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Odetola FO, Gebremariam A. Epidemiology of Acute Respiratory Failure in US Children: Outcomes and Resource Use. Hosp Pediatr 2024:e2023007166. [PMID: 38953120 DOI: 10.1542/hpeds.2023-007166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE Acute respiratory failure recalcitrant to conventional management often requires specialized organ-supportive technologies to optimize outcomes. Variation in the availability of these technologies prompted testing of the hypothesis that outcomes and resource use will vary by not only patient characteristics but also hospital characteristics and receipt of organ-supportive technology. METHODS Retrospective study of children 0 to 20 years old hospitalized for acute respiratory failure using the 2019 Kids' Inpatient Database. Multivariable regression models identified factors associated with mortality, length of hospitalization, and costs. RESULTS Of an estimated 75 365 hospitalizations nationally, 97% were to urban teaching hospitals, 57% were of children < 6 years, and 58% were of males. Complex chronic conditions (CCC) existed in 62%, multiorgan dysfunction in 35%, and extreme illness severity in 54%. Mortality was 7%, length of stay 15 days, and hospital costs $77 168. Elevated mortality was associated with cumulative organ dysfunction (odds ratio [OR]:2.31, 95% confidence interval [CI]: 2.22-2.42), CCC (OR: 5.49, 95% CI: 4.73-6.37), transfer, higher illness severity, and cardiopulmonary resuscitation. Lower mortality was associated with extracorporeal membrane oxygenation (OR: 0.36, 95% CI: 0.28-0.47) and new tracheostomy (OR: 0.30, 95% CI: 0.25-0.35). Longer hospitalization was associated with transfer, infancy, CCC, higher illness severity, cumulative organ dysfunction, and urban hospitals. Higher costs accrued with noninfants, cumulative organ dysfunction, private insurance, and urban teaching hospitals. CONCLUSIONS Hospitalizations for pediatric acute respiratory failure incurred substantial mortality and resource consumption. Efforts to reduce mortality and resource consumption should address interhospital transfer, access to organ-supportive technology, and drivers of higher severity-adjusted resource consumption at urban hospitals.
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Affiliation(s)
- Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine Department of Pediatrics and
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
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Rand A, Spieth PM. [Extracorporeal cardiopulmonary resuscitation-An orientation]. Med Klin Intensivmed Notfmed 2024; 119:327-334. [PMID: 38530387 DOI: 10.1007/s00063-024-01135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 03/28/2024]
Abstract
Both in-hospital and out-of-hospital cardiac arrests are associated with a high mortality. In the past survival advantages for patients could be achieved by optimizing the chain of rescue and postresuscitation treatment; however, for patients with refractory cardiac arrest, there have so far been few promising treatment options. For selected patients with refractory cardiac arrest who do not achieve return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR), extracorporeal (e)CPR using venoarterial extracorporeal membrane oxygenation is an option to improve the probability of survival. This article describes the technical features, important aspects of treatment, and the current data situation on eCPR in patients with in-hospital or out-of-hospital cardiac arrest.
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Affiliation(s)
- Axel Rand
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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3
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Roberts SH, Schumer EM, Sullivan M, Grotberg J, Jenkins B, Fischer I, Damiano M, Schill MR, Masood MF, Kotkar K, Pawale A. Percutaneous decannulation reduces procedure length and rates of groin wound infection in patients on venoarterial extracorporeal membrane oxygenation. JTCVS OPEN 2024; 18:80-86. [PMID: 38690437 PMCID: PMC11056445 DOI: 10.1016/j.xjon.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 05/02/2024]
Abstract
Objective Open decannulation from femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) carries high risk of morbidity, including groin wound infection. This study evaluated the impact of percutaneous decannulation on rates of groin wound infection in patients decannulated from femoral VA-ECMO. Methods Between January 1, 2022, and April 30, 2023, 47 consecutive patients received percutaneous femoral VA-ECMO and survived to decannulation. A percutaneous suture-mediated closure device was used for decannulation in patients with relatively smaller arterial cannulas. Patients with larger arterial cannulas or unsuccessful percutaneous closures underwent surgical cutdown and repair of the femoral artery. The primary outcome was arterial site wound infection following decannulation. Results Among the 47 patients who survived to decannulation from VA-ECMO, 21 underwent percutaneous decannulation and 27 underwent surgical cutdown. One patient underwent 2 VA-ECMO runs, one with percutaneous decannulation and one with surgical cutdown. Percutaneous decannulation was attempted in 22 patients, with 21 of 22 (95.5%) success rate. Decannulation procedure length was significantly shorter in the percutaneous group (79 minutes vs 148 minutes, P = .0001). The percutaneous group had significantly reduced rates of groin wound complications (0% vs 40.7%, P = .001) and groin wound infections (0% vs 22.2%, P = .03) when compared with the surgical cutdown group. Three patients (14.3%) in the percutaneous group experienced vascular complications, including pseudoaneurysm at the distal perfusion catheter site and nonocclusive thrombus of the common femoral artery. Conclusions Percutaneous decannulation may reduce decannulation procedure length and rate of groin wound infection in patients who survive to decannulation from VA-ECMO.
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Affiliation(s)
- Sophia H. Roberts
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Erin M. Schumer
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Mary Sullivan
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - John Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Bianca Jenkins
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Irene Fischer
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Marci Damiano
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Matthew R. Schill
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Muhammad F. Masood
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Kunal Kotkar
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Amit Pawale
- Division of Cardiac Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Mo
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4
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Shah NR, Spencer BL, Maselli KM, Williams KM, Sood V, Gadepalli SK, Thirumoorthi AS. Lower extremity complications in children following femoral cannulation for extracorporeal membrane oxygenation. Perfusion 2023:2676591231216326. [PMID: 37977555 DOI: 10.1177/02676591231216326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation cannulation strategies vary between adults and children. Femoral approach is common in adults and extremity morbidity is well-documented. Aside from limb ischemia, complications in children are theorized and have yet to be studied. This study aims to comprehensively evaluate implications of pediatric femoral cannulation. METHODS This is a single-center retrospective review of children <21 years, undergoing femoral venoarterial (VA) or venovenous (VV) cannulation between 2015 and 2022. The primary outcome was incidence of lower extremity complications on ECMO (groin hematoma/hemorrhage, vascular thrombosis, North-South syndrome, compartment syndrome, limb loss). Secondary outcome was incidence of post-decannulation extremity complications (pseudoaneurysm, surgical site infection, vascular thrombosis, motor/sensory deficits). RESULTS 29 children were cannulated via femoral approach. Most required VA support (89%). Common sites were right femoral artery (70.8%) and right femoral vein (56%). 18 patients (75%) had distal reperfusion cannulas (DPC) placed. Short-term lower extremity complication rate was 59%, most frequently groin hematoma/hemorrhage (30%) and North-South syndrome (19%). Compartment syndrome occurred in 3 patients (11%), though none suffered digit/limb loss. There were no significant differences in complications between cannulation approach (open vs percutaneous) or vessel laterality (ipsilateral vs contralateral). Of those decannulated (n = 15), median ECMO duration was 8 days. Following decannulation, 20% suffered pseudoaneurysm. Ten (63%) experienced ipsilateral motor weakness which resolved in 50% of patients at 1-month follow-up; 20% suffered sensory deficits all resolving by discharge. CONCLUSION Approximately one third of children who underwent femoral cannulation suffered groin hematoma/hemorrhage and nearly 20% experienced North-South syndrome. Following decannulation, most had extremity weakness while sensory deficits were rarer. This marked risk of extremity morbidity prompts proactive inpatient monitoring and close surveillance after discharge.
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Affiliation(s)
- Nikhil R Shah
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Brianna L Spencer
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Kathryn M Maselli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Keyonna M Williams
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Vikram Sood
- Congenital Heart Center, Section of Pediatric Cardiovascular Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Arul S Thirumoorthi
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
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5
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Rand A, Spieth PM. [Extracorporeal cardiopulmonary resuscitation-An orientation]. DIE ANAESTHESIOLOGIE 2023; 72:833-840. [PMID: 37870617 DOI: 10.1007/s00101-023-01342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 10/24/2023]
Abstract
Both in-hospital and out-of-hospital cardiac arrests are associated with a high mortality. In the past survival advantages for patients could be achieved by optimizing the chain of rescue and postresuscitation treatment; however, for patients with refractory cardiac arrest, there have so far been few promising treatment options. For selected patients with refractory cardiac arrest who do not achieve return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR), extracorporeal (e)CPR using venoarterial extracorporeal membrane oxygenation is an option to improve the probability of survival. This article describes the technical features, important aspects of treatment, and the current data situation on eCPR in patients with in-hospital or out-of-hospital cardiac arrest.
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Affiliation(s)
- Axel Rand
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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Joyce PR, Hodgson CL, Bellomo R, Gregory SD, Raman J, Stephens AF, Taylor K, Paul E, Wickramarachchi A, Burrell A. Smaller Return Cannula in Venoarterial Extracorporeal Membrane Oxygenation Does Not Increase Hemolysis: A Single-Center, Cohort Study. ASAIO J 2023; 69:1004-1008. [PMID: 37549666 DOI: 10.1097/mat.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
The aim of this study was to explore the association between arterial return cannula diameter and hemolysis during peripheral VA ECMO. We identified 158 adult patients who received peripheral VA ECMO at our institution from the national ECMO database (EXCEL) between January 2019 and July 2021. We classified patients into a small cannula group (15 Fr diameter, n = 45) and a large cannula group (≥17 Fr diameter, n = 113), comparing incidences of clinical hemolysis and plasma free hemoglobin ( pf Hb). Moderate hemolysis is defined as having pf Hb 0.05-0.10 g/L and severe hemolysis as having pf Hb >0.10 g/L sustained for at least two consecutive readings or leading to a circuit change. There were no significant differences in rates of moderate hemolysis between small and large cannula groups (1 vs . 6; p = 0.39) and severe hemolysis (0 vs . 3; p = 0.27), nor was the pf Hb level significantly different at 4 hours (0.086 ± 0.096 vs . 0.112 ± 0.145 g/L; p = 0.58) and at 24 hours (0.042 ± 0.033 vs . 0.051 ± 0.069 g/L; p = 0.99). There were no increased rates of hemolysis when comparing small versus large arterial return cannula diameter in peripheral VA ECMO.
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Affiliation(s)
- Patrick R Joyce
- From the Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carol L Hodgson
- From the Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- ANZ Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- ANZ Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Clayton, Victoria, Australia
| | - Jaishankar Raman
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrew F Stephens
- ANZ Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - Kieran Taylor
- From the Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Clayton, Victoria, Australia
| | - Aidan Burrell
- From the Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- ANZ Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
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Malinowski D, Fournier Y, Horbach A, Frick M, Magliani M, Kalverkamp S, Hildinger M, Spillner J, Behbahani M, Hima F. Computational fluid dynamics analysis of endoluminal aortic perfusion. Perfusion 2023; 38:1222-1229. [PMID: 35549763 PMCID: PMC10466979 DOI: 10.1177/02676591221099809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In peripheral percutaneous (VA) extracorporeal membrane oxygenation (ECMO) procedures the femoral arteries perfusion route has inherent disadvantages regarding poor upper body perfusion due to watershed. With the advent of new long flexible cannulas an advancement of the tip up to the ascending aorta has become feasible. To investigate the impact of such long endoluminal cannulas on upper body perfusion, a Computational Fluid Dynamics (CFD) study was performed considering different support levels and three cannula positions. METHODS An idealized literature-based- and a real patient proximal aortic geometry including an endoluminal cannula were constructed. The blood flow was considered continuous. Oxygen saturation was set to 80% for the blood coming from the heart and to 100% for the blood leaving the cannula. 50% and 90% venoarterial support levels from the total blood flow rate of 6 l/min were investigated for three different positions of the cannula in the aortic arch. RESULTS For both geometries, the placement of the cannula in the ascending aorta led to a superior oxygenation of all aortic blood vessels except for the left coronary artery. Cannula placements at the aortic arch and descending aorta could support supra-aortic arteries, but not the coronary arteries. All positions were able to support all branches with saturated blood at 90% flow volume. CONCLUSIONS In accordance with clinical observations CFD analysis reveals, that retrograde advancement of a long endoluminal cannula can considerably improve the oxygenation of the upper body and lead to oxygen saturation distributions similar to those of a central cannulation.
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Affiliation(s)
- Daniel Malinowski
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Yvan Fournier
- Fluid Mechanics, Energy and Environment Dpt., EDF R&D, Chatou, France
| | - Andreas Horbach
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Michael Frick
- Department of Cardiology, Angiology, and Intensive Care, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Mirko Magliani
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sebastian Kalverkamp
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Martin Hildinger
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jan Spillner
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Mehdi Behbahani
- Institute for Bioengineering, Biomaterials Laboratory, University of Applied Sciences Aachen, Aachen, Germany
| | - Flutura Hima
- Division of Thoracic Surgery and Thoracic Organ Support, University Hospital Medical Faculty, RWTH Aachen University, Aachen, Germany
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Haddad P, Chasin C, Xu J, Peden E, Rahimi M. Single-center surgical site infection rate after peripheral ECMO decannulation and surgical repair. Ther Adv Infect Dis 2022; 9:20499361221132148. [PMID: 36311554 PMCID: PMC9597017 DOI: 10.1177/20499361221132148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
Objective: Extracorporeal membrane oxygenation (ECMO) is used to provide heart–lung
bypass support in cases of acute respiratory and cardiac failure. The two
main classifications of ECMO are venoarterial (VA) and venovenous (VV).
After the patient recovers from an acute state, ECMO decannulation from the
groin often requires femoral exploration and vessel repair. This study was
performed to quantify the rate of surgical site infection (SSI) after ECMO
decannulation. Methods: Retrospective single-institutional review of patients requiring ECMO from
January 2016 to October 2019 was conducted. The study examined incidence of
SSI. We evaluated preoperative risk factors, VA versus VV
ECMO, Szilagyi infection score, and postoperative management. Results: Initial search began with 176 ECMO cases, of which 106 patients were deceased
before development of any infection. Eighteen were eliminated because of
central ECMO access, and four were lost to chart privacy. Of the 154
patients requiring femoral ECMO, 48 (31%) survived, with 22 VA and 26 VV
ECMO. Twelve patients were classified as infected, resulting in an overall
SSI rate of 25%. Surgical repair of the femoral arterial cannulation site
was required in the 22 VA ECMO patients, and 10 of these became infected,
resulting in an infection rate of 45%. The remaining two infected were VV
ECMO and did not require surgery. The VV ECMO SSI rate was 7.7%. The
infected group of VA ECMO consisted of eight primary surgical repairs and
two patch repairs. Eight of the patients required multiple reoperations and
two required antibiotics and wound care alone. There was no instance of limb
loss. Statistical analysis showed intraoperative transfusion of >250 ml
and blood loss of >300 ml as the only predictive factors of infection.
The Szilagyi score was found to be worse in patients requiring patch
angioplasty. Conclusion: Surgical repair of ECMO arterial cannulation sites had postoperative SSIs in
nearly half of the patients (45%). The VV ECMO SSI rate was found to be
7.7%. Severity of infection was worse in more complicated repairs. Overall
ECMO mortality was high at 69%. Although we found no clear correlation with
common risk factors, transfusions >250 ml and blood loss >300 ml were
found to be predictive. Vascular surgeons should be aware of high risk of
SSI with repair of femoral ECMO cannulation sites.
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Affiliation(s)
- Paul Haddad
- Department of Cardiovascular Surgery, Houston
Methodist Hospital, Houston, TX, USA
| | - Cara Chasin
- Department of Cardiovascular Surgery, Houston
Methodist Hospital, Houston, TX, USA
| | - Jiaqiong Xu
- Department of Cardiovascular Surgery, Houston
Methodist Hospital, Houston, TX, USA
| | - Eric Peden
- Department of Cardiovascular Surgery, Houston
Methodist Hospital, Houston, TX, USA
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Predictors of mortality following extracorporeal membrane oxygenation support in an unselected, critically ill patient population. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:290-297. [PMID: 34819965 PMCID: PMC8596723 DOI: 10.5114/aic.2021.109149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/18/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Mechanical circulatory support (MCS) has been established as a means of augmenting circulation in patients with critically decreased systolic function due to a variety of underlying clinical reasons. Different methods of MCS may be used, with the venous-arterial extracorporeal membrane oxygenation system (VA-ECMO) being one of the most utilized devices in everyday care. Aim To determine independent predictors influencing mortality outcomes following VA-ECMO therapy in a large, unselected, adult, critically ill patient population in cardiogenic shock (CS). Material and methods Data on 235 consecutive, real-world VA-ECMO treatments were assessed. Analysis was conducted for all subjects requiring MCS with the VA-ECMO as the first instalment, regardless of underlying cause or eventual upgrade. All potential clinical factors influencing mortality were examined and evaluated. Results Overall mortality was ~66% at median 28 days follow-up and significantly depended upon pH < 7.3 (HR = 3.56; p < 0.001), and age ≥ 65 years (HR = 1.96; p = 0.001). Acute coronary syndrome (ACS) as an indication for VA-ECMO displayed a nearly significant value (HR = 1.44; p = 0.07). Heart transplant (hTX) primary graft failure as an indication for the VA-ECMO displayed a clearly favorable outcome (HR = 0.51, p = 0.025); all data based on multivariate Cox regression analysis. Conclusions Mortality in patients requiring VA-ECMO remains high. We conclude that only decreased pH values and advanced age clearly influence mortality in this MCS scenario. ACS also bodes unfavorably, whereas hTX as an indication clearly shows better survival.
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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11
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Osofsky R, Owen B, Elks W, Das Gupta J, Clark R, Kraai E, Rana MUA, Marinaro J, Guliani S. Protocolized Whole-Body Computed Tomography Imaging After Extracorporeal Membrane Oxygenation (ECMO) Cannulation for Cardiac Arrest. ASAIO J 2021; 67:1196-1203. [PMID: 34261871 DOI: 10.1097/mat.0000000000001516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Evaluate the utility of whole-body computed tomography (WBCT) imaging in detecting clinically significant findings in patients who have undergone extracorporeal membrane oxygenation (ECMO) cannulation for cardiac arrest (extracorporeal cardiopulmonary resuscitation or "eCPR"). Single-center retrospective review of 52 consecutive patients from 2017 to 2019 who underwent eCPR and received concomitant WBCT imaging. WBCT images were reviewed for clinically significant findings (compression-related injuries, cannulation-related complications, etiology of cardiac arrest, incidental findings, and evidence of hypoxic brain injury) as well as the frequency of interventions performed as a direct result of such findings. Thirty-eight patients met inclusion criteria for analysis. Clinically significant WBCT findings were present in 37/38 (97%) of patients with 3.3 ± 1.7 findings per patient. An intervention as a direct result of WBCT findings was performed in 54% (20/37) of patients with such findings. Evidence of hypoxic brain injury on WBCT was associated with clinical brain death as compared with those without such findings (10/15 [67%] vs 1/22 [4%], P < 0.001), respectively. WBCT scan after eCPR frequently detects clinically significant findings which commonly prompt an intervention directly affecting the patient's clinical course. We advocate for protocolized use of WBCT imaging in all eCPR patients.
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Affiliation(s)
| | | | | | | | - Ross Clark
- From the Department of Surgery
- Division of Vascular Surgery
| | | | | | - Jonathan Marinaro
- Division of Critical Care, University of New Mexico School of Medicine, MSC10 5610, Albuquerque, New Mexico
| | - Sundeep Guliani
- From the Department of Surgery
- Division of Vascular Surgery
- Division of Critical Care, University of New Mexico School of Medicine, MSC10 5610, Albuquerque, New Mexico
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12
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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13
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Zhou H, Mei Y, Lv J, Li W, Zhang G, Hu D, Zhang J, Chen X. Ultrasound-Measured Femoral Arterial/Venous Parameters for Guiding Extracorporeal Membrane Oxygenation (ECMO) Catheterization. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The femoral artery/vein are commonly used for vascular access in clinical practice. The position, adjoining relationship, and anatomic variation of the femoral artery/vein may affect the success rate of catheterization. Clinically, we found a proportion of anatomic variations in the
common position of the femoral artery catheterization. We intended to determine the positioning data of the femoral artery/vein to provide a partial clinical basis for catheterization by ultrasound. At the common femoral artery catheterization site, we used ultrasound to collect data on the
femoral artery/vein of 208 samples. We found that the distance from the midpoint of the pubic symphysis to the surface position of the femoral artery, the distance between the central points of the femoral artery/vein, and the inner diameter of the femoral artery were significantly correlated
with height, weight, and gender, and were not correlated with age, shock, hypertension, diabetes, and coronary heart disease. If branching of the femoral artery was higher than the inguinal ligament, the inner diameter of the femoral artery at the catheterization site was significantly reduced.
We believe that height, weight, gender, and anatomic variation are important factors influencing the adjoining relationship and the inner diameter of the femoral artery. During extracorporeal membrane oxygenation (ECMO) catheterization, if an arterial branch is found at the femoral artery
catheterization site, it is recommended to adjust the catheterization protocol.
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Affiliation(s)
- Hao Zhou
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Yong Mei
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Jinru Lv
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Wei Li
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Gang Zhang
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Deliang Hu
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Jinsong Zhang
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
| | - Xufeng Chen
- Emergency Department, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, NanJing City, China
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Fleet D, Morris I, Faulkner G, Harvey C. Experience with the Crescent ® cannula for adult respiratory VV ECMO: a case series. Perfusion 2021; 37:819-824. [PMID: 34254557 DOI: 10.1177/02676591211031462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Crescent® is a recently introduced dual lumen cannula by which veno-venous extracorporeal membrane oxygenation (VV ECMO) is delivered. It has a number of features that enhance its ease of placement, pressure-flow dynamics and may reduce catheter-related complication rates. METHODS We present the first case series of its kind analysing this device by means of a retrospective observational study of prospectively collected data from the first year of its use in a high volume severe acute respiratory failure centre (Glenfield, UK). We compare complication rates of the Crescent®, with data from the international ELSO database and our own historic centre data and discuss subjective clinician experience of introducing this device. RESULTS Over the first 12 months of its use (23/09/2019-23/09/2020), 54 patients were cannulated using a Crescent® catheter. There were no serious/life-threatening adverse events and a low number of minor cannula-related complications. Subjectively users found it has a number of advantages over other devices and configurations, not captured within current data collection frameworks. CONCLUSION The Crescent® is a safe and effective device by which to deliver VV ECMO support to patients with severe acute respiratory failure.
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Affiliation(s)
- Daniel Fleet
- Department of adult Intensive Care Medicine, Glenfield General Hospital, Leicester, UK
| | - Idunn Morris
- Department of adult Intensive Care Medicine, Glenfield General Hospital, Leicester, UK
| | - Gail Faulkner
- Department of adult Intensive Care Medicine, Glenfield General Hospital, Leicester, UK
| | - Chris Harvey
- Department of adult Intensive Care Medicine, Glenfield General Hospital, Leicester, UK
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15
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Son AY, Karim AS, Joung RHS, McGregor R, Wu T, Andrei AC, Pawale A, Ho KJ, Pham DT. Ankle-brachial index to monitor limb perfusion in patients with femoral venoarterial extracorporeal membrane oxygenation. J Card Surg 2021; 36:3119-3125. [PMID: 34155679 DOI: 10.1111/jocs.15757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limb ischemia is a major complication of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Use of ankle-brachial index (ABI) to monitor limb perfusion in VA-ECMO has not been described. We report our experience monitoring femoral VA-ECMO patients with serial ABI and the relationships between ABI and near infrared spectroscopy (NIRS). METHODS This is a retrospective single-center review of consecutive adult patients placed on femoral VA-ECMO between January 2019 and October 2019. Data were collected on patients with paired ABI and NIRS values. Relationships between NIRS and ABI of the cannulated (E-NIRS and E-ABI) and non-cannulated legs (N-NIRS and N-ABI) along with the difference between legs (d-NIRS and d-ABI) were determined using Pearson correlation. RESULTS Overall, 22 patients (mean age 56.5 ± 14.0 years, 72.7% male) were assessed with 295 E-ABI and E-NIRS measurements, and 273 N-ABI and N-NIRS measurements. Mean duration of ECMO support was 129.8 ± 78.3 h. ECMO-mortality was 13.6% and in-hospital mortality was 45.5%. N-ABI and N-NIRS were significantly higher than their ECMO counterparts (ABI mean difference 0.16, 95% confidence interval [CI]: 0.13-0.19, p < .0001; NIRS mean difference 2.51, 95% CI: 1.48-3.54, p < .0001). There was no correlation between E-ABI versus E-NIRS (r = .032, p = .59), N-ABI versus N-NIRS (r = .097, p = .11), or d-NIRS versus d-ABI (r = .11, p = .069). CONCLUSION ABI is a quantitative metric that may be used to monitor limb perfusion and supplement clinical exams to identify limb ischemia in femorally cannulated VA-ECMO patients. More studies are needed to characterize the significance of ABI in femoral VA-ECMO and its value in identifying limb ischemia in this patient population.
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Affiliation(s)
- Andre Y Son
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Azad S Karim
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachel Hae-Soo Joung
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Randy McGregor
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tingqing Wu
- Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adin-Cristian Andrei
- Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amit Pawale
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karen J Ho
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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16
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Sunder T. Extracorporeal membrane oxygenation and lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:327-337. [PMID: 33487892 PMCID: PMC7813619 DOI: 10.1007/s12055-020-01099-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
The use of extracorporeal membrane oxygenation has had a positive impact on the outcomes after lung transplantation. Extracorporeal membrane oxygenation has a role in all phases of lung transplantation-preoperative, intraoperative, and postoperative periods. It serves as a bridge to transplantation in appropriate patients awaiting lung transplantation. Extracorporeal membrane oxygenation is used as a preferred method of cardiopulmonary support in some centres during implantation; and, after lung transplantation, it can be used to salvage the implanted lung in cases of severe primary graft dysfunction or as a planned extension of intraoperative extracorporeal membrane oxygenation onto the postoperative period. It has now gained acceptance as a mandatory tool in most lung transplant units. This article reviews the history of extracorporeal membrane oxygenation and lung transplantation, their subsequent development, and the current use of extracorporeal membrane oxygenation during lung transplantation. Our institutional practice and experience are described. The implications of the current global coronavirus disease pandemic on extracorporeal membrane oxygenation and lung transplantation are also briefly discussed.
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17
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Fordyce CB, Katz JN, Alviar CL, Arslanian-Engoren C, Bohula EA, Geller BJ, Hollenberg SM, Jentzer JC, Sims DB, Washam JB, van Diepen S. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e379-e406. [DOI: 10.1161/cir.0000000000000909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non–CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.
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18
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Minc SD, Hayanga HK, Thibault D, Woods K, Marone L, Badhwar V, Hayanga JWA. Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States. Semin Thorac Cardiovasc Surg 2020; 33:397-406. [PMID: 32977018 DOI: 10.1053/j.semtcvs.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022]
Abstract
Patients on extracorporeal membrane oxygenation (ECMO) who suffer vascular complications frequently accrue additional procedures and costs. We sought to evaluate the effect of ECMO-related vascular complications on hospital charges and in-hospital mortality. Adult discharges involving ECMO from 2004 to 2013 in the National Inpatient Sample were examined. There were 12,636 patients in the cohort. Vascular complications, focusing on arterial complications were identified using ICD-9-CM diagnosis and procedure codes. A multivariable survey linear regression model using median hospital charges was used to model the effect of vascular complications on charges. We used multivariable survey logistic regression to evaluate the effect of vascular complications on in-hospital mortality. Of the 12,636 patients examined, 6467 (51.2%) had ECMO-related vascular complications. Median charges in patients with vascular complications were $ 477,363 (interquartile range: 258,660-875,823) and were $ 282,298 (interquartile range: 130,030-578,027) without vascular complications. On multivariable analysis, patients with vascular complications had 24% higher median charges than patients without vascular complications (Ratio: 1.24; 95% confidence interval [CI]: 1.16-1.33; P < 0.0001) and 34% higher odds of experiencing in-hospital mortality than patients without vascular complications (adjusted odds ratio: 1.34; 95% CI:1.08-1.66; P = 0.009). Vascular complications occur in over half of ECMO patients and are associated with an increased risk of high hospital charges and in-hospital mortality. These findings support the need for identification and modification of risk factors for ECMO-related vascular complications. Furthermore, the standardization of protocols using evidence-based measures to mitigate vascular complications may improve overall ECMO outcomes.
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Affiliation(s)
- Samantha D Minc
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.
| | - Heather K Hayanga
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Kaitlin Woods
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Luke Marone
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Vinay Badhwar
- Division of Cardiac Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - J W Awori Hayanga
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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19
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Son AY, Khanh LN, Joung HS, Guerra A, Karim AS, McGregor R, Pawale A, Pham DT, Ho KJ. Limb ischemia and bleeding in patients requiring venoarterial extracorporeal membrane oxygenation. J Vasc Surg 2020; 73:593-600. [PMID: 32623105 DOI: 10.1016/j.jvs.2020.05.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/24/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Acute limb ischemia (ALI) and cannulation site bleeding are frequent complications of venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and are associated with worse outcomes. The goals of this study were to assess our rates of ECMO-related ALI and bleeding and to evaluate the efficacy of strategies to prevent them, such as distal perfusion cannula (DPC) and ultrasound-guided cannulation. METHODS This is a single-center retrospective cohort study of adult patients placed on peripheral VA-ECMO at a tertiary medical center between 2014 and 2018. ALI was defined as new ischemia of the extremity ipsilateral to arterial cannulation. Significant cannulation site bleeding was defined as excessive bleeding requiring intervention (eg, transfusion or reoperation). Univariate analyses were used to identify factors associated with ALI, bleeding, and in-hospital mortality. RESULTS During the study period, 105 patients were placed on peripheral VA-ECMO (61.3% female; mean age, 54.9 ± 14.8 years). Nearly half (46.6%) had ECMO implantation in an extracorporeal cardiopulmonary resuscitation setting and 37 (44.0%) had a DPC. Average duration of support was 5.6 ± 5.0 days. Overall in-hospital mortality and death on ECMO support were 65.1% and 50%, respectively. ALI occurred in 21 (20%) and cannulation-related bleeding occurred in 24 (22.9%) patients who were treated with a total of 27 procedures, including thromboembolectomy (22.2%), vascular repair (18.5%), and fasciotomy (25.9%). On univariate analysis, cannulation in the operating room (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.08-0.77; P = .02) was associated with decreased risk of ALI, whereas cannulation in the operating room (OR, 2.65; 95% CI, 1.09-6.45; P = .03) and cutdown approach (OR, 4.96; 95% CI, 2.32-10.61; P < .0001) were associated with increased risk of bleeding. Ultrasound-guided placement was associated with decreased risk of bleeding (OR, 0.81; 95% CI, 0.04-0.84; P = .03). DPC was not associated with either ALI (P = .47) or bleeding (P = .06). ALI (OR, 2.68; 95% CI 1.03-6.98; P = .04), age (OR, 1.94; 95% CI, 1.03-3.69; P = .04), and worse baseline heart failure (OR, 2.01; 95% CI, 1.02-3.97; P = .04) were associated with greater risk of in-hospital mortality. Ultrasound-guided cannulation (OR, 0.41; 95% CI, 0.20-0.87; P = .02) was associated with decreased risk of in-hospital mortality. CONCLUSIONS ALI and significant bleeding are common occurrences after peripheral VA-ECMO cannulation. Whereas DPC placement did not significantly decrease risk of ALI, ultrasound-guided cannulation decreased the risk of bleeding. Cannulation in the operating room is associated with decreased risk of ALI at the expense of increased risk of bleeding. ALI, older age (≥65 years), and worse heart failure increased risk of in-hospital mortality.
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Affiliation(s)
- Andre Y Son
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Linh Ngo Khanh
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Hae Soo Joung
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Andres Guerra
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Azad S Karim
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Randy McGregor
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Amit Pawale
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Karen J Ho
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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20
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Djordjevic I, Eghbalzadeh K, Sabashnikov A, Deppe AC, Kuhn E, Merkle J, Weber C, Ivanov B, Ghodsizad A, Rustenbach C, Adler C, Rahmanian P, Mader N, Kuhn-Regnier F, Zeriouh M, Wahlers T. Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock. J Card Surg 2020; 35:1037-1042. [PMID: 32227395 DOI: 10.1111/jocs.14526] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/03/2020] [Accepted: 03/13/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. METHODS Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. RESULTS Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). CONCLUSION Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Julia Merkle
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ali Ghodsizad
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, Jackson Health System, Miami, Florida
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Christoph Adler
- Department of Cardiology, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Regnier
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Centre, University Hospital Cologne, Cologne, Germany.,ECMO Centre, University Hospital Cologne, Cologne, Germany
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21
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Hoetzenecker K, Benazzo A, Stork T, Sinn K, Schwarz S, Schweiger T, Klepetko W. Bilateral lung transplantation on intraoperative extracorporeal membrane oxygenator: An observational study. J Thorac Cardiovasc Surg 2019; 160:320-327.e1. [PMID: 31932054 DOI: 10.1016/j.jtcvs.2019.10.155] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/05/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Intraoperative extracorporeal membrane oxygenation (ECMO) is usually reserved to support patients during complex lung transplantation. We hypothesized that a routine application of intraoperative ECMO in all patients improves primary graft function. METHODS Patients receiving a bilateral lung transplantation between November 2016 and July 2018 at the Medical University of Vienna were included in this prospective, single-center observational study. All transplantations were uniformly performed on central venoarterial ECMO support, with the possibility to extend ECMO into the early postoperative period whenever graft function did not meet established quality criteria at the end of implantation. Primary graft dysfunction (PGD) grades were evaluated at 24, 48, and 72 hours after transplantation. Perioperative complications and survival outcome were assessed. RESULTS A total of 159 patients were included in the study. At 24 hours post-transplantation, 38.4% (n = 61) of patients were already extubated, 48.4% (n = 77) were classified as PGD0, 4.4% (n = 7) as PGD1, 3.1% (n = 5) as PGD2, 2.5% (n = 4) as PGD3, and 3.1% (n = 5) were "ungradable" due to prophylactic postoperative prolongation of ECMO. At 72 hours after transplantation, 76.7% (n = 122) of the patients were extubated, as opposed to only 1.3% (n = 2) of patients classified as PGD3. The median time of mechanical ventilation was 29 hours (interquartile range, 17-58). The 90-day-mortality was 3.1%, and 2-year survival was 86%. CONCLUSIONS Routine use of intraoperative ECMO resulted in excellent primary graft function and mid-term outcome in patients undergoing lung transplantation. To the best of our knowledge, the herein measured PGD rates are the lowest reported in the literature to date. Our results advocate a routine intraoperative use of ECMO in bilateral lung transplantation.
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Affiliation(s)
- Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Theresa Stork
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Katharina Sinn
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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22
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Bell SM, Kovach C, Kataruka A, Brown J, Hira RS. Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:146. [PMID: 31758275 DOI: 10.1007/s11886-019-1249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF THE REVIEW Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient. RECENT FINDINGS Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.
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Affiliation(s)
- Sean M Bell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Kovach
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Akash Kataruka
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Josiah Brown
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ravi S Hira
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA. .,Cardiac Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA, USA.
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23
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Odetola FO, Gebremariam A. Resource Use and Outcomes for Children Hospitalized With Severe Sepsis or Septic Shock. J Intensive Care Med 2019; 36:89-100. [PMID: 31707898 DOI: 10.1177/0885066619885894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe patient and hospital characteristics associated with in-hospital mortality, length of stay (LOS), and charges for children with severe sepsis or septic shock who often require specialized organ-supportive technology to enhance outcomes, availability of which might vary across hospitals. DESIGN Retrospective study among children hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. Multivariate regression methods identified factors associated with mortality, LOS, and charges. MEASUREMENTS AND MAIN RESULTS Of an estimated 11 972 hospitalizations for pediatric severe sepsis or septic shock, most hospitalizations (85%) were to urban teaching hospitals. Hospitalizations were more frequent among neonates and older adolescents than other age groups. Mortality was 17%, average LOS was 24 days, and average hospital charges were US$314 950. Higher mortality was associated with neonates, cumulative organ dysfunction, more comorbidities, and cardiopulmonary resuscitation. Longer hospitalization and higher charges were associated with neonates, more comorbidities, higher illness severity, invasive medical technology, and urban hospitals. CONCLUSIONS Efforts to mitigate the substantial in-hospital mortality and resource use observed in pediatric severe sepsis or septic shock should be age-specific and focused on the influence of comorbidities and organ dysfunction on outcomes. Future research should elucidate reasons for higher resource use at urban hospitals.
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Affiliation(s)
- Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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24
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Liem S, Cavarocchi NC, Hirose H. Comparing in-patient extracorporeal cardiopulmonary resuscitation to standard cardiac treatment group of extracorporeal membrane oxygenation patients: 8 years of experience at a single institution. Perfusion 2019; 35:73-81. [PMID: 31296118 DOI: 10.1177/0267659119860735] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years. METHODS Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval. RESULTS Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018). CONCLUSION Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.
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Affiliation(s)
- Spencer Liem
- Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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25
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Foltan M, Philipp A, Göbölös L, Holzamer A, Schneckenpointner R, Lehle K, Kornilov I, Schmid C, Lunz D. Quantitative assessment of peripheral limb perfusion using a modified distal arterial cannula in venoarterial ECMO settings. Perfusion 2019; 34:503-507. [DOI: 10.1177/0267659118816934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In cases of severe cardiopulmonary deterioration, quick establishment of venoarterial extracorporeal membrane oxygenation (ECMO) represents a support modality. After successful arterial peripheral cannulation, a certain grade of peripheral limb malperfusion is a fairly common phenomenon. Detection of peripheral malperfusion is vital, since it can result in compartment syndrome or even loss of the affected limb. To prevent or resolve emerging lower limb ischaemia, a newly designed perfusion catheter is placed into the superficial femoral artery, distal to the arterial cannula via ECMO. The aim of our study was to evaluate flow and haemodynamic characteristics of this novel distal limb perfusion cannula for ECMO therapy and present these important findings for the first time. The distal perfusion cannula blood flow increases in linear correlation with ECMO blood flow The variability of distal perfusion cannula blood flow with a 15 Fr cannula ranges between 160 ± 0.40 mL min−1 at 1.5 L min−1 ECMO flow rate and 480 ± 80 mL min−1 at 5.0 L min−1 ECMO blood flow, respectively. Comparatively, the 17-Fr-sized cannula performs on a scale of 140 ± 20 to 390 ± 60 mL distal perfusion cannula blood flow at 1.5-5.0 L min−1 ECMO blood flow, respectively. The quantitative assessment of the distal perfusion cannula blood flow has revealed that distal perfusion cannula blood flow can measure up to 10% of the ECMO blood flow. Furthermore, it has been also well demonstrated that the novel distal perfusion cannula is sufficient to compensate peripheral limb ischaemia.
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Affiliation(s)
- Maik Foltan
- ECMO Centre University Hospital Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- ECMO Centre University Hospital Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Laszlo Göbölös
- Cardiac Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Andreas Holzamer
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Igor Kornilov
- Anesthesiology, National Medical Research Center, Novosibirsk, Russian Federation
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesia, University Hospital Regensburg, Regensburg, Germany
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