ECMO : the clinician’s view

Background: Extra corporeal membrane oxygenation (ECMO) is a complex rescue therapy used to provide cardiac and/or respiratory support for critically ill patients who have failed maximal conventional medical management. ECMO is based on a modified cardiopulmonary bypass (CPB) circuit, and can provide cardiopulmonary support for up-to several months. It can be used in a veno venous configuration for isolated respiratory failure, (VV-ECMO), or in a veno arterial configuration (VA-ECMO) where support is necessary for cardiac +/- respiratory failure. The ECMO circuit consists of five main components: large bore cannulae (access cannulae) for drainage of the venous system, and return cannulae to either the venous (in VV-ECMO) or arterial (in VA ECMO) system. An oxygenator, with a vast surface area of hollow filaments, allows addition of oxygen and removal of carbon dioxide; a centrifugal blood pump allows propulsion of blood through the circuit at upto 10 L/minute; a control module and a thermoregulatory unit, which allows for exact temperature control of the extra corporeal blood. Methods: The first successful use of ECMO for ARDS in adults occurred in 1972, and its use has become more commonplace over the last 30 years, supported by the improvement in design and biocompatibility of the equipment, which has reduced the morbidity associated with this modality. Whilst the use of ECMO in neonatal population has been supported by numerous studies, the evidence upon which ECMO was integrated into adult practice was substantially less robust. Results: Recent data, including the CESAR study (Conventional Ventilatory Support versus Extra corporeal membrane oxygenation for Severe Respiratory failure) has added a degree of evidence to the role of ECMO in such a patient population. The CESAR study analysed 180 patients, and confirmed that ECMO was associated with an improved rate of survival. More recently, ECMO has been utilized in numerous situations within the critical care area, including support in high-risk percutaneous interventions in cardiac catheter lab; the operating room, emergency department, as well in specialized inter-hospital retrieval services. The increased understanding of the risk:benefit profile of ECMO, along with a reduction in morbidity associated with its use will doubtless lead to a substantial rise in the utilisation of this modality. As with all extra-corporeal circuits, ECMO opposes the basic premises of the mammalian inflammation and coagulation cascade where blood comes into foreign circulation, both these cascades are activated. Anti-coagulation is readily dealt with through use of agents such as heparin, but the inflammatory excess, whilst less macroscopically obvious, continues un-abated. Platelet consumption and neutrophil activation occur rapidly, and the clinician is faced with balancing the need of anticoagulation for the circuit, against haemostasis in an acutely bleeding patient. Alterations in pharmacokinetics may result in inadequate levels of disease modifying therapeutics, such as antibiotics, hence paradoxically delaying recovery from conditions such as pneumonia. Key elements of nutrition and the innate immune system maysimilarly be affected. Summary: This presentation will discuss the basic features of ECMO to the nonspecialist, and review the clinical conundrum faced by the team treating these most complex cases.

Whole System Design : An Integrated Approach to Sustainable Engineering

Whole System Design is increasingly being seen as one of the most cost effective ways to both increase the productivity and reduce the negative environmental impacts of an engineered system. A focus on design is critical, as the output from this stage of the project locks-in most of the economic and environmental performance of the designed system throughout its life, which can span from a few years to many decades. Indeed, it is now widely acknowledged that all designers – particularly engineers, architects and industrial designers – need to be able to understand and implement a whole system design approach. This book provides a clear design methodology, based on leading efforts in the field, and is supported by worked examples that demonstrate how advances in energy, materials and water productivity can be achieved through applying an integrated approach to sustainable engineering. Chapters 1–5 outline the approach and explain how it can be implemented to enhance the established Systems Engineering framework. Chapters 6–10 demonstrate, through detailed worked examples, the application of the approach to industrial pumping systems, passenger vehicles, electronics and computer systems, temperature control of buildings, and domestic water systems.

Controlled synthesis of a large fraction of metallic single-walled carbon nanotube and semiconducting carbon nanowire networks

Controlled synthesis of both single-walled carbon nanotube and carbon nanowire networks using the same CVD reactor and Fe/Al2O3 catalyst by slightly altering the hydrogenation and temperature conditions is demonstrated. Structural, bonding and electrical characterization using SEM, TEM, Raman spectroscopy, and temperature-dependent resistivity measurements suggest that the nanotubes are of a high quality and a large fraction (well above the common 33% and possibly up to 75%) of them are metallic. On the other hand, the carbon nanowires are amorphous and semiconducting and feature a controlled sp2/sp3 ratio. The growth mechanism which is based on the catalyst nanoisland analysis by AFM and takes into account the hydrogenation and temperature control effects explains the observed switch-over of the nanostructure growth modes. These results are important to achieve the ultimate control of chirality, structure, and conductivity of one-dimensional all-carbon networks.

In situ reaction furnace for real-time XRD studies

The new furnace at the Materials Characterization by X-ray Diffraction beamline at Elettra has been designed for powder diffraction measurements at high temperature (up to 1373 K at the present state). Around the measurement region the geometry of the radiative heating element assures a negligible temperature gradient along the capillary and can accommodate either powder samples in capillary or small flat samples. A double capillary holder allows flow-through of gas in the inner sample capillary while the outer one serves as the reaction chamber. The furnace is coupled to a translating curved imaging-plate detector, allowing the collection of diffraction patterns up to 2[theta] [asymptotically equal to] 130°.

Hierarchical multilevel arrays of self-assembled gold nanoparticles : Control of resistivity-temperature dependence

The possibility to control the electric resistivity-temperature dependence of the nanosized resistive components made using hierarchical multilevel arrays of self-assembled gold nanoparticles prepared by multiple deposition/annealing is demonstrated. It is experimentally shown that the hierarchical three-level patterns, where the nanoparticles of sizes ranging from several nanometers to several tens of nanometer play a competitive roles in the electric conductivity, demonstrate sharp changes in the activation energy. These patterns can be used for the precise tuning of the resistivity-temperature behavior of nanoelectronic components.

Effective control of nanostructured phases in rapid, room-temperature synthesis of nanocrystalline Si in high-density plasmas

An innovative and effective approach based on low-pressure, low-frequency, thermally nonequilibrium, high-density inductively coupled plasmas is proposed to synthesize device-quality nanocrystalline silicon (nc-Si) thin films at room temperature and with very competitive growth rates. The crystallinity and microstructure properties (including crystal structure, crystal volume fraction, surface morphology, etc.) of this nanostructured phase of Si can be effectively tailored in broad ranges for different device applications by simply varying the inductive rf power density from 25.0 to 41.7 mW/cm3. In particular, at a moderate rf power density of 41.7 mW/cm3, the nc-Si films feature a very high growth rate of 2.37 nm/s, a high crystalline fraction of 86%, a vertically aligned columnar structure with the preferential (111) growth orientation and embedded Si quantum dots, as well as a clean, smooth and defect-free interface. We also propose the formation mechanism of nc-Si thin films which relates the high electron density and other unique properties of the inductively coupled plasmas and the formation of the nanocrystalline phase on the Si surface.

Self-organized ZnO nanodot arrays : effective control using SiNx interlayers and low-temperature plasmas

An advanced inductively coupled plasma (ICP)-assisted rf magnetron sputtering deposition method is developed to synthesize regular arrays of pear-shaped ZnO nanodots on a thin SiNx buffer layer pre-deposited onto a silicon substrate. It is shown that the growth of ZnO nanodots obey the cubic root-law behavior. It is also shown that the synthesized ZnO nanodots are highly-uniform, controllable by the experimental parameters, and also feature good structural and photoluminescent properties. These results suggest that this custom-designed ICP-based technique is very effective and highly-promising for the synthesis of property- and size-controllable highly-uniform ZnO nanodots suitable for next-generation light emitting diodes, energy storage, UV nanolasers, and other applications.

Construction, application and validation of selection evaluation model (SEM) for intelligent HVAC control system

Design teams are confronted with the quandary of choosing apposite building control systems to suit the needs of particular intelligent building projects, due to the availability of innumerable ‘intelligent’ building products and a dearth of inclusive evaluation tools. This paper is organised to develop a model for facilitating the selection evaluation for intelligent HVAC control systems for commercial intelligent buildings. To achieve these objectives, systematic research activities have been conducted to first develop, test and refine the general conceptual model using consecutive surveys; then, to convert the developed conceptual framework into a practical model; and, finally, to evaluate the effectiveness of the model by means of expert validation. The results of the surveys are that ‘total energy use’ is perceived as the top selection criterion, followed by the‘system reliability and stability’, ‘operating and maintenance costs’, and ‘control of indoor humidity and temperature’. This research not only presents a systematic and structured approach to evaluate candidate intelligent HVAC control system against the critical selection criteria (CSC), but it also suggests a benchmark for the selection of one control system candidate against another.