Use Of ECMO Research Articles

Predictors of Infections and Mortality in Adult Patients Undergoing Extracorporeal Membrane Oxygenation

BackgroundExtracorporeal membrane oxygenation (ECMO) has been used in various clinical settings, such as acute respiratory distress syndrome, cardiogenic shock and refractory septic shock. One of the associated risks is acquisition of infections during bypass because of the multiple cannulation sites. The purpose of this study was to evaluate the predictors of healthcare associated infections (HAI) and mortality in adult patients on ECMO.MethodsThis was a retrospective descriptive study at a 1550 bed University- affiliated tertiary medical center in Miami, Florida. We looked at patients over 18 years old on ECMO for > 48 hours between January 1–August 31, 2016. The presence of an infection before ECMO placement or acquired during ECMO support were noted. Only culture- proven infections were included. The primary outcome was to identify risk factors associated with HAI or mortality.Results40 patients undergoing ECMO during the study period were identified. 25 patients met the inclusion criteria and were included in the analysis. During a total of 364 ECMO days, 12 patients out of 25 had microbiologically proven infection (48 %). There were 7 ventilator associated pneumonias (41%), 5 bacteremias (29%), 2 pleural empyemas (12%), 2 Clostridium difficile colitis (12%) and 1 mediastinitis (6%). Candida species were the predominant blood isolates (60%). The rate of infection per 1,000 ECMO days was 46.7.The overall in-hospital mortality was 64%. There was no impact of infection on mortality, length of ICU,or hospital stay. ECMO use for < 7 days was associated with overall less episodes of infection vs ECMO use for > 7 days. (P-value 0.0136, OR 0.089, CI: 0.01–0.6). Charlson-comorbidity score of 5 or more was associated with higher episodes of bacteremia (P = 0.0023, OR = 16, CI = 1.38–185.41).ConclusionInfections did not have an impact on mortality. Patients on ECMO for less than 8 days had less episodes of infections. Patients with Charlson-comorbidity index of 5 or more were associated with higher episodes of bacteremia. Further prospective cohort studies are necessary to address causality and to determine infection and mortality predictors that can be modified for patients undergoing ECMO.Disclosures All authors: No reported disclosures.

Risk factors for postoperative mortality in congenital diaphragmatic hernia: a single-centre observational study

BackgroundThe management of congenital diaphragmatic hernia (CDH) is a major challenge. The mortality is dependent on associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension and iatrogenic lung injury associated with aggressive mechanical ventilation. The aims of the study were to investigate the mortality over time in a single paediatric surgical centre, to compare the results with recent reports and to define the risk factors for mortality.MethodsThe medical records of infants with CDH from two time periods: 1995–2005 and 2006–2016 were reviewed. Cox regression was used for statistical analysis.ResultsThe study included 113 infants. The mortality rate was significantly decreased in the later time period, compared to the earlier, 4.4 and 17.9%, respectively. At the early time period five patients (7.5%) were treated with ECMO and in the later time period ECMO was used in three patients (6.5%). The mortality in ECMO-treated patients was 50% in both time periods. Prenatal diagnosis, intrathoracic liver, low Apgar score and low birth weight were defined as independent risk factors for mortality.ConclusionDespite no significant differences in the incidence of independent risk factors and the use of ECMO between the two time periods, mortality decreased over time. The mortality was lower than previously reported. The results indicate that there are many important factors involved in a successful outcome after CDH repair. Large multicentre studies are necessary to define those critical factors and to determine optimal treatment strategies.

Venovenous extracorporeal membrane oxygenation for ARDS: outcome analysis of a Croatian referral center for respiratory ECMO.

The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) as arescue therapy in severe acute respiratory distress syndrome (ARDS) has become well established; however, the affirmation of evidence on VV-ECMO application and the analysis of patient outcomes after VV-ECMO treatment for ARDS continues. The aim of the study is to identify variables that affected the outcome of patients treated with VV-ECMO for severe ARDS outside amajor ECMO center. The study included adult patients with severe ARDS treated with ECMO at atertiary care hospital in Zagreb, Croatia between October 2009 and July 2014. Patients were recruited from aprospective database. The study enrolled 40 patients, 20 of whom had H1N1-induced ARDS. The hospital mortality was 38%. The difference in mortality and long-term outcome in H1N1-induced ARDS as compared to non-H1N1-induced ARDS was not significant. Variables associated with mortality included immunosuppression, shock at time of admission, acute renal failure, occurrence of heparin-induced thrombocytopenia antibodies, nosocomial sepsis and duration of ECMO. The results of our study indicate that ECMO use in severe ARDS is feasible with low mortality and identify or assert the variables associated with adverse outcomes.

Extracorporeal membrane oxygenation without systemic anticoagulation for complex multi-organ system trauma patient

Introduction: Use of ECMO has been shown to be an acceptable intervention for patients with respiratory failure refractory to optimal ventilator management. As experience with ECMO grows the indications for its use are also expanding. Case: Our patient is a 20-year-old female who was found lying on the roadside after being hit by a moving vehicle. She was rushed into the trauma room where she was intubated for low Glasgow coma scale, CT head, chest, abdomen and pelvis showed severe head injury with possible diffuse axonal injury, blunt chest injury, blunt abdominal injury with splenic injury was admitted under the care of TICU, repeat CT head showed multiple hemorrhagic contusions. Ventriculostomy with ICP monitoring device was inserted. She was aggressively treated for severe brain injury by neuroprotective interventions. Over following days had severe ARDS. Despite appropriate antibiotic therapy, lung protective ventilation, HFOV, patient had severe hypoxemia. Patient was evaluated for ECMO despite her severe neurological injury with ICH, possible poor neurological recovery. After discussions involving primary team, ECMO was considered initiated using femoral-Jugular cannulation. No systemic anticoagulation was used. Tracheostomy was placed and was weaned off ECMO over next week. ECMO decannulation was performed on 7th day. Patient had multiple interventions by the orthopaedic, weaned off decannulation in 18 days and tracheostomy was closed. Patient had neurological recovery was discharged to the rehabilitation. Discussion: ECMO is an established salvage therapy for profound respiratory failure and the need for systemic anticoagulation has often contraindicated its use in patients with severe intracranial pathology, and in particular, recent hemorrhage like our patient. Advances in circuit and oxygenator technology have challenged this concern and cases of ECMO support with intracranial pathology have been recently described. Risks and benefits of systemic anticoagulation need to be considered during ECMO support. Conclusions: Extracorporeal membrane oxygenation is an acceptable therapy for patients with profound respiratory failure secondary to trauma and intracranial pathology contraindicating the use of systemic anticoagulation.

Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO.

To examine the outcomes of prolonged (≥14 days) extracorporeal membrane oxygenation (P-ECMO) for adult severe respiratory failure and to assess characteristics associated with survival. The use of ECMO for treatment of severe respiratory adult patients is associated with overall survival rates of 50% to 70% with median ECMO duration of 10 days. No prior multi-institutional studies have examined outcomes of P-ECMO for severe respiratory failure. Data on all adult (≥18 years) patients who required P-ECMO for severe respiratory failure from 1989 to 2013 were extracted from the Extracorporeal Life Support Organization international multi-institutional registry. We examined outcomes over 23 years and compared the 2 more recent time periods of 1989 to 2006 versus 2007 to 2013. Up to 974 patients, mean age 40.2 (18-83) years, had ECMO duration of mean 25.2 days/median 21.0 days (range: 14-208 days). Venovenous ECMO support was most common (venovenous: 79.5%, venoarterial: 9.9%). Reason for ECMO discontinuation included native lung recovery (54%), organ failure (23.7%), family request (6.7%), hemorrhage (2.7%), and diagnosis incompatible with life (5.6%). Forty patients (4.1%) underwent lung transplant with 50% postoperative in-hospital mortality. Increased prevalence of P-ECMO was noted with 72% (701/974) of all cases reported since 2008. Survival to hospital discharge was 45.4% (443/974) and did not vary with ECMO duration. Multivariate logistic regression analysis confirmed that P-ECMO patients 2007 to 2013 had a lower risk of death [odds ratio (OR): 0.650; 95% confidence interval (CI), 0.454-0.929; P = 0.010] compared with 1989 to 2006. Factors independently associated with survival were younger age (OR: 0.983; 95% CI, 0.974-0.993; P < 0.001) and lower PaCO2 (OR, 0.991; 95% CI, 0.986-0.996; P < 0.001). Prolonged ECMO use for adult respiratory failure was associated with a lower (45.4%) hospital survival rate, compared with prior reported survival rates of short duration ECMO. Prolonged ECMO survival significantly increased in recent years, and increasing ECMO duration did not alter the survival fraction in the 1989 to 2013 study cohort. Although P-ECMO survival rates are less than short ECMO runs, P-ECMO support is justified.

Cytokine Reduction in the Setting of an ARDS-Associated Inflammatory Response with Multiple Organ Failure.

A 45-year-old male was admitted to our hospital with a small bowel obstruction due to torsion and was immediately scheduled for surgical intervention. At anesthesia induction, the patient aspirated and subsequently developed a severe SIRS with ARDS and multiple organ failure requiring the use of ECMO, CRRT, antibiotics, and low dose steroids. Due to a rapid deterioration in clinical status and a concurrent surge in inflammatory biomarkers, an extracorporeal cytokine adsorber (CytoSorb) was added to the CRRT blood circuit. The combined treatment resulted in a rapid and significant reduction in the levels of circulating inflammatory mediators. This decrease was paralleled by marked clinical stabilization of the patient including a significant improvement in hemodynamic stability and a reduced need for norepinephrine and improved respiratory function as measured by PaO2/FIO2, ventilator parameters, lung mechanics, and indirect measures of capillary leak syndrome. The patient could be discharged to a respiratory weaning unit where successful respiratory weaning could be achieved later on. We attribute the clinical improvement to the rapid control of the hyperinflammatory response and the reduction of inflammatory mediators using a combination of CytoSorb and these other therapies. CytoSorb treatment was safe and well tolerated, with no device-related adverse effects observed.

Abstract 14827: Nitric Oxide During Cardiopulmonary Bypass Improves Clinical Outcome: A Blinded, Randomized Controlled Trial

Background: Children requiring cardiac surgery with cardiopulmonary bypass (CPB) frequently develop Low Cardiac Output Syndrome (LCOS), particularly when very young, A pilot study of 16 children by Checchia et al. (2013) showed that the delivery of nitric oxide (NO) to the CPB circuit shortened duration of mechanical ventilation and ICU stay. We hypothesized that administering NO to oxygenator gas flow during CPB would decrease the incidence of LCOS and effect subsequent clinical outcomes. Methods: We conducted a prospective, blinded, randomized controlled trial in children with congenital heart disease having surgery with CPB. Randomization was stratified by age and ‘blocked’ at six in each group. Children received oxygen alone or 20 ppm gaseous NO and oxygen to the CPB gas administration line. Only the study perfusionist was aware of the allocation and all equipment and devices were otherwise identical in each group; in particular the cardiac surgeon and anesthetist remained blinded to patient allocation. Results: 198 children were enrolled following written consent. There were no differences in patient characteristics, diagnoses or surgeries between groups. 101 children received NO and had a significant reduction in LCOS (14% vs 31%, p=0.004), use of ECMO (1% vs 8%, p=0.014) and a non-significant reduction in ICU length of stay (48hrs vs 72hrs, p=0.111), compared to the 97 children who did not receive NO. The reduction in LCOS was most pronounced in children less than 6 weeks of age (20% vs 52%, p=0.012) and in those aged 6 weeks to 2 years (6% vs 24%, p=0.026), who also had significantly reduced ICU length of stay (43hrs vs 84hrs, p=0.031). LCOS occurred equally between groups in children greater than 2 years of age (17% vs 21%, p=0.678). There was no difference in the amount of post-operative bleeding in any age group. Children greater than 2 years of age who received NO required fewer blood transfusions (8.3% vs 24.1%, p=0.096). Conclusions: Delivery of NO to the CPB circuit for children undergoing cardiac surgery significantly reduces the incidence of LCOS, use of ECMO and ICU length of stay by varying degrees, according to age group.

Abstract 13543: Brain Injury in Adolescents With Single Ventricle Heart Disease Compared to Healthy Controls

Background: Adolescents with single ventricle heart disease (SVHD), who have undergone staged surgical palliation, have increased risk for neurocognitive deficits. However, the type and location of brain injury in SVHD adolescents remains unclear. Purpose: Examine brain injury, using Diffusion Tensor Imaging (DTI) based axial (gray matter injury) and radial diffusivity (white matter injury) procedures in adolescents with SVHD who have undergone surgical palliation compared to controls. Methods: Six SVHD (age 16.2±1 years; 4 males; BMI 20±3.5 kg/m2), and 8 controls (age 16.2±1 years; 4 males; BMI 25.4±8.1 kg/m2) were examined via brain DTI on a 3T MRI. No subject had a history of prematurity, cardiac arrest, ECMO use, genetic syndrome, head trauma or severe developmental delays. Whole-brain axial/radial diffusivity maps were calculated. Statistics consisted of ANCOVA, with age and gender as covariates (uncorrected threshold, p &lt; 0.005). Results: Increased axial diffusivity in SVHD compared to controls were found in several brain sites that include frontal gyrus (p=.03), temporal gyrus (p=.01), parahippocampal gyrus (p=.008), occipital gyrus (p=.02), insular cortex (p=.04), cerebellar cortex (p=.004), pons (p=.02), and cingulate gyrus (p=.006) (Fig1). Increased radial diffusivity appeared in frontal gyrus (p=.01), cingulate gyrus (p=.001), corpus callosum (p=.04), cerebellum (p=.004), temporal gyrus (p=.004), parahippocampal gyrus (p=.004), and pons (p=.004) (Fig2). Conclusions/Implications: Brain injury was more extensive in gray matter than white matter and was located in autonomic and cognitive areas of the brain in adolescents with SVCHD. These findings indicate that the neurocognitive deficits commonly reported in SVCHD are likely related to brain injury. Further investigation is needed to clarify these relationships and to evaluate potential interventions to repair and/or protect these brain regions in this high risk patient population.

Establishment of a Neonatal ECMO Programme on the Basis of a Special Training Programme--A 6-year Analysis

Internationally the need for neonatal ECMO is decreasing and the Extracorporeal Life Support Organization (ELSO) recommends that centres providing neonatal ECMO should treat at least 6 children per year. After a one-year training programme and preparation of the clinical application, neonatal ECMO was established and subsequently 41 infants [median age 1 day (1-172 days), median weight 3.25 kg (1.27-5.79 kg)] with severe respiratory failure have been treated within a 6-year period (fall 2008-fall 2014). For rescue therapy we provide inhaled nitric oxide, high-frequency oscillation and other differentiated ventilator strategies. Parallel to the clinical use of ECMO all employees have been trained in a special programme at 3-monthly intervals. By establishing an elaborate training programme and concentrating the treatment of critically ill newborns in one centre, the expertise of both running and preventing of neonatal ECMO due to pulmonary failure can be achieved. The diagnoses correlate to those of other centres which perform neonatal ECMO. 13 infants needed ECMO. The resulting overall survival rate was 11/12 (91.7%) infants treated with ECMO with a curative approach. All patients could be weaned from ECMO. In the context of a specialised university hospital with all treatment options for critically ill newborns and with the establishment of a specialised training programme, neonatal ECMO for pulmonary failure can achieve equally good results in comparison to those of national and international ECMO centres.

Intraoperative veno-venous extracorporeal lung support in thoracic surgery: a single-centre experience.

Intraoperative extracorporeal lung support (ECLS) during thoracic surgical procedures is a modern concept that is gaining increasing acceptance. So far, cardiopulmonary bypass (CPB), veno-arterial extracorporeal membrane oxygenation (v-a-ECMO) or pumpless arterio-venous interventional lung assist (iLA) were utilized for intraoperative support. Only a few case reports have described the use of veno-venous ECMO for intraoperative ECLS. Here, we report our experience with intraoperative ECLS using different veno-venous low-flow and high-flow settings adapted to the individual patient requirements. Between April 2014 and April 2015, 9 patients underwent pulmonary resections under ECLS. In 6 patients, a twin-port double-lumen cannula was inserted percutaneously into the right femoral vein for low-flow ECLS. In 3 patients, high-flow ECLS was achieved either by femoro-atrial (n = 1) or femoro-jugular cannulation. Indications for ECLS were severely impaired lung function (n = 3), previous pulmonary resections including contralateral pneumonectomy (n = 4), previous single-lung transplantation (sLTX) (n = 1) and extended carinal pneumonectomy (n = 1). Procedures included segmentectomy (n = 3), extended lobectomy with bronchial and vascular anastomoses (n = 1), VATS lobectomy (n = 2), extended left-sided carinal pneumonectomy (n = 1) as well as extended metastasectomy (n = 2). Low-flow ECLS allowed for apnoea up to 45 min in patients with previous pneumonectomy (n = 3) and facilitated protective single-lung ventilation in patients (n = 3) with severely impaired pulmonary function. During trans-sternal carinal pneumonectomy (n = 1), high-flow ECLS achieved by femoro-atrial cannulation allowed for apnoea for 40 min, avoiding cross-field ventilation. In 2 patients requiring extended metastasectomy after previous lobectomy of the contralateral lower lobe (n = 1) or pulmonary metastases in the graft after sLTX for end-stage fibrosis (n = 1), high-flow ECLS by percutaneous femoro-jugular cannulation allowed for extensive metastasectomy under optimal atelectasis of the lung. For intraoperative ECLS, different modes may be applied depending on the intended procedures and required mechanical ventilation. In our experience, different settings of veno-venous ECLS provide sufficient partial or complete lung support, avoiding possible complications associated with other forms of extracorporeal support such as CPB or v-a-ECMO.

Use of ECMO in adult patients with cardiogenic shock: a position paper of the Austrian Society of Cardiology

The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.

Ethical dilemmas with the use of ECMO as a bridge to transplantation

Ethical dilemmas with the use of ECMO as a bridge to transplantation

Overall Hospital Cost Estimates in Children with Congenital Heart Disease: Analysis of the 2012 Kid's Inpatient Database.

This study sought to determine overall hospital cost in children with congenital heart disease (CHD) and to compare cost associated with cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical admissions. The 2012 Healthcare Cost and Utilization Project Kid's Inpatient Database was used to evaluate hospital cost in neonates and children with CHD undergoing cardiac surgery, cardiac catheterization, non-cardiac surgical procedures, and medical treatments. Multivariable logistic regression was applied to determine independent predictors for increased hospital cost. In 2012, total hospital cost was 28,900 M$, while hospital cost in children with CHD represented 23% of this total and accounted for only 4.4% of hospital discharges. The median cost was $51,302 ($32,088-$100,058) in children who underwent cardiac surgery, $21,920 ($13,068-$51,609) in children who underwent cardiac catheterization, $4134 ($1771-$10,253) in children who underwent non-cardiac surgery, and $23,062 ($5529-$71,887) in children admitted for medical treatments. Independent predictors for increased cost were hospital bed size <400 beds (P < 0.001), more than four procedures performed during the same hospitalization (P = 0.001), use of ECMO (P < 0.001), length of hospital stay exceeding 14 days (P < 0.001), cardiac failure (P < 0.001), sepsis (P < 0.001), acute kidney injury (P < 0.001), and neurologic (P < 0.001) and thromboembolic complications (P < 0.001). Hospital cost in children with CHD represented 23% of global cost while accounting for only 4.4% of discharges. This study identified factors associated with increased cost of cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical management in children with CHD.

The role of ECMO in neonatal &amp; paediatric patients

ECMO or Extracorporeal Membrane Oxygenation has now been part of healthcare for over 40 years. During that time, changes in circuit technology have resulted in improved survival and have facilitated the use of ECMO in more challenging patient groups in whom ECMO was previously considered to be contraindicated. Further advances have allowed ECMO to progress out of the specialist centres and nearer to patients, in the form of mobile ECMO. Patient selection remains key to a successful outcome since ECMO is a supportive therapy utilised whilst waiting for a reversible condition to resolve through other treatment strategies.

(238) - Contemporary Use of Continuous Flow Left Ventricular Assist Devices Are No Longer Associated With Post-Transplant Mortality

PurposeUse of mechanical circulatory support before transplant has been traditionally associated with worse post-transplant survival. However, this association has not been confirmed in the era of continuous flow left ventricular assist devices (LVADs). We sought to investigate the association between contemporary practices of hemodynamic support strategies and survival after orthotopic heart transplantation.MethodsWe retrospectively reviewed all adult patients (age >18 years) who received heart transplantation between 2008 and 2013 in the UNOS registry. We used cox proportional hazard model to assess the association between hemodynamic support (extracorporeal membrane oxygenation - (ECMO), left ventricular assist devices (LVADs), intra-aortic balloon pumps (IABP), and intravenous inotropes) and post-transplant survival.ResultsOf 11148 patients who were transplanted during the study period, 8240 (73.9%) required hemodynamic support before transplant. Of those, 75.8% were male, 67.4% were Caucasian, 34.3% with ischemic cardiomyopathy, 63.4% status 1A at transplant, with mean age of 52.6 years. IABP was used in 7.1%, ECMO in 1.1%, inotropes in 53.2%, LVAD in 43.0%, and BiVADs in 4.3%. After adjusting for recipient age, gender, ethnicity, UNOS status at transplant, dialysis, creatinine, HLA mismatch, PRA, length of stay, diabetes, donor age and gender, post-transplant mortality was predicted by ECMO (OR 2.55, p<0.001) and BiVAD (OR 1.59, p=0.002) but not inotropes (OR 1.06, p=0.57), LVAD (OR 1.18, p=0.16) or IABP (OR 1.25, p=0.065).ConclusionContemporary LVADs are no longer associated with post-transplant mortality, whereas ECMO and BiVAD use remain risk factors for death following heart transplantation. PurposeUse of mechanical circulatory support before transplant has been traditionally associated with worse post-transplant survival. However, this association has not been confirmed in the era of continuous flow left ventricular assist devices (LVADs). We sought to investigate the association between contemporary practices of hemodynamic support strategies and survival after orthotopic heart transplantation. Use of mechanical circulatory support before transplant has been traditionally associated with worse post-transplant survival. However, this association has not been confirmed in the era of continuous flow left ventricular assist devices (LVADs). We sought to investigate the association between contemporary practices of hemodynamic support strategies and survival after orthotopic heart transplantation. MethodsWe retrospectively reviewed all adult patients (age >18 years) who received heart transplantation between 2008 and 2013 in the UNOS registry. We used cox proportional hazard model to assess the association between hemodynamic support (extracorporeal membrane oxygenation - (ECMO), left ventricular assist devices (LVADs), intra-aortic balloon pumps (IABP), and intravenous inotropes) and post-transplant survival. We retrospectively reviewed all adult patients (age >18 years) who received heart transplantation between 2008 and 2013 in the UNOS registry. We used cox proportional hazard model to assess the association between hemodynamic support (extracorporeal membrane oxygenation - (ECMO), left ventricular assist devices (LVADs), intra-aortic balloon pumps (IABP), and intravenous inotropes) and post-transplant survival. ResultsOf 11148 patients who were transplanted during the study period, 8240 (73.9%) required hemodynamic support before transplant. Of those, 75.8% were male, 67.4% were Caucasian, 34.3% with ischemic cardiomyopathy, 63.4% status 1A at transplant, with mean age of 52.6 years. IABP was used in 7.1%, ECMO in 1.1%, inotropes in 53.2%, LVAD in 43.0%, and BiVADs in 4.3%. After adjusting for recipient age, gender, ethnicity, UNOS status at transplant, dialysis, creatinine, HLA mismatch, PRA, length of stay, diabetes, donor age and gender, post-transplant mortality was predicted by ECMO (OR 2.55, p<0.001) and BiVAD (OR 1.59, p=0.002) but not inotropes (OR 1.06, p=0.57), LVAD (OR 1.18, p=0.16) or IABP (OR 1.25, p=0.065). Of 11148 patients who were transplanted during the study period, 8240 (73.9%) required hemodynamic support before transplant. Of those, 75.8% were male, 67.4% were Caucasian, 34.3% with ischemic cardiomyopathy, 63.4% status 1A at transplant, with mean age of 52.6 years. IABP was used in 7.1%, ECMO in 1.1%, inotropes in 53.2%, LVAD in 43.0%, and BiVADs in 4.3%. After adjusting for recipient age, gender, ethnicity, UNOS status at transplant, dialysis, creatinine, HLA mismatch, PRA, length of stay, diabetes, donor age and gender, post-transplant mortality was predicted by ECMO (OR 2.55, p<0.001) and BiVAD (OR 1.59, p=0.002) but not inotropes (OR 1.06, p=0.57), LVAD (OR 1.18, p=0.16) or IABP (OR 1.25, p=0.065). ConclusionContemporary LVADs are no longer associated with post-transplant mortality, whereas ECMO and BiVAD use remain risk factors for death following heart transplantation. Contemporary LVADs are no longer associated with post-transplant mortality, whereas ECMO and BiVAD use remain risk factors for death following heart transplantation.

Use of ECMO in adult patients with cardiogenic shock: a position paper of the Austrian Society of Cardiology

The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.

Acupressure for post-operative nausea and vomiting: A pilot randomised controlled trial

Results: Four RCTs have been conducted in patients with acute lung failure; all of which concluded with no difference in all-cause mortality. One trial reported higher survival in the ECMO group at 6 months post-intervention. Medical and technological advancements around the year 2000 introduced clinical heterogeneity that prevented meta-analyses of the four RCTs. There were no completed RCTs in cardiac failure or cardiac arrest. We found two RCTs recruiting patients with cardiac arrest and two RCTs recruiting patients with acute lung failure. Conclusion(s): ECMOuse in patientswith acute respiratory failure remains inconclusive. ECMO use in cardiac failure or arrest is a new area with no completed RCTs available. We recommend matching and combining of ongoing RCTs with RCTs conducted after the year 2000.

Extracorporeal membrane oxygenation for critically ill adults.

Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain. The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications. We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support. Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest). Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.

Acute respiratory distress syndrome in an 11-month-old girl leading to extracorporeal membrane oxygenation

Acute respiratory distress syndrome (ARDS) is a condition recognised for al-most fifty years, and is related to high mor-bidity and mortality in children. From its recognition, medical experts tried to make joint efforts to make recommendations and optimize treatment in children and adult population. The new definition of ARDS suggests treatment by introducing three levels of severity, according to PaO2/FiO2 and positive end-expiratory pres-sure. Lung-protective ventilation remains crucial in achieving better outcome in pae-diatric acute respiratory distress syndrome (PARDS), but promising therapies based on paediatric studies include non-invasive ventilation, endotracheal surfactant, high-frequency oscillatory ventilation (HFOV), and use of ECMO as „rescue“ therapy. Nevertheless, PARDS is a real challenge for the paediatric critical care provider, and even if current state-of-the-art treatment methods are delivered, this disease often leads to fatal outcome. We report the case of an 11-month-old female infant who developed ARDS, was treated by current up-to-date treatment methods, including ECMO, and despite this, succumbed to her illness. With this case report we would like once more to bring to consideration the current knowl-edge on etiology, epidemiology, diagnosis and treatment of ARDS in children, and emphasize the high morbidity and mortal-ity related to this syndrome.

Use of Venovenous Extracorporeal Membrane Oxygenation to Anticipate Difficult One Lung Ventilation in Thoracic surgery

Thoracic surgery may create clinical scenarios where the maintenance of a correct oxygenation and ventilation may be challenging and could lead to incomplete surgery despite cardiovascular stability. Recently, venovenous extracorporeal membrane oxygenation (V-V ECMO) has emerged as an alternative to manage these situations when neither one lung ventilation (OLV) nor other ventilation and oxygenation techniques are feasible or sufficient due to associated lung disease or difficult airway. Here, we report the use of V-V ECMO support in two cases of thoracic surgery in which difficult OLV was anticipated. From the experience gathered in these two cases, we recommend to consider the use of V-V ECMO in selected patients with compromised airway or significant disease of the contralateral surgical hemithorax where conventional options cannot guarantee a correct ventilation and oxygenation. However, V-V ECMO use is not free of complications, being bleeding one of the most frequent and severe problems in surgical patients, which must be thoroughly prevented and treated by the anesthesiologist, the surgeon and the perfusionist.