Advertisement

Intensive Care Medicine

, Volume 42, Issue 5, pp 712–724 | Cite as

Venovenous extracorporeal membrane oxygenation for acute respiratory failure

A clinical review from an international group of experts
  • Eddy FanEmail author
  • Luciano Gattinoni
  • Alain Combes
  • Matthieu Schmidt
  • Giles Peek
  • Dan Brodie
  • Thomas Muller
  • Andrea Morelli
  • V. Marco Ranieri
  • Antonio Pesenti
  • Laurent Brochard
  • Carol Hodgson
  • Cecile Van Kiersbilck
  • Antoine Roch
  • Michael Quintel
  • Laurent Papazian
Review

Abstract

Despite expensive life-sustaining interventions delivered in the ICU, mortality and morbidity in patients with acute respiratory failure (ARF) remain unacceptably high. Extracorporeal membrane oxygenation (ECMO) has emerged as a promising intervention that may provide more efficacious supportive care to these patients. Improvements in technology have made ECMO safer and easier to use, allowing for the potential of more widespread application in patients with ARF. A greater appreciation of the complications associated with the placement of an artificial airway and mechanical ventilation has led clinicians and researchers to seek viable alternatives to providing supportive care in these patients. Thus, this review will summarize the current knowledge regarding the use of venovenous (VV)-ECMO for ARF and describe some of the recent controversies in the field, such as mechanical ventilation, anticoagulation and transfusion therapy, and ethical concerns in patients supported with VV-ECMO.

Keywords

Critical care Extracorporeal membrane oxygenation Intensive care units Respiratory distress syndrome, adult Respiratory failure Review Ventilation, artificial 

Notes

Acknowledgments

We would like to acknowledge Alberto Goffi, MD (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada) for creating the figures for this manuscript. He was not compensated for this work.

Compliance with ethical standards

Conflicts of interest

Dan Brodie is currently on the medical advisory boards of ALung Technologies and Kadence. All compensation for these activities is paid to Columbia University. Alain Combes received funding for research from Maquet Cardiovascular and is currently on the Medical Advisory Board of Xenios and Baxter. Thomas Müller received fees from Maquet for travel support to invited lectures. Antonio Pesenti received funding for research and travel from Maquet Cardiovascular and is currently on the Medical Advisory Board of Novalung and Baxter. He holds a number of patents related to CO2 removal technology. Matthieu Schmidt received fees from Maquet for lectures. All other authors have no conflicts of interest to declare.

Supplementary material

134_2016_4314_MOESM1_ESM.docx (108 kb)
Supplementary material 1 (DOCX 107 kb)

References

  1. 1.
    Hill JD, O’Brien TG, Murray JJ et al (1972) Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 286:629–634. doi: 10.1056/NEJM197203232861204 CrossRefPubMedGoogle Scholar
  2. 2.
    Gille JP, Bagniewski AM (1976) Ten years of use of extracorporeal membrane oxygenation (ECMO) in the treatment of acute respiratory insufficiency (ARI). Trans Am Soc Artif Intern Organs 22:102–109PubMedGoogle Scholar
  3. 3.
    Zapol WM, Snider MT, Hill JD et al (1979) Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 242:2193–2196CrossRefPubMedGoogle Scholar
  4. 4.
    Kolobow T, Gattinoni L, Tomlinson T, Pierce JE (1978) An alternative to breathing. J Thorac Cardiovasc Surg 75:261–266PubMedGoogle Scholar
  5. 5.
    Gattinoni L, Iapichino G, Kolobow T (1979) Hemodynamic, mechanical and renal effects during “apneic oxygenation” with extracorporeal carbon dioxide removal, at different levels of intrapulmonary pressure in lambs. Int J Artif Organs 2:249–253PubMedGoogle Scholar
  6. 6.
    Gattinoni L, Kolobow T, Tomlinson T et al (1978) Control of intermittent positive pressure breathing (IPPB) by extracorporeal removal of carbon dioxide. Br J Anaesth 50:753–758CrossRefPubMedGoogle Scholar
  7. 7.
    Cressoni M, Caironi P, Polli F et al (2008) Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome. Crit Care Med 36:669–675. doi: 10.1097/01.CCM.0000300276.12074.E1 CrossRefPubMedGoogle Scholar
  8. 8.
    Lamy M, Eberhart RC, Fallat RJ et al (1975) Effects of extracorporeal membrane oxygenation (ECMO) on pulmonary hemodynamics, gas exchange and prognose. Trans Am Soc Artif Intern Organs 21:188–198PubMedGoogle Scholar
  9. 9.
    Guervilly C, Dizier S, Thomas G et al (2014) Comparison of femorofemoral and femorojugular configurations during venovenous extracorporeal membrane oxygenation for severe ARDS. Intensive Care Med 40:1598–1599. doi: 10.1007/s00134-014-3427-0 CrossRefPubMedGoogle Scholar
  10. 10.
    Combes A, Brodie D, Bartlett R et al (2014) Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med 190:488–496Google Scholar
  11. 11.
    Brodie D, Bacchetta M (2011) Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 365:1905–1914. doi: 10.1056/NEJMct1103720 CrossRefPubMedGoogle Scholar
  12. 12.
    Del Sorbo L, Cypel M, Fan E (2014) Extracorporeal life support for adults with severe acute respiratory failure. Lancet Respir Med 2:154–164. doi: 10.1016/S2213-2600(13)70197-8 CrossRefPubMedGoogle Scholar
  13. 13.
    Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D et al (2009) Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 302:1888–1895. doi: 10.1001/jama.2009.1535 CrossRefGoogle Scholar
  14. 14.
    Noah MA, Peek GJ, Finney SJ et al (2011) Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 306:1659–1668. doi: 10.1001/jama.2011.1471 CrossRefPubMedGoogle Scholar
  15. 15.
    Pham T, Combes A, Chevret S et al (2013) Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 187:276–285. doi: 10.1164/rccm.201205-0815OC
  16. 16.
    Mikkelsen ME, Woo YJ, Sager JS et al (2009) Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J 55:47–52. doi: 10.1097/MAT.0b013e3181901ea5 CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Frenckner B, Palmér P, Lindén V (2002) Extracorporeal respiratory support and minimally invasive ventilation in severe ARDS. Minerva Anestesiol 68:381–386PubMedGoogle Scholar
  18. 18.
    Fuehner T, Kuehn C, Hadem J et al (2012) Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med 185:763–768. doi: 10.1164/rccm.201109-1599OC
  19. 19.
    Barbaro RP, Odetola FO, Kidwell KM et al (2015) Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the Extracorporeal Life Support Organization registry. Am J Respir Crit Care Med 191:894–901. doi: 10.1164/rccm.201409-1634OC CrossRefPubMedGoogle Scholar
  20. 20.
    Rich PB, Awad SS, Crotti S et al (1998) A prospective comparison of atrio-femoral and femoro-atrial flow in adult venovenous extracorporeal life support. J Thorac Cardiovasc Surg 116:628–632CrossRefPubMedGoogle Scholar
  21. 21.
    Broman M, Frenckner B, Bjällmark A, Broomé M (2015) Recirculation during veno-venous extra-corporeal membrane oxygenation—a simulation study. Int J Artif Organs 38:23–30. doi: 10.5301/ijao.5000373 CrossRefPubMedGoogle Scholar
  22. 22.
    Rastan AJ, Lachmann N, Walther T et al (2006) Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO). Int J Artif Organs 29:1121–1131PubMedGoogle Scholar
  23. 23.
    Combes A, Leprince P, Luyt C-E et al (2008) Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med 36:1404–1411. doi: 10.1097/CCM.0b013e31816f7cf7 CrossRefPubMedGoogle Scholar
  24. 24.
    Cooper E, Burns J, Retter A et al (2015) Prevalence of venous thrombosis following venovenous extracorporeal membrane oxygenation in patients with severe respiratory failure. Crit Care Med 43:e581–e584. doi: 10.1097/CCM.0000000000001277 CrossRefPubMedGoogle Scholar
  25. 25.
    Lubnow M, Philipp A, Foltan M et al (2014) Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange—retrospective analysis of 265 cases. PLoS One 9:e112316. doi: 10.1371/journal.pone.0112316 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Müller T, Lubnow M, Philipp A et al (2011) Risk of circuit infection in septic patients on extracorporeal membrane oxygenation: a preliminary study. Artif Organs 35:E84–E90. doi: 10.1111/j.1525-1594.2010.01185.x CrossRefPubMedGoogle Scholar
  27. 27.
    Glick D, Dzierba AL, Abrams D et al (2015) Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. J Crit Care 30:1190–1194. doi: 10.1016/j.jcrc.2015.07.030 CrossRefPubMedGoogle Scholar
  28. 28.
    Pan KC, McKenzie DP, Pellegrino V et al (2015) The meaning of a high plasma free haemoglobin: retrospective review of the prevalence of haemolysis and circuit thrombosis in an adult ECMO centre over 5 years. Perfusion. doi: 10.1177/0267659115595282 PubMedGoogle Scholar
  29. 29.
    Weingart C, Lubnow M, Philipp A et al (2015) Comparison of coagulation parameters, anticoagulation, and need for transfusion in patients on interventional lung assist or veno-venous extracorporeal membrane oxygenation. Artif Organs 39:765–773. doi: 10.1111/aor.12464 CrossRefPubMedGoogle Scholar
  30. 30.
    Peek GJ, Mugford M, Wilson A et al (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351–1363. doi: 10.1016/S0140-6736(09)61069-2 CrossRefPubMedGoogle Scholar
  31. 31.
    Patroniti N, Zangrillo A, Pappalardo F et al (2011) The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med 37:1447–1457. doi: 10.1007/s00134-011-2301-6 CrossRefPubMedGoogle Scholar
  32. 32.
    Combes A (2011) Extracorporeal membrane oxygenation (ECMO) pour les syndromes de détresse respiratoire aiguë (SDRA) sévères. Reanimation 20:49–61. doi: 10.1007/s13546-010-0002-8 CrossRefGoogle Scholar
  33. 33.
    Luyt C-E, Combes A, Becquemin M-H et al (2012) Long-term outcomes of pandemic 2009 influenza A(H1N1)-associated severe ARDS. Chest 142:583–592. doi: 10.1378/chest.11-2196 CrossRefPubMedGoogle Scholar
  34. 34.
    Schmidt M, Zogheib E, Rozé H et al (2013) The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med 39:1704–1713. doi: 10.1007/s00134-013-3037-2 CrossRefPubMedGoogle Scholar
  35. 35.
    Schmidt M, Bailey M, Sheldrake J et al (2014) Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 189:1374–1382. doi: 10.1164/rccm.201311-2023OC CrossRefPubMedGoogle Scholar
  36. 36.
    Hodgson CL, Hayes K, Everard T et al (2012) Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia. Crit Care 16:R202. doi: 10.1186/cc11811 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Hemmila MR, Rowe SA, Boules TN et al (2004) Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 240:595–605. doi: 10.1097/01.sla.0000141159.90676.2d (discussion 605–7)PubMedPubMedCentralGoogle Scholar
  38. 38.
    Roch A, Hraiech S, Masson E et al (2014) Outcome of acute respiratory distress syndrome patients treated with extracorporeal membrane oxygenation and brought to a referral center. Intensive Care Med 40:74–83. doi: 10.1007/s00134-013-3135-1 CrossRefPubMedGoogle Scholar
  39. 39.
    Grasso S, Terragni P, Birocco A et al (2012) ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med 38:395–403. doi: 10.1007/s00134-012-2490-7 CrossRefPubMedGoogle Scholar
  40. 40.
    Amato MBP, Meade MO, Slutsky AS et al (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755. doi: 10.1056/NEJMsa1410639 CrossRefPubMedGoogle Scholar
  41. 41.
    Gattinoni L, Pesenti A, Mascheroni D et al (1986) Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 256:881–886CrossRefPubMedGoogle Scholar
  42. 42.
    Gattinoni L, Agostoni A, Pesenti A et al (1980) Treatment of acute respiratory failure with low-frequency positive-pressure ventilation and extracorporeal removal of CO2. Lancet 2:292–294CrossRefPubMedGoogle Scholar
  43. 43.
    Schmidt M, Stewart C, Bailey M et al (2015) Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Crit Care Med 43:654–664. doi: 10.1097/CCM.0000000000000753 CrossRefPubMedGoogle Scholar
  44. 44.
    Schmidt M, Pellegrino V, Combes A et al (2014) Mechanical ventilation during extracorporeal membrane oxygenation. Crit Care 18:203. doi: 10.1186/cc13702 CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Kolobow T, Gattinoni L, Tomlinson TA, Pierce JE (1977) Control of breathing using an extracorporeal membrane lung. Anesthesiology 46:138–141CrossRefPubMedGoogle Scholar
  46. 46.
    Karagiannidis C, Lubnow M, Philipp A et al (2010) Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support. Intensive Care Med 36:2038–2044. doi: 10.1007/s00134-010-1982-6 CrossRefPubMedGoogle Scholar
  47. 47.
    Mauri T, Bellani G, Foti G et al (2011) Successful use of neurally adjusted ventilatory assist in a patient with extremely low respiratory system compliance undergoing ECMO. Intensive Care Med 37:166–167. doi: 10.1007/s00134-010-2030-2 CrossRefPubMedGoogle Scholar
  48. 48.
    Marhong JD, Telesnicki T, Munshi L et al (2014) Mechanical ventilation during extracorporeal membrane oxygenation. An international survey. Ann Am Thorac Soc 11:956–961. doi: 10.1513/AnnalsATS.201403-100BC CrossRefPubMedGoogle Scholar
  49. 49.
    Marhong JD, Munshi L, Detsky M et al (2015) Mechanical ventilation during extracorporeal life support (ECLS): a systematic review. Intensive Care Med 41:994–1003. doi: 10.1007/s00134-015-3716-2 CrossRefPubMedGoogle Scholar
  50. 50.
    Byrnes J, McKamie W, Swearingen C et al (2011) Hemolysis during cardiac extracorporeal membrane oxygenation: a case–control comparison of roller pumps and centrifugal pumps in a pediatric population. ASAIO J 57:456–461. doi: 10.1097/MAT.0b013e31822e2475 CrossRefPubMedGoogle Scholar
  51. 51.
    Bembea MM, Annich G, Rycus P et al (2013) Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med 14:e77–e84. doi: 10.1097/PCC.0b013e31827127e4 CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Chu DC, Abu-Samra AG, Baird GL et al (2015) Quantitative measurement of heparin in comparison with conventional anticoagulation monitoring and the risk of thrombotic events in adults on extracorporeal membrane oxygenation. Intensive Care Med 41:369–370. doi: 10.1007/s00134-014-3574-3 CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Herbert DG, Buscher H, Nair P (2014) Prolonged venovenous extracorporeal membrane oxygenation without anticoagulation: a case of Goodpasture syndrome-related pulmonary haemorrhage. Crit Care Resusc 16:69–72PubMedGoogle Scholar
  54. 54.
    Abrams D, Agerstrand CL, Biscotti M et al (2015) Extracorporeal membrane oxygenation in the management of diffuse alveolar hemorrhage. ASAIO J 61:216–218. doi: 10.1097/MAT.0000000000000183 CrossRefPubMedGoogle Scholar
  55. 55.
    Biscotti M, Gannon WD, Abrams D et al (2015) Extracorporeal membrane oxygenation use in patients with traumatic brain injury. Perfusion 30:407–409. doi: 10.1177/0267659114554327 CrossRefPubMedGoogle Scholar
  56. 56.
    Lynch WR, MacLaren G, Wilson JM, Bartlett RH (2012) ECMO: extracorporeal cardiopulmonary support in critical care, 4 edn. Extracorporeal Life Support Organization, Ann ArborGoogle Scholar
  57. 57.
    Combes A, Bacchetta M, Brodie D et al (2012) Extracorporeal membrane oxygenation for respiratory failure in adults. Curr Opin Crit Care 18:99–104. doi: 10.1097/MCC.0b013e32834ef412 CrossRefPubMedGoogle Scholar
  58. 58.
    Agerstrand CL, Burkart KM, Abrams DC et al (2015) Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg 99:590–595. doi: 10.1016/j.athoracsur.2014.08.039 CrossRefPubMedGoogle Scholar
  59. 59.
    Voelker MT, Busch T, Bercker S et al (2015) Restrictive transfusion practice during extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome. Artif Organs 39:374–378. doi: 10.1111/aor.12385 CrossRefPubMedGoogle Scholar
  60. 60.
    Esper SA, Levy JH, Waters JH, Welsby IJ (2014) Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion. Anesth Analg 118:731–743. doi: 10.1213/ANE.0000000000000115 CrossRefPubMedGoogle Scholar
  61. 61.
    Puthucheary ZA, Rawal J, McPhail M et al (2013) Acute skeletal muscle wasting in critical illness. JAMA 310:1591–1600. doi: 10.1001/jama.2013.278481 CrossRefPubMedGoogle Scholar
  62. 62.
    TEAM Study Investigators, Hodgson C, Bellomo R et al (2015) Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 19:81. doi: 10.1186/s13054-015-0765-4 CrossRefGoogle Scholar
  63. 63.
    Hermans G, Van Mechelen H, Clerckx B et al (2014) Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 190:410–420. doi: 10.1164/rccm.201312-2257OC CrossRefPubMedGoogle Scholar
  64. 64.
    Hodgson CL, Fan E (2013) A step up for extracorporeal membrane oxygenation: active rehabilitation. Respir Care 58:1388–1390. doi: 10.4187/respcare.02606 CrossRefPubMedGoogle Scholar
  65. 65.
    Abrams D, Javidfar J, Farrand E et al (2014) Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study. Crit Care 18:R38. doi: 10.1186/cc13746 CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    AVERT Trial Collaboration group, Bernhardt J, Langhorne P et al (2015) Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 386:46–55. doi: 10.1016/S0140-6736(15)60690-0 CrossRefGoogle Scholar
  67. 67.
    Fan E, Pham T (2014) Extracorporeal membrane oxygenation for severe acute respiratory failure: yes we can! (But should we?). Am J Respir Crit Care Med 189:1293–1295. doi: 10.1164/rccm.201404-0711ED
  68. 68.
    Moratti S (2009) The development of “medical futility”: towards a procedural approach based on the role of the medical profession. J Med Ethics 35:369–372. doi: 10.1136/jme.2008.027755 CrossRefPubMedGoogle Scholar
  69. 69.
    Abrams DC, Prager K, Blinderman CD et al (2014) Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest 145:876–882. doi: 10.1378/chest.13-1138 CrossRefPubMedGoogle Scholar
  70. 70.
    Pappalardo F, Pieri M, Greco T et al (2013) Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMOnet score. Intensive Care Med 39:275–281. doi: 10.1007/s00134-012-2747-1 CrossRefPubMedGoogle Scholar
  71. 71.
    Enger T, Philipp A, Videm V et al (2014) Prediction of mortality in adult patients with severe acute lung failure receiving veno-venous extracorporeal membrane oxygenation: a prospective observational study. Crit Care 18:R67. doi: 10.1186/cc13824 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Eddy Fan
    • 1
    • 2
    Email author
  • Luciano Gattinoni
    • 3
  • Alain Combes
    • 4
  • Matthieu Schmidt
    • 4
  • Giles Peek
    • 5
  • Dan Brodie
    • 6
  • Thomas Muller
    • 7
  • Andrea Morelli
    • 8
  • V. Marco Ranieri
    • 8
  • Antonio Pesenti
    • 3
  • Laurent Brochard
    • 1
    • 9
  • Carol Hodgson
    • 10
  • Cecile Van Kiersbilck
    • 11
  • Antoine Roch
    • 12
  • Michael Quintel
    • 13
  • Laurent Papazian
    • 12
  1. 1.Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoCanada
  2. 2.Extracorporeal Life Support ProgramToronto General HospitalTorontoCanada
  3. 3.Dip Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda, Ospendale Maggiore Policlinico, Dip Fisiopatologia Medico Chirurgica e dei trapiantiUniversita degli Studi di MilanoMilanItaly
  4. 4.Medical Intensive Care Unit, Groupe Hospitalier Pitie-Salpetriere, Institute of Cardiometabolism and NutritionPierre Marie Curie UniversityParisFrance
  5. 5.Division of Pediatric Cardiothoracic Surgery and Pediatric Heart Centre, Montefiore Health SystemAlbert Einstein UniversityNew YorkUSA
  6. 6.Division of Pulmonary, Allergy and Critical Care MedicineColumbia University Medical Center/New York-Presbyterian HospitalNew YorkUSA
  7. 7.Department of Internal Medicine IIUniversity Medical Center of Regensburg, University of RegensburgRegensburgGermany
  8. 8.Department of Anesthesiology and Intensive Care, Policlinico Umberto 1Sapienza University of RomeRomeItaly
  9. 9.Keenan Research Centre, Li Ka-Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  10. 10.Department of Epidemiology and Preventive Medicine, ANZIC-RCMonash University and Physiotherapy Department, The AlfredMelbourneAustralia
  11. 11.Réanimation des Détresses Respiratoires et Infections Sévères, CHU NordAix-Marseille UniversitéMarseilleFrance
  12. 12.Réanimation des Détresses Respiratoires et Infections Sévères, CHU Nord, UMR CNRS 7278Aix-Marseille UniversitéMarseilleFrance
  13. 13.Anaesthesiologie II-Operative IntensivmedizinUniversitatsklinikum GottingenGottingenGermany

Personalised recommendations