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Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study
Critical Care volume 17, Article number: R73 (2013)
Mortality of patients on extracorporeal membrane oxygenation (ECMO) remains high. The objectives of this study were to assess the factors associated with outcome of patients undergoing ECMO in a large ECMO referral centre and to compare veno-arterial ECMO (VA ECMO) with veno-venous ECMO (VV ECMO).
We reviewed a prospectively obtained ECMO database and patients' medical records between January 2005 and June 2011. Demographic characteristics, illness severity at admission, ECMO indication, organ failure scores before ECMO and the ECMO mode and configuration were recorded. Bleeding, neurological, vascular and infectious complications that occurred on ECMO were also collected. Demographic, illness, ECMO support descriptors and complications associated with hospital mortality were analysed.
ECMO was initiated 158 times in 151 patients. VA ECMO (66.5%) was twice as common as VV ECMO (33.5%) with a median duration significantly shorter than for VV ECMO (7 days (first and third quartiles: 5; 10 days) versus 10 days (first and third quartiles: 6; 16 days)). The most frequent complications during ECMO support were bleeding and bloodstream infections regardless of ECMO type. More than 70% of the ECMO episodes were successfully weaned in each ECMO group. The overall mortality was 37.3% (37.1% for the patients who underwent VA ECMO, and 37.7% for the patients who underwent VV ECMO). Haemorrhagic events, assessed by the total of red blood cell units received during ECMO, were associated with hospital mortality for both ECMO types.
Among neurologic, vascular, infectious and bleeding events that occurred on ECMO, bleeding was the most frequent and had a significant impact on mortality. Further studies are needed to better investigate bleeding and coagulopathy in these patients. Interventions that reduce these complications may improve outcome.
Extracorporeal membrane oxygenation (ECMO) is a rescue therapy to support severe cardiac and/or pulmonary failure. Both veno-venous (VV) and veno-arterial (VA) ECMO (or extracorporeal life support (ECSL)) are increasingly being used [1–6]. VV ECMO support for severe influenza A (H1N1) pneumonitis was reported during the 2009 pandemic [3, 7–9]. Despite increasing experience with ECMO and recent technical improvements, the mortality of patients receiving ECMO remains high, but varies between centres, patient subgroups and by indication [2, 4, 10–12]. While more randomised controlled trials are needed to define the place of ECMO in critically ill patient management, observational series may provide some useful data on factors associated with mortality and complications.
Outcome of patients on ECMO is influenced not only by factors independent of ECMO (patient illness severity, type of illness, other organ support) but also by the potential complications related to ECMO. Clarification of the impact of key ECMO complications on outcome could inform safer care and improve outcomes. ECMO complications may be mechanical (relating to the ECMO circuit components) or medical [9]. The latter are the most frequent and include bleeding, infection, embolism causing vascular and neurological complications, and limb ischaemia. Haemorrhage and infection are the most frequent adverse events [2, 9, 13–20]. Nonetheless, neurologic complications are probably underestimated and can have devastating consequences on the prognosis [3, 21]. Vascular complications such as amputation may be delayed and also perhaps under-reported. Bloodstream infections during ECMO have been associated with a poor outcome in paediatric patients [17, 22] but the association remains uncertain in adults [15, 19, 23]. Bleeding is another frequent adverse event in these patients who are critical ill, exposed to anticoagulation and susceptible to coagulopathy and platelet dysfunction. The impact of bleeding on prognosis depends in part on how bleeding events are defined and recorded in the studies [2, 9, 24]. Mechanical complications and haemolysis have decreased with the introduction of centrifugal pumps, low-resistance polymethylpentene membranes and modern heparin-coated surfaces.
This study describes the experience of a single ECMO referral centre during a stable period of practice. The aim of this study was also to identify factors that were independently associated with outcome for VV and VA ECMO.
The Alfred Hospital is a university referral hospital in Melbourne (Australia), which provides heart and lung transplantation services for the states of Victoria, South Australia and Tasmania. It is one of two adult trauma centres in Victoria and is the state Burns Centre. The intensive care unit (ICU) is one of the largest Australian ICUs with capacity for 45 beds and more than 2,000 admissions a year. The Alfred ICU operates an ECMO referral service and retrieves patients on ECMO from the southern Australian states.
Data were retrospectively extracted from a prospectively updated local registry of ECMO patients and ICU clinical database. Further clinical details were obtained from retrospective review of patient medical records. This study was approved by the Alfred Health Human Research Ethics Committee and no consent was needed.
Patients over the age of 16 years who received ECMO support between January 2005 and June 2011 were included. Demographics, co-morbidities, hospital and ICU lengths of stay, acute physiology and chronic health evaluation (APACHE II) score and main diagnosis at admission were recorded. The following parameters were collected at ECMO initiation: presence of cardiac arrest, sequential organ failure assessment (SOFA) score [25], plasma lactate level and arterial partial pressure of oxygen to inspired oxygen fraction (PaO2/FiO2) ratio. Days in ICU and days on mechanical ventilation (MV) before ECMO, days on ECMO, and the requirement for catecholamines and renal replacement therapy (RRT) were recorded.
Patient selection, ECMO configurations and routine care
The decision to use ECMO was made by the treating intensive care specialist or cardiac surgeon (for intra-operative cardiac support). Criteria for assessing the need to commence VV ECMO for severe respiratory failure and VA ECMO for severe cardiac failure are listed in Table 1. For respiratory failure, VV ECMO was delivered through percutaneously placed single-stage femoro-femoral cannulae (Medtronic, Minneapolis, MN, USA) under ultrasound guidance with an additional jugular access cannula inserted if required. Double lumen jugular cannulae (Avalon Elite™; Avalon Laboratories, Rancho Dominguez, CA, USA) were used in two patients. Mechanical ventilation settings were not standardised in patients undergoing MV. Our practice generally involved pressure-controlled ventilation with low respiratory rate and maintenance of tidal volume below 6 ml/kg (predicted body weight) and peak pressure below 30 cm H2O. Percutaneous VA ECMO for cardiac support was delivered through peripheral femoro-femoral ECMO cannulae and routinely included an ante-grade 8.5 French distal perfusion cannula (Mayo, Rochester, MN, USA) to prevent limb ischaemia. Central VA ECMO was initiated intra-operatively at the discretion of the managing cardiac surgeon. Management of failing heart was not standardised but low doses of inotropes were administered to maintain pulsatility and some native cardiac output, if these were severely depressed on support. Femoral artery cannulation sites were repaired surgically after decannulation. Continuous renal replacement (Prisma™ and then Prismaflex™; Gambro, Lund, Sweden) was performed via the ECMO circuit. ECMO care was delivered using Rotaflow pumps and Quadrox or PLS membranes with simplified Bioline-coated circuits (Maquet, Rastatt, Germany) without connectors, bridges or venous saturation monitoring. To avoid air emboli, we did not monitor pre-pump pressure and there were no pre-pump circuit access ports. Bedside care was delivered by trained ICU nursing staff with a patient-nurse ratio of 1:1 under the supervision of ECMO-trained intensive care specialists.
Anticoagulation, management of bleeding and circuit changes
Invasive procedures were minimised while on ECMO. Platelet transfusions were given to maintain platelet count > 80,000/mm3. Minimum haemoglobin of 80 g/l was generally targeted, consistent with reported literature [26]. Patients with no active bleeding received heparin targeted to an activated partial thromboplastin time (APTT) of 50 to 70 seconds. Heparin was withheld at the discretion of the intensivist in patients who required surgical procedures or in those who had clinically significant bleeding. Administration of clotting factors, platelets, antifibrinolytics or recombinant factor VIIa for bleeding patients was determined by the intensivist in consultation with a specialist haematologist. Pre and post oxygenator pressures were monitored to detect progressive oxygenator thrombosis. Screening for haemolysis (plasma-free haemoglobin) and fibrinolysis (fibrinogen and D-dimer levels) was performed at least daily. Elective circuit changes were performed if significant trends in fibrinogen decline and D-dimer elevation were observed.
Antibiotic management and microbiological samples
Antibiotic prophylaxis for ECMO was not routine. Patients undergoing open heart surgery were given prophylaxis with cefazolin plus rifampicin or vancomycin plus rifampicin in the operating room in accordance with hospital guidelines. Suspected and/or confirmed sepsis was routinely treated with antibiotics following specimens being taken for culture.
The following complications were recorded: i) haemorrhagic and coagulopathy: surgical interventions for bleeding (recorded prospectively), transfusion requirement: total red blood cell (RBC) units, total of platelets bags, fresh frozen plasma (FFP) and cryoprecipitate issued during ECMO at the Alfred hospital (recorded retrospectively); ii) bloodstream infections: defined using the Centre for Disease Control and Prevention/National Nosocomial Infections Surveillance System criteria [27] and occurring between 48 hours after ECMO initiation and 72 hours after ECMO cessation (recorded retrospectively); iii) neurologic: defined as a cerebral haemorrhage or ischaemia reported on CT scan with no other potential aetiology; iv) vascular: vascular repair, fasciotomy, embolectomy or a limb amputation during or after ECMO (recorded prospectively).
Primary outcomes considered were the proportion of patients successfully weaned from ECMO without bridging support and hospital mortality. When they occurred, deaths were classified as related to the primary illness, ECMO care, or occurring subsequently after weaning from ECMO. Hospital and ICU length of stay (LOS), ICU mortality and the percentage of survivors discharged home after hospital discharge were also recorded.
Statistical analysis
All analyses were performed using Stata 10.0 (College Station, TX, USA). VV and VA ECMO were analysed separately. However, changes over the study period considered all the ECMO episodes in the same analysis. When ECMO was initiated in another centre, only the days at the Alfred hospital were taken into account for the number of RBC units given per day on ECMO. When the mode of ECMO was changed, only the first type was considered for analysis. Categorical variables were compared between groups with a Fisher exact test and continuous variables were compared with a Mann-Whitney U test for non-parametric data. Statistical regression models were constructed based on factors found to be associated with hospital mortality using backwards stepwise regression based on P < 0.02 or factors considered relevant. In the mortality models, data available at the time of starting ECMO were considered in a prognostic model and the effect of complications was considered in a complications model. To avoid interaction between days on support and number of RBC units per day, the number of RBC units transfused has been considered when applicable. When variables were expected to be collinear (for example SOFA score and APACHE II score), only one was included in the model. A two-sided P value of 0.05 was considered to be statistically significant.
Patient characteristics
Between January 2005 and June 2011, there were 9,350 adult admissions to ICU; 151 (1.7%) patients were hospitalised and underwent ECMO support on 158 occasions. Ninety-nine patients underwent 105 VA ECMO for a median duration of 7 days (first and third quartiles: 5 to 10 days), while 52 patients underwent 53 episodes of VV ECMO for a median duration of 10 days (first and third quartiles: 6 to 16 days). The primary indications for ECMO support according to the type of ECMO are described in Figure 1. Forty patients were transferred to the hospital on ECMO, they were mostly on VV ECMO (41% versus 22%, P = 0.002), and in 34 (85%) patients, ECMO was initiated less than 24 hours prior to arrival. Two patients changed modes from VA to VV ECMO. Patients and ECMO characteristics are detailed per type of ECMO in Table 2. In the VA ECMO group, the SOFA score before ECMO initiation was higher in patients with peripheral ECMO than in those with central ECMO (12 (first and third quartiles: 11 to 14) versus 11 (first and third quartiles: 10 to 12.5), P = 0.0225).
Haemorrhagic complications were an issue for most of the patients on VA and VV ECMO and only four of them did not receive a RBC transfusion (one patient on VA ECMO post heart transplant was a Jehovah's Witness, a second had VA ECMO for acute myocardial ischaemia, and two others (one VV and one VA) were on ECMO for less than 48 hours). More than one-third of patients on VA ECMO required surgery for bleeding, while 17% of the patients on VV ECMO underwent surgery for bleeding issues. Surgical details on procedures to achieve haemostasis were not collected. The median number of RBC units transfused per day on ECMO was higher in patients who underwent VA ECMO than VV ECMO (Table 2) and was higher in patients who died regardless the types of ECMO (Tables 3, 4; Figure 2). Central VA ECMO was associated with a higher requirement of blood products than peripheral VA ECMO (17 RBC units (first and third quartiles: 12 to 26) versus 10 RBC units (first and third quartiles: 5 to 24), P = 0.005; and a median of 2.8 RBC units per day (first and third quartiles: 2 to 3.6) versus 2 RBC units per day (first and third quartiles: 1 to 3.3), P = 0.0018). Platelets, FFP and cryoprecipitate transfusion was also consistent, especially in the VA ECMO group, with only four patients who did not received platelets in the group (Table 2).
Bloodstream infections ranked second behind haemorrhagic complications, in both types of ECMO. Of the 146 ECMO episodes that were continued for more than 48 hours, 24 bloodstream infections occurred during 21 ECMO episodes (14.4%). The median delay between ECMO initiation and bloodstream infection occurrence was 8 days (range 2 to 59 days) and the most frequent pathogens were Gram-negative bacilli including Enterobacteriaeceae, Candida sp. and Enterococcus sp. Neurologic complications of ECMO occurred in one patient in each ECMO type group. One patient, who was on heparin and had an international normalised ratio (INR) equal to 2, had a bilateral cerebral hemisphere haemorrhage, the other patient, who also was on heparin, had an intracerebral haematoma with intraventricular extension. Vascular complications occurred in eight patients, all who received VA ECMO (1/43 (2.3%) central and 7/62 (11.2%) peripheral, P = 0.14). The vascular complications were: a false aneurysm (one case), dissection of the femoral artery (one case), ischaemia secondary to delayed insertion of the distal perfusion cannula (two cases), venous thrombosis following surgical repair (one case) and data were not available for three cases. Two patients required a lower limb amputation because of ECMO. One had femoral vein injury and thrombosis following surgical repair of the artery at ECMO decannulation and developed venous infarction, the other did not have backflow cannula and developed arterial ischaemia.
Patient outcomes
Of the 39 patients who died in the VA ECMO group (Table 5), mortality was attributed to the ECMO procedure in six (15%), to other treatment-related complications in 14 (36%) patients and to the primary illness in 19 cases (49%). The factors associated with increased risk of death in the univariate analysis are shown in Table 3. In the multivariate logistic regression analysis, the only factor independently associated with death was the number of RBC units (OR = 1.058, 95% CI 1.016 to 1.102, P = 0.007) (Table 6).
Of the 20 patients who died in the VV ECMO group (Table 5), mortality was attributed to the ECMO procedure in five (25%), to other treatment-related complications in three (15%) patient and to the primary illness in 12 cases (60%) (Table 5). In univariate analysis, the number of RBC units and platelets transfused were associated with mortality (Table 4). In multivariate analysis, only platelet transfusion remained significantly and independently associated with hospital mortality (OR = 1.458, 95% CI 1.087 to 1.955, P = 0.012) (Table 6).
Among the 27 VA ECMO episodes unsuccessfully weaned (25.7%), 16 involved patients who were never weaned from ECMO and 11 involved patients who underwent bridging procedures to transplantation. In univariate analysis, vascular complications were negatively associated with successful weaning, while post-operative VA ECMO had a higher chance to be successfully weaned (Additional file 1). Sixteen patients who underwent VV ECMO were never weaned; the volume of platelets transfused was predictive of unsuccessful weaning (Additional file 1).
Fifty-six percent and 45% of patients were discharged directly home in the VA and the VV ECMO group, respectively, while the others were transferred to another health service, including rehabilitation (Table 5).
Changes over the study period
Trends over time were considered in two periods; from 2005 to 2007 when less than 20 ECMO procedures a year (a total of 59 ECMO) were performed, and from 2008 to 2011 when more than 20 ECMO episodes a year (a total of 99 ECMO) were performed. The proportion of VV ECMO trended to increase (25.4% of all the procedures during the first period versus 38.4% in the second period, P = 0.118). Peripheral ECMO became more frequent than central VA ECMO (22/44 during the first period versus 40/61 during the second period, P = 0.321). Between the first and the second periods, patient aged 44 (first and third quartiles: 30 to 58) years versus 48 (first and third quartiles: 36 to 57) years, P = 0.0869) and patient illness severity (APACHE II (19 (first and third quartiles: 14 to 23) versus 20 (first and third quartiles: 14 to 26), P = 0.292) and SOFA score (12 (first and third quartiles: 11 to 14) versus 11 (first and third quartiles: 10 to 14), P = 0.0661) were not significantly different. There was no difference in the number of RBC units transfused between the first study period (14 (first and third quartiles: 7 to 22) RBC units/episode or 1.8 (first and third quartiles: 0.9 to 3.3) RBC unit per day) and the second study period (12 (first and third quartiles: 5 to 25) RBC units/episode or 1.5 (first and third quartiles: 0.7 to 2.4) RBC unit per day). In addition, the occurrence of vascular (7/59 versus 5/99, P = 0.218), neurological (1/59 versus 1/99 versus, P = 1.0) complications and bloodstream infection (7/53, versus 17/93, P = 0.493) were similar between both study periods. There was also no statistical difference in mortality in the two time periods (40.68% versus 34.34%, P = 0.496).
We report the experience of a large Australian ECMO referral centre over a period of 5 1/2 years. For both types of ECMO, bleeding complications were the most frequent. For VA ECMO, bleeding complications, when expressed by the number of RBC units transfused during ECMO, was an independent factor of mortality. In patients who underwent VV ECMO, volume of platelets transfused was independently associated with hospital mortality.
Around a quarter of ECMO episodes required surgery for haemorrhage, which is similar to the 10 to 30% of haemorrhagic complication reported in the literature [28, 29]. Surgery for haemorrhage was not associated with an increased risk of death while mortality increased with the number of RBC units transfused, suggesting that a readily identifiable and correctable site of bleeding was not as important as ongoing bleeding and transfusion. These results are comparable to previous publications and may also highlight the negative consequences of RBC transfusion in ICU patients [10, 13, 30, 31]. Bleeding complications using alternative definitions have also been associated with poorer outcomes [2, 13, 24, 32]. For instance, in a study in paediatric cardiac surgical patients, bleeding complication defined as 'uncontrolled mediastinal bleeding requiring surgical intervention' was independently predictive of death [24]. Bleeding events also estimated by gastrointestinal or pulmonary haemorrhage still affected the prognosis of 1,473 adults with ECMO [2]. Furthermore, we found that VA ECMO required more RBC units and other blood products than VV ECMO, possibly because half of VA ECMO was instituted in the operating room and intraoperative transfusions were included or because bleeding was a common feature of open chest central VA ECMO. In addition, transfusion policies in specific patient groups differ; for example, the transfusion threshold is higher in cardiac patients with uncorrected ischaemic heart disease. The association between the number of RBC units transfused and mortality in patients who underwent VA ECMO may be related to potential confounders including blood administered in the theatre for post-surgery ECMO. Interestingly transfusion of platelets was associated with a higher risk of death only for VV ECMO. The significance of this association remains uncertain. Platelet transfusion in VA ECMO may be only related to peri-operative haemorrhagic complications, while thrombocytopenia in patients on VV ECMO could be related either to coagulopathy that occurred on ECMO, or illness severity.
Infection ranked second among the complications, with bloodstream infections affecting 13% regardless of the type of ECMO. Our findings are in accordance with the literature reported where the percentage of patients who experienced bloodstream infections varied between 3.4% and 11.4% [14, 17, 19]. The impact of such infection on the outcome is controversial. Some authors highlight that sepsis and nosocomial infections acquired on ECMO increase the risk of death [13, 14] whereas others do not report an independent relationship between infection and mortality [15, 19]. Our findings support that bloodstream infections were not independently associated with an increased risk of death; however, our study may be underpowered to detect such association. Neurologic complications were rare in our series and may have been underestimated because of the difficulty in performing brain imaging procedures and the absence of systematic post mortem determination of intracranial pathology. Neurologic complications are highly variable in terms of incidence (between 4 and 37%). The majority consists of haemorrhage [3, 21]. Vascular complications including leg amputation occurred exclusively in patients undergoing VA ECMO and in the same proportion as those reported by Wang et al. in a cohort of 62 VA ECMO for cardiogenic shock [33]. We found that vascular complications were associated with unsuccessful weaning in univariate analysis. In a cohort of 174 VV and VA ECMO episodes, vascular complications were not associated with mortality [34]. Larger studies are required to evaluate the impact of these complications on the chance of successful weaning.
We found that the lactate level before VA ECMO deployment was associated with poor outcome in univariate analysis but not in multivariate analysis (possibly because of a lack of power). Other studies have described plasma lactate 24 hours or 48 hours after ECMO initiation (as a marker of the adequacy of tissue perfusion) was a good predictor of death [13, 35]. The absence of correlation between PaO2/FiO2 ratio prior to VV ECMO deployment and outcome was not surprising and in accordance with a recent report [2]. In our study, spontaneous cardiac arrest prior to ECMO initiation was not predictive of death. This result is in contrast to other studies, some of which included both before and after ECMO initiation [2, 11, 36]. Finally, for both types of ECMO, the duration of ECMO did not influence mortality in accordance with a previous report [12].
Although no change was significant between both periods of the study, ECMO patients in the second period tended to be older, have a higher severity of illness, whilst mortality tended to decrease.
Strengths and limitations
Our study has several limitations. First, this is a single-centre retrospective study. Nonetheless, ECMO data and patients' characteristics were collected prospectively. Second, although this represents the totality of our experience over more than 5 years, the numbers of ECMO episodes was not high, precluding detailed subgroup analyses, which are likely to be underpowered for some outcomes. Although we did not collect data on haemoglobin levels prior to transfusion, previous work has suggested a high rate of concordance with the National Australian Transfusion Guidelines [37]. Furthermore, the study did not allow us to classify the bleeding complications and to explore the presence of coagulopathy or the anticoagulation characteristics. Similarly, information about oxygenator changes was not available and any correlation between oxygenator exchange and bleeding could not be done. We focused our infections analysis on bloodstream infections, because bloodstream infections have the highest impact on prognosis. Describing all infection types was not the aim of this study and has been already performed [23]. In addition, we were not able to establish correlation between infections and ECMO. Quality of life, really relevant outcome in this population, was not available and we were not able to evaluate long-term disability. Finally, our study did not include 'traditional' complications such as oxygenator failure, pump malfunction, air embolism, haemolysis or tubing rupture. Although current technology, staff training and simplified circuits have greatly reduced or completely removed the impact of these complications [9], the incidence of these complications was not recorded and therefore we were unable to assess their impact.
In conclusion, ECMO implemented in a referral centre is a useful supportive therapy for temporary life-threatening cardiac and/or respiratory failure. Among the pre-ECMO parameters and the ECMO complications, the number of RBC units was independently associated with the mortality of patients on VA ECMO, while the volume of platelets transfused was associated with the risk of death in patients with VV ECMO. Our work supports the need to further explore prospectively the association between bleeding, blood products transfusion and mortality in patients with VV ECMO and VA ECMO.
Key messages
Bleeding is the most frequent issue in patients undergoing ECMO.
Our study identified the volume of blood transfusion during ECMO, surrogate of bleeding, as an independent risk factor of mortality for VA ECMO.
Platelet volume requirement in patients undergoing VV ECMO is an independent risk factor of death suggesting that coagulopathy in these patient group impacts on the outcome.
Further studies identifying bleeding risk factors and coagulopathy management should occur to improve ECMO management and prognostic.
acute physiology and chronic health evaluation
activated partial thromboplastin time
extracorporeal life support
extracorporeal membrane oxygenation
fresh frozen plasma
intensive care unit
international normalised ratio
length of stay
mechanical ventilation
- PaO2/FiO2:
arterial partial pressure of oxygen to inspired oxygen fraction ratio
- RBC unit:
red blood cell unit
renal replacement therapy
sequential organ failure assessment
veno-arterial ECMO
veno-venous ECMO.
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Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Bréchot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A: Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 2013, 39: 838-846. 10.1007/s00134-012-2785-8
Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM: CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988, 16: 128-140. 10.1016/0196-6553(88)90053-3
Bartlett RH, Gattinoni L: Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol 2010, 76: 534-540.
Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH: Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 2004, 240: 595-605. discussion 605-607
Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999, 340: 409-417. 10.1056/NEJM199902113400601
Marik PE, Corwin HL: Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 2008, 36: 2667-2674. 10.1097/CCM.0b013e3181844677
Kasirajan V, Smedira NG, McCarthy JF, Casselman F, Boparai N, McCarthy PM: Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg 1999, 15: 508-514. 10.1016/S1010-7940(99)00061-5
Wang J, Han J, Jia Y, Zeng W, Shi J, Hou X, Meng X: Early and intermediate results of rescue extracorporeal membrane oxygenation in adult cardiogenic shock. Ann Thorac Surg 2009, 88: 1897-1903. 10.1016/j.athoracsur.2009.08.009
Bisdas T, Beutel G, Warnecke G, Hoeper MM, Kuehn C, Haverich A, Teebken OE: Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg 2011, 92: 626-631. 10.1016/j.athoracsur.2011.02.018
Kolovos NS, Bratton SL, Moler FW, Bove EL, Ohye RG, Bartlett RH, Kulik TJ: Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg 2003, 76: 1435-1441. discussion 1441-1442 10.1016/S0003-4975(03)00898-1
Thiagarajan RR, Brogan TV, Scheurer MA, Laussen PC, Rycus PT, Bratton SL: Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults. Ann Thorac Surg 2009, 87: 778-785. 10.1016/j.athoracsur.2008.12.079
Investigators TBOS: Transfusion practice and guidelines in Australian and New Zealand intensive care units. Intensive Care Med 2010, 36: 1138-1146.
Cecile Aubron received an Alfred Intensive Care Department-Monash University research fellowship. Allen Cheng was supported by a National Health and Medical Research Council Career Development Fellowship. D Jamie Cooper was supported by an NHMRC Practitioner Fellowship.
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The authors declare they have no competing interests.
Authors' contributions
VP maintained prospectively the ECMO registry and DP maintained the ICU clinical database. CA collected clinical and biological data not available in the original databases and built a unique database. CA and AC performed the statistical analysis. CA, AC, DP and VP analysed the results. CA, AC, DP and VP wrote the manuscript. TL, CS, JC, GM helped to draft the manuscript. All authors revised and approved the final version of the manuscript.
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Additional file 1: Variables associated with successful weaning from veno-venous extracorporeal membrane oxygenation (VV ECMO) and veno-arterial (VA) ECMO (univariate analysis). (DOCX 17 KB)
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Aubron, C., Cheng, A.C., Pilcher, D. et al. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care 17, R73 (2013). https://doi.org/10.1186/cc12681
DOI: https://doi.org/10.1186/cc12681


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Classics Illustrated Vol. 14: Wuthering Heights
Rick Geary adapts Emily Bronte's masterpiece! Bronte's romantic classic established the quintessentially dark, brooding antihero in the form of Heathcliff. Heavily influenced by the poet Lord Byron, the beautiful flow of her words is matched by Rick Geary's art in this comics adaptation. Eisner Award-winner Geary's comics work in historical fiction is unparalleled, from his earlier Classics Illustrated adaptations to his exceptional graphic novel series A Treasury of Victorian Murder and A Treasury of 20th Century Murder.
Cover Illustrator

subset: commoncrawl


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Industry analysts predict that storage will grow 35% per year for the next several years and network traffic will grow by 33%. LSI is uniquely positioned to address this rising flood of data. We design semiconductors and software that accelerate storage and networking in datacenters and mobile networks. Our technology is the intelligence critical to enhanced application performance, and is applied in solutions created in collaboration with our partners.
URL: http://www.lsi.com


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Most Popular Hair Styles for Men
- By: Lordhair Team
If you are trying a new hairstyle to change up your look, you must not miss these fashionable styles.
Fade hairstyles have been quite popular in recent years. The fade hairstyle comes in multiple forms, like low cut, mid cut and high cut, etc. The fade also is a part of the pompadour and undercut hairstyles – long hair on top and fades on the sides. You can choose the length of the hair according to your personal preference and style it freely.
Pompadour is a very classic Rock star style, think Elvis Presley. It has short on the back and sides and long hair on the top. If you Comb the hair in the front backward, the high volume hair in front will stand high, and then gradually recede towards the back.
The undercut style features shaved short hair on the sides and long hair on the top. Whether your hair is straight, wavy, curly or Afro, you can try the undercut style. You can comb the hair on top backward, sideward or even spike it up.
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Main opposition Republican People's Party (CHP) Chairman Kemal Kiliçdaroglu gave his blessing to the ongoing Turkish intervention in Syria to clear Jarabulus and the border of radical elements, saying his party would support the military until the end.
"Our army has now entered Jarabulus. We will support it to the end," Kiliçdaroglu was quoted as saying by the official Anadolu news agency. "I hope our soldiers will return home unharmed."
The CHP has expressed support for the military intervention against the terrorist Islamic State in Iraq and the Levant (ISIL) in northern Syria across the Turkish border.
Party spokesperson Selin Sayek Böke said on Wednesday after the operation was launched that Turkey has paid a huge price, losing the lives of innocent civilians at home for inaction against the radical extremism that threatens national security. She said Turkey must continue its fight against extremists both at home and abroad.
The CHP had long been critical of the Justice and Development Party (AK Party) government's Syria policies and strongly opposed its open border policy. The opposition party believed that the policy facilitated the crossing of militants into Syria.
According to the party, a series of bomb attacks that targeted Turkey in 2015 and 2016 are the consequences of Ankara's own crumbling Syria policy. But with the intervention in Jarabulus, the party has set aside its differing policy views over Syria and declared unwavering support for the military move against jihadist elements that threaten the country across the Turkish-Syrian border.


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Dear Canada Bound:
Congratulations on your acceptance at Dalhousie University! Also, we would like to thank you for
your kind comments about our portal.
You must at once initiate the visa process with the Canadian High Commission, if you have not
already done so. The visa process should not take 3 months, unless there are complications.
The Canadian High Commission is fully aware of when the academic session begins. To avoid
complications, you must ensure that your application is complete with all supporting
documentation. The most common reason for complications is the evidence of financial resources
to sustain oneself through one�s stay in Canada. Make sure that you have good documentary
evidence for financial means.
Although the classes may begin on September 4, the late registration process continues 2 weeks
past the start date. Although you would miss 2 weeks of classes, you would still be allowed to join
the program. If you really are pressed for time, you can have Dalhousie University send you a
letter of extension in which the absolute deadline for arrival would be the same as the last day of
late registration. Good luck!


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'Killer' mom's lone surviving kid details bloody rampage
A mother accused of fatally stabbing her husband and four children in Georgia told caseworkers she felt a "devil-like spirit" during a family trip prior to the alleged killings, according to a state child welfare report.
The report by the state's Division of Family and Children Services, obtained by the Atlanta Journal-Constitution, includes an interview with Isabel Martinez, 33, who claimed she felt the "devil-like spirit" during a trip to Savannah, where she felt waves trying to take her and her children away.
Martinez also told DFCS caseworkers that she was innocent and claimed a "family friend" committed the gruesome killings on July 6 at the family's home in Loganville. Martinez even tried to stop the friend, but he cut her on her wrist, according to the report, which also contains an account from the lone survivor in the home, Martinez's 9-year-old old daughter, Diana Romero, who was seriously injured.
Diana told caseworkers she saw Martinez stabbing the rest of her family and said she was "going to the sky to see Jesus" before attacking her. The girl replied that she didn't want to see Jesus and reported that her father tried to stop Martinez but was unable to do so.
Read more on FOX NEWS.


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Recently Visited Pages
Take advantage of this at-a-glance look at the pages on the SCC website you most often visit. Use this as a tool to navigate quickly to info you need the most. Take it one step further and click the star in the top right corner to ensure your favorite pages remain on your list of Visited Pages.
Rights & Responsibilities
Need Assistance?
If in immediate danger, call 911 or DPS/Campus Police. Campus phone: Ext. 8545 Cell phone: 636-922-8545 For immediate 24/7 assistance related to a sexual assault, call the Bridgeway 24-hour crisis lines: If you are in St. Charles County, call 1-877-946-6854 or 636-946-6854. If you are in Lincoln County, call 1-877-462-1758. If you are outside St. Charles County, call the RAINN at 1-800-656-HOPE (4673) or visit rainn.org.
Whether you are a reporting party or a responding party, you have rights.
Rights of Involved Parties in Cases Involving Allegations of Sexual Harassment and Sexual Violence
The following rights, procedures, and guidelines apply in cases involving allegations of sexual harassment and sexual violence.
- The opportunity to have an advisor of the individual's choosing present during any investigative and/or disciplinary meetings. The role of the advisor is solely to support the individual. The advisor is not permitted to ask or answer questions, serve as a witness, or make a statement on behalf of the complainant or accused. The College is not responsible for providing an advisor.
- The right of the reporting party or the responding party to receive timely notice of meetings in which they are a participant.
- Subject to applicable law, the right to receive timely and equal access to any information relied on as part of the investigation/disciplinary procedures.
- Equal opportunity to provide information through the investigation/disciplinary procedures
- The reporting party and responding party will not be permitted to directly question each other.
- Each party will be granted the same meaningful access to information that will be used during disciplinary meetings including the investigation report.
- Each party will be granted the opportunity to respond to the investigation report in writing in advance of the decision of responsibility.
- If the investigation/disciplinary procedures result from a report of sexual harassment, both the reporting party and the responding party will be notified in writing of the finding of responsible/not responsible and the disciplinary sanction(s) imposed. The reporting party will only be notified of those that directly relate to the reporting party, like an order that the responding party stay away from the reporting party, and the right to appeal.
- If the investigation/disciplinary procedures result from a report of sexual violence, both the reporting party and the responding party will be simultaneously notified in writing of the finding of responsible/not responsible and the disciplinary sanction(s) imposed, the right to appeal, any changes to the result of investigation/disciplinary procedures, and when such results become final.
Other Responsible Parties
Ensuring that SCC is free of sexual misconduct is a shared responsibility of all members of the College community. A person does not have to be the direct target or victim of the sexual misconduct to report it. This policy covers conduct occurring on property owned or operated by the College, at College-sanctioned functions, and may also apply to off-campus conduct that adversely affects the campus environment. As such, conduct that occurs off-campus may violate this policy and should be reported.
If employee sexual misconduct is observed by, or reported to a College official (administrators, managers, and supervisors), then that official has the duty to immediately report the matter. If student sexual misconduct is observed by, or reported to any employee who could be reasonably perceived to have authority or duty to report or address these issues (administrator, manager, supervisor, faculty member, dean, coach, Athletic Director, academic counselor/advisor, club advisor, law enforcement or public safety officer, or Student Life Director), then that official has the duty to immediately report the matter. The fact that the alleged victim does not wish to file a complaint does not relieve the official of this responsibility.
If sexual misconduct of any kind is observed by or reported to an employee not listed above, that employee should report the matter. No employee or representative of the College, except for the Mental Health Counselor, can or should promise confidentiality.
While all reports of sexual misconduct, other than those made to the mental health counselor, must be shared with the Title IX Coordinator, such reports should be treated as confidential and shared only with persons who have a business need to know due to their involvement in the investigation/disciplinary procedures related to the individual and their involvement in delivering resources or support services to involved parties.
Bystanders play a critical role in the prevention of sexual and relationship violence. They are "individuals who observe violence or witness the conditions that perpetuate violence. They are not directly involved but have the choice to intervene, speak up or do something about it." We want to promote a culture of community accountability where bystanders are actively engaged in the prevention of violence without causing further harm. We may not always know what to do even if we want to help. Below is a list of some ways to be an active bystander.
- Watch out for your friends and fellow students/employees. If you see someone who looks like they could be in trouble or need help, ask if they are okay.
- Confront people who seclude, hit on, and try to make out with or have sex with people who are incapacitated.
- Speak up when someone discusses plans to take sexual advantage of another person.
- Believe someone who discloses sexual assault, abusive behavior or experience with stalking.
- Refer people to on- or off-campus resources listed in this document for support in health, counseling or with legal assistance.
If you or someone else is in immediate danger, dial 911. This could be when a person is yelling at or being physically abusive towards another and it is not safe for you to interrupt.
Attend a Step UP! bystander intervention program to learn how to be proactive in helping others. Step UP! training will prepare you to identify a situation as a problem and to intervene safely, thereby reducing the outcomes of problematic behaviors. SCC offers several sessions throughout the year.
Strategies for Effective Helping – There are a number of strategies you can use for effective helping in emergency and non-emergency situations (stepupprogram.org).
Help Someone You Care About – What to do if someone tells you they've been sexually assaulted (rainn.org).
Board Policy Statement
The College prohibits any actions of sexual harassment by students, employees, or visitors. The College adheres to Title IX of the Education Amendments of 1972, Violence Against Women Act (VAWA), Title VII of the Civil Rights Act, Jeanne Clery Act, and similar laws and regulations and takes appropriate action to address concerns of sexual harassment in a fair and timely manner.
Employee Title IX |


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26-Year-Old Rapper FBG Duck Died in a Drive-By Shooting in Chicago
Aug. 4 2020, Updated 9:27 p.m. ET
Today, it was reported that 26-year-old rapper FBG Duck (Charlton D Weekly) passed away. According to sources, he was shot to death in Chicago, Illinois in a drive-by shooting.
During a press conference, Deputy Chief for the Chicago Police Department, Daniel O'Shea, announced that three people in total were killed. "At approximately 16:37 hours today, right here in the 100 block of East Oak Street, we had three individuals shopping. Two vehicles pulled up. Four individuals exited those vehicles, two from each vehicle, and began firing at the individuals that were on the sidewalk outside of one of the stores here. They also struck a female that was in one of the vehicles, which was also parked outside one of the stores here."
Who killed FBG Duck?
Currently, we don't know who killed FBG Duck. Chicago's local CBS 2 station featured a witness who said some kind of altercation happened and it led to gunfire. The witness said one man ran toward Michigan Avenue, and after that, more shots were fired. It's unclear who was involved right now, but Twitter is demanding to know. Currently, there's footage of the crime scene from a witness (we're choosing not to share it, since the clip contains disturbing material).
Ja'Mal Green, a former Chicago mayoral candidate, tweeted his dissatisfaction with how the crime scene was handled. He initially wrote, "Popular rapper FBG Duck has just been pronounced dead after being shot in the Gold Coast an hour ago. Prayers up for his family, bring justice to them after this senseless act."
Green additionally tweeted, "I'm super questioning how long it took for the ambulance to arrive on scene. Someone on the scene, please dm me and tell me how long you were there before paramedics arrived. I saw way too many videos of Officers scared to approach and not enough paramedics there to help!"
He added, "Police neglected to offer basic medical aid to FBG Duck and I'm sure their excuse is going to be "Covid". He laid there needing help and it took way too long for him to get help. How many black men and women die because of time everyday after being shot? SICKENING!"
A Twitter user agreed, writing, "Black rapper in the Gold Coast, or better yet black man. No rush needed. Sadly."
Another Twitter user, who assumably saw the video, wrote, "It's crazy how the police didn't even do basic first aid like not even applying pressure to the wound in order to prevent blood loss."
Some Twitter users have pointed out that not only is Chicago losing a legend, but a young girl is losing her father. Although FBG Duck was fairly private about his personal life, from time to time he posted photos from his everyday life, like this one of his little girl. "My Baby Girl Getting Big On Me Daddy Love You With Every Bone & My Body," he captioned the photo posted on April 12.
Rest in power, FBG Duck.


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Superheroes come in many different guises, be it Superman, Batman, Cat Woman, Wonder Woman, or Spiderman, but one of the most recent and most humourous superheroes to grace our screens has to be Deadpool. The huge success of the film has made this go mainstream, and you can bet your bottom dollar that this Halloween there will be several Deadpools out on the loose around parties and streets that particular night!
Of course, dressing as Deadpool is going to require a certain amount of patience, especially when trying to go to the toilet! This is a full body, spandex outfit, with a mask, and it is certainly skin tight, so don't expect much in the way of forgiveness! The plus point however is that you will get everything you need when you buy the costume as a package, so no need to put it together yourself. If you want to add accessories, which may or may not be included, then really all you need is the sword holster, to give it a bit of extra authenticity oomph. Of course, if you feel a little suffocated, you don't have to wear the mask, but it really would ruin the look.
Deadpool himself is played by Ryan Reynolds, and is actually a character called Wade Wilson. Wilson works for the Special Forces and he is captured by evil scientist Ajax, who turns him into Deadpool after a series of experiments. What is left is a hugely funny hero with accelerated healing powers. You can certainly have some fun with this outfit, studying the moves and one-liners beforehand and putting them into action on the night as you transform yourself into Deadpool himself – ideal party fodder!
Of course, children can dress up as Deadpool too, and there are adult and child costumes available for purchase.
Deadpool is a costume that is really designed to make people laugh, rather than scare people, and that is great for door to door trick or treating too, because you will have your residents in stitches as they laugh at you – hey, they might even give you an extra treat as a result! Kids will certainly pull this role off well too, grabbing more than a few laughs. Halloween doesn't have to be scary all the time!


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Restrictions on people's movements during the various COVID-19-related lockdown stages last year appear not to have helped reduce the number of murders on South Africa's farms and smallholdings.
In fact, according to statistics collected by TAU SA, 71 of these murders occurred nationwide in 2020, or a 26,8% increase on the 56 murders on farms and smallholdings during 2019 (2018: 54).
According to Chris van Zyl, TAU SA's assistant general manager, the organisation defined farm attacks and farm murders as acts of violence against residents and workers on, and visitors to, farms and smallholdings.
TAU SA said in a statement that the organisation collected its data on these attacks and murders from a range of direct and indirect sources, and aimed to verify the accuracy as far as possible.
Its latest statistics showed that the 71 farm murders that the organisation recorded in 2020, occurred in 397 farm attacks during the same year (2019: 419).
Victims of these murders reportedly comprised 44 farmers, 13 spouses or other direct family members of farmers, nine workers, and five visitors.
Breaking down last year's farm attacks and farm murders by province, the statistics revealed that Gauteng had 16 murders in 101 attacks (one murder per 6,3 attacks); KwaZulu-Natal had 15 murders in 33 attacks (one murder per 2,2 attacks); the Free State had 10 murders in 50 attacks (one murder per five attacks); Mpumalanga had eight murders in 45 attacks (one murder per 5,6 attacks); and the Eastern Cape had eight murders in 19 attacks (one murder per 2,4 attacks).
In Limpopo there had been seven murders in 56 attacks (one murder per eight attacks); the Western Cape had four murders in 22 attacks (one murder per 5,5 attacks); the Northern Cape had three murders in eight attacks (one murder per 2,7 attacks); and North West had zero murders in 63 attacks.
In a late December 2020 statement, Free State Agriculture expressed great concern about the escalation in the province's farm attacks and farm murders during the period 1 April 2020 to 30 November 2020.
Free State Agriculture's safety risk analyst, Dr Jane Buys, said the organisation had recorded nine farm murders in 53 attacks across the province during this eight-month period. Over the same period in 2019, Free State Agriculture recorded six farm murders in 34 farm attacks.
"It is important that farmers empower themselves, their families and workers, and reduce their vulnerability as far as possible by always being vigilant. It is extremely important that farmers form part of organised security structures in their area," said Free State Agriculture's regional representative, Jacobus Stroebel.


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I am unable to access my sandbox instance properly as I am interrupted by the errors. I think it has to do something with recipient schema.
we are facing the following error while updating the database structure. along with circular dependency error.
We are also getting the following error while trying to view the structure of Schema: The graphical component 'schemaview5' has generated an error.
Could you please suggest the next steps of how to proceed / any ideas as of how to revert the schema back to original.
Kindly respond soon.
Best Regards,
Sai Mohan


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Canarian Egyptian Vultures
The Canarian Egyptian Vultures (Neophron percnopterus majorensis), or Guirre, is a large bird in the Gypaetinae subfamily of the Accipitridae.
It is an Egyptian Vulture subspecies that is endemic to the eastern Canary archipelago, in Macaronesia in the North Atlantic Ocean, where it is a scarce and endangered non-migratory resident.
There are three recognised subspecies of the Egyptian Vulture:
- N. p. percnopterus, the nominate subspecies, has the largest range, occurring in southern Europe, northern Africa (including the Cape Verde islands), the Middle East, Central Asia, and the north-west of the Indian subcontinent
- N. p. ginginianus, the smallest subspecies, occurs in most of the Indian subcontinent
- N. p. majorensis, by far the most restricted, is found only in the Canary Islands and was described in 2002 after data from mitochondrial DNA sequencing supported the hypothesis that Egyptian Vultures in the Canary Islands form a genetically as well as an ecologically isolated population. The trinomial "majorensis" comes from the ancient name of the island of Fuerteventura, "Majorata", in turn derived from its main tribe of native Guanches, called "Majos" by their Spanish conquerors in the 15th century.
The Canarian Egyptian Vulture is larger than the other subspecies, averaging about 2.4 kg in weight, some 18% heavier than vultures of the nominate subspecies from Iberia.
Adults are mainly white in plumage, with black primary feathers, but often show varying amounts of rufous colouration, especially on the breast, crown, nape, median wing coverts, and tail, from iron compounds in the local soils. The face is bare of feathers with yellow skin. The tail is diamond-shaped.
Distribution and habitat
The Canarian Egyptian Vulture was historically common, occurring on the islands of La Gomera, Tenerife, Gran Canaria, Fuerteventura, and Lanzarote.
Now it is restricted to Fuerteventura and Lanzarote, the two easternmost islands.
The total population was estimated in 2000 to comprise about 130 individuals, including 25–30 breeding pairs. It inhabits open, arid, and rugged landscapes.
The Canarian Egyptian Vulture generally nests on cliffs and in caves and crevices. The nests are located in breeding territories, of which there are about 27 that are active, 25 in Fuerteventura and 2 in Lanzarote, with the nests normally being reused every year. Sometimes other nest sites are used in the same territory. Rarely do the birds nest on the ground.
The Canarian Egyptian Vulture is a scavenger and carrion eater.
Status and conservation
Having undergone a major decline, leaving only a tiny relict population, the Canarian Egyptian Vulture is considered to be highly endangered. Threats to the birds include death from electrocution and collision with powerlines, illegal poisoning, and lead intoxication from ingesting bullets.
In 1998–2000 breeding success was very low, with only about 0.5 fledglings produced for each pair; theft of eggs and young from the nest, as well as other forms of disturbance by humans, may account for cases of breeding failure.
Conservation actions being taken or planned include measures to mitigate powerline mortality, increased surveillance of nesting areas, and public education. The further planned action is the creation of middens, or "vulture restaurants", with the cooperation of local livestock breeders, for the birds to find supplementary food.


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To order Gill™ Mask PRO products, visit here.


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Spiritus Hermeticum: part six
An investigation of the origins of Hermeticism and the true teachings of Hermes Trismegistus
In the first two parts of this 12-part investigation we discussed the origins of Hermeticism, the Greek and Egyptian conceptions of the God variously known as Thoth, Theuth, Tat, and Tahuti, and the origins and extent of the Corpus Hermeticum. This was followed in parts three, four and five by an examination of the actual teachings of Hermes as they have come down to us in the various Hermetic texts. In this part we delve into a portion of the Corpus Hermeticum called the Asclepios. Our principal aim, as we have explained from the beginning, is to uncover the original truths the man Hermes taught to his disciples, and to distinguish these without fail from the half-truths and speculations grafted onto them over the centuries.
In the afterwords accompanying this investigation we are meticulously dissecting the so-called Emerald Tablets of Thoth the Atlantean written by the 20th century occultist—Dr Maurice Doreal. In this afterword we continue our examination of the tablets themselves. If you have not read the previous parts now is the time to do so, for this investigation forms an ascending scale of revelation which cannot be understood by skimming through individual articles in a haphazard and piecemeal manner.
A Treatise on Initiations or Asclepios
We ended our previous discussion by telling you about the Net of temptation and its dangers. Although you won't find any mention of this mysterious 'net' in the Corpus Hermeticum we are in no doubt that it is a genuine teaching of Hermes since without it the doctrine of Regeneration discussed in part four and concluded in part five loses much if not all of its rationale. How can we be 'regenerated' if we are still tormented by the vices of ignorance, avarice, guile, anger, doubt and rashness the teacher enumerates in the dialogue with his pupil we re-constructed for you in part four? We are all tempted by the hooks, cords and weights of the Net, every minute of every day, but we are not all equally tempted. That is to say, certain types of souls (Higher Minds in our terminology) are more tempted than others or are tempted by different allurements because they have an innate attraction to them. In order to explain why this is, we turn now to that portion of the Corpus Hermeticum titled 'A Treatise on Initiations or Asclepios,' which you can find in Kingsford and Maitland's translation of The Virgin of the World. An e-text of this is available at the Internet Sacred Text Archive.
Before we examine this text it is important to point out that in the form we have it today it is most certainly not a 'Treatise on Initiations.' As we have seen in the previous parts of this investigation, the true teachings of Hermes are mixed up with many errors in the Corpus Hermeticum. The book known as the Asclepios—named after the Greek God of Healing—is no exception to this. The first error we encounter appears in the very first paragraph which reads: "It is a God who hath brought thee to us, Asclepios, that thou mayst assist at a divine discourse, and one which will be the most truly religious of all we have as yet held, or with which we have been inspired from on high."
Throughout this investigation we have repeatedly drawn your attention to the fact that there are two 'Hermes'—not one. The human teacher known as Hermes or Hermes Trismegistus and the God Thoth—the Divine Shepherd of Man—whom we told you about in part five. So what this passage really means is that the God Thoth—not the man Hermes—has made himself visible to Asclepios, because the latter was worthy and ready to behold Truth. So Thoth tells Asclepios to fetch Thoth's Son, Tat, so that he too can listen to his father's words. Asclepios then asks that Ammon might also be summoned, and Thoth replies that in view of the many explanatory writings he had in the past addressed to Ammon, that he also might attend. But, he adds, no more should be added to the audience, for the discussions will be so holy that it would be an impiety to make them known to many listeners, and the Teachings would thus be profaned. Thus, the four came together and the place was made holy by their pious awe and was filled with God's Presence. If we are to understand what follows we must also keep in mind that these four 'men' are Gods too according to the Egyptian belief, for their discourse does not take place on Earth but in a higher realm of being.
Thoth first reminds his listeners that although all human souls are immortal, they are not all of one kind. Different souls have been created in different ways, for souls differ in quality. But, all things are One just the same, for all things were in the Creator before He created them all. Thus, all things are part of Him, for He is the One who is all things. Please note that whenever 'souls' are mentioned it is what we call the Higher Mind or Self which is generally meant and not the Divine Soul discussed in our occult studies course article of the same name which, those of you who have taken the course will remember, never incarnates in a body of any kind at any time.
Thoth next tells his listeners that everything on Earth is derived from heaven. Air enters into earth and water, and fire enters into air. That which tends upward is life-giving; and that which tends downwards is subservient to it. Moreover, all that descends from on high is generative; and that which issues upward from below is nutritive. The experienced occultists among our readers may object at this point that all this is blindingly obvious so far as Gods are concerned who must surely be expected to know all the Laws of the Universe already. They would be right of course, but the Corpus Hermeticum was not written for the instruction of Gods but men; albeit not your average self-important, intellectual whose mind is firmly glued to the material plane, or even the average mystic or occultist, but those whose Minds have received the One Light of Truth and are therefore ready for this Wisdom. In saying this we may seem to contradicting what we told you earlier when we said the book was not a 'Treatise on Initiations,' but this is not so in reality, for there is an important distinction between being capable of beholding the Light and actually being initiated into the Mysteries by a qualified Master, as we discussed in our article on Initiates and Initiation.
We do not know who wrote this part of the Asclepios, but, as you will see as we proceed, it must have been someone who had access to fragments of the ancient Egyptian Mystery Teachings (if we may call them that), and was also possessed of the necessary insight and education to grasp some of the meanings of the scraps at his disposal. But his guesses were not always right, nor were his sources of information always reliable and true. All this is by way of introduction to the Asclepios itself, which contains some really fine material, excellently presented, as far as may be. So Thoth goes on, explaining the Universal Hermetic Laws to his auditors. He reminds them that the Earth alone stands fast in its own place (a teaching the real Thoth would never have promulgated as it is patently untrue), and that this Earth receives all that is generative into itself (which is true), and renders back all that it has received (also true).
One serious error seems to be that the Universe is regarded in the way we regard our Solar System, and that the One God of the Universe has Himself formed all things and beings within that Universe. As many of you will know this is quite wrong, for each Solar System, be it large or small, has its own Builder and Architects in the plural as we find described in The Secret Doctrine, The Golden Star and other books written by the genuine occultists, for there are uncountable numbers of solar systems in our own Universe alone as our telescopes reveal to us. But that all has ultimately sprung, or come forth from the Supreme Deity of the Universe is true. We must try to keep apart and separate these two conceptions of Universe and solar system, or we shall get into the same hopeless muddle as the ancient writers who compiled and translated the Corpus Hermeticum and the equally confused modern commentators upon it.
We will now quote directly from Kingsford and Maitland's translation of the text under discussion, for we want you to know the exact wording, so that you may reach your own conclusions about which parts are true and which are not without our help. Here it is; Hermes says to the three Gods or men, attending: "HEAVEN—God manifest—regulates all bodies. Their growth and their decline are determined by the sun and the moon. But He who directs heaven—the soul itself and all that exists in the world—is very God, the Creator." You will note that 'God' is not specified in this teaching. The writer speaks as if there were only One God who did everything by himself. But occult science teaches us that this is impossible. There are great hierarchies of Angels and other Ministers of God who all have to do their share in the government of our Solar System as we told you in our occult studies course. If by God the writer means the Supreme Deity of the Universe, this passage becomes still less true for the reasons we stated earlier.
Body, Mind and Soul
Later on in the Asclepios we encounter a passage which may well have given rise to the silly New Age nonsense of 'Group-Souls.' This reads: "Everything is in accordance with the designs of God; but that which originates from on high has been separated into individualities in the following manner. The types of all things follow their (representative) individualities in such way that the type is a whole; the individual is a part of the type." This is entirely wrong, for though we may belong, together with many others, to one of the Seven Rays of occult science described and explained in The Golden Star and The Secret Doctrine, each of us has his own, individual path to follow, and no two Souls, nor any multitude of them, form any sort of 'Group'. The writer continues: "Thus the Gods constitute a type, the genii also. Similarly, men, birds, and all beings which the world contains, constitute types producing individuals resembling them." This is all very well so far as it goes always provided we put the stress on the word individuals; if not—we get into a further muddle.
However, the teaching that all created beings are dependent on the Powers which created them and each individual creature is part of his own kind and they in turn generate others of the same nature as themselves by means of the powers the Gods have placed within their bodies is correct in every way. We must include all forms of plants that grow in water and on the land, for these too have individual forms and cannot produce anything else in their offspring, unless interfered with in the way of cross-breeding or genetic modification. All these beings can evolve, and do so, but occult science affirms that no creature of any sort can devolve. That is to say, it cannot return to a more primitive form of life which it inhabited earlier in its evolutionary progress. A bird, for instance, as an eternal individual being, cannot become a bacterium, having the bacterium's form as a living cloak to cover its inner self. All creatures can stand still in their development, but none can go backwards as we discuss in our occult studies course article about material and spiritual evolution.
However, the higher evolved individual can help onwards the lower, as in the case of Prometheus and his Brother Epimetheus whom we told you about when we analysed Shelley's immortal poem Prometheus Unbound. In fact, it is the duty of all to help forward those who are backward in any way; this is the work of the god-like man or woman. But though a demon can entice a Higher Mind into Hell as we learned in the story of the Jihadi and the Jinn, the deluded fanatic or evildoer may still progress upwards, though his sufferings and struggles will be very great indeed. But it is only Man who can lead onwards the lesser ones. This applies to animals too, by means of our kindness to them. Hence, a man should raise reverent eyes to heaven; tend the earth and all his duties, without running away from them at the least difficulty or setback; love all the forms below himself, even if they reject that love. In this way he is beloved of those Gods and Higher Beings which dwell in the Heavens and behold his works, his words, and his thoughts. The man who neglects his duties is doomed and judged by these same great Beings, and is compelled to reincarnate on Earth to 'enjoy' the manifold delights of further slavery after his present body perishes.
The foregoing is our own corrected version of part of the address to Asclepios by Thoth, but the next part is such a hopeless mess of contradictions and misstatements that we think it best to pick out the most important parts only. For instance, the lower self is here called 'soul', which, it is said, animals have, apart from a body. At the same time these beings are also called 'soulless'! Their 'soul' (which, at the same time they don't have!) is nourished by fire and air; their body by water and earth, which are here called the 'lower elements'. But 'Mind', which is bestowed on man only, namely the Higher Mind as we term it, is never the property of other beings, below man; and this part of the address is quite correct of course. It is by means of that 'Mind' that man can attain to a knowledge of God, and the truth concerning Him. But this is not altogether correct, for at best man can only partially apprehend God, and it is only the highest and most evolved of men and women who can have such an apprehension.
It is further stated that "For man alone is a dual creature. One of the two parts of which he consists is single, and, as the Greeks say, essential; that is, formed after the divine likeness. The part which the Greeks call Kosmic—that is, belonging to the world—is quadruple, and constitutes the body, which, in man, serves as an envelope to the divine principle. This divine principle, and that which belongs to it, the perceptions of the pure intelligence, conceal themselves behind the rampart of the body." This adds up to five principles or components (four plus one), and is mainly wrong. Man, as we point out in several of our articles, is a septenary being which we and others simplify into three parts, consisting of Soul, Higher Mind and lower mind or body. From this it is clear that the writer or writers were ignorant of the true principles of man. Hence they had no idea how to connect the fragments which had been collected together, and consequently were at a complete loss to understand them fully. And that—as we have said so often in this investigation—is the danger of all such works—both ancient and modern.
The next part deals with the reasons why God made man and sent him to Earth. As this is mostly speculation and fantasy we will pass it by. Near-truths are more dangerous than direct lies as we have also said so often before. In short, the book is a mixture of truth and speculation, and this is harder to fully understand than mere speculation by itself. Many minds have come together to produce the Asclepios, and the result is confusion and chaos, as it always must be when the many speculate upon that which is beyond their wit.
We are now told of a certain Law, as taught by Hermes, in which we are informed that: "Gross matter is the nutriment of bodies, and spirit is the nutriment of souls," meaning lower minds in this instance. "But besides these there is mind [Higher Mind], which is a gift from heaven, and one with which mankind alone are blessed—not indeed all men, but those few whose souls [lower minds] are of such quality as to be capable of receiving so great a boon." The interpolations in parenthesis are ours. This is indeed startling, as you will agree, and we fear that this fragment has been either misinterpreted, altered, or distorted by one who did not know the full significance of Soul, Higher Mind and body with its lower mind.
The statement should read as follows: enlightenment of the Higher Mind is given only to those who are capable of receiving so great a boon. There are but few whose Mind is capable of receiving the Light; for most humans function by means of the lower mind only; the Higher Mind is dormant in them and has to await the day of awakening. Only then does the Light begin to glimmer through to a small extent, and it takes very many lives before it is able to receive its full glory. Meanwhile, the struggles are fearful to behold, and it is sad to see how many fall by the wayside, over and over again, before the fierce grip of the lower mind is relaxed a little. The Path is indeed long and thorny and full of traps and snares!
The fragment goes on to say: "By the light of mind the human soul is illumined, as the world is illumined by the sun—nay, in yet fuller measure. For all things on which the sun shines are deprived of his light by the interposition of the earth, when night comes on; but when the mind has once been interfused with the soul of man, there results from the intimate blending of mind with soul a thing that is one and indivisible, so that such men's thought is never obstructed by the darkness of error."
If you bear in mind what we have said in our previous articles about the Soul, Higher Mind, and lower mind and body, the foregoing paragraph is correct. The next sentence, again, is of the greatest significance, for in it is stated that: "Hence it has been rightly said that the souls of gods consist wholly of mind." This is true too, for the gods have no need of a body, unless they wish to become visible for a moment or so, as we behold in the person of the Divine Shepherd of Man discoursing to his auditors. But, he explains, this cannot be said of all the gods, but of certain of the Highest only, and he here refers to the Sons and Daughters of Light mentioned in the afterword to our occult studies course article on Evolution, and to the Hidden Logos of our Kosmos. And he adds: "It is a weighty secret that I am about to disclose, a holy mystery I am about to reveal to you; and I pray for the Grace of Heaven to aid me as I speak. There are many kinds of gods; some of them are apprehensible by thought alone, and others are perceptible by sense.
"The gods apprehensible by thought are so called, not because it is held that they are not subject to our perception; for we perceive them more truly than we perceive those gods whom we call visible—but only if you exert to the uttermost your powers of thought. For so lofty is the doctrine of things divine, that it is beyond the reach of any effort of merely human thought; and if you do not hearken to my words with keen attention, my teaching (says Hermes) will wing its way beyond you, and flow past you, or rather, will flow back thither whence it came, and mingle with its source. Be it known to you that the intelligible Cosmos, that is to say, that Cosmos which is discerned by thought alone, is incorporeal, and that nothing corporeal can be mingled with its being—nothing, that is, which admits of determination by quality, magnitude, or number; for nothing of this kind exists in it. You cannot measure it as you would measure a body, affixing marks of length and breadth and height.
"There are then certain gods apprehensible by thought alone, who preside over all departments of the world, and are called 'Rulers over material things'; and subordinate to them are the gods perceptible by sense. These sensible gods bear the likeness of both the sources of their being; and these are they who make all things throughout the sensible world, working one through another, each pouring light into the things he makes." This refers in part to the hosts of elemental beings, among which we must include Nature Spirits of all kinds, whilst the 'light' poured into the things, or creations, of these gods is, in man, the Higher Mind together with its intuitions and capacity to stretch or reach out to higher Realms and Beings. That is, if is awake; in animals that light is of the lower mind only, with its instincts, which have to do with material conditions, and in so-called 'inanimate' things, that light is the light of its atomic nuclei.
Matter, Spirit and Space
One of the most colossal errors in the book appears in Part VII: "In the beginning were God and Matter. The elements of which the universe is composed were not then in existence, because they had not yet come into being; but they were already in that form in which they were to be generated." This silly paradox would not be out of place in Alice in Wonderland. Another priceless bit of non-information is: "Now all things which possess the faculty of generating are generative." If that were true, then there would be no need for a creating God, and we are here in the morass of thoughtless sayings spouted by the sort of scientist who denies God completely, for according to such nincompoops matter is self-generative and all is a matter of mere chance.
But the writer becomes even plainer when he says: "Matter, which is manifestly ungenerated, yet has in itself from the first the power of generating; for original fecundity is inherent in the properties of matter, which possesses in itself the power of conceiving things and giving birth to them." No need for God, then, if that writer were right. What a morass of misconceptions we have here! But the writer has not yet quite finished, for he states positively that: "Matter then is generative by itself, without the help of anything else. It undoubtedly contains in itself the power of generating all things." If that were true, Matter would be God!
The writer's speculations on the nature of Space are just as nonsensical, he writes: "Thus the space in which is contained the Universe with all things that are therein is manifestly ungenerated." We ask: why 'manifestly'? There can be nothing 'manifest' if a thing, or a universe, has not been generated. For if any thing is not manifested, in whatever way we may think about manifestation, the thing simply does not exist. This is obvious, is it not? So if the universe of matter has never been generated, where is it and where are we? But though the writer did not mean to say so, or even thought so, there is one thing we can conclude from his statement, and that is that ALL IS ILLUSION which, as many of you will know, is the ABC of occult science. Matter, as The Secret Doctrine tells us, whether as an illusion or an actuality, is dead, or sleeping, until God the Father has infused into it His Fiery Spirit. Until then it is Chaos; dust; darkness. It is the creative Fiery Spirit of God that awakens matter; manipulates it and causes it to bring forth multitudinous forms and beings. Only then can we begin to speak of the properties, magnitudes, positions and operations of matter.
Now we come to another gem of unwisdom when the writer tells us that matter contains both good and evil and that it was beyond the power of God to prevent evil from torturing us and the planet we dwell on. This erroneous notion has led a good many seekers after Truth into a lethal minefield of misunderstanding. The simple fact is that positive good and negative evil are the reverse of one another, as enshrined in the Kabbalistic motto Demon est Deus inversus. Further, no man can know the real meanings of good or evil in the ultimate, though we must try to live according to the best of our ideas about good, and ever flee from that which we know as evil. For though we do not know the laws of good and evil, we have certain intuitions and receive messages from the Soul which guide us in our quest for God. It is in the power of God to transmute evil into good if in His Wisdom He considers the time for this has come. But He does not 'stop' evil because He cannot do so, as the writer says. We cannot go wrong if we think of God as being All-wise; All-good, and All-Powerful.
And now, thank goodness, we come to another fragment which bears the seal of the real Hermes, giving forth a Teaching worthy of that divine Being. Here it is: "He whom we name God supreme, a God apprehended by thought alone, is the ruler and director of that god perceptible by sense, who embraces within himself all substances and all matter, and all things without exception that have to do with birth and production." The God supreme is the Logos of our own Solar System whilst the other 'god' is the Lord of a Ray. The fragment continues: "Spirit, which is subject to the will of the supreme God, and serves him as his instrument, is that by means of which are moved or directed all kinds of beings in the universe, each in accordance with the special character assigned to it by God." This God who assigns here is, again, a Lord of a Ray—one of many creators under the Logos of our little Kosmic atom. You can read about these Lords of the Ray in The Secret Doctrine and The Golden Star; to discuss them here would take us too far away from our theme as well as requiring long and complex explanations.
This excellent teaching is followed by: "The process is directed by God, who distributes life to all things in the universe, giving to each one of them as much as it needs. Into all things he infuses Spirit, assigning it to each in larger measure, in proportion as the things stand higher in the scale of being. These then are the primary things, the prior things, the heads of first principles of all things in the universe; for all cosmic things are contained in them, or wrought by means of them, or made of them." All this is most excellent indeed and makes up for the many errors we have pointed out to you earlier.
The Void
We now encounter a perfect teaching on what men call the Void which is absolutely correct in every way. It is only comparatively recently that scientists have been forced to abandon their theory that interstellar Space is a 'void.' So much for scientific 'progress'! Here is that remarkable teaching of Thoth. "But as to the Void, which most people think to be a thing of great importance, I hold that no such thing as the Void exists, or can have existed in the past, or will ever exist. For all the several parts of the Cosmos are wholly filled with bodies of various qualities and forms, each having its own shape and magnitude; and thus the Cosmos as a whole is full and complete. Of these bodies, some are larger, some are smaller; and they differ in the greater or lesser firmness of their substance. Those of them which are of firmer substance are more easily seen, as are also those which are larger; whereas small bodies, and those which are of less firm substance, are almost or quite invisible, and it is only by the sense of touch that we are made aware of their existence. Hence many people have come to think that these bodies do not exist, and that there are void spaces; but that is impossible. And the like holds good of what is called the extramundane, if indeed any such thing exists; for I hold that not even the region outside the Cosmos is void, seeing that it is filled with things apprehensible by thought alone, that is with things of like nature with its own divine being. And so our Cosmos also—the sensible universe, as it is called—is wholly filled with bodies, suited to its character. The shapes presented by these bodies to our sight differ in magnitude; some of these shapes are very large; others are very small, when the distance of the objects makes them appear small to us; and some things, on account of their extreme minuteness or tenuity, are wholly invisible to us, and are consequently supposed by many people to be 'non-existent.' "
You may well ask, how did the Teacher know all this without the use of microscopes or telescopes, which were not invented until many centuries, if not millennia later, confirming all that was said by Thoth thousands of years ago? The 19th century author, Bulwer-Lytton, drew upon this teaching in his occult novel Zanoni, in which we may read: "Each drop of the water in yon moat is an orb more populous than a kingdom is of men. Everywhere, then, in this immense design, science brings new life to light. Life is the one pervading principle, and even the thing that seems to die and putrefy but engenders new life, and changes to fresh forms of matter. Reasoning, then, by evident analogy: if not a leaf, if not a drop of water, but is, no less than yonder star, a habitable and breathing world,—nay, if even man himself is a world to other lives, and millions and myriads dwell in the rivers of his blood, and inhabit man's frame as man inhabits earth, commonsense (if your schoolmen had it) would suffice to teach that the circumfluent infinite which you call space—the countless Impalpable which divides earth from the moon and stars—is filled also with its correspondent and appropriate life."
And so, the Teacher continues, "you must not call anything void without saying what the thing in question is void of, as when you say that a thing is void of fire, or water, or the life. For it is possible for a thing to be void of such things as these; but the thing that seems void, however small it be, cannot possibly be empty of spirit or air. And the like must be said of Space, The word 'space' is unmeaning when it stands alone; for it is only by regarding something which is in space, that we come to see what space is; and apart from the thing to which it belongs, the meaning of the term 'space' is incomplete. Thus we may rightly speak of the space occupied by water, and fire, and so on (but not of space alone). For as there cannot be a Void, so it is impossible to determine what space is, if you regard it by itself. For if you assume a space apart from something which is in it, it will follow that there is a void space; and I hold that there is no such thing as that in the universe. If Void has no existence, then it is impossible to find any real thing answering to the word 'space' taken by itself."
How wonderful it is to find such wise words, written so very long ago! How remarkable that they have reached us almost intact. The very simplicity of this teaching stamps it with the crown of Wisdom, but such Wisdom was for the few only, for the rest will find it all so obvious that the real meaning escapes their comprehension, or the lack of any! And what of Creation, the fashioning of matter, which is dead or sleeping by itself? Is it not a firmer foundation for our peace of mind to believe that all things were fashioned and are ordered for the best, than that the whole Universe is the result of mere bungling and blundering, without any purpose or design, ill-favourably cobbled and jumbled together by the unguided agitation and rude shuffles of matter? And what about that which brings life to matter; makes it move, think, act, reproduce that life for good or ill? Can you really believe that you, a human being, are the mere result of chemical action? Anyone who does believe this is utterly incapable of any rational thought. He or she is a dead person who never came to life at all—a mindless robot—entirely worthless to God or man. Do not be swayed by those who tell you that a belief in intelligent creation and design requires 'blind faith.' All we need is the capacity to think clearly for ourselves by means of the Higher Mind, which will tell us that all is well; that we have a divine Destiny, and that we shall reach the Goal when all our preparations for the Higher life are complete. But no robot can think like this; he or she is a machine of no more than passing interest and will rust away and be forgotten by the real Man of God—Hermes, the bringer of Light and Life to the worthy.
Take this for your meditation until we resume our investigation of the true teachings of Hermes in part seven of our investigation.
© Copyright occult-mysteries.org. Article published 13 September 2020.
Updated 24 December 2022.


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Tips on Preventing Respiratory Problems in Rabbits
If pasteurella is a concern, keep your rabbit out of direct or indirect contact with other rabbits. If you decide to add a new rabbit, she should be quarantined for at least 90 days and be examined by a veterinarian at the beginning and end of quarantine. Consider having any new rabbit tested using a combination of an antibody test and a DNA probe-based test during quarantine. Purchase young rabbits from sources that provide documentation that each bunny has been tested for pasteurella prior to sale and never return a rabbit to a rabbitry if she has been exposed to other rabbits.
For more information, please read the article Rabbit Respiratory Disease.


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