Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States

Skin Tears Preventable With a Gentle Approach: A Case Series

Skin tears are a major problem for patients and the health care professionals who treat them. Although opinions on their prevalence differ, it is estimated that they are encountered more frequently than pressure sores but are overlooked. Recommendations based on strong evidence were presented for the prevention and treatment of skin tears as classified by the International Skin Tear Advisory Panel. This case series includes the clinical status of 3 patients who developed skin tears while receiving care in the hospital, and the corrective and preventive practices related to skin tears. This article will contribute to raising the awareness of health care professionals in predicting, preventing, evaluating, and treating skin tears.

Emergency and successful management for a case of inferior vena cava perforation caused by cannulation of venovenous extracorporeal membrane oxygenation: A case report

RATIONALE

Vascular complications associated with extracorporeal membrane oxygenation (ECMO) increase the in-hospital mortality. Perforation of the inferior vena cava (IVC) during venovenous extracorporeal membrane oxygenation (V-V ECMO) cannulation and subsequent emergency management prior to vascular surgery has rarely been reported.

PATIENT CONCERNS

A 72-year-old female was diagnosed with IVC perforation caused by venovenous extracorporeal membrane oxygenation cannulation.

DIAGNOSES

Abdominal computed tomography venography with 3D reconstruction confirmed that the cannula tip had perforated the abdominal cavity from the conjunction of the iliac vein and IVC. As a result, the patient was diagnosed with inferior vena cava perforation.

INTERVENTIONS

Attempts to reposition the dislocated cannula using digital subtraction angiography were unsuccessful. However, we found that ECMO could maintain a stable blood flow; therefore, we decided to keep ECMO running, and to minimize blood loss from the puncture site, we ensured adequate blood transfusion while operating V-V ECMO. Subsequently, emergency laparotomy was performed to fix the vascular lesion, and we established a new V-V ECMO circuit through cannulation of the bilateral internal jugular veins.

OUTCOMES

In the case of confirmed V-V ECMO-related vascular perforation of the IVC, it is crucial to continue ECMO device operation to maintain negative pressure in the IVC and position the dislocated catheter to block the perforation site, effectively controlling bleeding. Therefore, emergency laparotomy should be promptly performed for vascular repair. Fortunately, the patient recovered successfully and was subsequently discharged.

LESSONS

This case highlights several important lessons: When advancing a cannula, in this case, it is essential to first identify the guidewire placement to ensure proper guidance; In the event of a confirmed V-V ECMO-related vascular perforation of the IVC, maintaining negative pressure in the IVC through continued ECMO device operation and positioning the dislocated catheter to block the perforation site are crucial steps to control bleeding prior to emergency open vascular repair; After undergoing vascular repair, if ECMO support is still necessary, it is advisable to opt for a catheterization strategy that avoids previously repaired blood vessels.

Mortality and cost of post-cardiotomy extracorporeal support in the United States

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality.

METHODS

We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality.

RESULTS

There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently.

CONCLUSION

Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.

Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic?

OBJECTIVE

To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States.

METHODS

We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends.

RESULTS

Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first (p = .019) and second (p = .02) months of the 2 years, the first and second quarters (p < .001 and p = .042, respectively), and the first 6 months (p < .001) of 2019 and 2020.

CONCLUSION

Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.

Outcomes comparison between percutaneous decannulation with perclose ProGlide and surgical decannulation of veno-arterial extracorporeal membrane oxygenation

OBJECTIVE

Our study aimed to compare the decannulation-related outcomes of two different decannulation methods in patients who underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support, namely percutaneous decannulation with Perclose ProGlide device and conventional surgical repair.

BACKGROUND

Surgical vascular repair is a standard strategy when ECMO is to be terminated and sometimes associated with severe complications. Percutaneous decannulation using Perclose ProGlide has been reported to be feasible and safe in selected patients, but there is a paucity of literature to make systematic comparisons between the two decannulation methods.

METHODS

41 patients who were supported with VA-ECMO for refractory cardiogenic shock, cardiac arrest, or escort of complex interventions from December 2018 to December 2021 were enrolled. Of these, 30 underwent percutaneous Perclose ProGlide decannulation and 11 underwent surgical repair. The clinical characteristics and complication rates were analyzed.

RESULTS

Patients in the two groups showed a similar incidence of vascular-related complications, such as acute lower limb ischemia, major bleeding, severe hematoma, pseudoaneurysm, and arteriovenous fistula [20% versus 18.2%, p=.896]. The incidence of groin infection and delayed healing was significantly higher in the surgical removal group [3.3% versus 36.4%, p=.014].

CONCLUSIONS

Percutaneous decannulation of veno-arterial extracorporeal membrane oxygenation with the Perclose ProGlide device is a feasible and safe technique that simplifies the decannulation process, shortens the hospitalization duration, and lowers the potential risk of groin infection and delayed wound healing.

Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO.

METHODS

We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA).

RESULTS

5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2.

CONCLUSION

Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.