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Nukiwa R, Uchiyama A, Tanaka A, Kitamura T, Sakaguchi R, Shimomura Y, Ishigaki S, Enokidani Y, Yamashita T, Koyama Y, Yoshida T, Tokuhira N, Iguchi N, Shintani Y, Miyagawa S, Fujino Y. Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study. J Intensive Care 2022; 10:56. [PMID: 36585705 PMCID: PMC9802016 DOI: 10.1186/s40560-022-00649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an integral method of life support in critically ill patients with severe cardiopulmonary failure; however, such patients generally require prolonged mechanical ventilation and exhibit high mortality rates. Tracheostomy is commonly performed in patients on mechanical ventilation, and its early implementation has potential advantages for favorable patient outcomes. This study aimed to investigate the association between tracheostomy timing and patient outcomes, including mortality, in patients requiring ECMO. METHODS We conducted a single-center retrospective observational study of consecutively admitted patients who were supported by ECMO and underwent tracheostomy during intensive care unit (ICU) admission at a tertiary care center from April 2014 until December 2021. The primary outcome was hospital mortality. Using the quartiles of tracheostomy timing, the patients were classified into four groups for comparison. The association between the quartiles of tracheostomy timing and mortality was explored using multivariable logistic regression models. RESULTS Of the 293 patients treated with ECMO, 98 eligible patients were divided into quartiles 1 (≤ 15 days), quartile 2:16-19 days, quartile 3:20-26 days, and 4 (> 26 days). All patients underwent surgical tracheostomy and 35 patients underwent tracheostomy during ECMO. The complications of tracheostomy were comparable between the groups, whereas the duration of ECMO and ICU length of stay increased significantly as the quartiles of tracheostomy timing increased. Patients in quartile 1 had the lowest hospital mortality rate (19.2%), whereas those in quartile 4 had the highest mortality rate (50.0%). Multivariate logistic regression analysis showed a significant association between the increment of the quartiles of tracheostomy timing and hospital mortality (adjusted odds ratio for quartile increment:1.55, 95% confidence interval 1.03-2.35, p for trend = 0.037). CONCLUSIONS The timing of tracheostomy in patients requiring ECMO was significantly associated with patient outcomes in a time-dependent manner. Further investigation is warranted to determine the optimal timing of tracheostomy in terms of mortality.
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Affiliation(s)
- Ryota Nukiwa
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Akinori Uchiyama
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Aiko Tanaka
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan ,grid.413114.2Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan
| | - Tetsuhisa Kitamura
- grid.136593.b0000 0004 0373 3971Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Ryota Sakaguchi
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yoshimitsu Shimomura
- grid.136593.b0000 0004 0373 3971Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka Japan ,grid.410843.a0000 0004 0466 8016Department of Hematology, Kobe City Hospital Organization, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Suguru Ishigaki
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan ,grid.136593.b0000 0004 0373 3971Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Yusuke Enokidani
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Tomonori Yamashita
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yukiko Koyama
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Takeshi Yoshida
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Natsuko Tokuhira
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Naoya Iguchi
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yasushi Shintani
- grid.136593.b0000 0004 0373 3971Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Shigeru Miyagawa
- grid.136593.b0000 0004 0373 3971Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Yuji Fujino
- grid.136593.b0000 0004 0373 3971Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871 Japan
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Niec JA, Achey MA, Wallace MW, Patel A, Zhao S, Hatch LD, Morris EA, Danko ME, Pietsch JB, Lovvorn HN. Congenital Diaphragmatic Hernia Repair at the Bedside or Operating Theater. Am Surg 2022; 88:1814-1821. [PMID: 35337188 DOI: 10.1177/00031348221084941] [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: 11/17/2022]
Abstract
BACKGROUND For critically ill congenital diaphragmatic hernia (CDH) patients on high frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and/or inhaled nitric oxide (iNO), operative repair in the neonatal intensive care unit (NICU) has been proposed to avoid complications during transport to an operating room (OR). This study compared neonates with CDH who received herniorrhaphy in the NICU or OR, with a subgroup analysis considering only patients supported with ECMO. METHODS Patients admitted to the NICU in the first 2 weeks of life at a free-standing children's hospital between July 2004 and September 2021 were examined. Patients were categorized according to location of CDH repair, and impact on operative complications and survival was compared. RESULTS 185 patients were admitted to the NICU with posterolateral CDH and received operative repair. 48 cases were operated on at the bedside in the NICU and 137 in the OR. Patients repaired in the NICU had higher use of HFOV, pulmonary vasodilators, and ECMO (all P < .001). Children repaired in the NICU experienced significantly higher in-hospital death and overall mortality (P < .001). However, in multivariate analysis, repair location was not a significant predictor of survival to discharge in patients receiving ECMO. No significant difference in surgical site infection was detected for operative location (P = .773). DISCUSSION Congenital diaphragmatic hernia repair in the NICU occurred more frequently among higher risk patients who experienced worse survival. The rate of surgical site infection appeared similar overall and across subgroups suggesting adequate sterility and technique for bedside procedures, when necessary, despite restricted access to advanced operative equipment.
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Affiliation(s)
- Jan A Niec
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Meredith A Achey
- Department of Surgery, 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Anuradha Patel
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Shilin Zhao
- Department of Biostatistics, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Dupree Hatch
- Division of Neonatology, Department of Pediatrics, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Morris
- Division of Neonatology, Department of Pediatrics, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - John B Pietsch
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Robinson JR, Conroy PC, Hardison D, Hamid R, Grubb PH, Pietsch JB, Lovvorn HN. Rapid resolution of hyperammonemia in neonates using extracorporeal membrane oxygenation as a platform to drive hemodialysis. J Perinatol 2018; 38:665-671. [PMID: 29467521 PMCID: PMC6030490 DOI: 10.1038/s41372-018-0084-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We aimed to clarify the impact of extracorporeal membrane oxygenation (ECMO) as a platform to drive hemodialysis (HD) for ammonia clearance on outcomes of neonates with severe hyperammonemia. STUDY DESIGN All neonates treated for hyperammonemia at a single children's hospital between 1992 and 2016 were identified. Patient characteristics and outcomes were compared between those receiving medical management or ECMO/HD. RESULT Twenty-five neonates were treated for hyperammonemia, of which 13 (52%) received ECMO/HD. Peak ammonia levels among neonates treated with ECMO/HD were significantly higher than those medically managed (1041 [IQR 902-1581] μmol/L versus 212 [IQR 110-410] μmol/L; p = 0.009). Serum ammonia levels in the ECMO/HD cohort declined to the median of medically managed within 4.5 (IQR 2.9-7.0) hours and normalized within 7.3 (IQR 3.6-13.5) hours. All neonates survived ECMO/HD, and nine (69.2%) survived to discharge. CONCLUSION ECMO/HD is an effective adjunct to rapidly clear severe hyperammonemia in newborns, reducing potential neurodevelopmental morbidity.
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Affiliation(s)
- Jamie R. Robinson
- Department of Biomedical Informatics, Vanderbilt University,Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Patricia C. Conroy
- School of Medicine, Vanderbilt University,Department of Surgery, University of California, San Francisco
| | - Daphne Hardison
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Rizwan Hamid
- Department of Pediatric Genetics, Vanderbilt University Medical Center
| | - Peter H. Grubb
- Department of Pediatrics, Neonatology, Vanderbilt University Medical Center,Department of Pediatrics, Neonatology, University of Utah,Primary Children’s Hospital, Intermountain Healthcare Corporation
| | - John B. Pietsch
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center
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