Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. METHODS: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (\u3e300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. RESULTS: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. CONCLUSIONS: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery

Massive haemoptysis on veno-arterial extracorporeal membrane oxygenation.

A 49-year old female presented with severe heart failure with end-organ dysfunction and was placed on veno-arterial extracorporeal membrane oxygenation (ECMO) as a bridge to a decision for end-organ recovery. While on ECMO, the patient developed massive haemoptysis after a Swan-Ganz catheter manipulation. The haemoptysis was not controllable by conventional methods including bronchoscopy with cold saline and epinephrine lavage, bronchial blocker or angiography. The endotracheal tube was clamped to provide tamponade and the patient relied on full ECMO support for 36 h. After the haemoptysis resolved, the endotracheal tube was unclamped. The patient developed adult respiratory distress syndrome and was ventilated using the ARDSnet protocol with continued support from ECMO. On post-ECMO day 20, the patient underwent a successful ECMO wean and a Heart Mate II left ventricular assist device placement

Graduate Medical Education Program Mergers: Key Aspects and Considerations

The recent restructuring of the healthcare reimbursement system has led to financial pressure on all aspects of healthcare delivery. Naturally, this financial pressure will also trickle down to graduate medical education, resulting in mergers of residency programs. Historical examples of residency mergers will be presented and discussed in this chapter. Guidelines for merging residencies will be suggested for those programs undertaking this difficult process. These guidelines will address aspects of organization and leadership, educational philosophies and environment, program goals, culture, interpersonal relationships, communication, day-to-day operations, and finances. Special considerations for program mergers will also be discussed, including cultural differences, medical students, and surgical programs. The chapter concludes with a discussion on the relevancy of this information and important key concepts

Hydrogen Fuel Cell Pick and Place Assembly Systems: Heuristic Evaluation of Reconfigurability and Suitability

Proton Exchange Membrane Fuel Cells (PEMFCs) offer numerous advantages over combustion technology but they remain economically uncompetitive except for in niche applications. A portion of this cost is attributed to a lack of assembly expertise and the associated risks. To solve this problem, this research investigates the assembly systems that do exist for this product and systematically decomposes them into their constituent components to evaluate reconfigurability and suitability to product. A novel method and set of criteria are used for evaluation taking inspiration from heuristic approaches for evaluating manufacturing system complexity. It is proposed that this can be used as a support tool at the design stage to meet the needs of the product while having the capability to accept potential design changes and variants for products beyond the case study presented in this work. It is hoped this work develops a new means to support in the design of reconfigurable systems and form the foundation for fuel cell assembly best practice, allowing this technology to reduce in cost and find its way into a commercial space

The Use of a Complexity Model to Facilitate in the Selection of a Fuel Cell Assembly Sequence

Various tools and methods exists for arriving at an optimised assembly sequence with most using a soft computing approach. However, these methods have issues including susceptibly to early convergence and high computational time. The typical objectives for these methods are to minimise the number of assembly change directions, orientation changes or the number of tool changes. This research proposes an alternative approach whereby an assembly sequence is measured based on its complexity. The complexity value is generated using design for assembly metrics and coupled with considerations for product performance, component precedence and material handling challenges to arrive at a sequence solution which is likely to be closest to the optimum for cost and product quality. The case presented in this study is of the assembly of a single proton exchange membrane fuel cell. This research demonstrates a practical approach for determining assembly sequence using data and tools that are used and available in the wider industry. Further work includes automating the sequence generation process and extending the work by considering additional factors such as ergonomics

A Framework for Automatically Realizing Assembly Sequence Changes in a Virtual Manufacturing Environment

© 2016 The Authors. Global market pressures and the rapid evolution of technologies and materials force manufacturers to constantly design, develop and produce new and varied products to maintain a competitive edge. Although virtual design and engineering tools have been key to supporting this fast rate of change, there remains a lack of seamless integration between and within tools across the domains of product, process, and resource design-especially to accommodate change. This research examines how changes to designs within these three domains can be captured and evaluated within a component based engineering tool (vueOne, developed by the Automation Systems Group at the University of Warwick). This paper describes how and where data within these tools can be mapped to quickly evaluate change (where typically a tedious process of data entry is required) decreasing lead times and cost and increasing productivity. The approach is tested on a sub-assembly of a hydrogen fuel cell, where an assembly system is modelled and changes are made to the sequence which is translated through to control logic. Although full implementation has not yet been realized, the concept has the potential to radically change the way changes are made and the approach can be extended to supporting other change types provided the appropriate rules and mapping

Updates to Thoracic Procedures: Perioperative Care and Anesthetic Considerations

Thoracic surgery is a rapidly evolving field, as is the perioperative and anesthetic care of patients undergoing major thoracic surgery. As surgical techniques continue to evolve, new guidelines are needed to help standardize patient care. To this end, Enhanced Recovery After Surgery (ERAS) protocols were created and have seen increasingly widespread adoption within the field of thoracic surgery. Despite their name, the scope of these protocols includes not only the postoperative period, but also helps guide care in the preoperative and intraoperative periods. Thus, ERAS pathways are relevant to both thoracic surgeons and anesthesiologists. This chapter aims to summarize current guidelines for managing patients undergoing thoracic surgery (from the preoperative period all the way through to postoperative care) by discussing recent updates within the field as well as some more well established tenets that remain relevant to the topic

Management of Upper Aerodigestive Tract Bleeding in Patients on ECMO.

Introduction: Bleeding complications on Extracorporeal Membrane Oxygenation (ECMO) are often encountered. In a review of our own series, it was found that upper aero digestive tract bleeding was common and management was often difficult. We propose an algorithm to help manage upper aero digestive tract bleeding in the anticoagulated, ECMO patient. Hypothesis: Once an ECMO patient fails conservative management for upper aero digestive bleeding, more aggressive measures will prove successful, which will provide benefit to the patient. Methods: A retrospective chart review was performed of the patients who underwent venovenous or veno-arterial ECMO at our institution between July 2010 and July 2012. The patients that had upper aero digestive tract bleeding that required an Otolaryngology consultation were identified. They were further investigated to determine location of bleed and procedures performed to control the bleeding. Results: Among the 37 consecutive patients on ECMO, 11 (30%) had upper aero digestive tract bleeding events. Of these 11, 6 (55%) were secondary to an iatrogenic incident, such as placing a nasogastric tube or transesophageal echo probe. All 11 patients were treated at bedside with conservative management and 2 were treated in the operating room. 72.7 % of patients treated with conservative management required repeated procedures due to incomplete hemostasis, compared to 0% of patients once surgical intervention was complete. Conclusions: Approximately one third of the ECMO patients developed upper aero digestive tract bleeding. This bleeding should be controlled in a timely manner otherwise it may result in massive transfusions. Delaying intervention or conservative management may not be effective. We recommend surgical intervention if the initial conservative management failed and continued to bleed for more than 24-36 hours

The use of a complexity model to facilitate in the selection of a fuel cell assembly sequence

Various tools and methods exists for arriving at an optimised assembly sequence with most using a soft computing approach. However, these methods have issues including susceptibly to early convergence and high computational time. The typical objectives for these methods are to minimise the number of assembly change directions, orientation changes or the number of tool changes. This research proposes an alternative approach whereby an assembly sequence is measured based on its complexity. The complexity value is generated using design for assembly metrics and coupled with considerations for product performance, component precedence and material handling challenges to arrive at a sequence solution which is likely to be closest to the optimum for cost and product quality. The case presented in this study is of the assembly of a single proton exchange membrane fuel cell. This research demonstrates a practical approach for determining assembly sequence using data and tools that are used and available in the wider industry. Further work includes automating the sequence generation process and extending the work by considering additional factors such as ergonomi

Hydrogen fuel cell pick and place assembly systems : heuristic evaluation of reconfigurability and suitability

Proton Exchange Membrane Fuel Cells (PEMFCs) offer numerous advantages over combustion technology but they remain economically uncompetitive except for in niche applications. A portion of this cost is attributed to a lack of assembly expertise and the associated risks. To solve this problem, this research investigates the assembly systems that do exist for this product and systematically decomposes them into their constituent components to evaluate reconfigurability and suitability to product. A novel method and set of criteria are used for evaluation taking inspiration from heuristic approaches for evaluating manufacturing system complexity. It is proposed that this can be used as a support tool at the design stage to meet the needs of the product while having the capability to accept potential design changes and variants for products beyond the case study presented in this work. It is hoped this work develops a new means to support in the design of reconfigurable systems and form the foundation for fuel cell assembly best practice, allowing this technology to reduce in cost and find its way into a commercial space