No abstract

Recently diagnosed immunodeficiency is associated with a much better prognosis in ECMO-treated severe ARDS. However, low 6-month survival of our large cohort of immunocompromised patients supports restricting ECMO to patients with realistic oncological/therapeutic prognoses, acceptable functional status and few pre-ECMO mortality-risk factors.

OBJECTIVE -We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS-A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1-to 4-h intervals as requested by the protocols.RESULTS -The eMPC algorithm gave the best performance as assessed by time to target (8.8 Ϯ 2.2 vs. 10.9 Ϯ 1.0 vs. 12.3 Ϯ 1.9 h; eMPC vs. Matias vs. Bath, respectively; P Ͻ 0.05), average blood glucose after reaching the target (5.2 Ϯ 0.1 vs. 6.2 Ϯ 0.1 vs. 5.8 Ϯ 0.1 mmol/l; P Ͻ 0.01), time in target (62.8 Ϯ 4.4 vs. 48.4 Ϯ 3.28 vs. 55.5 Ϯ 3.2%; P Ͻ 0.05), time in hyperglycemia Ͼ8.3 mmol/l (1.3 Ϯ 1.2 vs. 12.8 Ϯ 2.2 vs. 6.5 Ϯ 2.0%; P Ͻ 0.05), and sampling interval (2.3 Ϯ 0.1 vs. 2.1 Ϯ 0.1 vs. 1.8 Ϯ 0.1 h; P Ͻ 0.05). However, time in hypoglycemia risk range (2.9 -4.3 mmol/l) in the eMPC group was the longest (22.2 Ϯ 1.9 vs. 10.9 Ϯ 1.5 vs. 13.1 Ϯ 1.6; P Ͻ 0.05). No severe hypoglycemic episode (Ͻ2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group.CONCLUSIONS -The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients. Diabetes Care 32:757-761, 2009

Aims Ventricular septal rupture (VSR) became a rare mechanical complication of myocardial infarction in the era of percutaneous coronary interventions but is associated with extreme mortality in patients who present with cardiogenic shock (CS). Promising outcomes have been reported with the use of circulatory support allowing haemodynamic stabilization, followed by delayed repair. Therefore, we analysed our experience with an early use of Veno‐Arterial Extracorporeal Membrane Oxygenation (V‐A ECMO) for postinfarction VSR. Methods and results We conducted a retrospective search of institutional database for patients presenting with postinfarction VSR from January 2007 to June 2016. Data from 31 consecutive patients (mean age 69.5 ± 9.1 years) who were admitted to hospital were analysed. Seven out of 31 patients with VSR who were in refractory CS received V‐A ECMO support preoperatively. ECMO improved end‐organ perfusion with decreased lactate levels 24 hours after implantation (7.9 mmol/L vs. 1.6 mmol/L, p = 0.01), normalized arterial pH (7.25 vs. 7.40, p < 0.04), improved mean arterial pressure (64 mmHg vs. 83 mmHg, p < 0.01) and lowered heart rate (115/min vs. 68/min, p < 0.01). Mean duration of ECMO support was 12 days, 5 out of 7 patients underwent surgical repair, 4 were weaned from ECMO, 3 survived 30 days and 2 survived more than 1 year. The most frequent complication (5 patients) and the cause of death (3 patients) was bleeding. Conclusions Our experience suggests that early V‐A ECMO in patients with VSR and refractory CS might prevent irreversible multiorgan failure by improved end‐organ perfusion. Bleeding complications remain an important limitation of this approach.

Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.