPSE with the non-anticoagulant heparin fragment NAH suggesting that the common administration of heparins in COVID-19 might positively influence eGC properties. Conclusion: Our results suggest that eGC degradation appears to be mechanistically linked to the release and activation of endothelial heparanase in COVID-19. Our results suggest that the protective effect of heparin in COVID-19 may be due to an eGC-protective off-target effect. Aim of the study: Here, we present a descriptive analysis on characteristics and outcome of critically ill patients with systemic rheumatic disease ( SRD). Methods: This is a single center retrospective study of patients with diagnosed SRD admitted to an intensive care unit ( ICU) at the Vienna General Hospital between 2012 and 2020. Logistic regression analysis was performed to identify potential predictors of 28-day mortality. Results: In total, 144 SRD patients (85 women; 59 %) accounting for 192 ICU admissions were included. The median age was 61 years [interquartile range ( IQR) 45-71 years]. In 29.2 % of these admissions critical care was required due to SRD-exacerbation, in 70.8 % SRD was documented as comorbidity not responsible for the acute critical illness. The median ICU length of stay was 10 days ( IQR 4-19 days). Connective tissue diseases (30.7 %), vasculitides (28.6 %) and rheumatoid arthritis (18.2 %) accounted for the most common SRDs observed. Leading causes for ICU admission were respiratory failure (47.9 %) and shock (22.4 %). In patients with SRD as a comorbidity, infectious disease, mainly sepsis and pneumonia, led to ICU admission in 44.1 %. Median SOFA-, SAPSII-and APACHEII-Score on day 1 of ICU admission were 9 ( IQR 6-11), 45 ( IQR 35-55) and 21 ( IQR 16-26.3), respectively. In total, 60.4 % of all patients required mechanical invasive ventilation ( MIV) with a median length of MIV of 10 days ( IQR 4-22). 72.9 % of patients received vasopressor therapy. In 42.2 % renal replacement therapy ( RRT) was performed, extracorporeal membrane oxygenation ( ECMO) in 8.4 %. Overall ICU mortality was 20.3 %, the 6-month mortality was 38.5 %. Age, SRD disease duration at ICU admission and disease severity as assessed by SOFA score were associated with poor outcome (figure). Conclusion: In conclusion, patients admitted to the ICU with concomitant SRD still represent a major clinical challenge. Connective tissues diseases and vasculitides are the most common rheumatic entities requiring ICU treatment. In our retrospective single center cohort respiratory failure was the leading cause of ICU admission. This fact is reflected by high rates of required MIV. Despite the high severity of critical illness, survival rates are comparable to a general ICU population.

Prevalence of lupus anticoagulant in patients treated with extracorporeal membrane oxygenation-a retrospective data analysis. Kornfehl Goal of the study: For monitoring of anticoagulation during extracorporeal membrane oxygenation ( ECMO) the activated partial thromboplastin time (aPTT) is commonly used. Prolongation of the aPTT can be caused by numerous factors, such as the presence of lupus anticoagulant [1] . The aim of this data analysis is to determine the prevalence of lupus anticoagulant during ECMO, its influence on clotting times and complications in ECMO patients and the reliability of a ratio to screen for lupus anticoagulant. Methods: This is a retrospective analysis including adult patients who received ECMO at a medical intensive care unit at the Medical University of Vienna, a tertiary care. The primary outcome was the prevalence of lupus anticoagulant in patients receiving ECMO. Secondary exploratory outcomes included determination of the optimal cut-off for the presence of lupus anticoagulant using an aPTT/AntiXa ratio, effects of presence of lupus anticoagulant on clinically significant complications during ECMO and factors contributing to development of lupus anticoagulant. Conclusio: In this cohort, one third of patients developed lupus anticoagulant during ECMO. Lupus anticoagulant should be considered as a potential confounder when using aPTT for monitoring of anticoagulation. Diverse parameters related to lupus anticoagulant in ECMO patients could be identified. However, it remains a major challenge to interpret the influence of this on the management of anticoagulation.

Goal of the Study: During extracorporeal membrane oxygenation ( ECMO) blood is inevitably exposed to large artificial surfaces, which leads to contact activation of the intrinsic coagulation pathway initiated by coagu-lation factor XII ( FXII). Very little is known about the prevalence of FXII deficiency, especially in ECMO patients (1) . The aims of this study are to determine the prevalence of FXII deficiency in ECMO patients as well as the resulting consequences on hemostasis, anticoagulation and clinical complications. Methods: In this single-center retrospective chart review, FXII activity as well as the aPTT, thrombin time and anti-Xa activity in adults receiving ECMO were analyzed. The primary endpoint was the prevalence of FXII deficiency ( FXII activity <60 %). Secondary outcomes included complications in respect to FXII levels and the interdependence between FXII activity and anticoagulation. Results and Discussion: Between January 2013 and August 2021 a total of 193 patients received ECMO at a medical intensive care unit at the Medical University of Vienna. FXII testing was performed in 64 (33 %) patients. Among these, 89 % showed a deficiency of FXII. Assuming all untested patients did not suffer from FXII deficiency (best-case), the present data shows a minimal prevalence of 29.5 %. On the contrary, a worst-case calculation yields a prevalence of 96.4 %. FXII deficiency distorts coagulation tests commonly used for monitoring of ECMO and anticoagulation. Less heparin was administered in patients with FXII deficiency (16,553.8 IE/d vs. 25,839.2 IE/d; p = 0.009). Favorable impacts on complications were observable for patients with FXII deficiency but limited by small population size (median event-free interval of 28d vs. 12d for bleedings and 16d vs. 13d for thromboembolic events). FXII deficiency is common during ECMO. Given the wide implications, inclusion in the monitoring routine of ECMO therapy should be considered. Further studies are needed to investigate the clinical consequences of FXII deficiency or inhibition during ECMO. Conclusion: The analysis shows FXII deficiency is frequent during ECMO and should be accounted for in therapy and anticoagulation monitoring. Goal of the Study: Cardiovascular dysfunction leading to shock essentially contributes to the unfavourable prognosis of patients with multiple organ dysfunction syndrome ( MODS). Shock treatment with vasopressors stabilizes blood pressure and thereby macrocirculation, yet does not optimize microcirculatory blood flow, as consequence of a shock-triggered loss in haemodynamic coherence. In an attempt to improve impaired vasomotion-a relevant trigger of abnormal microcirculatory flow-we tested, whether an electromagnetic field of low flux density coupled to biorhythmically defined impulse configuration (Physical Vascular Therapy BEMER â , PVT) in addition to vasopressor use can improve disturbed microcirculatory blood flow and thereby improve global haemodynamics in MODS patients. Methods: In a prospective, monocentric, one arm pilot study, 10 MODS patients ( APACHE II score 20-35) were treated-in addition to standard carefor 4 days with PVT (3 treatment periods of 8 min each day; day 1: field intensity 10.5 µT; day 2: 14 µT, day 3: 17.5 µT; day 4: 21.0 µT). Primary endpoint was the effect of PVT on sublingual microcirculatory flow as measured by sidestream darkfield technology ( SDF). Secondary endpoints were the effects of PVT on global haemodynamics (including: vasopressor use, cardiac index, cardiac power index) and of severity of MODS. Patient safety, adverse events and outcome were documented. Results and Discussion: 9 of the 10 patients registered could be included in the intention-to-treat-group and in the safety analysis. 4-day PVT was paralleled by a rise in microcirculatory flow of about 25 %-as determined by microcirculatory flow index ( MFI)-with the rise starting immediately after the first PVT and lasting over the total 4-day-treatment period. Concerning global haemodynamics, median vasopressor use could be stopped after two days of PVT, and haemodynamic stabilization paralleled PVT with an increase in cardiac index by about 30-40 % and an increase in cardiac power index by about 30 %. None of the AEs/SAEs were classified as causally related to the medical product ( PVT) or to the study. Three patients died within 28 days after inclusion, and a total of 4 patients during the 180-day-period. Conclusion: In our small, non-randomized pilot study with 10 MODS patients, complementary treatment with an electromagnetic field of low flux density coupled to biorhythmically defined impulse configuration (Physical Vascular Therapy BEMER®, PVT) over 4 days in addition to standard therapy was feasible and safe, could be performed without obstruction of standard patient care, and was paralleled by a rise in microcirculatory blood flow, a termination of vasopressor dependence and an improvement in global haemodynamics. Historical control group data point to substantial PVT effects, which, however, need proof in a randomized controlled trial. Hintergrund: In klinischen Studien zum kongestiven, kardiogenen Schock konnte gezeigt werden, dass der rechtsventikuläre Schlagvolumen-Arbeits-Index ( RVSWI) die schwere der Rechtsherzinsuffizienz reflektiert. Er errechnet sich aus dem Produkt von Schlagvolumenindex × (pulmonalarteriellem Mitteldruck -rechtsartrialem Druck) × 0,0136. Der Normalwert beim Menschen beträgt 8-12 g/ m/Schlag/m 2 . Ziel der Studie war die Etablierung eines akuten Tiermodells zum akuten Rechtsherzversagens bei Lungenembolie und Evaluation eines pulsatilen Rechtsherzunterstützungssystems ( RVAD). Methodik: In 12 Schafen (69,3 +/-2,9 kg) wurde mittels Injektion von 100 µm großen Mikropartikeln in den Pulmonalarterienstamm eine akute Lungenembolie simuliert. Die repetitiven Embolisationen wurden wiederholt, bis der pulmonalarterielle Mitteldruck ( PA) sich gegenüber dem Ausgangswert verdoppelt und der Cardiac Index ( CI) auf unter die Hälfte abgefallen war. Bei Abfall des arteriellen Mitteldrucks (PAo) auf unter 60 mmHg wurde dann ein pulsatiles RVAD ( PERKAT RV, Novapump GmbH, Jena) über die Vena femoralis implantiert. Dieses fördert pulsatil das Blut aus der Vena cava inferior über einen flexiblen Ausschlussschlauch in die Arteria pulmonalis. Ergebnisse: Infolge der repetitiven pulmonalen Embolisation stieg der PA-Mitteldruck von 14,2 +/-2,15 mmHg auf 35,8 +/-9,82 mmHg, der CI fiel von 2,5 +/-0,8 l/min/m 2 auf 1,0 +/-0,17 l/min/m 2 und der PAo von 81,4 +/-13,51 mmHg auf 49,3 +/-13,03 mmHg ab. Nach Implantation des PERKAT RV -Systems normalisierten sich CI (2,5 +/-0,58 l/min/m 2 ) und PAo (82,1 +/-29,08 mmHg), der PA-Druck ging nach einer Pumpdauer von 1 h leicht zurück (25,0 +/-6,42 mmHg). Der RVSWI wurde zu Beginn mit 5,1 +/-1,17 g/ m/Schlag/m 2 bestimmt, lag im Schock bei 3,0 +/-2,00 g/ m/Schlag/m 2 und wurde durch das RVAD wieder auf 4,1 +/-0,96 g/ m/Schlag/m 2 angehoben. Schlussfolgerung: Durch repetitive Mikroembolisationen kann im Großtierexperiment ein akutes Rechtsherzversagen bei Lungenembolie simuliert werden. Die akute rechtsventrikuläre Dekompensation wird durch den RVSWI reflektiert. Der RVSWI beträgt bei Schafen die Hälfte im Vergleich zum Menschen. Durch den Einsatz eines pulsatilen RVAD kann eine hämodynamische Stabilisierung im rechtsventrikulären Schockmodell erreicht werden.

Registry Report: International Summary

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure ( CESAR): a multicentre randomised controlled trial

Outcomes and long-term qualityof-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock*

Herpes simplex virus hepatitis: an analysis of the published literature and institutional cases

EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure

Heparin 2.0: A New Approach to the Infection Crisis

Heparanase contributes to disruption of the endothelial Glycocalyx in COVID-19

The lupus anticoagulant and its role in thrombosis

Prevalence and Clinical Impact of Reduced Coagulation Factor XII Activity in Patients Receiving Extracorporeal Membrane Oxygenation

Clinical Division of Gastroenterology and Hepatology, Department of Internal Medicine III; 2 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine; 3 Ludwig Boltzmann Institute for Digital Health and Patient Safety; 4 Department of Internal Medicine I, Intensive Care Unit 13i2

Acknowledgement: We thank the whole team of the medical ICU for their motivation to test novel innovative treatments and Jana Vertat for delivering us Seraph.

Aim of the study: Patients receiving extracorporeal membrane oxygenation ( ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for COVID-19 patients during ECMO therapy. The aim of this study is to describe nutrition support practices in a large single center cohort of COVID-19 patients during ECMO support and to investigate a possible association between energy delivery and ICU mortality. Methods: We conducted a retrospective analysis of COVID-19 patients requiring ECMO support at a large tertiary center. Nutrition goals were calculated using 25 kcal/kg actual body weight ( BW)/day. For obese patients ( BMI ≥ 30) adjusted BW was used. The time period between ECMO start and stop or death was used for the calculation of mean energy and protein delivery of each patient. Associations between nutrition support and outcome were evaluated using Kaplan Meyer and Multivariable Cox Regression analyses. Results: Nutrition support of 105 patients (71.4% male; median age 57 years [interquartile range ( IQR) 50-62 years] was analyzed. Median ICU length of stay was 34 ( IQR 21-57) days, median ECMO duration was 17 ( IQR 10-30) days. Median SAPS II-Score on day 1 at ECMO start was 40 ( IQR 34-49). ICU mortality was 41.9%. These 105 patients (71.4% male; median age 57 [interquartile range ( IQR) 50-62] years) accounted for 2262 nutrition support days during ECMO therapy. In 39.7% of these days, nutrition goals (= energy delivery 70-100% of calculated targets) were met. Undernutrition was found in 41.2%, overnutrition in 19.1%. The median mean energy delivery of each patient was 66.1% of requirements ( IQR 53.8-82.7), the median mean protein delivery 0.62 g/kg BW ( IQR 0.47-0.83). Mean energy intake of ≥ 70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity ( SAPS II) at ECMO start, ECMO runtime and BMI (adjusted hazard ratio: 0.464, p = 0.045). Conclusion: Patients with a mean energy delivery of ≥ 70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.