Cannula Site Research Articles

Outcomes of Transferred Adult Venovenous and Venoarterial Extracorporeal Membrane Oxygenation Patients: A Single Center Experience.

ObjectivesExtracorporeal membrane oxygenation (ECMO) patients with or without transport both have high hospital mortality rate and there are few data on adult VA-ECMO transport patients. Hence, this study was designed to analyze factors that affect the outcomes of patients with ECMO transport.MethodsThis study retrospectively enrolled 126 ECMO patients transferred from regional hospital to the First Affiliated Hospital of Zhengzhou University by our ECMO team during June 2012 to Sept 2020. Data were calculated and analyzed.ResultsThe median distance of transportation was 141 (76–228) km, the median transport time consuming was 3 (1.3–4) h, the percentage of complications during transport was 40.5% (except for bleeding on cannula site, and no one death during transport), and the survival rate in hospital was 38.9%. Compared with survivors, the non-survivors were older and showed higher SOFA score, longer time with ECMO assisted, longer time in ICU and in hospital. However, after divided into VA-ECMO and VV-ECMO groups, the older age showed no significant difference between survivors and non-survivors groups of VA-ECMO patients. Moreover, the Cox regression survival analysis showed that higher SOFA score and lactate level indicated higher ICU mortality of VA-ECMO patients while higher SOFA score, higher lactate level, older age and lower MAP after transportation (<70mmHg) indicated higher ICU mortality of VV-ECMO patients. However, there was no significant difference of comorbidities and complications in survivors and non-survivors groups of ECMO patients.ConclusionsThe transportation for ECMO patients can be feasible performed although life-threatening complications might occur. The SOFA score and the lactate level could be used to evaluate the risk of ICU mortality of transportation ECMO patients. Besides, lower MAP after transportation (<70mmHg) had potential predictive value for short-term outcome of VV-ECMO patients.

A Study to Assess the Occurrence and Risk Factors of Phlebitis among Peripheral Intravenous Cannulated Patients admitted in Emergency Wards of SKIMS, Soura, Srinagar with a view to develop Phlebitis Prevention Protocol

Introduction: Almost half of the patients who are administered intravenous fluid infusion or blood transfusion via IV cannula insertion develop phlebitis. This study was conducted to assess the occurrence and risk factors of phlebitis among peripheral intravenous cannulated patients admitted in the emergency wards of SKIMS, Soura, Srinagar with a view to develop phlebitis prevention protocol. Methodology: A non-experimental descriptive research design was used for the study. Convenient sampling technique was used for the selection of 250 patients. The prepared tool (semi-structured observation checklist) and phlebitis prevention protocol were validated by experts. Pre-testing and pilot study was conducted on patients other than the study sample. The data collected were analysed using descriptive and inferential statistics.Results: The results of our study showed that phlebitis occurred in more than half of the patients (58%). Among these, grade-1 phlebitis was seen in most of the patients (32.8%) and grade 4 phlebitis was seen in only 0.4%. Most of the patients developed phlebitis within the first 48 hours (26.4%) and 72 hours (20.4%) of cannulation time. There was a significant association of phlebitis with age and gender, site of cannulation, disinfection of cannula site, size/ gauge of cannula, infusion of ionotropic drugs and blood and its products, mode of infusion of IV fluids potassium chloride, and phenytoin, administration of piperacillin/ tazobactam, vancomycin, metronidazole, and imipenem. Conclusion: Staff nurses should be made aware of the various risk factors associated with phlebitis. Appropriate training and education programmes should be implemented.

Indications, outcomes and complications after ECMO implantation in the cath lab - a single-center retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite the increase of extracorporeal membrane oxygenation (ECMO) employment around the globe over the last decades, studies describing the emergency use of venoarterial (VA)-ECMO in the cardiac catheterization laboratory (CCL) are scarce. Purpose The aim of this study was to describe the patient population that received ECMO in the CCL of a tertiary care center and the associated complications and outcomes. Methods In this single-center retrospective study we reviewed the baseline clinical and laboratory characteristics, indications and outcomes of adult patients, who received VA-ECMO between 2011 and 2019. Results In the given time period, ECMO use in the CCL increased drastically. Mean age of the 83 patients was 58.3 ± 12.5 years, 78.3% were male. From 2011 to 2018 ECMO-use in the CCL increased drastically. The most common indication for ECMO implantation was cardiac arrest (66%), followed by cardiogenic shock (12%), high-risk PCI (11%), and procedure-related complications (10%). While 30-day mortality in the total study population was 69%, it varied greatly depending on the underlying indication for ECMO therapy (cardiac arrest 78%, cardiogenic shock 20%, high-risk PCI 44%, procedure-related complications 88%). The most commonly occurring complications were acute kidney injury (20%) and cannula site bleeding (20%), followed by extremity complications (19%), sepsis (18%), major bleeding (10%) and stroke (8%). Of interest, patients receiving ECMO therapy after in-hospital cardiac arrest showed greater survival rates (28.2%) as compared to patients after out of hospital cardiac arrest (18.2%; p=0.045). High serum lactate levels (p=0.018) and low baseline pH values (p=0.001) at baseline were associated with a significantly increased 30-day mortality after ECMO implantation. Conclusion The emergency use of VA-ECMO in the CCL increased over the last years and was associated with a high 30-day mortality in our study population. Still, a &amp;gt;20% survival rate in the group of patients with refractory cardiac arrest, an otherwise futile situation, suggests that VA-ECMO implantation is reasonable in selected patients. As high admission serum lactate levels and the baseline pH are strong predictors of outcome, such parameters may be used to guide decision making.

Padded Dressing with Lidocaine HCL for Reducing Pain during Intravenous Cannulation in Adult Patients: A Randomized Controlled Clinical Trial.

Objective In this study, we aimed to evaluate the effect of administering lidocaine as a local anesthetic at the puncture site prior cannulation on reduction of pain during intravenous cannulation (IVC). Methods A total of 77 patients were divided into two groups as the patients who received a local anesthetic prior IVC procedure (n = 40) and the control group (n = 37). Patients' demographic data, including age, gender, height, weight and body mass index, IV gauge, IV site, heart rate (HR), and oxygen saturation (SpO2) were recorded and analyzed. Patients in both groups scored the pain they felt during IVC through the visual analog scale (VAS) and the verbal descriptor scale (VDS). Results No statistically significant difference was found between the two groups in terms of the demographic features. There was no significant difference between the two groups in terms of the cannula gauges and site of IVC. The mean post-IVC HR value was statistically significantly higher compared to pre-IVC in the control group (p = 0.032), while no difference was found between the mean pre- and postprocedure HR in the lidocaine group. The mean VAS score was significantly lower in the lidocaine group compared to the control group (p < 0.001). There was a significant difference between the groups in terms of the current VDSs. The rate of the patients reporting mild pain was statistically significantly higher in the lidocaine group compared to the control subjects (p < 0.001). Conclusion According to the results of this study, lidocaine HCL-impregnated padded dressing prior IV cannulation significantly reduced pain sensation during IVC.

Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) afterload, potentially provoking LV distention and impairing recovery. LV mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) can prevent LV distension, potentially at the risk of more complications, and net clinical benefit remains uncertain. ObjectivesThis study aims to determine the association between MU and outcomes for patients undergoing VA-ECMO. MethodsThe authors queried the Extracorporeal Life Support Organization registry for adults receiving peripheral VA-ECMO from 2010 to 2019 and stratified them by MU with IABP or pVAD. The primary outcome was in-hospital mortality; secondary outcomes included on-support mortality and complications during VA-ECMO. ResultsAmong 12,734 VA-ECMO patients, 3,399 (26.7%) received MU: 2,782 (82.9%) IABP and 580 (17.1%) pVAD. MU patients were older (age 56.3 vs 52.7 years) and, before extracorporeal membrane oxygenation, more often required >2 vasopressors (41.7% vs 27.2%) and had respiratory (21.1% vs 15.9%), renal (24.6% vs 15.8%), and liver failure (4.4% vs 3.1%) (all P < 0.001). MU patients had lower in-hospital mortality (56.6% vs 59.3%, P = 0.006), which persisted in multivariable modeling (adjusted OR [aOR]: 0.84; 95% CI: 0.77-0.92; P < 0.001). MU was associated with more cannula site bleeding (aOR: 1.25; 95% CI: 1.11-1.40; P < 0.001) and hemolysis (aOR: 1.27; 95% CI: 1.03-1.57; P = 0.02). Compared to pVAD, MU patients with IABP had similar mortality (aOR: 0.80; 95% CI: 0.64-1.01; P = 0.06) and less medical bleeding (aOR: 0.45; 95% CI: 0.31-0.64; P < 0.001), cannula site bleeding (aOR: 0.72; 95% CI: 0.54-0.96; P = 0.03), and renal injury (aOR: 0.78; 95% CI: 0.62-0.98; P = 0.03). ConclusionsAmong adults receiving VA-ECMO, MU was associated with lower in-hospital mortality despite increased complications including hemolysis and cannulation site bleeding. Compared to pVAD, MU with IABP was associated with similar mortality and lower complication rates.

An audit of the adequacy of contrast enhancement in CT pulmonary angiograms in a South African tertiary academic hospital setting.

BackgroundUndiagnosed pulmonary embolism carries high mortality and morbidity. Computed tomography pulmonary angiogram (CTPA) is the diagnostic method of choice for accurate diagnosis. Inadequate contrast opacification is the second most common cause of indeterminate CTPAs.ObjectivesAudit the adequacy of CTPA contrast enhancement and determine whether inadequate enhancement is affected by the size and site of the intravenous cannula, flow rate, contrast volume, contrast leakage and day shift versus after hours services.MethodRetrospective and prospective audits of the adequacy of contrast enhancement of CTPAs at the Charlotte Maxeke Johannesburg Academic Hospital were conducted using the Royal College of Radiologists guidelines (≤ 11% of studies with < 210 HU). Protocol variables were collected prospectively from questionnaires completed by radiographers performing the CTPAs. Adequate versus inadequate groups were analysed.ResultsA total of 63 (retrospective) and 130 (prospective) patients were included with inadequate contrast enhancement rates of 19% (12/63) and 20.8% (27/130), respectively. The majority of CTPAs were performed during the day 56.2% (73/130) with a 20G cannula 66.2% (86/130) in the forearm 33.8% (44/130) injecting 100 mL – 120 mL contrast 43.1% (56/130) at 3 mL/s 63.1% (82/130). The median flow rate (3 mL/s) and contrast volume (80 mL) were identical in both adequate and inadequate groups, while the remaining variables showed no statistical difference.ConclusionThe rate of inadequately enhanced CTPAs in this study was high. The protocol variables did not have a significant influence on the rate of inadequate enhancement. Further research, particularly using flow rates > 4 mL/s, is required for protocol optimisation.

Effectiveness of Protocol Based Nursing Care of Patients with Intravenous Line Cannula in Selected Hospital at Ambala City

Health team members are always bound to be right for the betterment of patient, but when it becomes difficult to keep up there comes the need for a guidance to lead them on the right track. Nurses have to perform many important procedures while caring patients and one among those is the administration of intravenous fluids. The process is being so common but a standard protocol is needed to follow in order to prevent the arising complications. Material and Methods: A true experimental design to evaluate the Effectiveness of protocol based nursing care of patients with intravenous line cannula in a selected hospital at Ambala city. Thestudy was conducted on 30 samples each in experimental and control group having cannula for Intravenous Therapy. Data was collected from October 2019 to December 2019.A structured observational check list was used to evaluate the effectiveness of nursing care on patients with intravenous line cannula in selected hospital. Result: The data revealed that, patients with intravenous line cannula in control group were in inadequate levels of nursing care outcome of intravenous line cannula care whereas in experimental group (13.3%) had moderate nursing care outcome, (86.7%) had adequate level of nursing care outcome and none were in the inadequate level of nursing care outcome. Comparison of the mean scores of nursing care outcome of intravenous line cannula care in terms of starting daily monitoring and the removal of intravenous line cannula between control group and experimental group was assessed by unpaired‘t’ test analysis. The calculated unpaired‘t’ value for protocol based starting of intravenous line cannula is 23.8 (Table value-2) for protocol based daily monitoring of intravenous line cannula is 20.767 (Table Value-2) and for protocol based removal of cannula is 25.336 (Table Value-2). The result shows that calculated value is more than table value at 0.05 level of significance. Comparison of outcome assessment of intravenous line cannula care in terms of complication between control group and experimental group shows that in control group majority (56.7%) of patients with intravenous line cannula had 2 attempted pricks whereas in experimental group majority (63.3%) had one prick only. In control group about 53.3% of patient with intravenous line cannula had cannula change and site changes whereas in experimental group it is only 30%. Percentage of infiltration in control group is 40% and in experimental group it is 13.3%. Also the percentage of thrombophlebitis in control group is 20% whereas it is 7% in experimental group. The association between the nursing care outcome of intravenous line cannula care among experimental group and their selected variables like site of insertion (2(1) = 0.084) are not significant, since calculated value is less than table value (3.84). Duration of intravenous line cannula (2(2) = 6.036) is significant at P&lt;0.05 level of significance because calculated value is greater than table value (5.99). Thus the result suggests protocol based nursing care of patients with intravenous cannula was effective in prevention of complications. Conclusion: After the detailed analysis of this study it shows that effective use of protocol based nursing care of patients with intravenous cannula was effective in prevention of complications.

Incidence and Associated Factors of Failed First Peripheral Intravenous Catheters among Adult Patients at Medical Surgical Wards in Public Referral Hospitals of West Amhara, Ethiopia, 2021.

Background Complications of peripheral intravenous catheters cause problems in clinical practice and bring high costs in terms of morbidity and mortality of patients. Therefore, this study aimed to assess the incidence and associated factors of failed first peripheral intravenous catheters among adult patients in selected Public Referral Hospitals of West Amhara Regional State, Ethiopia, 2021. Materials and Methods An institution-based prospective observational study was conducted among 423 adult patients from January to February 2021. Patients were selected using systematic random sampling techniques. The data were collected using interviewer-based, structured questionnaires and observational checklists. EPI-DATA 3.1 and SPSS version-23 were used for data entry and analysis, respectively. Frequency, percentages, and means were calculated. The outcome variable was determined and graded based on phlebitis and infiltration scales. Binary and multivariable logistics regressions were computed. Results Four hundred and seventeen first peripheral cannula sites from 418 patients were followed for 2,565 peripheral catheter hours. A failed first peripheral intravenous catheter was observed in 124 (29.7%, CI: 25.6–34) adult patients. Patients who were female (AOR = 0.4, 95% CI: 0.22–0.74) had cannula duration of 49–72 hours (AOR = 0.31, 95% CI: 0.14–0.7) and 73–96 hours (AOR = 0.39, 95% CI: 0.17–0.9), and patients who had been given electrolytes (AOR = 0.31, 95% CI: 0.11–0.86) were more likely to have failed first peripheral intravenous cannula. Conclusions Failed first peripheral intravenous cannula is much higher as compared to the acceptable rate of ≤5% by the Infusion Nurses Society. Hence, all patients with peripheral intravenous catheters are screened for catheter failure at least once a day. Providing appropriate nursing care and patient education is also required to reduce the risks.

Progressive skin ulceration in a febrile returning traveller

Two weeks prior to admission, while in Cape Verde, a 66-year-old man developed a fever and a necrotic ulcer on his right leg following an insect bite. He was treated with intravenous Flucloxacillin, but subsequently developed an abscess at the intravenous cannula site on his left forearm. On his return to the UK, he underwent an incision & drainage of the abscess which yielded sterile fluid. During the next ten days the incision site progressively deteriorated and became necrotic, the right leg ulcer enlarged, and fever and rigors continued despite treatment with intravenous Piperacillin/Tazobactam and Clindamycin. We suspected pyoderma gangrenosum or a systemic vasculitis. Treatment commenced with high-dose Prednisolone, Meropenem and liposomal Amphotericin. A skin biopsy from the right leg confirmed pyoderma gangrenosum; no fungi were seen. Aspergillus fumigatus was cultured from the left forearm wound. A blood film showed a leucoerythroblastic picture with 3% blasts, and a bone marrow biopsy confirmed acute myeloid leukaemia. The skin lesions progressively improved and the anti-fungal therapy was changed to Posaconazole. He received chemotherapy for acute myeloid leukaemia, before proceeding to an allogeneic bone marrow transplant. He remains well one year post-transplant. Pyoderma gangrenosum should be considered in a febrile patient who has non-healing ulcer(s) at sites of trauma. It is often associated with a systemic disease, most commonly inflammatory bowel disease, inflammatory arthritis or haematological malignancies. Because these conditions and their treatments are associated with immunocompromise, patients with pyoderma gangrenosum may also be at risk of a superimposed cutaneous fungal infection.

Clinical Features and Risk Factors Analysis for Hemorrhage in Adults on ECMO.

Background: The use of extracorporeal membrane oxygenation (ECMO) to support critically ill patients with cardiorespiratory dysfunction has increased over the last decades. However, hemorrhagic complications occur frequently during ECMO support, and this has a significant impact on morbidity and mortality. Thus, this study aimed to identify the risk factors for hemorrhage in patients receiving ECMO.Methods: Our retrospective study included 60 patients, who were admitted to the Taihe Hospital in Shiyan City, Hubei Province, China from February 2017 to October 2020. About 18 patients developed hemorrhagic complications, and 42 patients did not demonstrate such complications. Data regarding patient demography, laboratory tests, and clinical manifestations prior to ECMO were collected to analyze their clinical features. Univariable and multivariable logistic analyses were used to explore the risk factors for hemorrhage in adults on ECMO. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the binary logistic model. The amount of blood transfusions was compared between the two groups, and the activated partial thromboplastin time (APTT), platelet count, and hemoglobin level before the initiation of ECMO.Results: Logistic analysis showed that a longer duration of ECMO support, higher APTT, and lower platelet count prior to ECMO were independent risk factors for hemorrhage in adults on ECMO. In addition, we found that the cannula site was the most common bleeding site. Most bleeding events occurred within the first 3 days of ECMO therapy. After the ECMO initiation, APTT was prolonged while the platelet count and hemoglobin levels were decreased. The amount of blood transfusion was significantly higher in the hemorrhage group than in the non-hemorrhage group.Conclusions: Clinicians should evaluate the risk of hemorrhage based on the coagulation function of patients, underlying disease, and the duration of ECMO support. In the first 3 days during ECMO support, special attention should be given to the cannula site, mucosal, and dermal regions, and digestive tract to detect any signs of hemorrhage. Moreover, increasing the platelet count transfusion threshold and accurately determining the amount of blood transfusion required may prevent bleeding events.

Is this cannula ok? 5 simple steps to assess the cannula site.

Is this cannula ok? 5 simple steps to assess the cannula site.

Lessons learned from catheter ablation of ventricular arrhythmias in patients with a fully magnetically levitated left ventricular assist device

IntroductionData on catheter ablation of ventricular arrhythmias (VA) are scarce in patients with left ventricular assist devices (LVADs) and current evidence predominantly consists of case reports with outdated LVAD. This prospective observational study reports our experience in terms of catheter ablation of VAs in patients with novel 3rd generation LVADs.Methods and resultsBetween 2018 and 2020, nine consecutive patients undergoing a total number of ten ablation procedures for VAs were analyzed. The mean duration between LVAD implantation and catheter ablation was 23 ± 16 months. Acute procedural success was achieved in all patients. VA substrates were not related to the LVAD scarring (cannula) site in the majority of patients. All procedures were conducted without any relevant procedure-related complications. In terms of follow-up, only one patient presented with a repeat episode of electrical storm requiring ICD-shocks 16 months after the initial ablation procedure. Four patients suffered of singular VA effectively treated with antitachycardia pacing via their ICD. The remainder were free of any VA relapse (n = 4). Two non-procedure-related deaths occurred during follow-up.ConclusionsCatheter ablation of VAs in patients with 3rd generation LVAD is feasible and leads to satisfying clinical results in terms of freedom from VA recurrence and quality of life. The majority of arrhythmia substrates in these patients are not directly related to the LVAD cannulation site and may represent a progress of heart failure.Graphic abstract

Long-Term Outcomes in Ventricular Assist Device Outflow Cannula Anastomosis to the Descending Aorta

BackgroundLeft ventricular assist device (LVAD) implantation via thoracotomy with outflow cannula anastomosis to the descending aorta is an alternative implantation technique that uses a single incision and avoids anterior mediastinal planes. We evaluated long-term survival and hospital readmissions after LVAD implantation via thoracotomy with outflow cannula anastomosis to the descending aorta. MethodsAdult patients implanted with a continuous flow centrifugal LVAD at an academic center were retrospectively analyzed. Patients were assigned to 1 of 2 cohorts based on the anastomosis site of the LVAD outflow cannula: ascending aorta cohort (Asc-Ao) and descending aorta cohort (Desc-Ao). Primary and secondary outcomes were survival and hospital readmissions during device support. Readmission analysis included patients with ≥30-day survival after discharge. Multivariable analysis and propensity score matching were performed. ResultsSurvival analysis included 330 patients (Asc-Ao: 272, Desc-Ao: 58). Readmission analysis included 277 patients (Asc-Ao: 231, Desc-Ao: 46) and a total of 1028 readmissions during 654 patient-years of follow-up were analyzed. There was no significant difference in in-hospital, 6-month, 1-year, 3-year, and 5-year mortality between the two cohorts. Readmission-free survival, 30-day readmission, number of admissions per year and hospital length of stay per year were not significantly different between the 2 cohorts after adjustment for patient characteristics. ConclusionsThis study found no difference in long-term survival or hospital readmissions between LVAD implantation via thoracotomy with outflow cannula anastomosis to the descending aorta and standard implantation.

Veno-arteriovenous extracorporeal membrane oxygenation-A single center experience.

Patients with combined circulatory shock and respiratory failure may benefit from veno-arteriovenous (V-AV) extracorporeal membrane oxygenation support (ECMO). We report our center's experience with V-AV ECMO and propose an algorithm to help identify patients that may benefit from early V-AV ECMO support. Clinical data were extracted from electronic medical records between November 1, 2016 and November 1, 2019. Out of a total of 369 patients placed on extracorporeal life support (ECLS), we identified a total of 26 patients who underwent hybrid ECMO placement. Three patients were excluded from our analysis due to veno-venoarterial extracorporeal membrane oxygenation (V-VA ECMO) configuration, therefore 23 patients were included in our analysis. The median age was 53 (range 25-73) years. Hybrid ECMO support was instituted most commonly for differential hypoxemia in patients on venoarterial (V-A) ECMO support, and cardiogenic shock in patients who were initially started on venovenous (V-V) ECMO. The initial ECMO cannulation was V-A in 12 patients, V-V in 8 patients, and directly V-AV in 3 patients. Nine out of 23 patients were successfully decannulated (39.1%) and survived until hospital discharge. The main ECMO-related complications included bleeding (n=10), circuit exchange either due to hemolysis or oxygenator failure (n=4), ECMO cannula site infection (n=2), deep venous thrombosis (n=2), and death during ECMO cannula exchange (n=1). V-AV ECMO represents a rescue strategy in critically ill patients with combined respiratory failure and cardio-circulatory shock.

Mobilization of Patients Receiving Extracorporeal Membrane Oxygenation Before Lung Transplant

Extracorporeal membrane oxygenation is increasingly used to provide cardiopulmonary support to patients awaiting lung transplant. Although studies have shown that these patients benefit from early mobilization, the care team often has concerns about related complications, particularly for patients requiring femoral cannulation. To assess the safety of mobilizing patients receiving extracorporeal membrane oxygenation before lung transplant using a standardized mobility protocol. A retrospective review was performed of the electronic health records of patients receiving extracorporeal membrane oxygenation before or immediately after lung transplant who were mobilized according to a standardized protocol from April through October 2018. The setting was an 18-bed cardiothoracic intensive care unit in a Magnet-designated teaching hospital. Patients were helped to ambulate by an interdisciplinary team, with careful assessment for any related complications. During the study period, 37 patients received extracorporeal membrane oxygenation, and 9 were mobilized. Two hundred forty-two therapy sessions were conducted involving 47 700 feet of ambulation. Patients experienced the following complications: chugging (1 patient), decrease in flow rate (2 patients), bleeding at the cannula site (2 patients), neck hyperextension (1 patient), fear/anxiety (1 patient), and shortness of breath (2 patients). Bleeding and neck hyperextension led to discontinuation of therapy until the problems were resolved. No changes were made to the protocol. Patients receiving extracorporeal membrane oxygenation before lung transplant, including those with femoral cannulation, can be mobilized safely with the use of an interprofessional ambulation protocol. Further evaluation is indicated, including research on clinical outcomes.

Extracorporeal Membrane Oxygenation Utilization in Blunt and Penetrating Traumatic Injuries: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used treatment modality for severe respiratory insufficiency in trauma patients. Examining ECMO use specifically in blunt and penetrating traumas can aid in directing future protocols. We aim to evaluate the outcomes of ECMO use in both blunt and penetrating trauma patients through a systematic review of current literature. An online search of 2 databases (PubMed and Google Scholar) was performed to analyze studies, which evaluated the use of ECMO in blunt and penetrating traumas. Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Grading of Recommendations Assessment, Development and Evaluation guidelines were followed. Data extracted included mechanism of injury, injury severity scores (ISSs), complications, and mortality rates. The search demonstrated 9 studies that met our review inclusion criteria. A total of 207 patients were included, of which 64 (30.9%) were non-survivors and 143 (69.1%) were survivors. There was a total of 201 blunt traumas with 61 (30.3%) deaths, whereas penetrating traumas had 2 deaths (33.3%) out of 6 total patients. Complications reported included acute renal failure, hemorrhage at the cannula site, and transient neurological deficits. Most studies found better survival rates and less complications in younger patients and those with lower ISS. Expanding the use of ECMO to include blunt and penetrating trauma patients provides the trauma surgeons with another crucial potentially lifesaving tool with an overall survival rate of 70%. Anticipating increased future use of ECMO in blunt and penetrating trauma patients, distinct protocols ought to be instilled to better address the care needed for these critically ill trauma patients.

Perifoveal Chorioretinal Atrophy after Subretinal Voretigene Neparvovec-rzyl for RPE65-Mediated Leber Congenital Amaurosis

To report an anatomic change following subretinal injection of voretigene neparvovec-rzyl (VN) for RPE65-mediated Leber congenital amaurosis. Multicenter, retrospective chart review. Patients who underwent subretinal VN injection at each of 4 participating institutions. Patients were identified as having perifoveal chorioretinal atrophy if (1) the areas of atrophy were not directly related to the touch-down site of the subretinal cannula; and (2) the area of atrophy progressively enlarged over time. Demographic data, visual acuity, refractive error, fundus photographs, OCT, visual fields, and full-field stimulus threshold (FST) were analyzed. Outcome measures included change in visual acuity, FST, visual fields, and location of atrophy relative to subretinal bleb position. A total of 18 eyes of 10 patients who underwent subretinal injection of VN were identified as having developed perifoveal chorioretinal atrophy. Eight of 10 patients (80%) developed bilateral atrophy. The mean age was 11.6 years (range, 5-20 years), and 6 patients (60%) were male. Baseline mean logarithm of the minimum angle of resolution visual acuity and FST were 0.82 (standard deviation [SD], 0.51) and-1.3 log cd.s/m2 (SD, 0.44), respectively. The mean spherical equivalent was-5.7 diopters (D) (range,-11.50 to+1.75 D). Atrophy was identifiable at an average of 4.7 months (SD, 4.3) after surgery and progressively enlarged in all cases up to a mean follow-up period of 11.3 months (range, 4-18 months). Atrophy developed within and outside the area of the subretinal bleb in 10 eyes (55.5%), exclusively within the area of the bleb in 7 eyes (38.9%), and exclusively outside the bleb in 1 eye (5.5%). There was no significant change in visual acuity (P= 0.45). There was a consistent improvement in FST with a mean improvement of-3.21 log cd.s/m2 (P < 0.0001). Additionally, all 13 eyes with reliable Goldmann visual fields demonstrated improvement, but 3 eyes (23.1%) demonstrated paracentral scotomas related to the atrophy. A subset of patients undergoing subretinal VN injection developed progressive perifoveal chorioretinal atrophy after surgery. Further study is necessary to determine what ocular, surgical delivery, and vector-related factors predispose to this complication.

Outcomes of extracorporeal membrane oxygenation in acute respiratory distress syndrome due to COVID‐19: The lessons learned from the first wave of COVID‐19

IntroductionExtracorporeal membrane oxygenation (ECMO) has been used as a refractory treatment for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID‐19), but there has been little evidence of its efficacy. We conducted this study to share our experience using ECMO as a bridge to recovery for ARDS due to COVID‐19.MethodsAll adult patients who were placed on ECMO for ARDS due to COVID‐19 between April 2020 and June 2020 (during the first wave of COVID‐19) were identified. The clinical characteristics and outcomes of these patients were analyzed with a specific focus on the differences between patients who survived to hospital discharge and those who did not.ResultsIn total, 20 COVID‐19 patients were included in this study. All patients were placed on veno‐veno ECMO. Comparing survivors and non‐survivors, older age was found to be associated with hospital mortality (p = .02). The following complications were observed: renal failure requiring renal replacement therapy (35%, n = 7), bacteremia during ECMO (20%, n = 4), coinfection with bacterial pneumonia (15%, n = 3), cannula site bleeding (15%, n = 3), stroke (10%, n = 2), gastrointestinal bleeding (10%, n = 2), and liver failure (5%, n = 1). The complications associated with patient mortality were culture‐positive septic shock (p = .01), culture‐negative systemic inflammatory response syndrome (p = .01), and renal failure (p = .01). The causes of death were septic shock (44%, n = 4), culture‐negative systemic inflammatory response syndrome (44%, n = 4), and stroke (11%, n = 1).ConclusionsBased on our experience, ECMO can improve refractory ARDS due to COVID‐19 in select patients. Proper control of bacterial infections during COVID‐19 immunomodulation therapy may be critical to improving survival.

Prophylactic use of vacuum-assisted closure system for cannula sites: A case of extracorporeal biventricular assist devices for 295 days

We report wound management using a vacuum-assisted closure (VAC) system for the cannula sites of extracorporeal biventricular assist devices (BiVADs) for 295 days in a 23-year old Chinese female patient with fulminant giant cell myocarditis, who finally underwent heart transplantation. When the cannula sites appeared necrotic 3 months after BiVADs placement, she received negative pressure wound therapy prophylactically for four cannula sites, using a VAC system for 3 months, followed by no infections. Such prophylactic VAC therapy, using the skin barrier paste usually used for the ostomy pouching system to create a flatter surface and airtightness, may be useful to avoid cannula site infections, which is still a fatal complication causing sepsis, especially in patients with extracorporeal BiVADs.

Preventing Hospital-Acquired Pressure Injuries by Using a Tiered Protocol in Children Receiving ECMO in the Pediatric Intensive Care Unit.

Preventing Hospital-Acquired Pressure Injuries by Using a Tiered Protocol in Children Receiving ECMO in the Pediatric Intensive Care Unit.