Is there, thank you again for a great session, is there any rule for any of these devices you talked about in non-cardiogenic shocks, spinal shock to be precise? I am the wrong person to answer that question for you, but I'm also very biased towards the devices, so I want to say I'm sure somebody can find an application outside of cardiogenic shock. Well, we use the balloon pump for our refractory spinal shock, that's why I bring it up. I am very happy to hear that you're using it. I have another question for Dr. Simi. What is your practice for anticoagulation trauma patients? As a new ECMO center, we've been struggling to get trauma patients on because there's a lot of hesitancy from some of my partners in anticoagulating, and I know it's a kind of touchy situation, so I'd appreciate your input on what you guys do. Well, my personal experience, we have the same issues, and it's basically, we do have a shock team though, so we have people that need to sit down and decide on patient by patient basis, and it makes it a little bit easier. I have no data to show, besides what I already show, that yes, you can do it, you don't have to anticoagulate. It also depends what type of device you're on, right, because we do have patients on ECMO that are not as anticoagulated, we just use the lower ACTs, higher ACTs, I'm sorry. But I think the best personal recommendation would be get with the trauma surgeons together, sit down, come up with protocols for your own place, start collecting data, so you're able to go back to the institution and be like, hey, listen, we're doing one at a time, one at a time, and this is what we can show you. I can totally tell you, there's no data right now that's going to recommend anything specific. Hi, I'm Gerberg from Cleveland Clinic. Regarding the pulse pressure variation test, which is very popular, first I'm wondering, nobody's ventilating at eight cc's per kilogram, so you have to especially change the ventilator to that volume. Secondly, you did not mention the contribution of respiratory muscle in that test, since we need to get the value, you have to paralyze or have a relaxed respiratory muscle system to assess correctly the volume change. So I'm wondering, with those limitations, how would you interpret the data without paralysis? That's an excellent question. So assessing the fluid responsiveness, at least our experience, and what the data supports is what is published by Dr. Monette is his patients are paralyzed. So that's the way to do it, that's the way that you get the better number. So assessing the fluid responsiveness in patients that are not paralyzed without a tidal volume at lower than seven cc per kilo. So it's not a good number, it's not going to be reliable. I don't think that you can intervene based on those numbers if you are not doing it properly. Absolutely, I agree. Hi, Steven Xu here from MD Anderson. So as you're aware, our patient population is not the favorite, this is for Dr. Asimi, we're all populations that are not the favorite for any mechanical support due to severe thrombocytopenia and also very bad disease prognosis. With the advent of immunotherapy now and patients with a slightly longer survival curve, do you foresee that there will be a shift in more accepting of such populations in your service for mechanical support or it still will be a sort of a death sentence for these patients to simply contraindicated? I like the way you asked the question, do I foresee? I forgot my, you know, crystal ball, but I want to say yes. The thing is that people like us have to take up the research because if there's no research nobody's going to uptake anything. I don't know about you, but in my previous place we had a durable device, not an acute mechanical support devices, but all the durable ones, and we had a very strong program that was most of it is basically female medicine, unfortunately, because as you know, the chemotherapies for unfortunately not just breast cancer, but a lot of the gynecological cancers cause cardiogenic shocks later in the therapy and we had a very acute like active program there and that was over 10 years ago. So I am very hopeful, not just for the fact that we can implement devices, but also for the future of cancer care that we can provide support for those people to get to a point of where hopefully the heart can recover. Thank you. All right, I'm going to take the liberty of asking a question as well. So this is going to Dr. Lopez-Ruiz. So to play devil's advocate here, first off, I'm a very strong proponent of the use of fluid responsiveness, but for those in the room who may be a little skeptical, especially based on the level of evidence that we have right now, what is your interpretation? The classic and the Clover's trials can be interpreted in two different ways, right? So on one hand, it shows that the use of more conservative fluid strategies is not any, there's no added benefit over what's currently being done in practice. But the flip side to that is that it also doesn't worsen mortality. So however, most people I think would favor giving a little more judicious volume since it may prevent an ICU admission from the use of early vasopressors, et cetera. What is your argument, given the current literature base, for even doing fluid responsiveness if we know that liberal versus not doesn't really change management? And this is a lead-in question, of course, because again, I'm biased. Thank you. I think there are two ways to interpret because I heard that, so saying we can continue giving fluids so we can keep the patient on the floor. So or the other is, let's transfer the patient to the ICU and let's stop the fluids. So I will go for in favor of limited amount of fluids because if you continue giving fluids on the floor, I think that the complication of reaching this point of volume overload, the consequences are going to be more detrimental than transferring earlier the patient to the ICU when you give limited amount of fluids. So and I'm just focused on what is prolonged mechanical ventilation and AKI. So that's my answer.

devices in non-cardiogenic shocks

anticoagulation for trauma patients on ECMO

pulse pressure variation tests

mechanical support for patients with severe thrombocytopenia

fluid responsiveness in critical care