Congenital diaphragmatic hernia: To repair on or off extracorporeal membrane oxygenation?

Background: Congenital diaphragmatic hernia (CDH) can be repaired on or off extracorporeal membrane oxygenation (ECMO). In many centers, operating off ECMO is advocated to prevent bleeding complications. We aimed to compare surgery-related bleeding complications between repair on or off ECMO. Methods: All patients with CDH repair and ECMO treatment between January 1, 1995, and May 31, 2008, were retrospectively reviewed. Tranexamic acid was routinely given to all patients repaired on ECMO for 24 hours perioperatively after 2003. Extra-fluid expansion, transfusion, or relaparotomy caused by postoperative bleeding were scored as surgery-related bleeding complications and were related to the Extracorporeal Life Support Organization (ELSO) registry. We used χ 2 test and t test for statistics. Results: Demographic data and surgery-related bleeding complications in the on-ECMO group were not significantly different compared with the off-ECMO group (P =.331) in our institute. In contrast, more surgery-related bleeding complications were reported by ELSO in their on-ECMO group (P <.0001). Conclusion: In contrast to the data from the ELSO registry, we did not observe significantly more surgery-related bleeding complications after CDH repair on ECMO. Using a specific perioperative hemostatic treatment enabled us to perform CDH repair on ECMO with a low frequency of bleeding complications, thereby taking advantage of having the physiologic benefits of ECMO available perioperatively

Extracorporeal membrane oxygenation for refractory cardiac arrest

Extracorporeal cardiopulmonary resuscitation (ECPR) is the use of rapid deployment venoarterial (VA) extracorporeal membrane oxygenation to support systemic circulation and vital organ perfusion in patients in refractory cardiac arrest not responding to conventional cardiopulmonary resuscitation (CPR). Although prospective controlled studies are lacking, observational studies suggest improved outcomes compared with conventional CPR when ECPR is instituted within 30-60 min following cardiac arrest. Adult and pediatric patients with witnessed in-hospital and out-of-hospital cardiac arrest and good quality CPR, failure of at least 15 min of conventional resuscitation, and a potentially reversible cause for arrest are candidates. Percutaneous cannulation where feasible is rapid and can be performed by nonsurgeons (emergency physicians, intensivists, cardiologists, and interventional radiologists). Modern extracorporeal systems are easy to prime and manage and are technically easy to manage with proper training and experience. ECPR can be deployed in the emergency department for out-of-hospital arrest or in various inpatient units for in-hospital arrest. ECPR should be considered for patients with refractory cardiac arrest in hospitals with an existing extracorporeal life support program, able to provide rapid deployment of support, and with resources to provide postresuscitation evaluation and management

Extracorporeal Membrane Oxygenation in Critical Care: Past, Present, and Future

AbstractExtracorporeal membrane oxygenation (ECMO) provides support for cardiac and pulmonary failure, and it was introduced into clinical practice over 40 years ago. The translation of surgical extracorporeal circulation into long-term support was enabled by the development of efficient, biocompatible artificial lungs and blood pumps. Early clinical trials in adult patients did not support clinical benefit in acute respiratory failure, but they were plagued by lack of center experience, older approaches to management, and lack of understanding of ventilator-induced lung injury. Recent clinical trials and retrospective studies, however, suggest a benefit in selected patients. Three neonatal trials for respiratory failure led to ECMO as a standard of care in this population, as well as in the pediatric population despite lack of controlled trials. Cardiac support with ECMO took a foothold in the management of pediatric congenital heart disease in the perioperative period, and subsequently expanded to adult cardiac failure for both perioperative and nonsurgical indications. Presently, ECMO is used to support a variety of etiologies of cardiac and pulmonary failure in all age groups. Expanding indications include support of septic shock, cardiopulmonary arrest, and donation after cardiac death, as well as bridging patients with chronic disease to transplant or long-term support devices. The future is focused on developing integrated support systems, overcoming the requirement for anticoagulation, and perfecting long-term implantable or paracorporeal pulmonary support systems.</jats:p