Early Extracorporeal Membrane Oxygenation Support in Bupropion-Induced Cardiogenic Shock: A Case Series.

The use of extracorporeal membrane oxygenation (ECMO) during lung transplantation has progressively expanded and, in many centers, replaced conventional cardiopulmonary bypass. However, it remains unclear whether central or peripheral veno-arterial (VA) ECMO provides superior postoperative outcomes. This study aimed to compare central VA-ECMO (cVA-ECMO) and peripheral VA-ECMO (pVA-ECMO) during lung transplantation, with a focus on survival, primary graft dysfunction grade 3 (PGD3), postoperative ECMO support, and postoperative morbidity. Three databases were assessed through November 2025. Five retrospective observational studies including 866 patients were included. Overall survival was analyzed using reconstructed individual patient data derived from Kaplan-Meier curves. Random-effects models were applied for all pooled analyses. There was no significant difference in overall survival (HR 1.224, p=0.13) and in PGD3 at 72h incidence (OR 1.55; p=0.26) between cVA-ECMO and pVA-ECMO. However, pVA-ECMO was associated with a higher requirement for postoperative ECMO use (OR 6.05; p=0.04), longer duration of extracorporeal support (MD +1.61 days; p=0.01), prolonged mechanical ventilation (MD +2.73 days; p<0.01), and longer intensive care unit length of stay (MD +4.05 days; p<0.01). The risk of limb ischemia requiring invasive treatment was significantly higher with pVA-ECMO (OR 4.94; p=0.001). Although survival and PGD3 incidence were comparable, pVA-ECMO was associated with greater postoperative morbidity and vascular complications. These findings should be interpreted with caution, and cannulation strategy should be individualized according to patient risk profile, surgical context, and center-specific expertise rather than favoring one approach uniformly.

Association of pre-hospital shock team implementation with outcomes in ST-segment elevation myocardial infarction patients.

Comparison of Cadaveric Warming Rates in Accidental Hypothermia Between Continuous and Dwell Thoracic Lavage.

Comparative Outcomes of Transferred vs Nontransferred Cardiogenic Shock Patients Receiving Impella Support.

Venoarterial extracorporeal membrane oxygenation versus off-pump lung transplantation: Interim analysis of a prospective, randomized clinical trial.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) circuits typically utilise a continuous flow (CF) of blood to support patients suffering from refractory cardiorespiratory dysfunction. Pulsatile flow (PF) VA ECMO is an emerging technology being developed to overcome adverse effects associated with non-physiological CF VA ECMO such as worsening of microcirculatory and cardiac function. However, the flow dynamics associated with PF VA ECMO, such as positioning of the watershed region, wall shear stress, and ventricular unloading are still largely unknown. Therefore, to address this gap, our study aimed to utilise computational fluid dynamics (CFD) to compare the arterial cannula flow characteristics generated by CF and PF VA ECMO. A multiscale CFD model was created using a patient-specific aortic geometry and employed a closed-loop lumped parameter network as boundary conditions. Mean VA ECMO flow rates of 3, 4, and 5 L/min were simulated for both CF and counter-pulsed PF scenarios. The hemodynamic results demonstrated increased stroke volume, ejection fraction, and coronary flow during PF VA ECMO, and decreased left ventricular volumes, afterload, and pressure-volume areas, when compared to CF VA ECMO. Delivery of oxygen saturated blood from VA ECMO to the upper body decreased slightly during PF VA ECMO during 4 L/min of support. Lastly, wall shear stress on the aortic wall increased substantially during PF VA ECMO, when compared to CF VA ECMO. The findings from this study suggest varied hemodynamic and flow dynamic outcomes when comparing CF and PF VA ECMO, each with their own benefits and drawbacks.

Thrombocytopenia is a common and multifaceted complication in patients receiving heparin therapy during extracorporeal membrane oxygenation (ECMO). Its development may result from several mechanisms, such as platelet consumption, hemodilution, shear stress, circuit activation, and heparin-induced thrombocytopenia. Managing thrombocytopenia in this context can be challenging. Therefore, we present a patient who developed thrombocytopenia while receiving a heparin infusion, which resolved after changing the infusion diluent. We presented a case of a 64-year-old Pakistani male with multiple cardiac comorbidities who was admitted in a critical condition following cardiac arrest, requiring immediate resuscitation and veno-arterial ECMO initiation for circulatory support. During the ICU course, he developed thrombocytopenia while on heparin infusion diluted in D5W. Despite ruling out heparin-induced thrombocytopenia, his platelet counts continued to decline. As an alternative approach, the heparin diluent was switched to sodium bicarbonate, leading to recovery in platelet levels without the need for transfusion. This case highlights a possible association between using sodium bicarbonate as a diluent for heparin infusion and platelet recovery. While this finding warrants further investigation, additional studies are necessary to determine its broader clinical implications.

Extracorporeal Life Support in Post-Infarct Ventricular Septal Defect: Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

Extracorporeal membrane oxygenation (ECMO) provides lifesaving support for patients with cardiopulmonary failure but poses complex ethical challenges that may generate moral distress for clinicians, patients, and families. We convened a multidisciplinary panel of experts in cardiothoracic surgery, critical care, and palliative medicine to identify recurring ethical issues. The panel includes ECMO specialists working in the US, Canada, and the UK. The panel was nominated by organizers of a national critical care meeting. We analyzed four domains of ethical tension: 1) equitable ECMO candidacy decisions; 2) integration of palliative care and clinical ethics; 3) preservation of patient autonomy when institutional or benchmarking pressures influence care; and 4) responding to requests to continue ECMO when there is no exit strategy. Consensus recommendations emphasize transparent, team-based decisions, early involvement of ethics and palliative care, and consistent processes for ongoing review of candidacy and continuation of ECMO. Programs should recognize and mitigate institutional pressures that may undermine patient-centered care. As ECMO use expands, the development of ethical care frameworks is essential to ensure equity, uphold autonomy, and align treatments with patients' goals and values. This work provides a practical, consensus-based guide for addressing the ethical complexities of ECMO in contemporary critical care.

This review examines recent advances in pediatric airway management, including emerging technologies, updated guidelines, and innovative strategies for improving safety across diverse clinical settings. We address the unique challenges faced when managing airways in neonates, infants, and children with complex conditions. The 2024 ESAIC-BJA neonatal and infant airway guidelines provide the first evidence-based recommendations emphasizing preoperative identification of the difficult airway, the use of neuromuscular blockade, videolaryngoscopy, and optimized preoxygenation to mitigate risk in this vulnerable population. Use of videolaryngoscopy continues to increase, with multicenter randomized controlled trials demonstrating 5-10% absolute improvements in first-attempt success rates and significant reduction in severe complications including esophageal intubation and hypoxemia, particularly when combined with supplemental oxygen during laryngoscopy. Registry and meta-analysis data now provide robust evidence that neuromuscular blocking agents improve intubation conditions and reduce complications. Artificial intelligence applications show promise for predicting difficult airways and optimizing endotracheal tube sizing. Front-of-neck access strategies have been refined, acknowledging the limitations of cricothyrotomy in young children. Extracorporeal membrane oxygenation has emerged as a rescue strategy in anticipated cannot-intubate-cannot-oxygenate scenarios. Global disparities in pediatric anesthesia safety persist, with collaborative educational initiatives addressing workforce challenges in low- and middle-income countries. The future of pediatric airway management lies in individualized, technology-enhanced approaches guided by evidence-based algorithms, multidisciplinary collaboration, comprehensive education, and simulation-based training, with a commitment to equitable care delivery worldwide.

Overdoses of extended-release (ER) medications can cause life-threatening toxicity from prolonged gastrointestinal drug retention due to pharmacobezoar formation. This may result in severe complications including delayed serotonin syndrome and intestinal ischemia despite early use of enhanced elimination strategies. A 45-year-old woman presented with altered mental status following carbamazepine-venlafaxine ER overdose. Initial carbamazepine concentration was 163 μmol/L. She suffered a ventricular tachycardia arrest requiring venoarterial extracorporeal membrane oxygenation and enhanced elimination with continuous renal replacement therapy (CRRT). After CRRT, carbamazepine concentration rebounded from 33 to 80 μmol/L and clinical features of serotonin syndrome developed suggesting ongoing absorption. CT revealed cecal pneumatosis with obstruction. Laparotomy at day 9 revealed transmural ischemic necrosis with 4-6 L of retained charcoal and polyethylene glycol mixture; source control required a right hemicolectomy. Carbamazepine concentration declined postoperatively and serotonergic symptoms resolved. Carbamazepine-venlafaxine ER overdose with retained pill fragments can cause a variety of complications including prolonged toxicity. Rebounding drug concentration following enhanced elimination should trigger an investigation for gastrointestinal sequestration and prompt surgical consultation.

Social determinants of health (SDOH) are increasingly recognized as drivers of critical care outcomes but remain understudied in venoarterial extracorporeal membrane oxygenation (VA ECMO). We examined whether neighborhood-level SDOH were associated with 30 day post-discharge survival and prolonged length of stay (LOS) among VA ECMO patients. We retrospectively analyzed VA ECMO patients treated at Johns Hopkins Hospital, linking geocoded addresses to 12-digit Federal Information Processing Standards (FIPS) codes, 2022 American Community Survey data, 2023 Area Deprivation Index (ADI), and PolicyMap metrics. The primary outcome was 30 day mortality from discharge; secondary outcome was prolonged LOS (> 38 days, median among survivors). Multivariable logistic regression adjusted for preselected variables. Among 266 VA ECMO patients (median age: 59.50, 59% male), the median ADI percentile was 31.00, and LOS was 20.50 days. At 30 days, non-survivors (n = 133) were older (62 vs. 55 years, p = 0.002) and had higher body mass index (34.7 vs. 25.2, p < 0.001). Prolonged LOS was associated with longer ECMO duration, higher neighborhood insurance coverage, and greater commuting by car. In adjusted models, SDOH were not associated with mortality, but higher insurance coverage remained associated with prolonged LOS. Clinical factors influenced short-term survival, whereas neighborhood-level SDOH may affect discharge. Future studies should evaluate SDOH in long-term recovery. https://links.lww.com/ASAIO/B925.

Existing PICU early warning systems lack sufficient accuracy and timeliness for effective preparation. Machine learning approaches may improve prediction of critical deterioration events (CDEs), but their operational utility relative to existing tools remains unclear. To develop a machine learning model for early detection of CDEs and evaluate operational utility against existing tools using a novel alert burden analysis. PICU admissions (ages 0-24 yr, stay ≥ 24 hr) at a quaternary children's hospital from 2014 to 2020 (n = 12,771 patients; 21,141 admissions). CDEs (6% of patients) included cardiopulmonary resuscitation, extracorporeal membrane oxygenation initiation, dilute epinephrine administration, or unplanned intubation. Temporally distinct PICU admissions from 2021 to 2022 (n = 5144 patients; 6929 admissions; 6% CDE rate). An ensemble of extreme gradient-boosted models (PICU Warning INdex [P-WIN]) trained to predict CDEs at 1-12-hour horizons using 550 features derived from demographics, medications, laboratory results, and vital signs. P-WIN demonstrated excellent discrimination at 2-hour (area under the receiver operating characteristic curve [AUROC], 0.95 [95% CI, 0.94-0.96] and area under the precision-recall curve [AUPRC], 0.76 [95% CI, 0.72-0.80]) and 12-hour horizons (AUROC, 0.93 [95% CI, 0.92-0.94] and AUPRC, 0.68 [95% CI, 0.64-0.72]). To alert before 80% of events, P-WIN generated 0.20 alerts per patient-day at a median 10.17 hours before CDE. Compared with the existing rule-based PICU Warning Tool (alerting before 38% of events), P-WIN generated one-third the alert burden at equivalent sensitivity (0.03 vs. 0.10 alerts per patient-day). P-WIN accurately predicted PICU CDEs up to 12 hours in advance with low alert burden, providing a viable opportunity for shifting care from reactive rescue to proactive, resource-intensive preparation and prevention.

Background Anticoagulation practices during cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are critical for the success of these procedures, yet there exists significant variation in these practices across different regions and among healthcare professionals and institutes. Methods An international survey was conducted targeting perfusionists and other healthcare professionals involved in CPB and ECMO procedures. The survey collected data on professional roles, geographic practice locations, heparin usage in prime solutions, initial and maintenance dosing, anticoagulation monitoring methods, and alternative anticoagulants for patients with Heparin-Induced Thrombocytopenia (HIT). Results Responses were received from professionals in over 20 countries, predominantly perfusionists. A majority of respondents use heparin in the prime solution for CPB, with typical initial doses ranging from 3,000 to 10,000 units. Heparin administration before initiating CPB typically varies between 300 to 400 Units/Kg whereas for ECMO, doses are generally lower. Monitoring of anticoagulation primarily employs Activated Clotting Time (ACT), with a notable number also using Thromboelastography (TEG). For HIT cases, Bivalirudin and Argatroban were the most cited alternatives. Conclusion The survey highlights a diversity of anticoagulation practices in CPB and ECMO across different regions, reflecting variations in clinical protocols, regional standards, and available resources. This diversity highlights the need for ongoing international dialogue and standardization efforts to optimize outcomes in patients who require these critical procedures.

ABSTRACT Extracorporeal membrane oxygenation (ECMO) has been used to successfully minimize, replace, or avoid the use of mechanical ventilation in burned and non-burned populations. Further research on ECMO in the burned population is warranted, particularly with the insufficient patient numbers reported in the literature. A panel composed of national leaders in ECMO and/or burn injury discussed the use of ECMO in burned patients as part of the MedStar Washington Hospital Center Burn Center Multidisciplinary Lecture Series. Panelists examined current methods, institutional practices, and clinical controversies around the use of ECMO in burns. While institutional capacity and protocols vary widely, the discussion highlighted that need for both retrospective and prospective data demonstrating guidelines to maximize the clinical benefits of ECMO in burned patients. Further multicenter investigation is needed to define patient selection criteria, timing, and perioperative management strategies such as anticoagulation in this patient population.

Thermal injuries caused by external cold exposure remain one of the most significant multidisciplinary challenges in critical care medicine. In cases of refractory circulatory arrest resulting from hypothermia, the use of circulatory support methods, particularly the veno-arterial extracorporeal membrane oxygenation (VA ECMO) system, becomes specially grounded and desirable. Objective. To demonstrate the successful use of veno-arterial ECMO in a patient with severe accidental hypothermia complicated by refractory circulatory arrest during the prehospital phase. Materials and Methods. We present the clinical case of a 42-year-old patient with severe generalized hypothermia (temperature 20.0°C), marked hemodynamic instability, and subsequent development of refractory ventricular fibrillation. Given the ineffectiveness of standard resuscitation measures during the prehospital phase, we initiated VA ECMO followed by extracorporeal rewarming and comprehensive intensive care. Results. Following initiation of VA ECMO and controlled warming, restoration of cardiac rhythm and cardiorespiratory function was achieved. Weaning from VA ECMO was performed on the third day, and from respiratory support within the first two days of the hospital stay. On the 22 nd day, the patient was discharged in a stable somatic condition without significant neurological deficits. Conclusion. Early prehospital initiation of VA ECMO as a part of comprehensive intensive care may represent an effective treatment option for severe accidental hypothermia complicated by refractory circulatory arrest.

IntroductionBleeding and clotting phenotypes are common in patients supported with Extracorporeal Membrane Oxygenation (ECMO) and are associated with increased mortality. However, tools to distinguish bleeding from clotting phenotypes remain limited. Readily available platelet indices may help characterize these phenotypes.MethodsWe retrospectively studied patients admitted to neonatal, pediatric, and adult intensive care units (ICUs) at two centers from 2018 to 2022, who were on ECMO and required platelet transfusions. The association between pre-transfusion platelet indices (platelet count, mean platelet volume, platelet mass index) and bleeding or clotting on subsequent day was assessed with day-level univariable and multivariable logistic regression models.ResultsWe enrolled 268 patients receiving ECMO support (75% veno-arterial), with a median age was 51years (IQR 18.9-65.6). A total of 1395 platelet transfusion events were analyzed, of which 18% were followed by bleeding and 5% by thrombosis within 24h. After multivariable adjustment, higher pre-transfusion platelet counts independently associated with subsequent bleeding (adjusted odds ratio [aOR] 1.001, p = 0.03) but not with subsequent thrombosis (aOR 0.99, p = 0.18). Lower pre-transfusion mean platelet volume (MPV) were independently associated with increased bleeding risk (aOR 0.87, p = 0.049), while MPV was not associated with thrombosis (aOR 1.03, p = 0.47). Platelet mass index (PMI) was not independently associated with bleeding (aOR 1.00, p = 0.80) or thrombosis (aOR 1.00, p = 0.32). All platelet indices demonstrated poor discriminatory performance for predicting bleeding or thrombosis, with area under the curve values ranging from 0.42 to 0.55.ConclusionsAlthough platelet count and MPV were independently associated with subsequent bleeding, neither index reliably distinguished bleeding phenotypes. Improved tools are needed to predict hemostatic outcomes in patients supported with ECMO.

The roles and responsibilities of an advanced practice nursing team for coordinating extracorporeal life support in intensive care: A qualitative study.

Mobile ICU-supported ECMO rapid response team: A paradigm for regional critical care optimization.