医療倫理の進歩
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概要

Change of the paradigm: From absolute contraindication to extension of indication

Giovanna Panarello

Abstract

Introduction: Pneumocystis jiorvecii pneumonia is often AIDS exordium opportunistic infection. Evolution in respiratory distress syndrome is common and is potentially reversible but is still burdened by a mortality rate as high as 30% to 40% if managed by conventional treatment mainly based on optimal mechanical ventilation. Since 2009 the use of Extracorporeal Membrane Oxygenation has been shown to be very effective as salvage therapy in case of severe respiratory insufficiency not responsive to conventional therapy. HIV seropositivity has been considered a contraindication to extracorporeal life support. We report two cases of Pnumocystis jiorvecii pneumonia as AIDS exordium opportunistic infection. Both evolved to severe ARDS and were successfully treated with VV ECMO support.

 

Background: Extracorporeal layer oxygenation (ECMO) has been accessible to help serious respiratory disappointment since the 1970s. Be that as it may, high entanglement rates, to a great extent because of impediments in innovation, lead to helpless results at an opportune time. In later years, progresses in innovation and the executives have prompted clearly improved endurance with diminished intricacy rates, bringing about expanding utilization of ECMO for extreme intense respiratory trouble disorder (ARDS). While results have improved after some time, the advantage of ECMO when contrasted with traditional, standard of care the executives for ARDS still can't seem to be shown in thoroughly planned, randomized controlled preliminaries; as such it stays most ordinarily utilized as rescue treatment for the most serious instances of ARDS. As the field keeps on developing, there is expanding potential for ECMO to upgrade the manner in which ARDS is overseen, prominently through assistance of lung defensive ventilation and minimization of ventilator-related lung injury. Here we will audit the proof that bolsters the utilization of ECMO, the justification for its utilization and robotic advantages, commonsense parts of ECMO inception and the executives, and continuous examinations and future bearings.

 

Method:- The main multicenter randomized controlled preliminary using generally present day procedures in ECMO for ARDS is the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) preliminary, in which 180 patients with extreme intense respiratory disappointment were randomized to either get ordinary mechanical ventilation or be alluded to a particular place where they were considered for ECMO after an underlying time of ideal customary administration. A huge decrease was found in the composite result of death or extreme incapacity at a half year in patients who were alluded to a claim to fame community for thought of ECMO versus traditional administration (37% versus 53%; RR 0.69, 95% CI 0.05–0.97, P=0.03). Of note, just 76% of patients alluded to a forte place were at last dealt with ECMO, and an enormous bit of patients in the ordinary administration arm (30%) never got lung defensive ventilation whenever, making it hard to reach determinations about the advantage of ECMO itself on results. In spite of these and different impediments, referral of patients with extreme types of ARDS to an inside that has the capacity of performing ECMO, and holds fast to standard of care mechanical ventilation, might be helpful

 

Results: Given that the key objectives for ventilator the executives in ARDS are outfitted towards limiting ventilator-related lung injury, expelling the ventilator may hypothetically be the favored system. Furthermore, it could enhance other concentrated consideration based administration techniques, including minimization of sedation, decreases in nosocomial diseases (especially ventilator-related pneumonia) and boost of activation and enteral sustenance. Nonetheless, there is likely worry over compounding mechanical worry with unconstrained taking in ARDS (61-65). Despite the fact that ECCO2R has been appeared to be able to control ventilatory drive in select patients with serious, incessant respiratory disappointment (e.g., COPD), information proposes that it will be unable to adequately control the unconstrained and conceivably damaging respiratory endeavors of patients with extreme ARDS. Physical and word related treatment has been appeared to not exclusively be achievable, yet in addition have various positive results in patients with intense respiratory disappointment, eminently improving usefulness, decreasing insanity, and expanding sans ventilator days. The preparation of patients with respiratory disappointment requiring ECMO has been expanding generally, however this information is to a great extent restricted to patients who are anticipating lung transplantation. While patients requiring ECMO for ARDS may frequently be excessively basically sick to take an interest in dynamic recovery, it might be conceivable in proper patients who are at focuses that have a multidisciplinary way to deal with exercise based recuperation. The advantage of assembling ARDS patients on ECMO has not been very much characterized and should be weighed against the likely dangers of active recuperation in this populace.

 

Biography: Giovanna Panarello is chief of ICU working as intensivist and infectivologist. She is involved in the critical care of severe respiratory insufficiency due to infection disease and end stage lung disease as treatment provider and in the etiology study and in the implementation of Scientific trial.