Systemic infusion of unfractionated heparin (UFH) is the standard anticoagulation technique for continuous renal replacement therapy (CRRT) during extracorporeal membrane oxygenation (ECMO), but often fails to avoid CRRT circuit clotting. The aim of this study was to assess, in patients undergoing CRRT during venovenous ECMO (vv-ECMO), the efficacy and safety of adding regional citrate anticoagulation (RCA) for CRRT circuit anticoagulation (RCA + UFH group) compared with the sole systemic heparin anticoagulation (UFH group). We performed a retrospective chart review (2009–2018) of patients treated with CRRT during ECMO. We evaluated filter life span, rate of CRRT circuit clotting, and coagulation parameters. The incidence of citrate anticoagulation-related complications was recorded. Forty-eight consecutive adult patients underwent CRRT during vv-ECMO in the study period. The incidence of CRRT circuit clotting was lower in the RCA + UFH group (11% vs. 38% in the UFH group, p < 0.001). Log-rank survival analysis demonstrated longer circuit lifetime for RCA + UFH group. No complication ascribable to citrate anticoagulation was recorded. Regional citrate anticoagulation resulted a feasible, safe, and effective technique as additional anticoagulation for CRRT circuits during ECMO. Compared with systemic heparinization only, this technique allowed to reduce the rate of CRRT circuit clotting.

Severe mixed β-blocker and calcium channel blocker intoxication presents a significant risk for patient mortality. Although treatment is well-established, it sporadically fails to support the patient through massive overdoses, thus requiring non-conventional treatments. We report the use of extra-corporeal life support in a patient with refractory hemodynamic impairment due to multi-drug intoxication. Although sometimes used in clinical practice, extra-corporeal membrane oxygenation for intoxications has rarely been reported.

In Intensive Care Unit (ICU) survivors, critical illness has an impact on an individual’s long-term health status and quality of life. Adults who have recovered from intensive care management could develop muscle weakness, neurocognitive impairment, difficulties in managing activities of daily living and to returning to work, and psychological problems such as depression and anxiety. A prospective, observational study was designed. Data were collected from January to December 2018 from a structured follow-up program, at 3 time points after ICU discharge: at seven days, a visit in the general ward, a phone interview at three months and an ambulatory visit at six months. A total of 95 patients were enrolled, 36% female, with a median age of 65 (55–73) years and a median ICU length of stay of 13 (8–20) days. At the seven days follow-up, patients who had a positive Hospital Anxiety and Depression Scale showed a significantly longer time of intubation (p = 0.048) and length of ICU stay (p = 0.023). At three months, we observed a significant relationship between a positive Hospital Anxiety and Depression Scale and a median value of EuroQol-5D (p = 0.048). At six months, we observed that patients who had a positive Post-Traumatic Symptom Scale were significantly younger than the other group. Findings from the present study suggest that a longer time of intubation and length of ICU stay are associated with a higher level of anxiety and depression immediately after ICU discharge. Follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge.

Background: The interest in protective ventilation strategies and individualized approaches for patients with severe illness on veno venous extracorporeal support has increased in recent years. Wide heterogeneity exists among patients with COVID-19 related acute respiratory distress syndrome (C-ARDS) and ARDS from other etiologies (NC-ARDS). EIT is a useful tool for the accurate analysis of regional lung volume distribution and allows for a tailored ventilatory setting. The aim of this work is to retrospectively describe the results of EIT assessments performed in patients C-ARDS and NC-ARDS undergoing V-V ECMO support. Methods: A clinical EIT-guided decremental PEEP trail was conducted for all patients included in the study and mechanically ventilated. Results: 12 patients with C-ARDS and 12 patients with NC-ARDS were included in the study for a total of 13 and 18 EIT evaluations, respectively. No significant differences in arterial blood gas, respiratory parameters, and regional ventilation before and after the EIT exam were recorded. The subset of patients with NC-ARDS whose EIT exam led to PEEP modification was characterized by a lower baseline compliance compared with the C-ARDS group: 18 (16–28) vs. 27 (24–30) (p = 0.04). Overdistension significantly increased at higher steps only for the NC-ARDS group. A higher percentage of overdistension was described in patients with NC-ARDS when compared with patients with C-ARDS. Conclusions: EIT is feasible in patients with COVID-19-associated ARDS on veno-venous extracorporeal support and may help in tailoring the PEEP setting. Overall, severe COVID-19-related ARDS presents respiratory characteristics similar to severe “classical” NC-ARDS. However, C-ARDS is associated with a lower risk of overdistension at a higher PEEP level compared with NC-ARDS.

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.