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• W2021752679 abstract "Authors' reply SIR–In reply to Leclerc and colleagues, the seven patients with intractable shock due to meningococcal disease before ECMO did receive optimum conventional treatment. Central venous pressure is an unreliable indicator of left-heart filling, and Swan-Ganz catheters are rarely used in children. Indices to assess adequacy of cardiac output to meet metabolic demands are more relevant than the absolute value per se, and we therefore use a combination of clinical, echocardiographic, and biochemical indicators–eg, optimum fluid management entails repeated bolus challenges with clinical reassessment, left atrial filling and ventricular function can be assessed with echocardiography (done in three of seven patients), and biochemical markers such as lactate and acidosis are serially measured. We do not accept that norepinephrine is the inotrope of choice in refractory septic shock, but is rather the vasoconstrictor of choice in the early vasodilatory phase of septic shock. As shock progresses with myocardial failure, inotropic drugs such as dopamine, dobutamine, and epinephrine with β-adrenergic effects are needed. If the myocardium fails to respond to high doses of inotropes, then ECMO is an alternative form of cardiac support. These workers' comments on the inability to distinguish the beneficial effects of ECMO and haemofiltration were addressed in our report. At present information on haemofiltration in septic shock is anecdotal with no randomised trials yet published. The PRISM score was designed only for population-based studies, not for predicting mortality in individual patients. However, in an attempt to convey the degree of illness of our patients we presented the range of severity of illness scores. The PRISM score in the seven patients with intractable shock was, in fact, 32 (range 28–40, predicted risk of mortality 81%), GMSPS was 13 (ten to 15, positive predictive value of death >88%), and each patient had four (three to six) organ failures. Furthermore, four of these seven patients needed external cardiac massage and one received repeated boluses of epinephrine before ECMO. We believe that these patients were sicker than those of Vos and colleagues, in whose study the mortality predicted by PRISM was 32%. The overall mortality rate for the rest of the patients presenting with meningococcal disease to intensive care in the institutions reporting in this study was 14% (22/155), similar to that cited by Leclerc et al. Ideally any new treatment should be evaluated by prospective trials before being recommended. However, as we stated, “a randomised ECMO trial in this group would be difficult because of the problems in standardising selection criteria, small numbers of patients (15 world-wide so far), and the ethical question of randomising patients at a point near death”. Four of seven of our patients who we believe would have died without ECMO survived. This finding suggests that ECMO may have a role in the management of refractory shock due to meningococcal disease. ECMO for refractory cardiorespiratory failure due to meningococcal diseaseGoldman and colleagues (Feb 15, p 466)1 report their experience with extracorporeal membrane oxygenation (ECMO) in patients with refractory cardiorespiratory failure due to meningococcal disease. We have several points to raise about the seven patients with intractable shock. Full-Text PDF" @default.
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• W2021752679 title "ECMO for refractory cardiorespiratory failure due to meningococcal disease" @default.
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