Cannula-related Complications Research Articles

Flow capabilities of arterial and drainage cannulae during venoarterial extracorporeal membrane oxygenation: A simulation model.

Large cannulae can increase cannula-related complications during venoarterial extracorporeal membrane oxygenation (VA ECMO). Conversely, the ability for small cannulae to provide adequate support is poorly understood. Therefore, we aimed to evaluate a range of cannula sizes and VA ECMO flow rates in a simulated patient under various disease states. Arterial cannulae sizes between 13 and 21 Fr and drainage cannula sizes between 21 and 25 Fr were tested in a VA ECMO circuit connected to a mock circulation loop simulating a patient with severe left ventricular failure. Systemic and pulmonary hypertension, physiologically normal, and hypotension were simulated by varying systemic and pulmonary vascular resistances (SVR and PVR, respectively). All cannula combinations were evaluated against all combinations of SVR, PVR, and VA ECMO flow rates. A 15 Fr arterial cannula combined with a 21 Fr drainage cannula could provide >4L/min of total flow and a mean arterial pressure of 81.1 mmHg. Changes in SVR produced marked changes to all measured parameters, while changes to PVR had minimal effect. Larger drainage cannulae only increased maximum circuit flow rates when combined with larger arterial cannulae. Smaller cannulae and lower flow rates could sufficiently support the simulated patient under various disease states. We found arterial cannula size and SVR to be key factors in determining the flow-delivering capabilities for any given VA ECMO circuit. Overall, our results challenge the notion that larger cannulae and high flows must be used to achieve adequate ECMO support.

Muscle ultrasound shear wave elastography for detection of early onset lower limb ischemia in patients with veno-arterial extracorporeal membrane oxygenation

Background and objectivesLimb ischemia or compartment syndrome, requiring surgery, are some of the frequent cannula-related complications in patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this exploratory study is to depict and evaluate the dynamic changes in the lower limb muscles with ultrasound shear wave elastography as marker for early lower limb ischemia.MethodsEleven patients with VA-ECMO after cardiac arrest were included in this study. Seven patients received distal perfusion cannula (DPC) after implantation of the VA-ECMO, whereas 4 had no DPC after VA-ECMO. Compartment syndrome was clinically excluded in all patients. Both lower limbs, e.g., with and without arterial cannula, were monitored with near-infrared spectroscopy (NIRS) for the oxygen saturation of the local tissue. We performed ultrasound shear wave elastrography (SWE) to assess dynamic changes of the medial gastrocnemius muscle at maximum passive muscle stretch (exercise) of both legs. Color-coded duplexsonography was conducted to examine the blood flow velocity of the popliteal artery of the lower limb.ResultsWe found no difference between DPC and no DPC (p = 0.115) during use of VA-ECMO. However, we detected marked lower limb muscle perfusion deficits of cannulated (58.9 ± 13.5 kPa) vs. cannula-free limb (95.7 ± 27.9 kPa: p < 0.001), applying SWE. No relationship was detected between NIRS measurements and SWE values (kPa) of both lower limbs. The mean peak systolic velocity of the popliteal artery at the cannulated side (30.0 ± 11.7 cm/s) was reduced compared to the non-cannulated side (39.3 ± 18.6 cm/s; p = 0.054).ConclusionsRegardless of DPC after implantation of VA-ECMO, the gastrocnemius muscles seem to lose function due to cannula-related microcirculatory deficits. Muscle function analysis via SWE combined with NIRS might offer a sensitive indicator for early onset leg ischemia during VA-ECMO-related arterial cannulation.

Small Arterial Return Cannulae in Veno-Arterial Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is used to support refractory cardiogenic shock. The arterial return cannula size is typically chosen to maximise flow based on the largest cannula the patient can safely accommodate. However, smaller arterial return cannulae may be easier to insert and reduce cannula-related complications. This in vitro study aimed to quantify the haemodynamic effects of different arterial return cannula sizes on a simulated cardiogenic shock patient.

Incidence, time to occurrence and predictors of peripheral intravenous cannula-related complications among neonates and infants in Northwest Ethiopia: an institutional-based prospective study

BackgroundPeripheral intravenous cannulas (PIVC) are venous access devices commonly used for the administration of intravenous fluids, drugs, blood products, and parenteral nutrition. Despite its frequent use, it has complications that can seriously threaten patient safety, prolong hospital stays, and increases medical care costs. PIVC complications are associated with increased morbidity and reinsertion attempts are painful and anxiety-provoking for children and their parents. Therefore, this study was aimed to assess the incidence, time to occurrence and identify predictors for PIVC complications among infants admitted to Debre Tabor Comprehensive Specialized Hospital (DTCSH), Northwest Ethiopia.Methods and settingAn institutional-based prospective cohort study was conducted on 358 infants admitted to a neonatal intensive care unit and pediatric ward, DTCSH from January 1 to April 30, 2022. A systematic sampling technique was employed.ResultsThe incidence rate of PIVC complication was 11.6 per 1000 person-hours observation. PIVC complication was observed in 56.4% (202) of PIVCs, of which infiltration (42.1%) was the most common complication followed by phlebitis (29.7%). The median time to complication was 46 h. Anatomical insertion site (AHR = 2.85, 95%CI: 1.63–6.27), admission unit (AHR = 1.88, 95%CI: 1.07–4.02), sickness (AHR = 0.24, 95% CI: 1.31–4.66), medication type (AHR = 2.04, 95%CI: 1.13–3.66), blood transfusion (AHR = 0.79, 95%CI: 0.02–0.99), clinical experience (AHR = 0.52, CI:0.26–0.84), and flushing (AHR = 0.71, 95%CI: 0.34–0.98) were potential predictors of PIVC complication.ConclusionKnowing the predictor factors helps clinicians to provide effective care and to detect complications early.

Partial Flow Extracorporeal Life Support Strategy for Refractory Cardiogenic Shock

<h3>Purpose</h3> There is a paucity of evidence on cannulation and flow strategy for extracorporeal life support (ECLS). Our center employs a partial flow ECLS strategy for cardiogenic shock (CS) in which patients on peripheral ECLS are managed with partial flow using a 15F-17F arterial cannula regardless of patient body size to minimize cannula-related complications. Here we describe our clinical experience of partial flow ECLS strategy for CS. <h3>Methods</h3> We retrospectively reviewed 145 cases who developed CS requiring ECLS insertion between January 2019 and June 2021. We excluded 6 cases who were cannulated at outside hospital and 29 cases of central ECLS. <h3>Results</h3> Etiology for cardiogenic shock was as follows (including 6 cases of extracorporeal cardiopulmonary resuscitation): Post-cardiotomy shock 15, acute on chronic heart failure 25, acute ischemic cardiogenic shock 20, primary graft dysfunction 6, distributive shock 10, acute myocarditis 7, acute right ventricular failure 4, arrhythmia 5, and other 14. Mean age was 57.3 years and length of ECLS support was 7.2 days. Left ventricular venting strategy was used in 63% (67/106) of cases (IABP 50, Impella 17). Arterial cannula size: 15Fr 92%, 17Fr 7% and distal perfusion catheter was placed in 30% of cases. Average ECLS flow was 1.57L/min/m2 (3.0L/min). 53% (57/106) recovered and were decannulated, 28% (30/106) were bridged to advanced therapy (extracorporeal VAD 11, Impella 7, durable LVAD 6, transplant 6). ECLS related complications were as follows: Vascular injury 1, toe necrosis 1, leg ischemia required fasciotomy 0, bleeding from cannulation site 2, pseudoaneurysm 1, permanent neurodeficit 1, transient neurodeficit 2, Groin complication (dehiscence/infection/lymphocele) 11. The rate of survival to discharge was 61% (65/106). <h3>Conclusion</h3> Partial flow strategy is a feasible approach with a low rate of fatal complications and can effectively bridge patients to recovery or other advance therapy. Cannula-related complications complications remain a problem with this strategy.

Hemodynamics of small arterial return cannulae for venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (ECMO) provides mechanical support for critically ill patients with cardiogenic shock. Typically, the size of the arterial return cannula is chosen to maximize flow. However, smaller arterial cannulae may reduce cannula-related complications and be easier to insert. This in vitro study quantified the hemodynamic effect of different arterial return cannula sizes in a simulated acute heart failure patient. Baseline support levels were simulated with a 17 Fr arterial cannula in an ECMO circuit attached to a cardiovascular simulator with targeted partial (2.0L/min ECMO flow, 60-65mmHg mean aortic pressure-MAP) and targeted full ECMO support (3.5L/min ECMO flow and 70-75mmHg MAP). Return cannula size was varied (13-21 Fr), and hemodynamics were recorded while keeping ECMO pump speed constant and adjusting pump speed to restore desired support levels. Minimal differences in hemodynamics were found between cannula sizes in partial support mode. A maximum pump speed change of +600rpm was required to reach the support target, and arterial cannula inlet pressure varied from 79 (21 Fr) to 224mmHg (13 Fr). The 15 Fr arterial cannula could provide the target full ECMO support at the targeted hemodynamics; however, the 13 Fr cannula could not due to the high resistance associated with the small diameter. A 15 Fr arterial return cannula provided targeted partial and full ECMO support to a simulated acute heart failure patient. Balancing reduced cannula size and ECMO support level may improve patient outcomes by reducing cannula-related adverse events.

Perforated duodenum with hemorrhage while on V-V ECMO: Diagnostic challenge

ECMO and cannula-related complications remain a concern in critical care, and may conceal serious unrelated underlying medical or surgical problems. A 22 month-old male patient was put on veno-venous ECMO for H1N1 infection using jugular and femoral cannulas. Iliac vein perforation by the cannula was suspected following abdominal distention and fresh blood in the abdomen. Emergent laparotomy unexpectedly revealed a perforated duodenum, which was primarily repaired. This is the first reported case of a duodenal perforation in a child on ECMO. With increasing use of ECMO, more attention should be given to rare complications related to the underlying diseases.

Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population.

Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population. A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement. During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33). There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.

Month-long Respiratory Support by a Wearable Pumping Artificial Lung in an Ovine Model.

A wearable artificial lung could improve lung transplantation outcomes by easing implementation of physical rehabilitation during long-term pretransplant respiratory support. The Modular Extracorporeal Lung Assist System (ModELAS) is a compact pumping artificial lung currently under development. This study evaluated the long-term in vivo performance of the ModELAS during venovenous support in awake sheep. Feedback from early trials and computational fluid dynamic analysis guided device design optimization along the way. The ModELAS was connected to healthy sheep via a dual-lumen cannula in the jugular vein. Sheep were housed in a fixed-tether pen while wearing the device in a holster during support. Targeted blood flow rate and support duration were 2-2.5 L/min and 28-30 days, respectively. Anticoagulation was maintained via systemic heparin. Device pumping and gas exchange performance and hematologic indicators of sheep physiology were measured throughout support. Computational fluid dynamic-guided design modifications successfully decreased pump thrombogenicity from initial designs. For the optimized design, 4 of 5 trials advancing past early perioperative and cannula-related complications lasted the full month of support. Blood flow rate and CO2 removal in these trials were 2.1 ± 0.3 L/min and 139 ± 15 mL/min, respectively, and were stable during support. One trial ended after 22 days of support due to intradevice thrombosis. Support was well tolerated by the sheep with no signs of hemolysis or device-related organ impairment. These results demonstrate the ability of the ModELAS to provide safe month-long support without consistent deterioration of pumping or gas exchange capabilities.

Clinical outcomes according to cannula configurations in patients with acute respiratory distress syndrome under veno-venous extracorporeal membrane oxygenation: a Korean multicenter study

BackgroundRecirculation during veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a known drawback that limits sufficient oxygenation. This study aimed to compare the short-term oxygenation and long-term mortality based on cannula configuration in patients with acute respiratory distress syndrome (ARDS) who receive VV-ECMO, especially in the absence of newly developed dual-lumen, single cannula.MethodsData of patients with severe ARDS who received VV-ECMO from 2012 to 2015 at six hospitals were retrospectively analyzed. Primary outcomes were the partial pressure of oxygen (PaO2) at 1, 4, and 12 h after ECMO initiation and 180-day mortality.ResultsPatients (n = 335) were divided into two groups based on the return cannula site: femoral vein (n = 178) or internal jugular vein (n = 157). The propensity score matching analysis generated 90 pairs, and baseline characteristics at admission, including PaO2, were similar between the groups. PaO2 at 1, 4 and 12 h after ECMO initiation were not different according to cannula configuration. Moreover, the increment in oxygenation from the baseline values was not different between the femoral and jugular group. PaCO2 level at 1, 4 and 12 h were significantly lower in the jugular group. The two groups did not differ in terms of mortality at 180 days after ECMO, however more cannula-related complications occurred in the jugular group.ConclusionRegardless of the cannula configuration, patients with ARDS managed with VV-ECMO showed comparable clinical outcomes in terms of short-term oxygenation and long-term mortality. Nevertheless, further well-designed randomized control trials are warranted.

A paediatric case of severe tracheobronchial injury successfully treated surgically after early CT diagnosis and ECMO safely performed in the hybrid emergency room

BackgroundIn paediatric trauma patients, tracheobronchial injury can be a rare, life-threatening trauma. In 2011, we instituted a new trauma workflow concept called the hybrid emergency room (Hybrid ER) that combines a sliding CT scanning system with interventional radiology features to permit CT examination and emergency therapeutic intervention without moving the patient. Extracorporeal membrane oxygenation (ECMO) can lead to cannula-related complications. However, procedures supported by moveable C-arm fluoroscopy and ultrasonography equipment can be performed soon after early CT examination. We report a paediatric patient with tracheobronchial injury diagnosed by CT examination who underwent rapid resuscitation and safe installation of veno-venous (VV) ECMO in our Hybrid ER and was successfully treated by surgery.Case presentationA 11-year-old boy was admitted to our Hybrid ER suffering blunt chest trauma. His vital signs were unstable with low oxygen saturation. Early CT examination was performed without relocation. CT revealed bilateral hemopneumothorax, bilateral lung contusion, left multiple rib fractures, and right bronchus intermedius injury. Because his oxygenation was severely low with a PaO2/FiO2 ratio (P/F) of 109, he was at very high risk during transport to the operating room and changing to one-lung ventilation. Thus, we established VV ECMO in the Hybrid ER before we performed thoracotomy under left lung ventilation in the operating room. After the P/F ratio improved, he was transferred to the operating room under VV ECMO. We performed middle- and lower-lobe resection and sutured the stump of the right bronchus intermedius to treat the complete tear of this branch. After his respiratory function recovered, VV ECMO was removed on postoperative day 5. After in-patient rehabilitation, he was discharged home on postoperative day 68 without sequelae.Conclusions It is feasible to perform VV ECMO in the Hybrid ER, but one case does not conclude it is safe. In this case, the blood oxygenation improved, but there are no evidence to support the safety of the procedure or the advantage of ECMO initiation in the Hybrid ER rather than in the operating room.

Elective replacement of intravenous cannula in neonates-a randomised trial.

Peripheral intravenous cannula (PIVC) insertion is one of the most common invasive procedures performed in neonates and is frequently associated with adverse events. There are no studies in the neonatal population looking at the possibility of reducing the risk of PIVC-related complications by elective replacement of PIVC. A randomised, non-blinded, control trial was conducted in a tertiary level neonatal unit in Melbourne, Australia, to examine rates of extravasation in neonates with elective replacement of PIVC as compared to standard practice. Neonates born at 32weeks of gestation or more were randomly assigned to have their PIVC replaced electively (every 72-96h) or when clinically indicated in a 1:1 allocation ratio after parental consent. Primary outcome studied was rate of extravasation. Secondary outcomes included rates of phlebitis, leakage or spontaneous dislodgement of PIVC. One hundred thirteen infants were enrolled. Extravasation was noted in 33 (60%) of standard practice group vs. 28 (48.3%) of elective replacement (RR 0.80, CI 0.57-1.13, p = 0.21) infants. Time to first extravasation was similar between the groups (hazard ratio 0.69, CI 0.42-1.15). Extravasation events per 1000 IV hours were also similar between groups. Similar results were seen by both intention to treat and per protocol analyses. There was an increase in leaking rates (HR1.98, CI 1.03-3.81, p = 0.04) in the elective group, while phlebitis and spontaneous dislodgement rates were similar to standard group.Conclusion: Elective replacement of PIVC in neonates is not associated with reduction in extravasation rates.Trial registration: This trial has been registered with the Australian and New Zealand Clinical Trials Register. Identifier: ACTRN12615000827538. What is Known: • The reported incidence of extravasation injury is as high as 70% in the neonatal and paediatric population and has an association with cannula dwell time. • Adult studies have done to look at the possibility of reducing intravenous cannula-related complications with routine replacement of the cannulas but no similar studies have been done in the neonatal population. What is New: • Routine replacement of intravenous cannula in neonates between 72 and 96h of use does not reduce the rate of extravasation injuries. • There might be some added complications associated with such a practice.

Peripheral Intravenous Catheter (PIVC) Related Local Complications among Patients in KFCH-Jizan

Background: Peripheral intravenous catheterization is a common invasive nursing procedure performed in healthcare institutions. It is a technique which involves insertion of a needle into the peripheral veins for various reasons. As one of the commonest nursing procedures being performed, it also brought significant risks to patients resulting to prolong hospital stay and delay in recovery period if not properly executed. Objectives: The study primarily aims to determine the incidence rate of peripheral intravenous cannula related local complications in the hospital. Design: The study is a descriptive type of research since it mainly deals with identifying the incident rate of phlebitis, infiltration, extravasation and hematoma and its underlying causes. Settings: Study was conducted in one of the Ministry of Health hospitals in Jazan, Saudi Arabia. Participants: All the patients admitted in the hospital during the data gathering period was included regardless of their demographic status. A total of 406 patients, with 458 peripheral cannula were assessed. Methods: The study is quantitative type of research since it mainly sought to find out the number of phlebitis, infiltration, extravasation and hematoma cases in the above mentioned healthcare institution. Result: The findings show that the rate of phlebitis, infiltration, extravasation and hematoma are 21, 7, 3.5, 12 percent respectively. Conclusions: There were high incidence of intravenous cannula related complications in the hospital which needs to be reduced or completely eradicated in order to improve overall patient's health outcome.

Plastic in patient study: Prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications.

Peripheral intravenous cannula (PIVC) insertion is a universal intervention for inpatients and is associated with multiple complications. Effective, simple, reproducible interventions specific to PIVC complication prevention are few and often extrapolated from central venous catheter complication prevention strategies. The objective of this study is to improve compliance with documentation and monitoring PIVC guidelines in the medical ward of a secondary care center. This study is a prospective run-in audit of adherence to PIVC documentation and monitoring guidelines between the dates of August 30-November 14, 2014, with data recollection from December 25, 2014-January 30, 2015, after intervention implementation. Three interventions were implemented. The Plastic in Patient (PIP) strip is a dedicated column on the journey board, identifying inpatients with PIVCs, prompting assessment of indication at daily multidisciplinary meetings. PIP row is a prompt in the medical admission proforma to review PIVC indication. PIP poster is a visual cue on PIVC trolleys highlighting PIVC management practices. Baseline demographics were similar in the pre- and postintervention groups. Documentation significantly improved in the postintervention group (36.4 vs 50%, P = .025). Early identification of nonindicated PIVCs improved in the postintervention group (88.8% vs 97.1%, P = .018) and a trend toward a reduced PIVC-related early phlebitis rate (3.7% vs 0, P = .08). Simple, cost-effective interventions result in improvements in adherence to practice guidelines. Our results suggest a trend toward reduction in phlebitis rates.

Direct complications of the Avalon bicaval dual-lumen cannula in respiratory extracorporeal membrane oxygenation (ECMO): Single-center experience.

Cannulation for veno-venous extracorporeal membrane oxygenation (VVECMO) may involve a single site when using a dual-lumen cannula. Benefits include a decrease in blood recirculation, easier patient mobilization, and lower risk of dislodgment. We aimed to review all complications related to the cannula. The study included all adult patients admitted to a single intensive care unit (ICU), between November 2009 and September 2013, requiring VVECMO in whom an Avalon Cannula was inserted. The list of patients, complications, and patient data were retrieved from the local ECMO database and the intensive care Clinical Information System (CIS). Seventy two patients were cannulated with an Avalon cannula between November 1, 2009 and September 31, 2013. Forty-four patients had no cannula-related complications. A total of 35 complications were recorded in 28 patients, 6 of whom required further intervention. Successful cannulation was possible in all patients with the majority of complications graded as minor.

Effect of prone positioning on cannula function and impaired oxygenation during extracorporeal circulation

Prone ventilation is an effective method for improving oxygenation in patients with acute respiratory failure. However, in extracorporeal circulation, there is a risk of cannula-related complications when changing the position. In this study, we investigated cannula-related complications when changing position for prone ventilation and the effect of prone ventilation on impaired oxygenation in patients who underwent extracorporeal membrane oxygenation (ECMO). The study subjects were patients who underwent prone ventilation during ECMO in the period from 2004 to 2011. Indication for prone ventilation was the presence of dorsal infiltration shown by lung computed tomography. Factors investigated were cannula insertion site, dislodgement or obstruction of the cannula, malfunction of vascular access and unplanned dislodgement of the catheters when changing position. Mean arterial pressure, PaO2/FiO2, PEEP level, blood flow and rotation speed of the pump were also determined before and after position change. Five patients were selected as study subjects. The mean duration of prone positioning was 15.3 ± 0.5 h. Strict management during position changes prevented cannula-related complications in the patients who underwent extracorporeal circulation. There were no significant changes in mean arterial pressure, PEEP level, blood flow and rotation speed of the pump when changing position. Low PaO2/FiO2 prior to prone ventilation was significantly increased after supine to prone and then prone to supine position. Prone positioning to improve impaired oxygenation is a safe procedure and not a contraindication in patients receiving extracorporeal circulation.

Bi-Caval Dual Lumen Catheter for Veno-Venous Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation for Cystic Fibrosis

Purpose Extracorporeal Membrane Oxygenation (ECMO) is now considered as a useful technique for severe respiratory failure in end stage cystic fibrosis (CF) patients. Muscle deconditioning, sepsis and multiple organ failure must be avoided to allow lung transplantation (LT). We evaluate the feasibility of “awake” ECMO and outcome of a strategy based on systematic double lumen bi-caval cannula (DLC) for V-V ECMO as a bridge to LT. Methods and Materials From 06/10 to 06/12 we systematically used a DLC (Avalon®) for V-V ECMO as a bridge to LT, in a single institution. Insertion in the right jugular vein was performed with fluoroscopic or transoesophageal echocardiographic guidance. CF patients were considered for this strategy in the absence of general sepsis or extra respiratory organ failure. Results 10 CF patients (7 females, median aged 24 years, range 17-32) were included. Before ECMO, patients were hypercapnic (100+-10mmHg) and hypoxemic (PaO2/FiO2: 133+−91mmHg) despite optimization of mechanical ventilation. Patients received antibiotics and steroids. DLC implantation was successful in 8. In the 2 other cases failure was related to intrathoracic venous stenosis secondary to previous central access port and a conventional V-V ECMO was used. Gas exchange correction was rapidly achieved. 6 patients could be awakened with spontaneous breathing. Physical therapy, active rehabilitation and proper alimentation were then easily continued. No cannula related complications were observed. All patients were transplanted within 3.4+−1.7 days. Intraoperatively, we systematically switched V-V to Veno-Arterial ECMO. 5/10 required ECMO support after transplantation during 3.4+−2.8 days. The mean lengths of mechanical ventilation and ICU stay were respectively 8+−12 days and 17+/−14 days. 3 patients died at day 41, 59 and 61 from septic complications. Conclusions A strategy based on DLC for V-V ECMO is suitable as a bridge for LT in end stage CF patients.

Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience

IntroductionSevere trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg.MethodsA retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval.ResultsBetween April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32 ± 14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9 ± 10.5, the mean lung injury score was 3.3 ± 0.6 and the Sequential Organ Failure Assessment score was 10.5 ± 3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2 ± 7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9 ± 3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n = 5); vv-ECMO, 12% (n = 3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%).ConclusionPumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Venovenous extracorporeal membrane oxygenation for acute lung failure in adults

Acute lung failure (ALF) is an increasing problem that can be treated with venovenous extracorporeal membrane oxygenation (vv-ECMO). This report summarizes prospectively collected data of an institutional experience with vv-ECMO. From January 2007 to December 2010, 176 patients (mean age, 48 ± 16; range, 14-78 years) with ALF refractory to conventional therapy were supported with vv-ECMO. The general indication for vv-ECMO was a partial oxygen pressure/fraction of inspired oxygen (Fio(2)) < 80 mm Hg under a Fio(2) of 1.0, a positive end-expiratory pressure of 18 cm H(2)O, and refractory respiratory acidosis (pH < 7.25), despite optimization of conservative therapy. All patients underwent peripheral cannulation. In 59 cases, vv-ECMO was placed in another facility with ECMO transport by helicopter or ambulance. The mean vv-ECMO support interval was 12 ± 9.0 days (range, 1-67 days). During ECMO, 12 patients (7%) could be extubated and stepwise mobilized. Cannula-related complications during long-term support occurred in 14%, which was mostly minor bleeding. Overall survival was 56%: 58 patients (33%) died during mechanical support, and 20 (11%) died after weaning from the system. The best outcome was noted in trauma patients. Risk factors were mainly advanced age and multiorgan failure. Modern vv-ECMO is an excellent treatment in patients with severe ALF and should be more liberally used.

Support time-dependent outcome analysis for veno-venous extracorporeal membrane oxygenation

The majority of patients suffering from pulmonary failure refractory to mechanical ventilation require extracorporeal membrane oxygenation (ECMO) support between 1 and 2 weeks. This study was designed to evaluate differences in outcome depending on ECMO duration. A retrospective analysis on n = 127 patients requiring veno-venous (VV) ECMO support at our institution between April 2006 and March 2010 was applied. The patient population was divided into three groups according to the support duration (A: 0-10 days), 75 patients; B: 11-20 days, 32 patients; C: >21 days, (max. 67 days), 19 patients). Statistical comparisons between groups were calculated. Mean age of all patients (♀ = 42 patients ♂=85 patients) was 48 ± 16 years (range 15-78 years). Bilateral pneumonia due to bacterial infection (n = 45 patients) or due to aspiration (n = 19 patients) was the main cause for pulmonary failure, other causes were extrapulmonary sepsis (n = 27 patients), major surgery (n = 17 patients), and severe trauma (n = 12 patients). Mean lung injury score (LIS) according to Murray was 3.4 ± 0.4, and mean sequential organ failure assessment (SOFA) score was 12.6 ± 3.7. Statistical comparisons revealed no significant difference in demographic parameters between groups. VV ECMO support immediately improved oxygenation, within 2h the PaO(2)/FiO(2) ratio rose from 80 ± 42 mm Hg to 129 ± 72 mm Hg (p = 0.001). Overall survival to discharge was 51.2%. There was a statistical difference in survival between groups (A = 59%, B = 31%, C = 52%; p = 0.029). Multivariate logistic regression analysis revealed renal failure (odds ratio (OR) 12.1; confidence interval (CI) 3.9-30.0; p < 0.001) and the use of NO (OR=5.8; CI=1.9-24.9; p=0.002) as risk factors for mortality. Complications consisted of cannula-related complications (14%), bleeding issues (13%), partial vein thrombosis of the cannulated vessels (9.5%), and pumphead failure (1.5%). VV ECMO in patients suffering from severe lung failure is effective in improving gas exchange with an overall survival of higher than 50%. Prolonged need of ECMO support does not have an impact on survival.