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

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

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

Direct administration of 2-hydroxypropyl-beta-cyclodextrin into guinea pig cochleae: Effects on physiological and histological measurements

<p>Cochlear response measurements from two different animals made before (red) and after (blue) treatment with HPβCD (Panel A) and TTX (Panel B) to 80 dB SPL 4 kHz tone bursts. Cochlear response waveform maintained CAP-like morphology after HPβCD treatment, consistent with reduced mechanical drive to neural excitation (Panel B, blue). In contrast, response waveform is EPSP-like following TTX treatment. Unlike TTX, results from HPβCD do not support the hypothesis that the auditory nerve is a site of action for 13 mM HPβCD.</p

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

Acute myocardial infarction complicated by cardiogenic shock: an algorithm based ECMO program can improve clinical outcomes.

Objective: Extracorporeal membrane oxygenation (ECMO) in our institution resulted in near total mortality prior to the establishment of an algorithm-based program in July 2010. We hypothesized that an algorithm based ECMO program improves the outcome of patients with acute myocardial infarction complicated with cardiogenic shock. Methods: Between March 2003 and July 2013, 29 patients underwent emergent catheterization for acute myocardial infarction due to left main or proximal left anterior descending artery occlusion complicated with cardiogenic shock (defined as systolic blood pressure \u3c 90mmHg despite multiple inotropes, +- balloon pump, lactic acidosis). Of 29 patients, 15 patients were before July 2010 (Group 1, old program), 14 patients were after July 2010 (Group 2, new program). Results: There were no significant differences in the baseline characteristics, including age, sex, coronary risk factors and left ventricular ejection fraction, between the two groups. Cardiopulmonary resuscitation prior to ECMO was performed in 2 cases (13%) in Group 1 and 4 cases (29%) in Group 2. ECMO support was performed in 1 case (6.7%) in Group 1 and 6 cases (43%) in Group 2. The 30-day survival of Group 1 vs. Group 2 was 40% vs. 79% (p = 0.03), and one-year survival rate was 20% vs. 56% (p=0.01). The survival rate for patients who underwent ECMO was 0% in Group 1 vs. 83% in Group 2 (p = 0.09). In Group 2, the mean duration on ECMO was 9.8 ± 5.9 days. Of the 6 patients who required ECMO in Group 2, 100% were successfully weaned off ECMO or were bridged to ventricular assist device implantation. Conclusions: Initiation of an algorithm based ECMO program improved the outcomes in patients with acute myocardial infarction complicated by cardiogenic shock

First-principles study of electron transport through C20C_{20} cages

Electron transport properties of C$_{20}$ molecules suspended between gold electrodes are investigated using first-principles calculations. Our study reveals that the conductances are quite sensitive to the number of C$_{20}$ molecules between electrodes: the conductances of C$_{20}$ monomers are near 1 G$_{0}$, while those of dimers are markedly smaller, since incident electrons easily pass the C$_{20}$ molecules and are predominantly scattered at the C$_{20}$-C$_{20}$ junctions. Moreover, we find both channel currents locally circulating the outermost carbon atoms.Comment: 8 pages and 3 figure