Ambulation With Femoral Arterial Cannulation Can Be Safely Performed on Venoarterial Extracorporeal Membrane Oxygenation

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support can be associated with significant deconditioning due to the requirement for strict bedrest as a result of femoral arterial cannulation. To address this issue, we evaluated our experience with ambulation in patients with peripheral femoral cannulation for VA-ECMO. Methods: All patients that were peripherally cannulated for VA-ECMO over a 2-year period were retrospectively reviewed. Patients that ambulated at least once while supported with VA-ECMO were included in the analysis. The primary outcomes were safety and feasibility of ambulation, defined as the absence of major bleeding, vascular, or decannulation events. Results: Of 104 patients placed on VA-ECMO, 15 ambulated with a femoral arterial cannula. Forty-six percent of patients were placed on VA-ECMO for decompensated heart failure, and 54% for massive pulmonary embolism. Twenty-seven percent of patients were cannulated during active cardiopulmonary resuscitation. The median length of time from cannulation to out of bed was 3 (range, 0 to 26) days. The median length of time from cannulation to initial ambulation was 4 (range, 1 to 42) days. The median distance of the first postcannulation walk was 300 feet. Neither flow nor speed decreased during or after ambulation. There were no major bleeding events, vascular complications, or decannulation events associated with ambulation. The median intensive care unit length of stay and hospital length of stay were 12 and 21 days, respectively. One-year survival was 100% for ambulating patients. Conclusions: Ambulating patients supported with VA-ECMO, despite femoral arterial cannulation, appears feasible and safe in carefully selected patients

Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support

Timing of tracheostomy placement for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation support is variable and continues to depend on surgeon preference. We retrospectively reviewed all consecutive adult patients supported with peripheral venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome at a single institution with the hypothesis that early tracheostomy (within 7 days of extracorporeal membrane oxygenation initiation) decreases the duration of extracorporeal membrane oxygenation support. The primary endpoint was duration of extracorporeal membrane oxygenation support. Secondary endpoints included mortality, overall and intensive care unit length of stay, duration of mechanical ventilation, and time from extracorporeal membrane oxygenation initiation to liberation from ventilator, intensive care unit discharge, and hospital discharge. Overall and extracorporeal membrane oxygenation–associated hospital costs were compared. A total of 50 patients were identified for inclusion (early n = 21; late n = 29). Baseline characteristics including indices of disease severity were similar between groups. Duration of extracorporeal membrane oxygenation support was significantly shorter in the early tracheostomy group (12 vs. 21 days; p = 0.005). Median extracorporeal membrane oxygenation–related costs were significantly decreased in the early tracheostomy group ($3,624 vs.$5,603, p = 0.03). Early tracheostomy placement is associated with decreased time on extracorporeal membrane oxygenation support and reduced extracorporeal membrane oxygenation–related costs in this cohort. Validation in a prospective cohort or a clinical trial is indicated

Early Decompressive Laparotomy for Intra-Abdominal Hypertension following Initiation of Venovenous Extracorporeal Membrane Oxygenation

Patients supported with venovenous extracorporeal membrane oxygenation are at risk for intra-abdominal hypertension and abdominal compartment syndrome. Flow through the return cannula may be compromised in these patients, resulting in inadequate support and end-organ malperfusion. Early decompressive laparotomy can mitigate these complications and potentially improve outcomes. Here we review a series of nine patients undergoing early decompressive laparotomy for abdominal compartment syndrome at a single institution and propose an algorithmic approach to the management of these patients

Mu Opioid Receptor Binding Correlates with Nicotine Dependence and Reward in Smokers.

The rewarding effects of nicotine are associated with activation of nicotine receptors. However, there is increasing evidence that the endogenous opioid system is involved in nicotine's rewarding effects. We employed PET imaging with [11C]carfentanil to test the hypotheses that acute cigarette smoking increases release of endogenous opioids in the human brain and that smokers have an upregulation of mu opioid receptors (MORs) when compared to nonsmokers. We found no significant changes in binding potential (BPND) of [11C]carfentanil between the placebo and the active cigarette sessions, nor did we observe differences in MOR binding between smokers and nonsmokers. Interestingly, we showed that in smokers MOR availability in bilateral superior temporal cortices during the placebo condition was negatively correlated with scores on the Fagerström Test for Nicotine Dependence (FTND). Also in smokers, smoking-induced decreases in [11C]carfentanil binding in frontal cortical regions were associated with self-reports of cigarette liking and wanting. Although we did not show differences between smokers and nonsmokers, the negative correlation with FTND corroborates the role of MORs in superior temporal cortices in nicotine addiction and provides preliminary evidence of a role of endogenous opioid signaling in frontal cortex in nicotine reward

Line plots of mean concentrations across subjects of nicotine in plasma versus time of active and placebo cigarette scans.

<p>PET data acquisition began between 5 and 10 min on the time axis in individual subjects.</p

Concentrations of nicotine and metabolites in plasma during active and placebo cigarette scans.

<p>Mean ± standard deviation (ng/mL) of individual subjects' means across 2–75 min, except for the second nicotine row representing nicotine concentrations only from 2–10 min.</p><p>Limits of quantification were 1 ng/mL for cotinine, OH-cotinine and norcotinine, and 2.5 ng/mL for nicotine at individual time point.</p><p>* Active cigarette scan values > placebo cigarette scan value at p<0.01; paired t-test.</p>#<p>Smoker > nonsmoker at p<0.00001; t-test.</p><p>Concentrations of nicotine and metabolites in plasma during active and placebo cigarette scans.</p

Clusters of Δ[¹¹C]carfentanil BP_ND (placebo - active) to ΔVAS (active - placebo) correlation.

<p>Significance criteria: p<0.001, uncorrected and volume >0.4 mL.</p><p>Percentages in the last column indicate anatomical constituents of clusters.</p><p>Clusters of Δ[¹¹C]carfentanil BP_ND (placebo - active) to ΔVAS (active - placebo) correlation.</p

Positive correlation clusters of Δ[¹¹C]carfentanil binding potential (BP_ND) (placebo - active) versus ΔVAS of feel the effect category in smokers, displayed on trans-axial images of a gray-matter probability maps.

<p>Scatter plots of cluster Δ[¹¹C]carfentanil BP_ND values to ΔVAS are shown together with regression lines. VAS stands for the visual analog scale of smoking effects, and <i>R²</i> stands for the coefficient of determination of linear regression.</p

Correlation clusters of [¹¹C]carfentanil binding potential (BP_ND) of placebo-cigarette scans versus the Fagerström Test for Nicotine Dependence (FTND) in smokers, displayed on trans-axial images of a gray-matter probability maps.

<p>Right panels show scatter plots using cluster [¹¹C]carfentanil BP_ND, together with regression line. In regression equations, <i>R²</i> stands for the coefficient of determination.</p