Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database

Extracorporeal Membrane Oxygenation-Associated Compartment Syndrome: Review of a National Database

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy.

METHODS

Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders.

RESULTS

A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330).

CONCLUSIONS

ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences.

Acute Compartment Syndrome in Pediatric Patients on Extracorporeal Membrane Oxygenation Support

BACKGROUND

When acute compartment syndrome (ACS) occurs in pediatric patients requiring venoarterial extracorporeal membrane oxygen (VA ECMO) support, there is little data to guide surgeons on appropriate management. The purpose of this study is to characterize the presentation, diagnosis, timeline, and outcomes of patients who developed this complication.

METHODS

This is a single-center retrospective case series of children below 19 years old on VA ECMO support who subsequently developed extremity ACS between January 2016 and December 2022. Outcomes included fasciotomy findings, amputation, mortality, and documented function at the last follow-up.

RESULTS

Of 343 patients on VA ECMO support, 18 (5.2%) were diagnosed with ACS a median 29 hours after starting ECMO. Initial cannulation sites included 8 femoral, 6 neck, and 4 central. Femoral artery cannulation was associated with an increased risk of ACS [odds ratio=6.0 (CI: 2.2 to 15), P <0.0001]. In the hospital, the mortality rate was 56% (10/18). Fourteen (78%) patients received fasciotomies a median of 1.2 hours after ACS diagnosis. Only 4 (29%) patients had all healthy muscles at initial fasciotomy, while 9 (64%) had poor muscular findings in at least 1 compartment. Patients with worse findings at fasciotomy had a significantly longer duration between ischemia onset and ACS diagnosis. Patients required a median of 1.5 additional procedures after fasciotomy, and only 1 (7%) developed a surgical site infection. Of the 7 surviving fasciotomy patients, 2 required amputations, 3 developed an equinus contracture, 1 developed foot drop, and 3 had no ACS-related deficits. Four patients did not receive fasciotomies: 3 were deemed too ill and later died, and 1 was diagnosed too late to benefit. The only surviving nonfasciotomy patient required bilateral amputations.

CONCLUSIONS

Pediatric ECMO-associated ACS is not exclusive to patients with femoral artery cannulation. The majority of fasciotomy patients were diagnosed with ACS after muscle necrosis had already started. We were unable to definitively conclude whether fasciotomies provide better outcomes. There is a need for increased awareness and earlier recognition of this rare yet potentially devastating complication.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Nursing Management of a Patient With Fulminant Myocarditis and Electrical Storm Receiving ECMO: A Case Report

INTRODUCTION

Fulminant myocarditis is a devastating disease with significant mortality and complications. The care of patients with fulminant myocarditis is rarely reported.

CLINICAL FINDINGS

A 17-year-old female patient was admitted to the emergency department with dizziness, amaurosis fugax, and chest tightness. Initial assessment revealed elevated levels of troponin T (4.753 ng/mL), troponin I (49.540 ng/mL), creatine kinase (1306 U/L), creatine kinase-MB isoenzymes (75.71 ng/mL), lactate dehydrogenase (509 U/L), and N-terminal pro-B-type natriuretic peptide (6345 pg/mL). The patient had recurrent ventricular tachycardia and failed to maintain a sinus rhythm after multiple electrical cardioversions.

DIAGNOSIS

Echocardiography revealed a left ventricular ejection fraction of 34%. Magnetic resonance imaging results confirmed the diagnosis of myocarditis.

INTERVENTIONS

The patient received extracorporeal membrane oxygenation for 6 days, intra-aortic balloon pump support for 7 days, and mechanical ventilation for 5 days. Norepinephrine and dopamine were used to keep circulation stable, lidocaine and amiodarone were used to control heart rate, and glucocorticoids and immunoglobulins were used to modulate immunity.

OUTCOMES

The patient was discharged after 23 days. A month after discharge, echocardiography showed that the ejection fraction was 60%. The patient reported complete resolution of signs and symptoms of fulminant myocarditis at follow-up assessment.

CONCLUSION

This case report presents the activities of bedside nurses in caring for a patient with fulminant myocarditis and broadens the literature describing nursing interventions for patients with fulminant myocarditis.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.