Prone position: Does it help with acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO)?

Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salvage ventilation in cases where poor compliance restricts the use of traditional ventilation with ARDS. In addition to ventilator therapy, prone positioning has been used to improve oxygenation. We presented a challenging case of ARDS, which failed medical management extracorporeal membrane oxygenation (ECMO) support and oscillatory ventilation. Prone positioning was initiated which improved oxygenation, respiratory compliance and posterior atelectasis. Case presentation: A 41-year-old morbid obese female developed ARDS due to influenza pneumonia. The patient remained hypoxic despite optimum medical and ventilator management and required veno-venous extracorporeal membrane oxygenation (VV ECMO). CT scan of the chest showed ARDS with posterior consolidation. Despite ARDSnet ventilation support, antiviral therapy and ECMO support, there was no clinical improvement. High frequency oscillatory ventilation was initiated on ECMO day #13, which resulted in no respiratory improvement over the next 5 days. On ECMO day #18, the patient was placed on a Rotaprone? bed Therapy, utilizing a proning strategy of 16 hours a day. The clinical improvements observed were resolving of the consolidation on CXR, improvements in ventilatory parameters and decreased oxygen requirements. The patient was successfully weaned off ECMO on POD#25 (8 days post prone bed). Conclusions: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it might facilitate early weaning

Systemic inflammatory response syndrome (SIRS) after extracorporeal membrane oxygenation (ECMO): Incidence, risks and survivals.

INTRODUCTION: Systemic inflammatory response syndrome (SIRS) is frequently observed after extracorporeal membrane oxygenation (ECMO) decannulation; however, these issues have not been investigated well in the past. METHODS: Retrospective chart review was performed to identify post-ECMO SIRS phenomenon, defined by exhibiting 2/3 of the following criteria: fever, leukocytosis, and escalation of vasopressors. The patients were divided into 2 groups: patients with documented infections (Group I) and patients with true SIRS (Group TS) without any evidence of infection. Survival and pre-, intra- and post-ECMO risk factors were analyzed. RESULTS: Among 62 ECMO survivors, 37 (60%) patients developed the post-ECMO SIRS phenomenon, including Group I (n = 22) and Group TS (n = 15). The 30-day survival rate of Group I and TS was 77% and 100%, respectively (p = 0.047), although risk factors were identical. CONCLUSIONS: SIRS phenomenon after ECMO decannulation commonly occurs. Differentiating between the similar clinical presentations of SIRS and infection is important and will impact clinical outcomes

Point-of-care versus central testing of hemoglobin during large volume blood transfusion.

BACKGROUND: Point-of-care (POC) hemoglobin testing has the potential to revolutionize massive transfusion strategies. No prior studies have compared POC and central laboratory testing of hemoglobin in patients undergoing massive transfusions. METHODS: We retrospectively compared the results of our point-of-care hemoglobin test (EPOC®) to our core laboratory complete blood count (CBC) hemoglobin test (Sysmex XE-5000™) in patients undergoing massive transfusion protocols (MTP) for hemorrhage. One hundred seventy paired samples from 90 patients for whom MTP was activated were collected at a single, tertiary care hospital between 10/2011 and 10/2017. Patients had both an EPOC® and CBC hemoglobin performed within 30 min of each other during the MTP. We assessed the accuracy of EPOC® hemoglobin testing using two variables: interchangeability and clinically significant differences from the CBC. The Clinical Laboratory Improvement Amendments (CLIA) proficiency testing criteria defined interchangeability for measurements. Clinically significant differences between the tests were defined by an expert panel. We examined whether these relationships changed as a function of the hemoglobin measured by the EPOC® and specific patient characteristics. RESULTS: Fifty one percent (86 of 170) of paired samples\u27 hemoglobin results had an absolute difference of ≤7 and 73% (124 of 170) fell within ±1 g/dL of each other. The mean difference between EPOC® and CBC hemoglobin had a bias of - 0.268 g/dL (p = 0.002). When the EPOC® hemoglobin was \u3c 7 g/dL, 30% of the hemoglobin values were within ±7, and 57% were within ±1 g/dL. When the measured EPOC® hemoglobin was ≥7 g/dL, 55% of the EPOC® and CBC hemoglobin values were within ±7, and 76% were within ±1 g/dL. EPOC® and CBC hemoglobin values that were within ±1 g/dL varied by patient population: 77% for cardiac surgery, 58% for general surgery, and 72% for non-surgical patients. CONCLUSIONS: The EPOC® device had minor negative bias, was not interchangeable with the CBC hemoglobin, and was less reliable when the EPOC® value was \u3c 7 g/dL. Clinicians must consider speed versus accuracy, and should check a CBC within 30 min as confirmation when the EPOC® hemoglobin is \u3c 7 g/dL until further prospective trials are performed in this population

Prompt Reversal of Airway Obstruction Secondary to Angiotensin Converting Enzyme Inhibitor (ACEI) Induced Angioedema by Ecallantide: A Case Report

Case: A 54 year old African-American male with a history of hypertension treated with lisinopril daily, remote cocaine abuse associated myocardial infarction, seizures and prostate cancer, presented with a 2 day history of facial and throat swelling along with dysphagia. He was treated in the emergency department with intravenous methylprednisolone, epinephrine and diphenhydramine. He was admitted, but angioedema progressed overnight, confirmed by laryngoscopy. ICU transfer and intubation was undertaken the next morning for airway protection. Tryptase level was 2 ng/ml. C3 and C4 and routine chemistries were normal. Ecallantide 30mg was administered subcutaneously at 1014 hours. Presented at: American Academy of Allergy Asthma and Immunology annual conference in Orlando Florida

A New Social Contract for Governing Industrial Risk in the Community

Despite extensive regulation of hazardous industrial activities, residents of many communities that host these activities fear risks to their health and safety and suffer impacts that degrade the local environment. The concept of a New Social Contract (NSC) is presented as a supplement to regulation. It would involve company-community negotiation of an agreement, either enforceable or trust based, that provides company commitments to address the local risks and impacts. The concept is then examined with reference to experience with the negotiation of good neighbor agreements and the corporate social responsibility movement, and followed by discussion of the negotiation process for securing company commitments and implementation issues. Recommendations based on best practices and lessons learned from relevant experience are then presented for optimal use of the NSC concept

The Social Control of Science and Technology

Science and technology increasingly work changes in the complex matrix of society. These changes pervade our ecological systems and our physical and psychic health. Less perceptibly, they pervade our culture, our values, and our value based institutions such as the law. In turn, our values and institutions shape the progress and utilization of science and technology. As we know, science and technology have provided society with enormous material benefits and a higher standard of living and health. But we now realize that this process has been accompanied by alarming rates of resource consumption and many new hazards to ecological systems and health. Social response to these unexpected problems has been of a remedial nature - e.g., how to diminish pollution through regulation and technology. But it must be repeated that our values and institutions shape the progress and use of science and technology, and therefore the fundamental social response must be of a preventative or a priori nature to the extent that this is possible. This important task can be described as the need to formulate coherent and humane social controls on science and technology

Localization of HCN1 channels to presynaptic compartments: novel plasticity that may contribute to hippocampal maturation.

Increasing evidence supports roles for the current mediated by hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, I(h), in hippocampal maturation and specifically in the evolving changes of intrinsic properties as well as network responses of hippocampal neurons. Here, we describe a novel developmental plasticity of HCN channel expression in axonal and presynaptic compartments: HCN1 channels were localized to axon terminals of the perforant path (the major hippocampal afferent pathway) of immature rats, where they modulated synaptic efficacy. However, presynaptic expression and functions of the channels disappeared with maturation. This was a result of altered channel transport to the axons, because HCN1 mRNA and protein levels in entorhinal cortex neurons, where the perforant path axons originate, were stable through adulthood. Blocking action potential firing in vitro increased presynaptic expression of HCN1 channels in the perforant path, suggesting that network activity contributed to regulating this expression. These findings support a novel developmentally regulated axonal transport of functional ion channels and suggest a role for HCN1 channel-mediated presynaptic I(h) in hippocampal maturation

Case Series on Veno - venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to complete recovery in influenza type A related refractory ARDS

Introduction: Influenza A sequelae range from mild symptoms to acute respiratory distress syndrome (ARDS), which can be refractory to conventional ventilator therapy. We present a case series of three non-H1N1 Influenza patients with ARDS, who completely recovered after VV-ECMO. Case Presentation: In January and February 2013, we experienced three cases of Influenza A induced ARDS that failed conventional ARDS ventilator therapy. All three patients presented with typical flu-like symptoms, which deteriorated over several days, requiring intubation. They were all treated with oseltamivir. They had bilateral chest infiltrates on chest x-rays. After a few days of failing conventional treatment these patients were placed on VV-ECMO using Avalon Dual Lumen catheters. Presented 24th Annual ELSO Conference