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In the last five decades, human activities have resulted in the release of increasing quantities of carbon dioxide and other greenhouse gases, thus contributing to global climate change by additional heating of the atmosphere. In consequence, in future, the European intensivist - who already should be aware of uncommon vector-borne diseases due to global tourism - must be further sensitized to presently uncommon or tropical mosquito-borne diseases such as malaria and dengue, or other vector-borne viral, fungal, or bacterial transmissions like coccidioidomycosis or avian influenza. It seems that a rise in mortality, emergency room visits, and (intensive care) hospitalization due to cardiopulmonary diseases attendant on heat stress, extreme weather conditions, or air pollution are more certain than worst-case horror scenarios. It has been shown that acute and intensive care services vary substantially across economic regions, in high-income as well as in low-income countries [[17]], and it is debatable whether the current structure of intensive care is yet armed for needs related to climate change. [Extracted from the article]

The history of critical care is littered with examples of the "cost" of trying to normalize abnormal physiology during critical illness in the attempt to improve outcomes - supranormal oxygen delivery, liberal red cell transfusion, ventilation to normal blood gas parameters, and intensive glycemic control [[1]]. Extracorporeal membrane oxygenation (ECMO) is a complex, costly, and resource-intensive intervention for patients with severe cardiac and/or pulmonary failure. Finally, the highest mortality rates for patients supported with ECMO (or who are critically ill in general) are those who are more than 75 years and/or are frail, making these important factors when considering whether to offer ECMO to these patients. Critical care costs account for nearly 1% of GDP in the United States [[13]], and ECMO is a good example of a high-cost intervention delivered in the ICU. [Extracted from the article]

Purpose: The evolution of the epidemiology and mortality of extracorporeal membrane oxygenation (ECMO) remains unclear. The present study investigates the evolving epidemiology and mortality of various ECMO techniques in Germany over time, used for both severe respiratory and cardiac failure.Methods: Data on all patients receiving venovenous (vv-ECMO) and venoarterial (va-ECMO) ECMO as well as pumpless extracorporeal lung assist/interventional lung assist (PECLA/ILA) outside the operating room in Germany from 1 January 2007 through 31 December 2014 were obtained from the Federal Statistical Office of Germany and analyzed.Results: The incidence of vv-ECMO and va-ECMO in the population increased threefold from 1.0:100,000 inhabitants/year in 2007 to a maximum of 3.0:100,000 in 2012, and from 0.1:100,000 in 2007 to 0.7:100,000 in 2012 and to a maximum of 3.5:100,000 in 2014, respectively. The incidence of arteriovenous PECLA/ILA also increased from 0.4:100,000 to a maximum of 0.6:100,000 in 2011, but decreased thereafter to 0.3:100,000 in 2014. The relative proportion of older patients receiving ECMO is steadily increasing. In-hospital mortality decreased over time and reached 58 and 66 % for vv-ECMO and va-ECMO in 2014, respectively. In addition, mortality steadily increased with age and was especially high in the first 48 h of ECMO use.Conclusions: In a high-income country like Germany, the use of ECMO has been rapidly increasing since 2007 for both respiratory and cardiac support, with a recent plateau in vv-ECMO use. In-hospital mortality decreased with increasing ECMO utilization, but remains high, especially in older patients and in the first 48 h of use. [ABSTRACT FROM AUTHOR]

Purpose: Extracorporeal membrane oxygenation (ECMO) can support oxygenation and carbon dioxide elimination in severe lung failure. Usually it is accompanied by controlled mechanical ventilation. Neurally adjusted ventilatory assist (NAVA) is a new mode of ventilation triggered by the diaphragmatic electrical activity and controlled by the patient's respiratory centre, which may allow a close interaction between ventilation and extracorporeal perfusion. This pilot study intended to measure the physiologic ventilatory response in patients with severe lung failure treated with ECMO and NAVA. We hypothesized that the combination of both methods could automatically provide a protective ventilation with optimized blood gases. Methods: We report a case series of six patients treated with ECMO for severe lung failure. In the recovery phase of the disease, patients were ventilated with NAVA and ventilatory response and gas exchange parameters were measured under different sweep gas flows and temporarily inactivated ECMO. Results: Tidal volumes on ECMO ranged between 2 and 5 ml/kg predicted body weight and increased up to 8 ml/kg with inactivated ECMO. Peak inspiratory pressure reached 19-29 cmHO with active, and 21-45 cmHO with inactivated ECMO. Ventilatory response to decreased sweep gas flow was rapid, and patients immediately regulated PaCO tightly towards a physiological pH value. Increase in minute ventilation was a result of increased breathing frequency and tidal volumes, and protective ventilation was only abandoned if pH control was not achieved. Conclusions: With NAVA ventilatory response to decreased ECMO sweep gas flow was rapid, and patients immediately regulated PaCO tightly towards a physiological pH value. Therefore, combination of NAVA and ECMO may permit a closed-loop ventilation with automated protective ventilation. [ABSTRACT FROM AUTHOR]

The article reports on five patients with severe chronic obstructive pulmonary disease (COPD) exacerbation and invasive mechanical ventilation that developed following intubation. Topics discussed include the effectiveness of veno-venous extracorporeal CO2, and the potential of ECCO2OR to rapidly correct respiratory acidosis and to significantly reduce elevated mean pulmonary artery pressure (PAP) values in severe COPD.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19. [ABSTRACT FROM AUTHOR]

Purpose: The question of whether cancer patients with severe respiratory failure benefit from veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains unanswered. We, therefore, analyzed clinical characteristics and outcomes of a large cohort of cancer patients treated with vv-ECMO with the aim to identify prognostic factors. Methods: 297 cancer patients from 19 German and Austrian hospitals who underwent vv-ECMO between 2009 and 2019 were retrospectively analyzed. A multivariable cox proportional hazards analysis for overall survival was performed. In addition, a propensity score-matched analysis and a latent class analysis were conducted. Results: Patients had a median age of 56 (IQR 44–65) years and 214 (72%) were males. 159 (54%) had a solid tumor and 138 (47%) a hematologic malignancy. The 60-day overall survival rate was 26.8% (95% CI 22.1–32.4%). Low platelet count (HR 0.997, 95% CI 0.996–0.999; p = 0.0001 per 1000 platelets/µl), elevated lactate levels (HR 1.048, 95% CI 1.012–1.084; p = 0.0077), and disease status (progressive disease [HR 1.871, 95% CI 1.081–3.238; p = 0.0253], newly diagnosed [HR 1.571, 95% CI 1.044–2.364; p = 0.0304]) were independent adverse prognostic factors for overall survival. A propensity score-matched analysis with patients who did not receive ECMO treatment showed no significant survival advantage for treatment with ECMO. Conclusion: The overall survival of cancer patients who require vv-ECMO is poor. This study shows that the value of vv-ECMO in cancer patients with respiratory failure is still unclear and further research is needed. The risk factors identified in the present analysis may help to better select patients who may benefit from vv-ECMO. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the risk of mortality in patients undergoing venovenous due to H1N1-influenza-A using the ECMOnet score tools by F. Pappalardo and colleagues in the 2013 issue.