Use Of ECMO Research Articles

Evaluation of Extra Corporeal Membrane Oxygenation Support in Adult Cardio Respiratory Failure-An Observational Study.

Abstract Extracorporeal life support is a rescue therapy when mechanical ventilation is unable to maintain adequate tissue oxygenation in the setting of acute cardiac or respiratory failure. Outcome is influenced not only by factors independent of ECMO but also by the potential complications related to ECMO. The study is designed to understand the outcomes of Extracorporeal membrane oxygenation in the management of Acute Cardio Respiratory failure in adult population. The study is analytical and the data is prospectively collected from a local registry of ECMO patients and ICU clinical database. Further, clinical details were obtained from prospective review of patient medical records. The study period is from November 2013 and November 2015. A total of 30 patients were included in the study 36.7% were weaned off ECLS and 33.3% survived to hospital discharge. Incidence of Heparin Induced Thrombocytopenia was observed in 3 patients. 27 patients went into renal dysfunction. Both ICU duration (p-0.945) and duration of ECMO (0.736) support did not prove to be significant in predicting mortality. No cannula related vascular complications leading to limb ischemia or need for vascular repair were encountered in any patient. Mean number of blood transfusions required during ECMO support were 15.17 units. Infections acquired on ECMO support, p=0.052; 95% CI=0.007-1.707. Our results endorse the use of ECMO as a rescue therapy in adults, although there are some risks associated with a learning curve as well as an important increase in the days of patient stay. However, ECMO is still marred by frequent and significant complications such as renal derangement, bleeding and nosocomial infections.

Longitudinal impact of temporary mechanical circulatory support on durable ventricular assist device outcomes: An IMACS registry propensity matched analysis

Patients with advanced heart failure and cardiogenic shock (CS) often require temporary circulatory support (TCS) as a bridge to durable ventricular assist devices (dVADs). We aim to characterize longitudinal outcomes of patients with and without CS. Between 2013 and 2017, 13,813 adult patients classified as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profiles 1 to 3 with continuous flow left ventricular assist devices or biventricular assist devices were registered into the International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support. Patients were sub-grouped according to support type (extracorporeal membrane oxygenation [ECMO], intra-aortic balloon pump [IABP], and other TCS). Other TCS included all other surgical and percutaneous TCS devices. Estimated survival was compared based on need for pre-operative TCS and by profile. Pre-operative TCS was used in 5,632 (41%) cases. Of these, ECMO was used in 1,138 (20%) cases, IABP in 3,901 (69%) cases, and other TCS in 595 (11%) cases. Patients requiring ECMO had greater needs for biventricular support after dVAD (22% ECMO, 5% IABP, and 7% other TCS; p < 0.001) with longer post-implant intensive care stays (ECMO 24 days, IABP 14 days, and other TCS 12 days; p < 0.001).INTERMACS Profile 1 to 3 patients with pre-implant ECMO had the lowest longitudinal survival (82% at 1 month and 44% at 48 months) compared with IABP (93% at 1 month and 51% at 48 months), other TCS (92% at 1 month and 52% at 48 months), and non-TCS (95% at 1 months and 55 % at 48 months) (p < 0.0001). Propensity score matching analysis of the pre-implant ECMO INTERMACS Profile 1 group when compared with alternative pre-implant TCS strategies had an associated higher hazard impacting early phase survival vs other TCS (hazard ratio, 1.80; p < 0.01) and IABP (hazard ratio, 1.65; p < 0.01). In advanced heart failure with patients with CS, the use of ECMO before dVAD was associated with lower longitudinal survival and increased utilization of biventricular support compared with alternative TCS strategies. Research focused on longitudinal profiling in CS and pre-implant TCS is warranted to further understand these differences.

Discordant prenatal ultrasound and fetal MRI in CDH: wherein lies the truth?

PurposePrenatal risk assessment of congenital diaphragmatic hernia (CDH) relies on prenatal ultrasound (U/S) and fetal magnetic resonance imaging (MRI). When the modalities differ in prognosis, it is unclear which is more reliable. MethodsRetrospective chart review identified cases of prenatally diagnosed CDH from 4/2010–6/2018 meeting inclusion criteria. Demographic, radiologic, and postnatal outcomes data were collected.Ultrasound- versus MRI-based prognosis (mild, moderate, and severe) was compared with clinical outcomes. Kappa measures compared congruency in disease severity scaling between imaging modalities, while logistic regression and receiver operating characteristics curves compared the ability of each modality to predict outcomes. ResultsForty-two patients met criteria. Both U/S- and MRI-based prognosis categories differentiated for survival. MRI categories differentiated for ECMO use, surgical repair, and defect type. O/e TFLV better discriminated for survivors and defect type than o/e LHR. Seventeen (40.5%) had discordant prenatal prognostic categories. In 13/17 (76.5%), o/e TFLV predicted higher severity when compared to o/e LHR, but sample size was insufficient to compare accuracy in cases of discordance. ConclusionsClinical outcomes suggest fetal MRI may more accurately predict severe pulmonary hypoplasia compared to prenatal ultrasound. Our analysis suggests fetal MRI is a valuable adjunct in the prenatal evaluation of CDH. Level of EvidenceLevel III. Type of StudyRetrospective Review.

"Treatment Use of ECMO In Pregnancy or Peripartum Patient."

"Treatment Use of ECMO In Pregnancy or Peripartum Patient."

Comparative outcomes of right versus left congenital diaphragmatic hernia: A multicenter analysis

BackgroundCongenital diaphragmatic hernia (CDH) occurs in 1 out of 2500–3000 live births. Right-sided CDHs (R-CDHs) comprise 25% of all CDH cases, and data are conflicting on outcomes of these patients. The aim of our study was to compare outcomes in patients with right versus left CDH (L-CDH). MethodsWe analyzed a multicenter prospectively enrolled database to compare baseline characteristics and outcomes of neonates enrolled from January 2005 to January 2019 with R-CDH vs. L-CDH. ResultsA total of 588, 495 L-CDH, and 93 R-CDH patients with CDH were analyzed. L-CDHs were more frequently diagnosed prenatally (p=0.011). Lung-to-head ratio was similar in both cohorts. R-CDHs had a lower frequency of primary repair (p=0.022) and a higher frequency of need for oxygen at discharge (p=0.013). However, in a multivariate analysis, need for oxygen at discharge was no longer significantly different. There were no differences in long-term neurodevelopmental outcomes assessed at two year follow up. There was no difference in mortality, need for ECMO, pulmonary hypertension, or hernia recurrence. ConclusionIn this large series comparing R to L-CDH patients, we found no significant difference in mortality, use of ECMO, or pulmonary complications. Our study supports prior studies that R-CDHs are relatively larger and more often require a patch or muscle flap for repair. Type of studyPrognosis study Level of evidenceLevel II

ECMO usefulness in refractory shock secondary to Phenylephrine poisoning: About a case in a Pediatric subject

Introduction: Phenylephrine is an alpha-agonist with vasoconstrictor effect. Systemic absorption or adverse reaction can cause complications that can be lethal. In those cases of adverse drug reactions with failure to conventional management, the use of ECMO has been reported as a treatment modality. Clinical case: We report the case of a 13 years old teenager, who presented acute pulmonary edema and acute heart failure subsequent to the application of topical phenylephrine during the a rhino-septoplasty procedure, and that warranted placement of ECMO due to failure of conventional treatment. Discussion: Venoarterial ECMO was placed by central cannulation, with ventilatory and hemodynamic improvement, performing the explant successful 4th postoperative day. Conclusions: ECMO as a "bridge to recovery" may be an alternative in those cases of pulmonary or cardiac failure and refractory with a poor response to conventional treatment, as well as an option to save the life of these patients.

Comparison of In-Hospital Outcomes When Repair of Tetralogy of Fallot Is in the Neonatal Period Versus in the Post-Neonatal Period

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) and optimal timing for total repair of TOF is controversial. We hypothesize that TOF repair in the neonatal period is associated with worse outcomes compared with those who undergo repair later in infancy. We analyzed data using the Kids' Inpatient Database (KID) from 2003 to 2012. We used multivariable logistic regression analyses to compare the in-hospital outcomes between those who underwent total repair of TOF during the neonatal period vs the postneonatal period. There were 6,856 cases of TOF and 7.83% (n = 537) of those underwent repair during the neonatal period. The average mortality in all TOF repair was 2.1% (n = 147). In multiple regression model, compared with repair in postneonatal period, neonatal repair was associated with increased mortality, with adjusted odds ratio of 2.2 (95% confidence interval [CI]: 1.1 to 4.3, p = 0.023). Regarding complications, the neonatal group was associated with higher risk of acute renal failure (8.9% vs 2.3%, p <0.001), need for cardiac catheterization (18.6% vs 8.3%, p <0.001), and ECMO use (4.4% vs1.6%, p <0.001). There was no difference in the rates of arrhythmia, respiratory failure, pulmonary hypertension, or sudden cardiac arrest. Children who underwent repair in the neonatal period had longer hospital stay compared with the postneonatal group (45.5 days [95% CI: 39.3 to 51.7] vs 12.6 days [95% CI: 11.7 to 13.4], p <0.001). Hospital charges were higher for children who underwent repair in the neonatal period compared with those in the postneonatal period. In conclusion, TOF repair in the neonatal period is associated with higher rates of mortality, more postoperative complications, longer hospital stays, and higher hospitalization cost.

Experiences with venovenous extracorporeal membrane oxygenation (ECMO) support for thoracic surgery in Hungary. Retrospective clinical study

Introduction: Most modern thoracic operations are performed with single-lung ventilation balancing between convenient surgical approach and adequate gas exchange. The technical limitations include difficult airways or insufficient parenchyma for the intraoperative single-lung ventilation. Earlier, cardiopulmonary bypass was the only solution, however, today the extracorporeal membrane oxygenation is in the forefront. Aim: We retrospectively analysed our elective operations by use of venovenous ECMO to assess the indication, safety, perioperative morbidity and mortality. Patients and method: 12 patients were operated using venovenous (VV-) ECMO between 28 April 2014 and 30 April 2018 in the National Institute of Oncology. The main clinicopathological characteristics, data regarding the operation, the use of ECMO and survival were collected. Results: The mean age was 45 years, 2 patients had benign and 10 had malignant diseases. Extreme tracheal stricture was the indication for ECMO in 3 cases, while 4 patients had previous lung resection and lacked enough parenchyma for single-lung ventilation. 5 patients had both airway and parenchymal insufficiency. The average time of apnoea was 142 minutes without interruption in any of the cases. We did not experience any ECMO-related complication. We had no intraoperative death and 30-day mortality was 8.33%. Conclusion: In case of technical inoperability, when there is no airway or insufficient parenchyma for gas exchange, but pulmonary vascular bed is enough and there is no need for great-vessel resection, VV-ECMO can safely replace the complete gas exchange without further risk of bleeding. The use of VV-ECMO did not increase the perioperative morbidity and mortality. Previously inoperable patients can be operated with VV-ECMO. Orv Hetil. 2019; 160(42): 1655-1662.

A CASE OF HEMORRHAGE RESCUED BY EXTRACORPOREAL MEMBRANE OXYGENATION

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a well-known complication of many disease processes including vasculitides. DAH secondary to vasculitis, however rare, is one of the most devastating presentations of vasculidities carrying a substantial mortality. A significant percentage of patients with DAH progress to acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been described to improve oxygenation in ARDS while underlying etiologies are addressed. The role of VV ECMO in DAH secondary to vasculitis is unclear. CASE PRESENTATION: A 37-year-old woman presented with severe ARDS. In the preceding two weeks, she experienced polyarthralgias and a lower extremity rash. She presented to the emergency department after developing hemoptysis which necessitated intubation. On presentation to the intensive care unit, she was afebrile and had an oxygen saturation of 95% on an FiO2 of 1. Of note, the patient had non-blanching, palpable, hemorrhagic bullae. Lab-work was notable for a white blood cell count of 13,600, a hemoglobin of 8.4 g/dL, a PaO2/FiO2 (P/F) ratio of 92, and urinalysis with protein and dysmorphic red blood cells. Computed tomography of the chest demonstrated diffuse infiltrates sparing the periphery. She was paralyzed and placed in a prone position for severe ARDS. She was started on pulse-dose steroids and on plasma exchange for suspected DAH. On day three, her P/F ratio was 61 and she was placed on VV ECMO. Bronchoscopy was performed with sequentially bloodier returns on alveolar lavage. Further workup revealed negative bacterial cultures, a positive ANA titer of 1:320, a C-ANCA titer of 1:40, and an elevated PR3 antibody. The patient was diagnosed with granulomatosis with polyangiitis and was started on cyclophosphamide. She was decannulated from ECMO after four days, extubated two days thereafter, and was discharged from the hospital in her premorbid state. DISCUSSION: The causes of DAH are varied but are commonly due to autoimmune phenomena. The current evidence for use of ECMO in DAH is limited to case reports and case series. Before the more widespread deployment of extracorporeal support, the treatment of respiratory failure from DAH was limited to aggressive ventilator management and immunomodulating medications. Despite progress in immunosuppressive therapy, the mortality for DAH remains unacceptably high. The deployment of ECMO may provide enough time with sufficient oxygenation for the causes of DAH to be addressed. CONCLUSIONS: Though there is a dearth of high-quality evidence justifying the use of ECMO in DAH, our case demonstrates that VV ECMO can be used successfully to temporize the hypoxemia in DAH. This measure could provide the time necessary for immunosuppression to take effect and reduce overall mortality from the most devastating consequence of vasculitis. Reference #1: Park M. S. (2013). Diffuse alveolar hemorrhage. Tuberculosis and respiratory diseases, 74(4), 51-62. Reference #2: Guo, Z., Li, X., Jiang, L. Y., & Xu, L. F. (2009). Extracorporeal membrane oxygenation for the management of respiratory failure caused by diffuse alveolar hemorrhage. The journal of extra-corporeal technology, 41(1), 37-40. Reference #3: West S, Arulkumaran N, Ind PW, Pusey CD. (2013). Diffuse Alveolar Haemorrhage in ANCA-associated Vasculitis. Internal Medicine, 52(1):5-13. DISCLOSURES: No relevant relationships by Lisa Daniels, source=Web Response No relevant relationships by Joshua Detelich, source=Web Response No relevant relationships by Maxwell Hockstein, source=Web Response

2498 ECMO: A Bridge to Liver Transplant

INTRODUCTION: ECMO has been rarely used in the perioperative setting during liver transplantation (LT) and there is scarce data on its use. Many patients requiring LT have cardiopulmonary compromise due to complications of liver disease or other co-morbidities. We present a use of VA-ECMO as cardiopulmonary support during LT in a patient with pulmonary hypertension. CASE DESCRIPTION/METHODS: A 57-year-old man with a medical history of ETOH cirrhosis complicated by recurrent ascites, portal hypertension, and hypothyroidism was admitted for management of fluid overload despite compliance with low-salt diet and diuretics. He had multiple prior hospitalizations for fluid overload which were managed with intravenous diuretics. He was listed for liver and kidney transplant in New York. He was eventually started on hemodialysis for end stage kidney failure secondary to hepatorenal syndrome. He also had severe pulmonary hypertension (PH). He had an offer for liver transplant and went to the operating room (OR). However, a Swan-Ganz catheter was placed and showed mean PA pressure of 47 mm Hg with high cardiac output despite the use of vasodilators. After careful evaluation, his transplantation was aborted. Few weeks later, he was taken back to the OR for liver transplant and was placed on VA-ECMO electively. His cardiopulmonary status was carefully monitored and remained stable with VA-ECMO support during the procedure even with severe PH. His transplantation was successful, after which his hemodynamics improved significantly and the ECMO was removed in the OR. Subsequently, he underwent kidney transplant and his PH improved postoperatively. DISCUSSION: Severe cardiac and pulmonary dysfunction is a contraindication for LT. Hepatopulmonary syndrome is a complication of liver failure and can cause pulmonary hypertension, which was the case with our patient. Intraoperative use of ECMO, both VA and VV, have been used sparingly. However, over the recent years, the use of ECMO peri-operatively has had wider use although poor outcomes are still reported. Bleeding risk is extremely high due to the coagulopathic nature of liver disease as well as the anti-coagulation necessity during ECMO so it is imperative to limit the duration of ECMO. In conclusion, VV or VA- ECMO can be a useful therapeutic option in patients undergoing transplantation with significant cardiac or pulmonary compromise especially in New York where the waiting period for transplant is long.

USE OF EXTRACORPOREAL MEMBRANE OXYGENATION AND RIGID BRONCHOSCOPY FOR PLASTIC BRONCHITIS IN AN ADULT

SESSION TITLE: Pulmonary Pathology SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 1:00 PM - 2:00 PM INTRODUCTION: Plastic bronchitis is the expectoration of branching bronchial casts, often secondary to a defined pathologic entity like asthma, cystic fibrosis, or bronchiectasis.[1] Overall, it is a rare syndrome primarily affecting children after congenital heart surgery, and much rarer still in adults. Increasingly, lymphatic anomalies have been identified as the underlying etiology in cases previously considered idiopathic.[2] It is classically managed with mucolytics, aggressive pulmonary hygiene, and treatment of the underlying disease.[3] Mucus plugs form casts in the shape of the bronchi, and larger casts can obstruct the airway. When conservative measures fail, patients require bronchoscopic evacuation. If large enough, airway casts can lead to rapid clinical decline and even cause death by asphyxiation. Venovenous extracorporeal membrane oxygenation (VV ECMO) can secure ventilation in patients with central airway obstruction, but this has not been done previously for cases of plastic bronchitis in adults. CASE PRESENTATION: We report a case of a 34 year old female presenting with worsening cough and dyspnea in a setting of pulmonary lymphangiectasia. She described coughing up tree-like casts and noted numerous prior bronchoscopies. Early in her course, her work of breathing increased requiring intubation and mechanical ventilation. Despite aggressive pulmonary hygiene, she continued to decline. Flexible bronchoscopy revealed a large, rubbery cast descending from the tip of endotracheal tube into both main stem bronchi, occluding the airway. The obstruction could not be completely removed. With rising hypercapnia, she became more somnolent and hypoxic. An attempt at rigid bronchoscopy was deferred in favor of starting VV ECMO for stabilization. Her acidosis and hypoxemia were then rapidly corrected. With ventilation no longer compromised, her larynx was suspended and the endotracheal tube was removed, allowing unencumbered access to the airway. Alternating between rigid and flexible bronchoscopy, larger graspers were used to extract multiple portions of the cast. The airway was then widely patent. She was subsequently treated with inhaled alteplase and dornase alfa to thin secretions. She was weaned off ECMO and extubated within a week of original presentation. DISCUSSION: Among adults with plastic bronchitis, this is the first reported use of VV ECMO paired with rigid bronchoscopy. This is also the first case at our institution where ECMO was used for support in the face of central airway obstruction. The extracorporeal life support provided important stabilization without need for mechanical ventilation. Without the threat of immediate respiratory arrest, rigid bronchoscopy was safely performed to clear the occluded airway. CONCLUSIONS: Plastic bronchitis remains a rare disorder, but combined treatment with ECMO and rigid bronchoscopy may be a successful treatment option in select cases. Reference #1: Eberlein MH, Drummond MB, Haponik EF. Plastic bronchitis: a management challenge. Am J Med Sci 2008;335:163-169. Reference #2: Itkin MG, McCormack FX, Dori Y. Diagnosis and treatment of lymphatic plastic bronchitis in adults using advanced lymphatic imaging and percutaneous embolization. Ann Am Thorac Soc 2016;13:1689-1696. Reference #3: Brooks K, Caruthers RL, Schumacher KR, Stringer, KA. Pharmacotherapy challenges of Fontan-associated plastic bronchitis: a rare pediatric disease. Pharmacotherapy 2013;33:922-934. DISCLOSURES: no disclosure on file for Hatim Al-Jaroushi; No relevant relationships by Kyle Chapman, source=Web Response No relevant relationships by Jeremiah Hayanga, source=Web Response

An interesting case summary of tubercular pneumonia masquerading as viral pneumonia kept on extra-corporeal membrane oxygenation

Mortality in patients with pulmonary tuberculosis remains high, especially in those who develop acute respiratory distress syndrome (ARDS). We herein, report a case of 40 year old female, with ARDS due to severe pulmonary tuberculosis. She was admitted in the intensive care unit of a tertiary care centre. Owing to very poor ABG report, she was intubated and put on Mechanical ventilator support. Bronchoscopy was performed and BAL was extracted, which showed no growth. Further deterioration of gas exchange prompted the decision to put her on ECMO.During her stay on ECMO, she developed massive inta-alveolar hemorrhage following which repeated bronchoscopic interventions were done to remove blood clots. BAL extracted on day 4 and day 8 showed growth of A. baumannii and K. pneumoniae respectively. But BALGeneXpert on day 8 came out to be positive for Mycobacterium Tuberculosis and subsequently ATT was added to her treatment regimen.Her alveolar hemorrhage continued to worsen and subsequently ECMO was removed. After 12 days of hospitalization, she went on to develop bradycardia and could not be rescued. Though the patient's life was lost, this case provided many insights on the use of ECMO in the management of ARDS due to Pulmonary tuberculosis and it should be considered as one of the treatment options.

Clinical features and outcomes associated with tracheostomy in congenital diaphragmatic hernia.

The purpose of this study was to examine the clinical features/outcomes associated with tracheostomy in infants with congenital diaphragmatic hernia (CDH). The study population consisted of liveborn infants reported to the CDH Study Group registry between 2007 and 2017. Subjects were identified as having a tracheostomy if they were discharged or transferred to another hospital with tracheostomy and/or on mechanical ventilation. Multivariate mixed models were used for analyses. The registry population consisted of 5434 subjects, of whom 230 (4.2%) underwent tracheostomy placement. Only 3830 (70.5%) infants survived until discharge/transfer. The median age of tracheostomy placement was 3.3 months (range, 1.3-13.4 when known; n = 58 out of 154 survivors). The mortality rate among subjects with tracheostomy was 32.8% with a median of 37 days (range, 8-189 when known; n = 32 out of 75 deceased) ensuing between tracheostomy placement and death. The clinical features found to be associated with increased odds ratio of tracheostomy placement included male sex, birth weight, 5-minute APGAR score, defect size, liver in chest, ECMO use, cardiac abnormality, other congenital abnormalities, pulmonary hypertension, and the presence of a feeding tube. There was center variation in the rate of tracheostomy placement, which may be partially accounted for by disease severity, but not center size. There are several clinical features that are associated with increased likelihood of tracheostomy placement. Most deaths in subjects with tracheostomies occurred outside the immediate postoperative period. The utility of a standardized protocol for tracheostomy in infants with CDH should be considered.

Extracorporeal life support in pediatric trauma: a systematic review

IntroductionExtracorporeal membrane oxygenation (ECMO) was once thought to be contraindicated in trauma patients, however ECMO is now used in adult patients with post-traumatic acute respiratory distress syndrome (ARDS) and multisystem...

EOLIA trial: the future of extracorporeal membrane oxygenation in acute respiratory distress syndrome therapy?

In the EOLIA trial, early use of ECMO did not significantly improve mortality at 60 days in patients with severe ARDS, but when used as a rescue modality ECMO might help improve survival http://bit.ly/2XOjwSE

Role of oral sildenafil in neonates with persistent pulmonary hypertension of newborn

Persistent pulmonary hypertension of newborn is a devastating condition and leads to morbidity and mortality. Even after the increasing use of NO, ECMO and HFO many patients succumb to death. About 50% of the patients either have rebound hypertension or do not respond to the treatment. Hence the role of phosphodiesterase inhibitors (sildenafil) need to be evaluated. Methods is authors report a retrospective case series of 24 patients with PPHN admitted in NICU and treated with oral sildenafil. Results sildenafil was started on all patients on a mean of 1.46 days and stopped on mean of 3.8 days. Initial fio2 was 100%, which after starting sildenafil decreased gradually to 50% on mean of 10 days. Average length of stay in NICU was 20 days. 17(70.8%) patients survived whereas 7 (29%) expired No improvement in oxygen Index after 48 hours (p&lt;0.05) was the independent predicting risk factor for PPHN related mortality in the expired patients.Conclusion are oral sildenafil can be a used in conjunction with other treatment modalities for PPHN especially in resource limited settings.

Increasing Hospitalizations and Decreasing Mortality from Sudden Cardiac Arrest in Modern Era: An Analysis of the National Inpatient Sample

Introduction The national data on trends, patient characteristics, utilization of therapies and outcomes in patients with sudden cardiac arrest (SCA) are lacking. Methods Using the National Inpatient Sample (NIS) database we identified yearly trends, patient characteristics, utilization of therapies and differences of in-hospital outcomes among patients with in-hospital vs out-of-hospital CA between years 2007-2015 Results A total of 1018541 patients (87% in-hospital) were identified with SCA between 2007 and 2015 with an increasing yearly trend. Of those, 201231 (20%) had AMI and 112104 (11%) cardiogenic shock and 64886 (7%) of patients underwent revascularization during same hospitalization (Table 1). Overall, 37590 (3.5%), 38489 (0.3%) and 2969 (0.3%) of patients underwent IABP, percutaneous LVAD (pLVAD) and ECMO placements respectively. While pLVAD and ECMO use has been increasing steadily in recent years, IABP use is consistently decreasing. 190 (0.05%) of patients underwent durable LVAD implantation and 225 (0.02%) underwent orthotropic heart transplant (OHT) during same hospitalization (Table 2). The length of stay (LOS) for entire cohort was 8.1(±12.4) days and the mortality for entire cohort was 68% with decreasing trend over the study period (Figure 1). The mortality in patients who underwent ECMO, durable LVAD and OHT was lower than the overall cohort (p Conclusions There has been an increase in the number of SCA patients with a concomitant decreasing mortality trend in the recent era. The mortality in patients who underwent ECMO, durable LVAD and OHT was lower than the overall cohort.

Long-term neurocognitive outcome is not worsened by of the use of venovenous ECMO in severe ARDS patients

BackgroundVenovenous extracorporeal membrane oxygenation (VV-ECMO) is associated with a significant morbidity. There is the need to investigate long-term cognitive outcome among ARDS survivors treated with VV-ECMO. We aimed to compare the prevalence of long-term cognitive dysfunction and neuropsychological impairment using a highly specific test in severe ARDS survivors treated or not treated with VV-ECMO.MethodsSevere ARDS survivors treated between 2011 and 2017 in an ECMO Regional Referral Center were prospectively evaluated 2 years after their ICU discharge. Patients underwent an in-person interview and examination. The primary outcome was cognitive function, assessed by the Wechsler Adult Intelligence Scale 4th edition (WAIS-IV). Secondary outcomes included anxiety, depression, post-traumatic stress disorder (PTSD) and quality-of-life.ResultsWe investigated 40 consecutive patients surviving from severe ARDS treated (N = 22) or not (N = 18) with VV-ECMO at a median [interquartile range] of 20 [17–22] and 22 [18–23] months after ICU discharge, respectively. Regarding the main outcome, cognitive function was below normal ranges in 12 (55%) ECMO patients and 10 (56%) non-ECMO patients (p = 0.95). Eight (36%) ECMO patients had moderate-to-severe depressive symptoms as compared with 7 (39%) non-ECMO patients (p = 0.87). Twelve (55%) ECMO patients and eight (44%) non-ECMO patients had moderate-to-severe anxiety symptoms (p = 0.53). Seven (33%) ECMO patients and eight (44%) non-ECMO patients presented a PTSD (p = 0.48). Health-related quality of life did not differ between the two groups.ConclusionsUsing the WAIS-IV, VV-ECMO treatment does not appear to worsen long-term cognitive and neuropsychological outcomes in severe ARDS patients.

Renal outcome after simultaneous heart and kidney transplantation.

Simultaneous heart-kidney transplant (HKTx) is a valid treatment for patients with coexisting heart and renal failure. The aim of this study was to assess renal outcome in HKTx and to identify predictive factors for renal loss. A retrospective study was conducted among 73 HKTx recipients: Donors' and recipients' records were reviewed to evaluate patients' and renal transplants' survival and their prognostic factors. The mean follow-up was 5.36years. Renal primary non-function occurred in 2.7%, and complications Clavien IIIb or higher were observed in 67.1% including 16 (22%) postoperative deaths. Five-year overall survival and renal survival were 74.5% and 69.4%. Among survivors, seven returned to dialysis during follow-up. The postoperative use of ECMO (HR=6.04, P=0.006), dialysis (HR=1.04/day, P=0.022), and occurrence of complications (HR=31.79, P=0.022) were independent predictors of postoperative mortality but not the history of previous HTx or KTx nor renal function prior to transplantation. History of KTx (HR=2.52, P=0.026) and increased delay between the two transplantations (HR=1.25/hour, P=0.018) were associated with renal transplant failure. HKTx provides good renal transplant survival and function, among survivors. Early mortality rate of 22% underlines the need to identify perioperative risk factors that would lead to more judicious and responsible allocation of a scarce resource.

뇌사자 및 잠재적 뇌사자에서의 체외막산소화장치 이용문제와 장기구득에서의 윤리적태도

Organ preserving extracorporeal membrane oxygenation (OP-ECMO) is used as a method of donor management in donation after brain determination of death (DBDD) or potential brain-death to acquire organs in a way that stabilize vital sign in hemodynamically unstable donors. Because it can cause physical and psychological harm to donors and their family members OP-ECMO for DBDD or potential brain death raises ethical issues. Donors who refuse life-sustaining treatment may not receive the end of life care they want, and family members may have difficulty in accepting the patient’s death because of the use of ECMO even after a brain-death declaration. In cases of a potential brain-death, a medical professional who initiates ECMO without informed consent betrays the patient, the family, and any third-party payers. In light of scarce medical resources, the use of OP-ECMO should be carefully examined. To address the potential ethical issues related to ECMO use in organ donors, medical professionals should indicate that the purpose of organ donation is not merely to harvest organs but rather give to the gift of life and should approach donor-centered organ donation and the harvesting process with respect for donor.