Extracorporeal Membrane Oxygenation Machine Research Articles

The use of extracorporeal membrane oxygenation (ECMO) for critically-ill COVID-19 patient in clinical setting: A literature review

The use of ECMO may help sustain extracorporeal life support in cases where regular less-invasive modalities failed to adequately assist the body in maintaining basic life mechanisms. Typically, VV-ECMO is used in life-threatening respiratory failure. However, experts must consider relative contraindications, answering the question: ‘Will the patient really benefit from this treatment, or will it only add emotional and economic burden, also exposing the patient to various risks of complications?’. The physiology of oxygenation within the lungs, tissues, and ECMO machine, is a modification of the basic principles of respiratory physiology. In typical VV-ECMO cannula insertion, drainage cannula is inserted via the right femoral vein percutaneously and is guided upwards through inferior vena cava with its tip 10 cm below cavoatrial junction while the reinjection cannula will be inserted through the intrajugular vein. This places the artificial lungs in series with the normal lungs rather than in a parallel form. The artificially-oxygenated blood was then returned and mixed with the native venous blood. It is important to measure maximum drainage flow to prevent shunting of the veins by setting the ECMO to the highest flow. Frequent complications include co-infection up to sepsis and coagulopathy up to complications following it. Therefore, it is always beneficial to acquire multidisciplinary judgement, particularly with hematologists, intensivists, and infectious disease specialists prior, during, and post-ECMO use.

Abstract 17295: In Situ Recovery of Multiple Organs Using Venoarterial ECMO in a Murine Model of Uncontrolled DCD

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) for Donation after Circulatory Death (DCD) can substantially increase the donor pool, organ yield per donor, and organ shelf life. Clinical attempts to recover organs for transplantation after uncontrolled DCD are very complex and hard to reproduce. As a preliminary strategy for completing this endeavor, experimental protocols employing feasible animal models are strongly recommended. Hypothesis: The objective of the investigation was to develop a mouse model of ECMO-based cadaver management protocol for uncontrolled DCD donation after "out-of-hospital" death. Methods: Following 10 min after confirmed death, murine cadavers (C57BL/6 background) were administered with heparin-streptokinase and cannulated for veno-arterial ECMO. Cadaver bodies were connected to a murine ECMO machine 1 h post-mortem and subjected to extracorporeal circulation for subsequent 2 hrs. Blood gas parameters, cardiac activity, and general organ state were assessed using BGA analysis, ECG, and histology, accordingly. We have designed and incorporated into an ECMO circuit a previously unreported, miniaturized murine hemodialysis for the treatment of severe hyperkalemia and metabolic acidosis that arose following death. Results: Control BGA parameters recorded 1 h after death were incompatible with normal physiology: extremely low blood pH, profound negative base excess, and extraordinarily high lactate and K + levels. Two hours after ECMO support, blood pH values of a cadaver body restored from <6.5 to 7.3 ± 0.05, pCO 2 was lowered from >130 to 41.7 ± 10.5 mmHg, sO2, base excess, and HCO 3 were all elevated from below detection thresholds to 99.5 ± 0.6%, -4 ± 6.2 and 22.0 ± 6.0 mmol/L, respectively (Student T-test, p < 0.05). The implementation of hemodialysis resulted in a significant decrease in both hyperlactatemia and hyperkalemia. Conclusions: Our model presents novel opportunities for the management of cadaver organs in order to promote uncontrolled DCD donation, thereby contributing to the resolution of the organ shortage problem. Our approach enables the implementation of a variety of modern blood purification techniques in cadaveric organ recovery using ECLS.

Survey on the application of external cardiopulmonary resuscitation in Chinese children with sudden cardiac arrest

Objectives: To investigate the current application status and implementation difficulties of extracorporeal cardiopulmonary resuscitation (ECPR) in children with sudden cardiac arrest. Methods: This cross-sectional survey was conducted in 35 hospitals. A Children's ECPR Information Questionnaire on the implementation status of ECPR technology (abbreviated as the questionnaire) was designed, to collect the data of 385 children treated with ECPR in the 35 hospitals. The survey extracted the information about development of ECPR, the maintenance of extracorporeal membrane oxygenation (ECMO) machine, the indication of ECPR, and the difficulties of implementation in China. These ECPR patients were grouped based on their age, the hospital location and level, to compare the survival rates after weaning and discharge. The statistical analysis used Chi-square test and one-way analysis of variance for the comparison between the groups, LSD method for post hoc testing, and Bonferroni method for pairwise comparison. Results: Of the 385 ECPR cases, 224 were males and 161 females. There were 185 (48.1%) survival cases after weaning and 157 (40.8%) after discharge. There were 324 children (84.2%) receiving ECPR for cardiac disease and 27 children (7.0%) for respiratory failure. The primary cause of death in ECPR patients was circulatory failure (82 cases, 35.9%), followed by brain failure (80 cases, 35.0%). The most common place of ECPR was intensive care unit (ICU) (278 cases, 72.2%); ECPR catheters were mostly inserted through incision (327 cases, 84.9%). There were 32 hospitals (91.4%) had established ECMO emergency teams, holding 125 ECMO machines in total. ECMO machines mainly located in ICU (89 pieces, 71.2%), and the majority of hospitals (32 units, 91.4%) did not have pre-charged loops. There were no statistically significant differences in the post-withdrawal and post-discharge survival rates of ECPR patients among different age groups, regions, and hospitals (all P>0.05). The top 5 difficulties in implementing ECPR in non-ICU environments were lack of ECMO machines (16 times), difficulty in placing CPR pipes (15 times), long time intervals between CPR and ECMO transfer (13 times), lack of conventional backup ECMO loops (10 times), and inability of ECMO emergency teams to quickly arrive at the site (5 times). Conclusion: ECPR has been gradually developed in the field of pediatric critical care in China, and needs to be further standardized. ECPR in non-ICU environment remains a challenge.

Anticoagulation strategies in COVID-19 infected patients receiving ECMO support.

Hospitalized COVID-19 patients with hypoxemic respiratory failure may deteriorate despite invasive mechanical ventilation and thus require extracorporeal membrane oxygenation (ECMO) support. Unfractionated heparin (UFH) is the antithrombotic of choice, however, bivalirudin may offer more predictable pharmacokinetics resulting in consistent anticoagulant effects with lower bleeding and thrombotic occurrences. The aim of this study was to evaluate efficacy and safety outcomes in patients undergoing venovenous (VV) ECMO receiving bivalirudin or UFH-based anticoagulation. This retrospective, single-center, observational cohort study included patients with confirmed COVID-19 infection requiring VV ECMO support receiving anticoagulation with UFH or bivalirudin. Primary endpoints were time to reach therapeutic aPTT, percent time spent in aPTT range, and the occurrence of thrombotic events over the entire course of ECMO support. Secondary endpoints included the incidence of major/minor bleeding, the ability to wean off ECMO support, in-hospital mortality, and length of stay. Twenty-two patients were included in the study (n=10 UFH, n=12 bivalirudin). Time to therapeutic aPTT was achieved faster with UFH (10h vs. 20h). The percentage time spent within the goal aPTT range was similar between UFH and bivalirudin (50% vs. 52%). Thrombotic events were significantly higher in the UFH group (40% DVT, 40% PE, 80% oxygenator thrombus in ECMO machine, 10% ischemic stroke) versus bivalirudin (8% DVT, 17% PE, 33% oxygenator thrombus, no ischemic strokes) (CI 95%, p=0.04). The overall bleeding incidence was higher in the UFH arm (90% vs. 75%). The mortality rate was 90% in the UFH group and 58% in the bivalirudin group. The length of stay was similar between the two study arms. In hospitalized patients with COVID-19-associated acute respiratory distress syndrome (ARDS) on VV ECMO support, the use of bivalirudin showed to be a viable anticoagulation alternative in terms of efficacy compared to UFH and resulted in a favorable safety profile with lower rates of bleeding and thrombotic events.

Risk factors for cannula-associated arterial thrombosis following extracorporeal membrane oxygenation support: a retrospective study.

Hemostatic dysfunction during extracorporeal membrane oxygenation (ECMO) due to blood-circuit interaction and the consequences of shear stress imposed by flow rates lead to rapid coagulation cascade and thrombus formation in the ECMO system and blood vessels. We aimed to identify the incidence and risk factors for cannula-associated arterial thrombosis (CaAT) post-decannulation. A retrospective study of patients undergoing arterial cannula removal following ECMO was performed. We evaluated the incidence of CaAT and compared the characteristics, ECMO machine parameters, cannula sizes, number of blood products transfused during ECMO, and daily hemostasis parameters in patients with and without CaAT. Multivariate analysis identified the risk factors for CaAT. Forty-seven patients requiring venoarterial ECMO (VA-ECMO) or hybrid methods were recruited for thrombosis screening. The median Sequential Organ Failure Assessment score was 11 (interquartile range, 8-13). CaAT occurred in 29 patients (61.7%), with thrombosis in the superficial femoral artery accounting for 51.7% of cases. The rate of limb ischemia complications in the CaAT group was 17.2%. Multivariate analysis determined that the ECMO flow rate-body surface area (BSA) ratio (100 ml/min/m2) was an independent factor for CaAT, with an odds ratio of 0.79 (95% confidence interval, 0.66-0.95; P=0.014). We found that the incidence of CaAT was 61.7% following successful decannulation from VA-ECMO or hybrid modes, and the ECMO flow rate-BSA ratio was an independent risk factor for CaAT. We suggest screening for arterial thrombosis following VA-ECMO, and further research is needed to determine the risks and benefits of such screening.

The Characteristics and Risk Factors of Medical Device Related Pressure Injury in Intensive Care Unit Patients

Purpose : This study aimed to investigate the characteristics and risk factors associated with pressure injuries related to medical devices among patients admitted to the intensive care unit (ICU).Method : A retrospective study analyzed data from 462 ICU patients. Statistical analyses, including independent t-tests, Fisher’s exact tests, and logistic regression were performed to analyze the data.Results : Among the 154 subjects, there were a total of 198 medical device–related pressure injuries (MDRPI). Stage 2 and deep tissue pressure injuries were the most frequent. MDRPI occurred most frequently on the face, with nasogastric tubes being its leading cause, followed by endotracheal tubes. The risk factors for MDRPI included male sex (odds ratio [OR]=1.78, 95% confidence interval [CI]=1.12-2.83), department at the time of ICU admission (OR=4.29, 95% CI=2.01-9.15), post-surgery ICU admission (OR=0.43, 95% CI=0.25-0.73), application of extracorporeal membrane oxygenation machines (OR=2.72, 95% CI=1.06-6.95), number of medical devices (OR=1.16, 95% CI=1.05-1.30), inotropic drug administration (OR=2.33, 95% CI=1.19-4.60), and sedative use (OR=2.53, 95% CI=1.17-5.45).Conclusion : These results enable the determination of the characteristics and risk factors associated with MDRPI. It is crucial to acknowledge the risk factors for MDRPI in ICU patients and establish a prevention strategy.

Use the ARIMA and EMG Models to Predict the Confirmed Cases and ICU Bed Occupancy Data of COVID-19 in Massachusetts and Compare the Accuracy of the Two Models

Beginning in 2019, COVID-19 has invaded our lives and continues until now. People are still being effort made to control the spread of the virus and treat patients. Two variables in COVID-19 data are confirmed data and ICU bed occupancy data. Collect the data, use the ARIMA model and EMG model to predict the data, and then compare it with the actual data. Through comparison, it is found that there is a small gap between the ARIMA predicted value and the actual data, which can be used to predict the data of these two variables. In the process of fighting against COVID-19, it is very important to strengthen medical service capabilities, adequate treatment resources, and strengthen the construction of ICU wards. The construction of ICU is very complicated and involves many medical equipment, including ventilator, infusion pump, electrocardiogram machine, extracorporeal membrane oxygenation machine (ECMO), oximeter and so on. Therefore, the accuracy of data prediction is very important. Sufficient ICU beds and medical resources can be prepared according to the forecast. Do a good job of safeguarding the treatment work and medical services to ensure the level and quality of patient treatment and avoid causing panic.

A New Culture Method for the Detection of Non-Tuberculous Mycobacteria in Water Samples from Heater-Cooler Units and Extracorporeal Membrane Oxygenation Machines.

The isolation of non-tuberculous mycobacteria (NTM) from cultures is particularly laborious due to the potential overgrowth of coexisting non-acid fast bacilli. To reduce the overgrowth of these non-mycobacterial organisms, a decontamination step with NaOH or cetylpyridinium chloride is highly recommended before plating the samples on the culture medium. However, due to their toxicity, decontamination solutions tend to decrease NTM recovery from clinical and environmental samples. Here, we tested an alternative method for NTM recovery based on the use of NTM Elite agar, a selective medium that does not require a decontamination step. Using NTM Elite agar, we were able to detect non-tuberculous mycobacteria in 27.7% (30/108) of water samples analyzed. The average time to NTM detection was 18 days, but some strains required longer to grow, perhaps due to the stressful environmental conditions (periodical disinfection of devices). NTM Elite agar’s effectiveness in inhibiting background flora was proven by the isolation of NTM from samples with and without background flora, showing no statistically significant differences in detection rates for different total viable counts of background flora (p = 0.4989). In conclusion, our findings indicate that effective NTM recovery from HCU- and ECMO-derived water samples can be achieved via filtration and direct culture of the filters on NTM Elite agar. This simple procedure can speed up laboratory work and provide an improved method, successfully resulting in low contamination and high detection rate, in addition to being less time-consuming. Its sensitivity and lack of a decontamination step make this protocol particularly useful for monitoring the effectiveness of device disinfection in hospital settings, even in the presence of low NTM loads. Reading timeframes should probably be extended to 7 weeks (i.e., well beyond the standard 4 weeks advised by the manufacturer), in order to isolate even the slow-growing mycobacteria. However, an extended incubation period is not necessary for exclusion of M. chimaera contamination of the devices, as M. chimaera isolation times do not generally exceed 3 weeks.

Clinically Amyopathic Dermatomyositis With Rapid Progressive Interstitial Lung Disease Diagnosed in a Patient on Extracorporeal Membrane Oxygenation

Clinically amyopathic dermatomyositis (CADM) is characterized by skin manifestations with minimal to no muscle involvement. It is a unique subset of dermatomyositis, which may create a diagnostic challenge due to its vague presentation. Establishing the diagnosis is crucial as CADM is highly associated with rapidly progressive interstitial lung disease (RP-ILD), and patients who suffer from thereof have an abysmal prognosis. Herein, we described a case of a 46-year-old male who presented with a history of skin rash and then started to experience shortness of breath. His respiratory symptoms were progressing swiftly and affected his daily life activities. The initial blood tests were normal, but his chest imaging revealed fibrotic nonspecific interstitial pneumonia. The patient required intubation due to a critical respiratory condition, and later, he needed extracorporeal membrane oxygenation (ECMO). While the patient was connected to an ECMO machine, a bedside open lung biopsy (BOLB) was performed, and the results were in keeping with RP-ILD and CADM. The patient was started on cyclophosphamide without a response, and his chest computed tomography showed acute respiratory distress syndrome. His hospital course was complicated with pneumonia, severe kidney dysfunction requiring dialysis, and candidemia, which resulted in the patient’s death.

GoogleTrends as a patient therapeutic education resource on extracorporeal life support: What do patients want to know?

Extracorporeal membrane oxygenation (ECMO) is implemented as rescue therapy in COVID-19 related acute distress respiratory syndrome (ARDS) and refractory hypoxemia. Google Trends (GT) is an ongoing-developing web kit providing feedback on specific population's interests. This study uses GT to analyze the United States (US) general population interest in ECMO as COVD-19/ARDS salvage therapy. GT was used to access data searched for the term ECMO and COVID-19. The gathered information included data from March 2020 to July 2021 within US territories. Search frequency, time intervals, sub-regions, frequent topics of interest, and related searches were analyzed. Data were reported as search frequency on means, and a value of 100 represented overall peak popularity. The number of Google searches related to the terms ECMO and COVID-19 has surged and sustained interest over time ever since the initial reports of COVID-19 in the US, from an initial mean of 34% in March 2020 to a 100% interest by April 2020, resulting in an up-to-date overall average of 40% interest. Over time West Virginia, Gainesville, and Houston, lead the frequency of searches in sub-region, metro and city areas, respectively. Top search terms by frequency include: ECMO machine, COVID ECMO, what is ECMO, ECMO treatment and VV ECMO. Parallel to this, the related rising terms are: COVID ECMO, ECMO machine COVID, ECMO for COVID, ECMO machine coronavirus, and ECMO vs ventilator. Seemingly, medical-relevant websites fail to adequately address these for patient therapeutic education (PTE) purposes. GT complements the understanding of interest in ECMO for COVID-19. When properly interpreted, the use of these trends can potentially improve on PTE and therapy awareness via specific medical relevant websites.

The draw of the few: the challenge of crisis guidelines for extremely scarce resources

The COVID-19 pandemic has focused considerable attention on crisis standards of care (CSCs). Most public CSCs at present are effective tools for allocating scarce but not uncommon resources (like ventilators...

Comment on “Sustainable Health Financing for COVID ‐19 Preparedness and Response in Asia and the Pacific”

Kwon and Kim (2022) summarize the impact of COVID-19 on health and the economy in Asia and the Pacific and how countries have responded to the challenge. In addition, they propose ways to strengthen the health care system so that governments can better prepare for a pandemic. This is a timely study because many countries worldwide are still struggling with dealing with the COVID-19 pandemic successfully. The health care systems in the region are significantly different, and the pandemic response varies from country to country. As a result, there are ample opportunities to learn from the experiences of other countries, and Kwon and Kim (2022) do an excellent job of emphasizing them under a unified framework. I like Kwon and Kim's (2022) paper for four reasons. First, this paper is comprehensive and examines various aspects of the health care system that can increase resilience to a pandemic. In particular, Kwon and Kim (2022) highlight the importance of investing in financing, service delivery, and governance and provide some examples of how governments can do so. Second, it covers many countries in Asia and the Pacific with different income levels, which allows all countries to learn from other countries that share similar health care systems and challenges. Third, Kwon and Kim (2022) emphasize that pandemic “preparedness” is vital for a resilient health care system and urge governments to reassess existing arrangements and prepare for future crises. I agree with this. Finally, I find the discussion of “mobilizing private sector providers” stimulating and valuable. Private sector providers often play a crucial role in Asia and the Pacific, so it is essential to mobilize them during a pandemic. This is also a big problem in Japan, where I live. The rest of this comment will focus on this issue. Mobilizing private sector providers may not be easy. As Kwon and Kim (2022) state, many countries in Asia and the Pacific – such as the Republic of Korea, Japan, the Philippines, Cambodia, India, Indonesia, and Bangladesh – rely on private sector providers. In contrast, Thailand, Bhutan, Timor-Leste, Sri Lanka, and the Pacific Island nations rely primarily on public providers. If the health care system relies mainly on public sector providers, mobilizing providers in an emergency would be relatively easy. However, mobilizing private sector providers may not be straightforward, as the treatment of COVID patients can be costly and not financially attractive. For example, providers must bear the initial setup costs to prevent infection and purchase specialized equipment such as ventilators and extracorporeal membrane oxygenation machines. Treating COVID patients also require a significant number of nursing staff. The need to separate COVID and non-COVID patients may reduce bed turnover, and COVID patients may require longer hospital stays. Health care providers are also at risk of losing future patients if they refer non-COVID patients to other hospitals that do not accept COVID patients. Governments may mobilize private sector providers in two ways. The first is to increase provider payments to cover the higher cost of treating COVID patients. Kwon and Kim (2022) do a great job of discussing several such attempts in the region. For example, Japan doubled provider payments for treating critically ill COVID patients in intensive care since April 2020 (tripled since May 2020). More recently, in December 2020, the government began paying up to US$142,000 per bed to cover the initial setup costs and fixed costs to treat COVID patients. Unfortunately, however, these financial incentives did not appear to be sufficient to secure beds for COVID patients. In Japan, less than 1% of all hospital beds are available for COVID patients, significantly lower than in other countries such as the USA (11%) and the United Kingdom (23%). Kwon and Kim (2022) also discuss government responses in Bangladesh, India, and Korea. Like Japan, some of these countries have raised provider payments for treating COVID patients. Others have subsidized hospitals to cover the fixed costs of accepting COVID patients. A further discussion of better-combining provider payments and subsidies would help us prepare for future pandemics. A clear alternative to higher provider payments is the command-and-control approach. As Kwon and Kim (2022) state, countries can introduce legislation that mandates providers to accept COVID patients. This does help mobilize private sector providers and mitigate bed shortages in emergencies, but it may create another set of problems. For example, determining the amount and duration of compensation for private providers may not be easy, as the impact and length of the pandemic are unpredictable. Kwon and Kim (2022) discuss Thailand's approach, where private hospitals must take COVID patients when COVID patients at public hospitals exceed a threshold. This approach makes sense, and it would be further enlightening if Kwon and Kim (2022) could discuss similar or different regulatory strategies that other countries in the region have implemented.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

THORACO-ABDOMINAL NORMOTHERMIC REGIONAL PERFUSION OXYGEN STRATEGY IN A DCD PORCINE MODEL

Introduction: Lung transplantation is the treatment for end-stage lung disease patients. The most commonly used source are donation after brain death donors, however due to shortage, donation after circulatory death (DCD) donors are also used. In this group an agonal phase and a period of warm ischemia are inevitable. For DCD donors, a new technique called normothermic regional perfusion (NRP) presented with increased organ utilization rates.(1) Using an extracorporeal membrane oxygenation machine, abdominal circulation in-situ is restored post-mortem. This restores cellular energy substrates and enables one to assess organ function pre-procurement. First efforts in extending this technique to the thorax were highly beneficial for hearts, remarkably, almost no lungs were transplanted using an oxygen strategy of 21%.(2) Thoraco-abdominal NRP (TA-NRP) might be detrimental to the lungs, because the right ventricle is not loaded to create perfusion to the lungs. Furthermore, washout of inflammatory substances from other areas, into the lungs may cause significant harm. Here we present our first results on lungs comparing two oxygen strategies in TA-NRP Materials and Methods: Pigs were randomized into group 100% oxygen (n=6) and group 21% oxygen (n=6), anesthetized and centrally cannulated to a heart-lung machine. Ventilation was switched off to induce circulatory arrest (pulse <20 mmHg). After a no-touch period of 15 minutes, circulation and ventilation were restarted, sinus rhythm was restored, and the heart was gradually loaded to perfuse the lungs. After 35 minutes of reperfusion, pigs were weaned off of life support and oxygen went from 21% to 40% or 100% to 60%. A total reperfusion time of 3 hours post-circulatory arrest was upheld. Lung biopsies were taken at baseline, 10 minutes after no touch (No Touch 10), and 60 and 180 minutes after reperfusion (Post-R-60 and -180). Biopsies were dried for 24 hours at 60°C to determine oedema. Arterial and venous blood gases were taken throughout the procedure. Results: Dry weight as a percentage of wet weight did not differ significantly between 100% and 21% oxygen therapy group, respectively at baseline 87,5% and 88,4% (p = 0.74), NT10 84,1% and 84,5% (p = 0.93), R60 90,2% and 87,8% (p = 0,23), and R180 80,7% and 89,1% (p = 0,25).Arterial and venous blood gas saturation differed significantly starting at time point R3 until time point R25 (p <0.05).Arterial and venous pO2 (kPa) were also significantly higher in the 100% oxygen group, starting from R3 to R45.Conclusion: In our set-up, all lungs were able to reach 100% saturation and pO2 >14kPa, even after 15 minutes of circulatory arrest and TA-NRP treatment. No significant changes were seen in the dry weight/wet weight percentages. There seems to be no real harm done to the lungs, by either TA-NRP approach. However, the better venous pO2 in the 100% group indicates a better whole-body oxygenation.

Nurses' perception of their role in extracorporeal membrane oxygenation care: A qualitative assessment.

BackgroundRecently, there has been interest in the education of nursing personnel to provide veno‐venous extracorporeal membrane oxygenation in Kuwait. There is need to understand the experience of nurses who take on this new role.AimWe aimed to explore the perspectives of nurses about their role, with a special focus on their competencies and the challenges faced while caring for patients who require extracorporeal membrane oxygenation.MethodsWe used a qualitative descriptive approach, using in‐depth individual interviews. Nineteen nurses working with veno‐venous an extracorporeal membrane oxygenation machine in an adult intensive care unit of a general hospital in Kuwait were included in the study. Interviews were audio‐recorded, transcribed verbatim, and analysed thematically.ResultsThe role of nurses was found to be diverse and challenging and involved engaging in multiple responsibilities. Nurses worked with other health care providers in a team, which facilitated their performance. Nurses viewed themselves as competent to perform their role and attributed their competency mainly to the training received and the experience spent providing extracorporeal membrane oxygenation care. In executing their role, nurses reported encountering significant challenges, including heavy workload, inefficient communication among colleagues, and a lack of an organized/supportive system.ConclusionsThis study suggests that nurses play an integral role in the management of patients on extracorporeal membrane oxygenation. An understanding of their role and their competence, the challenges they face with in the care setting, and providing a supportive environment is essential for transformation in the practice of extracorporeal membrane oxygenation nursing.

Patient Perspective: Going Through a Clinical Trial

When I was diagnosed with idiopathic pulmonary arterial hypertension in late 2011, I was devastated, but I knew I had to be strong for my family. At the time, I had been juggling my life with being a wife and mother to two young children and working full time. I had difficulty with my breathing for years, and even after describing my symptoms of shortness of breath, chest pain, passing out, and feeling dizzy, the numerous doctors I saw told me that I was most likely depressed, had anxiety, or was just stressed due to being a mother.A friend of mine recommended a cardiologist in Monterey, CA. He discovered that my heart was enlarged and made arrangements for me to see the pulmonary hypertension (PH) team at Stanford Hospital. I met with Dr Roham Zamanian and the rest of the team and was hospitalized that same day. That was the day my life completely changed. I was no longer a person who thought about living into old age; now I had to think about living as if every day might be my last.The PH team started me on triple therapies, and I was to titrate rapidly due to the damage done to my heart. Each month that passed I was expecting to feel a difference in my condition. I was no longer passing out, but I still had chest pain and difficulty breathing due to how advanced my PH was. In March of 2012, my PH team started preparing me for a double lung transplant. I did all the necessary tests, but was hesitant because my daughter was just starting kindergarten and I didn't feel ready.In June I was approached again and told that I needed the transplant if I was to prolong my life, since my body was not reacting to the medications as well as they had hoped. In August of 2012, I was officially added to the lung transplant list. I was scared and didn't feel ready. Dr Zamanian called me that same day and reassured me that I needed to be on the list; then he asked me if I was open to trying a trial medication.I immediately agreed and started my journey with a clinical trial. Dr Zamanian and Dr Edda Spiekerkoetter were the doctors that I would work with during the trial process. I started taking the trial drug and did regular blood tests to ensure that I was within the range that was required. Within a month I couldn't believe how “normal” I felt. I wasn't winded when climbing stairs, my chest pain was gone, and I felt so much better. Within 2 months' time, I needed to follow up with the lung transplant team; when I described how I was feeling, my transplant doctor put my status on the lung transplant list on hold. I knew I couldn't forget that I had PH, but I felt that I could live a life that was productive for as long as I could.The trial therapy added to the standard of care gave me 5 years before I needed a heart and double lung transplant. During those 5 years I was able to volunteer at my children's school, enjoy birthday parties with them, and travel in and out of the country, making memories along the way.Due to the nature of PH, when you start to decline, it can happen fast. In December of 2016, my transplant team encouraged me to start the lung transplant process again. In my mind I was strong and thought I could make it a couple more years without transplantation, but my body was giving out. In January 2017 I was admitted to the hospital at Stanford with a central line infection. In the next few days I started to rapidly decline and was placed on the transplant list on February 14 for a heart and double lung transplant.My condition improved and I was allowed to go home and wait for the transplant call. I was home for almost 2 months when I started to cough up blood and was taken again to Stanford Hospital. I don't remember what happened during that period; I woke up 5 days later and realized I was connected to the extracorporeal membrane oxygenation machine in the intensive care unit.As I waited for my transplant, I would think about the extra time I gained with my family due to the trial therapy in addition to excellent care. Those memories brought me a lot of happiness, comfort, and peace. I was transplanted on June 4, 2017, and though I no longer have PH, I hope that my experience with trying the trial drug helps some other PH patients and encourages other to try trial drugs in the future.

Extracorporeal Membrane Oxygenation During the Coronavirus Disease 2019 Pandemic.

Extracorporeal Membrane Oxygenation During the Coronavirus Disease 2019 Pandemic.

Sepsis and ECMO.

Sepsis is being recognized as an important complication of extracorporeal membrane oxygenation (ECMO) and its presence is a poor prognostic marker and increases the overall mortality. The survival rate differs in the various types of cannulation techniques. Adult patients with prolonged duration of ECMO constitute the major risk population. Ventilator-associated pneumonia and bloodstream infections form the main sources of sepsis in these patients. It is important to know the most common etiological agents for sepsis in ECMO, which varies partly with the local epidemiology of the hospitals. A high index of suspicion, drawing adequate volumes for blood culture and early and timely administration of appropriate empirical antimicrobials can substantially decrease the morbidity and mortality in this high-risk population. The dosing of antimicrobials is influenced by the pharmacological variations on ECMO machine and is an important consideration. Infection control practices are of paramount importance and need to be followed meticulously to prevent sepsis in ECMO.

Surge capacity of intensive care units in case of acute increase in demand caused by COVID-19 in Australia.

ObjectivesTo assess the capacity of intensive care units (ICUs) in Australia to respond to the expected increase in demand associated with COVID‐19.DesignAnalysis of Australian and New Zealand Intensive Care Society (ANZICS) registry data, supplemented by an ICU surge capability survey and veterinary facilities survey (both March 2020).SettingsAll Australian ICUs and veterinary facilities.Main outcome measuresBaseline numbers of ICU beds, ventilators, dialysis machines, extracorporeal membrane oxygenation machines, intravenous infusion pumps, and staff (senior medical staff, registered nurses); incremental capability to increase capacity (surge) by increasing ICU bed numbers; ventilator‐to‐bed ratios; number of ventilators in veterinary facilities.ResultsThe 191 ICUs in Australia provide 2378 intensive care beds during baseline activity (9.3 ICU beds per 100 000 population). Of the 175 ICUs that responded to the surge survey (with 2228 intensive care beds), a maximal surge would add an additional 4258 intensive care beds (191% increase) and 2631 invasive ventilators (120% increase). This surge would require additional staffing of as many as 4092 senior doctors (245% increase over baseline) and 42 720 registered ICU nurses (269% increase over baseline). An additional 188 ventilators are available in veterinary facilities, including 179 human model ventilators.ConclusionsThe directors of Australian ICUs report that intensive care bed capacity could be near tripled in response to the expected increase in demand caused by COVID‐19. But maximal surge in bed numbers could be hampered by a shortfall in invasive ventilators and would also require a large increase in clinician and nursing staff numbers.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China.

Severe cases of coronavirus disease 2019 (COVID-19) cannot be adequately managed with mechanical ventilation alone. The role and outcome of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19 is currently unclear. Eight COVID-19 patients have received ECMO support in Shanghai with seven with venovenous (VV) ECMO support and one veno arterial (VA) ECMO during cardiopulmonary resuscitation. As of March 25, 2020, four patients died (50% mortality), three patients (37.5%) were successfully weaned off ECMO after 22, 40, and 47 days support, respectively, but remain on mechanical ventilation. One patient is still on VV ECMO with mechanical ventilation. The partial pressure of oxygen/fractional of inspired oxygen ratio before ECMO initiation was between 54 and 76, and all were well below 100. The duration of mechanical ventilation before ECMO ranged from 4 to 21 days. Except the one emergent VA ECMO during cardiopulmonary resuscitation, other patients were on ECMO support for between 18 and 47 days. In conclusion, ensuring effective, timely, and safe ECMO support in COVID-19 is key to improving clinical outcomes. Extracorporeal membrane oxygenation support might be an integral part of the critical care provided for COVID-19 patients in centers with advanced ECMO expertise.