Use Of Extracorporeal Support Research Articles

Perceptions on Specialist Palliative Care Involvement During and After Cardiopulmonary Resuscitation: A Qualitative Study

IMPORTANCE: Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care. OBJECTIVES: This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed. DESIGN, SETTING, AND PARTICIPANTS: A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical). ANALYSIS: The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz. RESULTS: Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors). CONCLUSIONS: Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

Variability for age at successful extubation in infants with congenital diaphragmatic hernia.

The objective of this study was to characterize clinical factors associated with successful extubation in infants with congenital diaphragmatic hernia. Using the Children's Hospitals Neonatal Database, we identified infants with congenital diaphragmatic hernia from 2017 to 2020 at 32 centers. The main outcome was age in days at the time of successful extubation, defined as the patient remaining extubated for 7 consecutive days. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards ratio equations were used to estimate associations between clinical factors and the main outcome. Observations occurred through 180days after birth. There were 840 eligible neonates with a median gestational age of 38weeks and birth weight of 3.0kg. Among survivors (n=693), the median age at successful extubation was 15days (interquartile range [IQR]: 8-29days, 95th percentile: 71days). For nonsurvivors (n=147), the median age at death was 21days (IQR: 11-39days, 95th percentile: 110days). Center (adjusted hazards ratio: 0.22-15, P<.01), low birth weight, intrathoracic liver position, congenital heart disease, lower 5-minute Apgar score, lower pH upon admission to Children's Hospitals Neonatal Database center, and use of extracorporeal support were independently associated with older age at successful extubation. Tracheostomy was associated with multiple failed extubations. Our findings suggest that infants who have not successfully extubated by about 3months of age may be candidates for tracheostomy with chronic mechanical ventilation or palliation. The variability of timing of successful extubation among our centers supports the development of practice guidelines after validating clinical criteria.

The Use of Extracorporeal Support to Rescue Patients With Acute Respiratory Distress Syndrome Following Thoracic Surgery.

Postoperative acute respiratory distress syndrome (ARDS) following a general thoracic procedure is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) offers an alternate means of cardiopulmonary support in the setting of refractory respiratory failure. We report indications and outcomes patients who after complex general thoracic surgery developed ARDS requiring ECMO support. We performed a retrospective analysis of all patients requiring venovenous (VV) ECMO support in the postoperative period following a general thoracic surgical procedure from January 2011 to December 2019. Exclusion criteria include those who underwent a cardiac procedure, venoarterial (VA) ECMO, cardiothoracic transplantation, or required ECMO only for intraoperative support. Forty instances of postoperative VV ECMO were utilized in patients who underwent a surgery with the thoracic surgical service. Lung procedures were the most common index operations performed (45%) followed by esophageal procedures (40%). Mean time to ECMO initiation from the index operation was 5.45 days with a range of 0 days to 1.3 months. Median length of ECMO support was 9.41 days with a range of 12 hours to 33 days. Patients were cannulated in an elective (70%) or emergent (30%) fashion. ECMO-related complications included a major bleeding event in seven patients. Thirty day survival was 62.5% for the entire cohort and 52.5% of patients were discharged from the hospital and 80.95% of these patients were still alive 90 days after discharge. ECMO is a viable means of cardiopulmonary support that can provide a survival advantage for patients who experience severe refractory respiratory failure following a complex general thoracic surgery.

Midterm outcomes of the Potts shunt for pediatric pulmonary hypertension, with comparison to lung transplant

ObjectiveFor children with severe pulmonary hypertension, addition of Potts shunt to a comprehensive palliation strategy might improve the outcomes afforded by medications and delay lung transplantation. MethodsA prospective analysis was conducted of all children undergoing Potts shunt (first performed in 2013) or bilateral lung transplant for pulmonary hypertension from 1995 to present. ResultsA total of 23 children underwent Potts shunt (20 surgical, 3 transcatheter), and 31 children underwent lung transplant. All children with Potts shunt had suprasystemic right ventricle pressures despite maximal medical treatment. In the majority of patients, the Potts shunt was performed through a left thoracotomy approach (90%, 18/20), by direct anastomosis (65%, 13/20), and without the use of extracorporeal support (65%, 13/20). Perioperative outcomes after Potts shunt were superior to lung transplant including mechanical ventilation time (1.3 vs 10.2 days, P = .019), median hospital length of stay (9.8 vs 34 days, P = .012), and overall complication rate (35% [7/20] vs 81% [25/31], P = .003). Risk factors for operative mortality after Potts shunt (20%, 4/20; compared with 6%, 2/31 for lung transplant, P = .195) included preoperative extracorporeal membrane oxygenation and significant right ventricle dysfunction. In midterm follow-up (median 1.8, maximum 6.1 years), patients with Potts shunt had durable equalization of right ventricle/left ventricle pressures and improved functional status. There was no significant survival difference in patients with Potts shunt and patients with lung transplant (P = .258). ConclusionsPotts shunt is an effective palliation for children with suprasystemic pulmonary hypertension that may become part of a strategy to maximize longevity and functional status for these challenging patients.

Extracorporeal Membrane Oxygenation for Adults With Refractory Septic Shock.

Because of a severe dysregulation of the host response to infection, septic shock may induce a profound imbalance between oxygen consumption and delivery, which in some cases may be refractory to conventional support measures. In this setting, extracorporeal membrane oxygenation (ECMO) may help to restore this ratio. Indeed, in neonates and children, this technique is already established as a valid salvage therapy. In spite of the rapid growth in the use of ECMO in recent years, the evidence of its benefits in adult patients is weak, particularly in cases of refractory septic shock. Nevertheless, several case series have reported good outcomes in selected cases with specific management. Here we explore the links between sepsis and ECMO, starting with the basic biology underlying the two entities. We then review the published literature on the use of extracorporeal support in adult patients with septic shock and finally conclude with a review of the key points of management that can optimize the results after this critical situation.

RIGHT VENTRICULAR SUPPORT IN FAT EMBOLISM SYNDROME: A ROLE FOR PULMONARY VASODILATORS AND EXTRACORPOREAL MEMBRANE OXYGENATION?

SESSION TITLE: Clinical Conundrums in ECMO SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 01:00 pm - 02:00 pm INTRODUCTION: Pulmonary fat embolism (PFE) is a common phenomenon in the setting of orthopedic trauma. Of all patients with PFE, only a minority go on to develop the more catastrophic fat embolism syndrome (FES) that is characterized primarily by hypoxemia, altered mentation, fever, and petechiae. Thought to occur as a result of mechanical embolization of fat from the bone marrow coupled with a dysregulated inflammatory response, FES has a mortality of up to 20% with clinical decompensation primarily driven by acute cor pulmonale and RV failure [1]. CASE PRESENTATION: A 39-year old male with a history of GERD presented to the ED after suffering a traumatic femur fracture and went for operative fixation on the same day. The next day, he decompensated with fever (100.9F), tachycardia (140-150 bpm) and hypoxemia (SpO2 85% on RA). Exam was notable for moderate respiratory distress, an S3 gallop, cool extremities, and bilateral lower extremity edema. Labs were notable for leukocytosis (17,000 /mm3), hemoglobin 11.3 gm/dL, normal renal and liver function, and an A-a gradient of 192mmHg (45% FiO2) with an increased pulmonary shunt fraction. Troponin and BNP were mildly elevated. CTA demonstrated an enlarged RV, dilated PA, and bilateral interstitial infiltrates with no pulmonary embolus. Lower extremity US was negative for DVT. TTE showed a hyperdynamic and under-filled LV as well as a markedly dilated RV with severely depressed systolic function and an estimated RVSP 75 mmHg. His condition worsened, with RHC demonstrating severely elevated mPAP (60mmHg) and PVR (7.4 Wood units). He continued to deteriorate requiring increasing high flow oxygen support. The decision was made to cannulate for VA-ECMO and initiate on inotropes as well as pulmonary vasodilators. After 7 days, he was decannulated and continued on vasodilator therapy. At 1-month follow-up, RV function had normalized, and vasodilator therapy was discontinued. DISCUSSION: Management of FES in this patient was extrapolated from treatment algorithms for massive thrombotic PE with cor pulmonale, including use of extracorporeal support and pulmonary vasodilators. Treatment of FES remains relatively under-investigated and is based on data from case reports and case series. Interventions may include heparin, aspirin, corticosteroids, and albumin, but the quality of evidence supporting these therapies is low [2]. At present, there are no published descriptions of pulmonary vasodilator use in patients with FES. CONCLUSIONS: ECMO and pulmonary vasodilator therapy may help support patients with severe respiratory failure due to FES [3]. Further research into these modalities is warranted. Reference #1: Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med. 1990;18(1):42-46. Reference #2: Bederman SS, Bhandari M, McKee MD, Schemitsch EH. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long-bone fractures? A meta-analysis. Can J Surg J Can Chir. 2009;52(5):386-393. Reference #3: Webb DP, McKamie WA, Pietsch JB. Resuscitation of fat embolism syndrome with extracorporeal membrane oxygenation. J Extra Corpor Technol. 2004;36(4):368-370. DISCLOSURES: No relevant relationships by Samuel McElwee, source=Web Response No relevant relationships by Takudzwa Mkorombindo, source=Web Response No relevant relationships by Raymond Wade, source=Web Response No relevant relationships by Keith Wille, source=Web Response

Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation.

Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.

Establishing and Sustaining an ECPR Program.

The use of extracorporeal support after failed return of a spontaneous ciruculation during cardiopulmonary resuscitation (ECPR) is well described. There are 4 distinct phases for resuscitation with ECPR and the time spent in each phase is critical for successful outcome. Recommendations for ECPR previously published by the American Heart Association provide the context for implementing a consistent and well-rehearsed system for ECPR, by people with the knowledge, experience and resources to deploy ECPR in the most optimal time frame possible in selected patient populations. In this manuscript we review the current status of ECPR for acute cardiac failure and the components we believe are necessary to develop and sustain a reliable and resilient program.

When the momentum has gone: what will be the role of extracorporeal lung support in the future?

There has been expanding interest in and use of extracorporeal support in respiratory failure concurrent with technological advances and predominantly observational data demonstrating improved outcomes. However, until there is more available data from rigorous, high-quality randomized studies, the future of extracorporeal support remains uncertain. Outcomes for patients supported with extracorporeal devices continue to show favorable trends. There are several large randomized controlled trials that are in various stages of planning or completion for extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) in the acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD), which may help clarify the role of this technology for these disease processes, and which stand to have a significant impact on a large proportion of patients with acute respiratory failure. Novel applications of extracorporeal lung support include optimization of donor organ quality through ex-vivo perfusion and extracorporeal cross-circulation, allowing for multimodal therapeutic interventions. Despite the ongoing rise in ECMO use for acute respiratory failure, its true value will not be known until more information is gleaned from prospective randomized controlled trials. Additionally, there are modalities beyond the current considerations for extracorporeal support that have the potential to revolutionize respiratory failure, particularly in the realm of chronic lung disease and lung transplantation.

Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients With Pulmonary Hypertension: Risk Factors and Outcomes

To identify preoperative predictors of extracorporeal support in patients with pulmonary hypertension (PH) undergoing bilateral sequential lung transplantation (LTx), and to examine outcomes associated with the use of extracorporeal support. Retrospective, observational study. Single organ transplantation and tertiary care university medical center. Adults with PH (preoperative mean pulmonary artery pressure (mPAP)≥25 mmHg) who underwent primary bilateral sequential LTx during 2007 to 2013. Of 262 patients with PH undergoing LTx, extracorporeal support was initiated intraoperatively in 149 (57%). Preoperative severe right ventricle (RV) dysfunction and moderate or severe tricuspid regurgitation (TR) were associated with extracorporeal support. In the remaining 208 patients without those factors, increasing preoperative oxygen requirement (odds ratio [OR] 1.30 per 1 L/min, 95% confidence intervals [CI] 1.11-1.52, p = 0.001), presence of RV dilation (OR 2.77, 95% CI 1.28-6.02, p = 0.010), and mPAP (OR 1.33 per 5-mmHg increase in mPAP, 95% CI 1.04-1.70, p = 0.021) were associated independently with extracorporeal support in the multivariable model. Analysis of 49 propensity-matched pairs showed longer intensive care unit (5 v 14 days, p = 0.006) and hospital stays (27 v 39 days, p = 0.016) and increased need for tracheostomy (16% v 41%, p = 0.017) in patients exposed to extracorporeal support but no differences in 30-day mortality, stroke, myocardial infarction, or dialysis. Severity of RV dysfunction, TR, RV dilatation, increasing oxygen requirement, and increasing mPAP showed significant associations with the need for extracorporeal support during LTX in patients with PH. Extracorporeal support was associated with increased length of stay and tracheostomy but not with mortality or other complications. © 2016 Elsevier Inc. All rights reserved.

Applicability of Combined Use of Extracorporeal Support and Temperature-Controlled Machine Perfusion Preservation for Liver Procurement of Donors After Cardiac Death in Pigs

BackgroundThe use of grafts from donors after cardiac death (DCD) would greatly contribute to the expansion of the donor organ pool. The objective of this study is to determine the benefits of extracorporeal membrane oxygenation (ECMO) and subnormothermic machine perfusion (MP) with rewarming in a large animal model of DCD liver. MethodsAfter cardiac arrest, the abdominal aorta and the inferior vena cava were cannulated and connected to an ECMO circuit. Porcine livers were perfused in situ with ECMO at 22°C for 60 minutes after 60 minutes of cardiac death. Then the livers were perfused for 4 hours by MP as a graft viability test. In group 1, non–in situ ECMO and grafts were preserved hypothermic MP. In group 2, non–in situ ECMO and grafts were preserved subnormothermic rewarming MP. In group 3, we used ECMO and subnormothermic rewarming MP. To assess potential methods and effect, effluent enzymes were measured. Portal vein and hepatic artery pressure during MP were evaluated. ResultsEffluent enzyme of AST, alanine aminotransferase and LDH as viability markers were significantly low (aspartate aminotransferase, 2899, 2292, and 972 IU/L; alanine aminotransferase, 134, 140, and 72 IU/L; and lactate dehydrogenase, 4354, 4455, and 1855 IU/L in each group, respectively). Portal vein and hepatic artery pressure during preservation came down smoothly in group 3 compared with group 1. ConclusionsThe combined use of in situ subnormothermic ECMO and machine preservation with rewarming is more essential for the recovery and resuscitating function of DCD liver grafts.

The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors.

Organ-preserving extracorporeal membrane oxygenation (OP-ECMO) is defined as the use of extracorporeal support for the primary purpose of preserving organs for transplantation, rather than to save the patient's life. This paper discusses the ethics of using OP-ECMO in donation after brain determination of death (DBDD) to avoid the loss of organs for transplantation. We review case reports in the literature and analyze the ethical issues raised. We conclude that there is little additional ethical concern in continuing OP-ECMO in patients already on ECMO if they become brain dead. The implementation of OP-ECMO in hemodynamically unstable brain-dead patients is ethically permissible in certain clinical situations but requires specific consent from relatives if the patient's wish to donate is not clear. If no evidence of a patient's wish to donate is available, OP-ECMO is not recommended. In countries with presumed consent legislation, failure to opt out should be considered as a positive wish to donate. If a patient is not-yet brain-dead or is undergoing testing for brain death, OP-ECMO is not recommended. Further research on OP-ECMO is needed to better understand the attitudes of professionals, families, and lay people to ensure agreement on key ethical issues.

Intercenter Cost Variation for Perinatal Hypoxic-Ischemic Encephalopathy in the Era of Therapeutic Hypothermia

To quantify intercenter cost variation for perinatal hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia across children's hospitals. Prospectively collected data from the Children's Hospitals Neonatal Database and Pediatric Health Information Systems were linked to evaluate intercenter cost variation in total hospitalization costs after adjusting for HIE severity, mortality, length of stay, use of extracorporeal support or nitric oxide, and ventilator days. Secondarily, costs for intensive care unit bed, electroencephalography (EEG), and laboratory and neuroimaging testing were also evaluated. Costs were contextualized by frequency of favorable (survival with normal magnetic resonance imaging) and adverse (death or need for gastric tube feedings at discharge) outcomes to identify centers with relative low costs and favorable outcomes. Of the 822 infants with HIE treated with therapeutic hypothermia at 19 regional neonatal intensive care units, 704 (86%) survived to discharge. The median cost/case for survivors was $58 552 (IQR $32 476-$130 203) and nonsurvivors $29 760 (IQR $16 897-$61 399). Adjusting for illness severity and select interventions, intercenter differences explained 29% of the variation in total hospitalization costs. The widest cost variability across centers was EEG use, although low cost and favorable outcome centers ranked higher with regards to EEG costs. There is marked intercenter cost variation associated with treating HIE across regional children's hospitals. Our investigation may help establish references for cost and enhance quality improvement and resource utilization projects related to HIE.

Extracorporeal life support for adult cardiopulmonary failure.

The use of extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO), as it is also known, has rapidly expanded over the past decade. The increase in ECMO use is a consequence of multiple factors including significant advancements in extracorporeal technology, the emergence of data supporting its use, and a growing number of potential clinical applications. This review focuses on the various modes of ECLS as well as the clinical indications and available evidence for the use of extracorporeal support.

Septic shock in ICU: advanced therapeutics, immunoparalysis and genomics. State of the art

New and important concepts have emerged for the advanced management of the child with septic shock in the recent decades. Attending physicians in the Pediatric intensive care unit must be fully aware of them to improve patient care in the critical care unit. It should be considered the use of immune therapy only in selected groups of patients. Continuous renal replacement therapies are well tolerated and their early use prevents deleterious fluid overload. Removal of inflammatory mediators by using high volume hemofiltration may play a role in hyperdynamic septic patients. The use of plasmapheresis is recommended in patients with thrombocytopenia-associated multiple organ failure. Extracorporeal support use should be considered in those with refractory septic shock despite goals directed therapy. The immunoparalysis has been associated with nosocomial infections and late mortality. The information from genetic markers may allow early intervention and preventive genomics-based medicine.

Bridging to Lung Transplant: What Method and for Whom?

Worldwide experience and expertise in lung transplant are increasing. For patients with end-stage respiratory disease this therapy greatly improves symptoms, eliminates the need for home oxygen therapy, and restores overall capacity. A major obstacle to increasing its availability as a treatment option is the limited number of donor organs. Patients who develop severe and progressive respiratory failure and are believed to be candidates for this treatment may be eligible for urgent lung transplantation. While waiting for donor organs to become available, methods to support respiratory function are essential to facilitate survival to transplant. Use of extracorporeal support to maintain gas exchange was first described two decades ago and has since developed substantially. We review current techniques available for bridging patients to lung transplant, and the indications and procedures for such support. Recent and historical clinical experience in this field is also discussed.

Successful use of extracorporeal membrane oxygenation for pH1N1-induced refractory hypoxemia in a child with hypoplastic left heart syndrome

To report the first successful use of extracorporeal membrane oxygenation for acute respiratory distress syndrome secondary to 2009 pH1N1 influenza A infection in a child status post the Fontan operation for hypoplastic left heart syndrome. Individual case report. Pediatric intensive care unit. We describe a 7-yr-old boy with a history of the Fontan operation for hypoplastic left heart syndrome admitted with acute respiratory distress syndrome secondary to 2009 pH1N1 influenza A infection. Cannulation for venoarterial extracorporeal membrane oxygenation. In this patient with a history of complex congenital heart disease and repair, extracorporeal membrane oxygenation was a successful rescue therapy for refractory pH1N1-induced respiratory failure. Extracorporeal membrane oxygenation can be successfully applied for refractory respiratory failure, even in the setting of significant underlying comorbidity. With emerging data to support the role of extracorporeal membrane oxygenation in improving mortality for refractory hypoxemia secondary to pH1N1, it is prudent to strongly consider the use of extracorporeal support in patients with underlying diseases or comorbidities that may have previously precluded them from being candidates for this therapy.

Risk, Clinical Features, and Outcomes of Thrombosis Associated With Pediatric Cardiac Surgery

Thrombosis, usually considered a serious but rare complication of pediatric cardiac surgery, has not been a major clinical and/or research focus in the past. We noted 444 thrombi (66% occlusive, 60% symptomatic) in 171 of 1542 surgeries (11%). Factors associated with increased odds of thrombosis were age <31 days (odds ratio [OR], 2.0; P=0.002), baseline oxygen saturation <85% (OR, 2.0; P=0.001), previous thrombosis (OR, 2.6; P=0.001), heart transplantation (OR, 4.1; P<0.001), use of deep hypothermic circulatory arrest (OR, 1.9 P=0.01), longer cumulative time with central lines (OR, 1.2 per 5-day equivalent; P<0.001), and postoperative use of extracorporeal support (OR, 5.2; P<0.001). Serious complications of thrombosis occurred with 64 of 444 thrombi (14%) in 47 of 171 patients (28%), and were associated with thrombus location (intrathoracic, 45%; extrathoracic arterial, 19%; extrathoracic venous, 8%; P<0.001), symptomatic thrombi (OR, 8.0; P=0.02), and partially/fully occluding thrombi (OR, 14.3; P=0.001); indwelling access line in vessel (versus no access line) was associated with lower risk of serious complications (OR, 0.4; P=0.05). Thrombosis was associated with longer intensive care unit (+10.0 days; P<0.001) and hospital stay (+15.2 days; P<0.001); higher odds of cardiac arrest (OR, 4.9; P<0.001), catheter reintervention (OR, 3.3; P=0.002), and reoperation (OR, 2.5; P=0.003); and increased mortality (OR, 5.1; P<0.001). Long-term outcome assessment was possible for 316 thrombi in 129 patients. Of those, 197 (62%) had resolved at the last follow-up. Factors associated with increased odds of thrombus resolution were location (intrathoracic, 75%; extrathoracic arterial, 89%; extrathoracic venous, 60%; P<0.001), nonocclusive thrombi (OR, 2.2; P=0.01), older age at surgery (OR, 1.2 per year; P=0.04), higher white blood cell count (OR, 1.1/10(9) cells per 1 mL; P=0.002), and lower fibrinogen (OR, 1.4/g/L; P=0.02) after surgery. Thrombosis affects a high proportion of children undergoing cardiac surgery and is associated with suboptimal outcomes. Increased awareness and effective prevention and detection strategies are needed.

Fulminant valvulitis from acute rheumatic fever: Successful use of extracorporeal support

To describe an unusual case of fulminant rheumatic fever presenting acutely as severe respiratory failure managed with extracorporeal membrane oxygenation and ultimately valve replacement while on extracorporeal membrane oxygenation. Case report. Large quaternary care pediatric intensive care unit. A 6-yr-old female with profound respiratory failure found to be due to mitral valve dysfunction stemming from acute fulminant rheumatic fever. The patient was originally maintained on venovenous extracorporeal membrane oxygenation but required conversion to venoarterial extracorporeal membrane oxygenation due to the progression of her mitral valve disease. Her condition did not improve with atrial septostomy, and she required valve replacement while anticoagulated. She was decannulated in the operating room and extubated 2 days later, and she survived to discharge. The institutional review board subsequently granted a waiver of consent for a report of this case. Manifestations of rheumatic fever can develop acutely even in the setting of an industrialized country. Valvulitis with severe, isolated mitral valve dysfunction may masquerade initially as respiratory failure. Multiple invasive procedures can be performed successfully while patients are fully anticoagulated and on extracorporeal membrane oxygenation support.

Experience in Renal and Extrarenal Transplantation with Donation after Cardiac Death Donors with Selective Use of Extracorporeal Support

Most reports of donation after cardiac death (DCD) donors are exclusive to kidney transplantation and report high rates of delayed graft function (DGF). From April 1, 2003, to October 3, 2007, we performed 53 kidney transplantations and 4 simultaneous kidney-pancreas transplantations from DCD donors. All DCD donor kidneys were managed with pulsatile perfusion preservation, and all simultaneous kidney-pancreas transplantation donors were managed with extracorporeal support. Of 53 DCD kidney transplantations, 44 (83%) were from standard criteria donors (SCD) and 9 (17%) from expanded criteria donors (ECD). With a mean followup of 12 months, actual patient and kidney graft survival rates were 94% and 87%, respectively. Patient and graft survival rates were 100% in the 4 simultaneous kidney-pancreas transplantations. Incidence of DGF was 57% (60% without versus 20% with extracorporeal support, p = 0.036). Comparison of the 53 DCD donor kidney transplantations with 316 concurrent donation after brain death (DBD) donor adult kidney transplantations (178 SCD, 138 ECD) revealed no differences in demographics or outcomes, except that the DCD donor group had fewer ECDs (17% DCD versus 44% DBD; p = 0.0002), fewer 0-antigen mismatch kidney transplantations (7.5% DCD versus 19% DBD; p = 0.05), and more kidneys preserved with pulsatile perfusion (100% DCD versus 52% DBD; p < 0.0001). Incidences of DGF (57% DCD versus 19% DBD; p < 0.0001) and acute rejection (19% DCD versus 10% DBD; p = 0.10) were higher in the DCD donor group, which resulted in a longer initial length of stay (mean 11 days DCD versus 8.0 days DBD; p = 0.006). Despite a high incidence of DGF in the absence of extracorporeal support and greater initial resource use, comparable short-term results can be achieved with DCD and DBD donor kidney transplantations.