Management of upper aerodigestive tract bleeding on extracorporeal membrane oxygenation.

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. Methods: A retrospective chart review was performed of the patients who underwent veno-venous 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, 7 (63.6%) 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 3 were treated in the operating room. Four patients (36%) treated with conservative management required repeated procedures due to incomplete hemostasis, compared to no repeated procedure required once surgical intervention in the operating room was complete. Conclusion: 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

Current Trend of Off-Pump Coronary Artery Bypass Grafting

Published in Front Lines of Thoracic Surgery , Edited by Stefano Nazari, ISBN 978-953-307-915-8, Published: February 3, 2012 under CC BY 3.0 license Coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) and cardioplegic arrest has been performed safely over several decades. Cardiac surgery under cardiac arrest provides a bloodless stable operative field, that can facilitate anastomosis. In last decade, CABG without CPB, off-pump CABG (OPCAB) has become more common with advances in surgical instruments and technique. This chapter summarizes the surgical technique, risks and benefits of OPCAB

Saving life and brain with extracorporeal cardiopulmonary resuscitation: A single-center analysis of in-hospital cardiac arrests.

OBJECTIVE: Despite advances in medical care, survival to discharge and full neurologic recovery after cardiac arrest remains less than 20% after cardiopulmonary resuscitation. An alternate approach to traditional cardiopulmonary resuscitation is extracorporeal cardiopulmonary resuscitation, which places patients on extracorporeal membrane oxygenation during cardiopulmonary resuscitation and provides immediate cardiopulmonary support when traditional resuscitation has been unsuccessful. We report the results from extracorporeal cardiopulmonary resuscitation at the Thomas Jefferson University. METHODS: Between 2010 and June 2014, 107 adult extracorporeal membrane oxygenation procedures were performed at the Thomas Jefferson University. Patient demographics, survival to discharge, and neurologic recovery of patients who underwent extracorporeal cardiopulmonary resuscitation were retrospectively analyzed with institutional review board approval. RESULTS: A total of 23 patients (15 male and 8 female; mean age, 46 ± 12 years) underwent extracorporeal cardiopulmonary resuscitation. All patients who met criteria were placed on 24-hour hypothermia protocol (target temperature 33°C) with initiation of extracorporeal membrane oxygenation. The mean duration of extracorporeal membrane oxygenation support was 6.2 ± 5.5 days. Nine patients died while on extracorporeal membrane oxygenation from the following causes: anoxic brain injury (4), stroke (4), and bowel necrosis (1). Two patients with anoxic brain injury on extracorporeal cardiopulmonary resuscitation donated multiple organs for transplant. The survival to discharge was 30% (7/23 patients) with approximately 100% full neurologic recovery. CONCLUSIONS: The extracorporeal cardiopulmonary resuscitation procedure provided reasonable patient recovery. Extracorporeal cardiopulmonary resuscitation also allowed for neurologic recovery and made multiorgan procurement possible. On the basis of the survival, extracorporeal cardiopulmonary resuscitation should be considered when determining the optimal treatment path for patients who need cardiopulmonary resuscitation. The proper use of extracorporeal cardiopulmonary resuscitation improved the hospital outcomes for patients with in-hospital cardiac arrest

Extracorporeal membrane oxygenation with multiple-organ failure: Can molecular adsorbent recirculating system therapy improve survival?

BACKGROUND: Liver dialysis, molecular adsorbent recirculating system (MARS) particularly, has been used in liver failure to bridge to transplantation. We expanded the indication for MARS to patients with acute shock liver failure and cardiopulmonary failure on extracorporeal membrane oxygenation (ECMO), aiming to improve survival to wean from ECMO. METHODS: Retrospective chart analysis of patients on ECMO between 2010 and 2015 found 28 patients who met the criteria for acute liver failure, diagnosed by hyperbilirubinemia (total bilirubin ≥10 mg/dl) or by elevated transaminase (alanine transaminase \u3e1,000 IU/liter). Of these patients, 14 underwent MARS treatment (Group M), and 14 were supported with optimal medical treatment without MARS (Group C). Patient characteristics, liver function, and survival were compared between groups. RESULTS: Demographics, clinical risk factors, and pre-ECMO laboratory data were identical between the groups. MARS was used continuously for 8 days ± 9 in Group M. Total bilirubin, alanine transaminase, and international normalized ratio were improved significantly in Group M. There were no MARS-related complications. Survival to wean from ECMO for Group M was 64% (9/14) vs 21% (3/14) for Group C (p = 0.02). Mortality related to worsening liver dysfunction during ECMO was 40% (2/5 deaths) in Group M and 100% (11/11 deaths) in Group C (p = 0.004). The 30-day survival after ECMO was 43% (6/14) in Group M and 14% (2/14) in Group C (p = 0.09). CONCLUSIONS: MARS therapy in patients on ECMO safely accelerated recovery of liver function and improved survival to wean from ECMO, without increasing complications

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

Simple new risk score model for adult cardiac extracorporeal membrane oxygenation: simple cardiac ECMO score.

BACKGROUND: Although the use of cardiac extracorporeal membrane oxygenation (ECMO) is increasing in adult patients, the field lacks understanding of associated risk factors. While standard intensive care unit risk scores such as SAPS II (simplified acute physiology score II), SOFA (sequential organ failure assessment), and APACHE II (acute physiology and chronic health evaluation II), or disease-specific scores such as MELD (model for end-stage liver disease) and RIFLE (kidney risk, injury, failure, loss of function, ESRD) exist, they may not apply to adult cardiac ECMO patients as their risk factors differ from variables used in these scores. METHODS: Between 2010 and 2014, 73 ECMOs were performed for cardiac support at our institution. Patient demographics and survival were retrospectively analyzed. A new easily calculated score for predicting ECMO mortality was created using identified risk factors from univariate and multivariate analyses, and model discrimination was compared with other scoring systems. RESULTS: Cardiac ECMO was performed on 73 patients (47 males and 26 females) with a mean age of 48 ± 14 y. Sixty-four percent of patients (47/73) survived ECMO support. Pre-ECMO SAPS II, SOFA, APACHE II, MELD, RIFLE, PRESERVE, and ECMOnet scores, were not correlated with survival. Univariate analysis of pre-ECMO risk factors demonstrated that increased lactate, renal dysfunction, and postcardiotomy cardiogenic shock were risk factors for death. Applying these data into a new simplified cardiac ECMO score (minimal risk = 0, maximal = 5) predicted patient survival. Survivors had a lower risk score (1.8 ± 1.2) versus the nonsurvivors (3.0 ± 0.99), P \u3c 0.0001. CONCLUSIONS: Common intensive care unit or disease-specific risk scores calculated for cardiac ECMO patients did not correlate with ECMO survival, whereas a new simplified cardiac ECMO score provides survival predictability

The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: There are various factors that can influence the survival of patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). Vascular complications from femoral cannulation are common and are potentially serious. We analyzed the impact of vascular complications on survival of patients receiving VA ECMO. METHODS: Patients supported with VA ECMO by means of femoral cannulation from October 2010 to November 2014 were enrolled in this study. Data were gathered retrospectively by reviewing our institutional database. Patients were separated into two groups depending on the presence of major vascular complications, defined as patients who required surgical intervention. We evaluated predisposing factors for vascular complications and compared survival of patients in each group. RESULTS: There were 84 patients enrolled in the study. The rates of overall ECMO survival and survival to hospital discharge were 60% and 43%, respectively. Major vascular complications requiring surgical intervention were seen in 17 (20%) patients. Ten patients (12%) had compartment syndrome requiring prophylactic fasciotomy, and 10 patients (12%) had bleeding or hematoma requiring surgical exploration. The only significant predisposing factor for vascular complications was the absence of a distal perfusion catheter (odds ratio, 14.8; p = 0.03). The rate of survival to discharge was 18% and 49% in patients with and without vascular complications, respectively (p = 0.02). Vascular complications were an independent factor of significantly worse survival in patients receiving VA ECMO by multivariate analysis (hazard ratio, 2.17; p = 0.02). CONCLUSIONS: Vascular complications negatively affect survival in patients receiving VA ECMO support by means of femoral cannulation. The utilization of a distal perfusion catheter can decrease the incidence of complications

Migrated Avalon Veno-Venous Extracorporeal Membrane Oxygenation Cannula: How to Adjust Without Interruption of Flow.

The Avalon dual lumen cannula is presently the cannula of choice for veno-venous extracorporeal membrane oxygenation (VV-ECMO) via right internal jugular cannulation. This cannula establishes VV-ECMO with a single cannulation; however, it requires appropriate positioning to gain adequate oxygenation. Malposition of this cannula can cause inadequate ECMO flow, hypoxia, and structural injury. We have experienced two cases of migration: one into the hepatic vein and the other into the right ventricle. The former was repositioned using echocardiographic guidance without using a guidewire. The latter was repositioned using a guidewire from the femoral vein under fluoroscopy, without antegrade wire placement into the Avalon cannula, discontinuation of ECMO, or bleeding