The impact of a new ECMO program on clinical outcomes of patients with acute myocardial infarction complicated by cardiogenic shock.

Objective: To investigate if a new ECMO program will improve the outcome of patients who had acute myocardial infarction complicated with cardiogenic shock. Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013

Case Series on Veno - venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to complete recovery in influenza type A related refractory ARDS

Introduction: Influenza A sequelae range from mild symptoms to acute respiratory distress syndrome (ARDS), which can be refractory to conventional ventilator therapy. We present a case series of three non-H1N1 Influenza patients with ARDS, who completely recovered after VV-ECMO. Case Presentation: In January and February 2013, we experienced three cases of Influenza A induced ARDS that failed conventional ARDS ventilator therapy. All three patients presented with typical flu-like symptoms, which deteriorated over several days, requiring intubation. They were all treated with oseltamivir. They had bilateral chest infiltrates on chest x-rays. After a few days of failing conventional treatment these patients were placed on VV-ECMO using Avalon Dual Lumen catheters. Presented 24th Annual ELSO Conference

Feasibility of diagnosis of postcardiotomy tamponade by miniaturized transesophageal echocardiography.

BACKGROUND: Pericardial tamponade after cardiac surgery is a critical diagnosis that can be difficult to diagnose using conventional cardiac monitoring. Transesophageal echocardiography can provide comprehensive information to make the diagnosis but is not always available, whereas transthoracic echocardiography has its utility limited because of the body habitus or other surgical effects. New monitoring devices, miniaturized hemodynamic transesophageal echocardiography (hTEE), which allows point of care assessment of cardiac filling and functions, may aid in diagnosis of postcardiotomy tamponade. METHODS: From May 2011 to July 2013, 21 patients underwent hTEE to rule out pericardial tamponade for clinical suspicion of tamponade after open heart surgery. The hTEE images were reviewed, and the patient outcomes were analyzed. RESULTS: Nine patients showed no evidence of pericardial collection and did not require reexploration. Two patients showed a presence of small hematoma without ventricular compression and also did not undergo exploration. Ten patients were positive for pericardial tamponade (effusion or hematoma with ventricular compression); eight of these cases underwent emergent surgical exploration. Of the two patients who did not undergo immediate reoperation, one was managed by chest tube manipulation and the other patient underwent subsequent surgical exploration after his extensive coagulopathy was corrected by medical treatment. CONCLUSIONS: The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE based on our limited experience. We avoided unnecessary explorations while concomitantly made prompt diagnosis in emergent situations. The hTEE device was a valuable tool in hemodynamic management in the intensive care unit, allowing rapid evaluations

A cost reducing ECMO model: a single institutional experience.

Background: The demand for ECMO support has grown. Its provision remains limited due to several factors (high cost, complicated technology, lack of expertise) which increase healthcare cost. Our goal was to assess if an ICU run ECMO model (without continuous bedside perfusion) would decrease costs while maintaining patient safety and outcomes. Method: We performed a retrospective review that analyzed the cost and safety benefits of a newly implemented ICU-run ECMO unit from 2011-2012. The program consisted of a dedicated ICU involving multidisciplinary providers (ICU RN, mid-level providers and intensivists). In year one, we introduced an education platform, new technology and dedicated space. In year two, the multidisciplinary providers (MDPs) adopted continuous bedside perfusion support. New management algorithms designating MDPs as first responders were established. The primary end point included total cost, while the secondary end points were the RN ratios and patients’ safety. We compared these parameters with the previous model. Results: During the study period, 75 patients were placed on ECMO (mean days: 10). The total hospital expenditure for the previous ECMO model was $623,070 compared to$302,328 respectively, showing a 46.8% decrease in cost. This cost decrease was attributed to a decreased utilization of perfusionist services and the introduction of longer lasting and more efficient ECMO technology. We did not find any significant changes in RN ratios or any differences in outcomes related to ICU safety events. Conclusion: We demonstrated that the ICU run ECMO model managed to lower hospital cost by reducing the cost of continuous bedside perfusion support with no loss in safety or outcomes. Presented at ASAIO’s 59th Annual Conference. Chicago, IL. June 12-15, 2013

Left ventricular thrombus found in a patient with ARDS and stress-induced cardiomyopathy requiring veno-arterial ECMO.

Presentation: 68 year-old male with a history of acute leukemia with complete remission after bone marrow transplant 4 months ago, coronary disease s/p LAD stents about 14 years ago with no chronic anti-platelet medication, and repeated episode of DVT despite appropriate anti-coagulation, presented with viral pneumonia (rhinovirus)

MRSA sepsis and acute respiratory distress syndrome during veno-arterial extracorporeal membrane oxygenation (ECMO).

Presentation: A 39 year old female African American presented with respiratory distress two days after ERCP for pancreatitis. The patient quickly deteriorated, required intubation, and developed severe hypotension requiring vasopressors. VA-ECMO was initiated for ARDS and SIRS due to on-going pancreatitis. Pre ECMO ABG: PH 7.01, PaCO2 70, PaO2 70 with FiO2 100% with PEEP 15 Profound hypotension, required 2 pressors Preliminary results of cultures were negative at the time of ECMO placement. Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013

Pulmonary Embolism: Surgical / Interventional Management

Presentation: 13:34 (Note: audio is cut off, complete set of PowerPoint slides can be found at bottom of page

Does skin pigmentation effect readings of cerebral oximeter devices while on cardiopulmonary support?

Introduction: Cerebral oximetry is utilized as a non-invasive method to ensure adequate cerebral perfusion. In a review of our clinical experience, it was noted that there were consistent inaccurate values from normal utilizing relative (INVOS, Covidien, Mansfield, MA) cerebral oximetry as opposed to absolute (FORESIGHT, CAS medical, Branford, CT) cerebral oximetry in darker skin patients. Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013

Antithrombin III deficiency in a patient requiring extracorporeal membrane oxygenation.

Introduction: Antithrombin or antithrombin III (ATIII) is a vitamin K-independent, natural anticoagulant that is the major inhibitor of thrombin. With the binding of heparin, a conformational change in antithrombin occurs that increases the inactivation of thrombin by antithrombin by 4000-fold. Antithrombin deficiency can be hereditary or acquired; the acquired form is frequently encountered in patients requiring mechanical circulatory support. Formulation of clots within the circuit of extracorporeal membrane oxygenation (ECMO) is a life-threatening emergency and requires emergent intervention. Decreased ATIII is associated with a hypercoagulable state, which can lead to dangerous complications for patients requiring mechanical circulatory support