ECMO simulation: How much, who to train, and a review of cost, fidelity and performance

BACKGROUND

Extracorporeal Membrane Oxygenation (ECMO) is a high-risk, low-volume procedure requiring repetition, skill and multiple disciplines with fidelity of communication. Yet many barriers exist to maintain proficiency and skills with variable cost and fidelity. We designed and implemented a low-cost monthly ECMO simulation and hypothesized providers would have increased familiarity and improved teamwork. We also review some key elements of cost, fidelity and evaluation of effectiveness.

METHODS

A structured, 1-hour ECMO simulation was performed on a customized mannikin on a monthly basis in 2022. Qualitative surveys were administered to each member post-simulation. Answers were categorized by theme, including satisfaction of patient care, evaluation of self and team dynamics, and areas for improvement.

RESULTS

Most participants were satisfied with their ability to take care of the patient, with common themes of communication and coordination of roles. Identified areas of improvement were mostly limited to technical skills, and soft skills such as communication and teamwork.

CONCLUSIONS

We designed and implemented a low-cost, monthly and multi-disciplinary ECMO simulation program with overall positive feedback and identified areas for improvement. There remains variability in cost, fidelity and evaluation of performance and retention. There may be a need to create guidelines for ECMO simulation training that can be applied at all institutions utilizing ECMO for patient care.

Impact of cerebrovascular accidents on lung transplant survival

BACKGROUND

Cerebrovascular accidents (CVA) are a source of postoperative morbidity. Existing data on CVA after lung transplantation (LT) are limited. We aimed to evaluate the impact of CVA on LT survival.

METHODS

A retrospective analysis of LT recipients at the University of Texas Southwestern Medical Center was performed. Data was obtained from the institutional thoracic transplant database between January 2012 and December 2018, which consisted of 476 patients. Patients were stratified by the presence of a postoperative CVA. Univariate comparisons of baseline characteristics, operative variables, and postoperative outcomes between the cohorts were performed. Survival was analyzed by Kaplan-Meier method. Aalen's additive regression model was utilized to assess mortality hazard over time.

RESULTS

The incidence of CVA was 4.2% (20/476). Lung allocation score was higher in the CVA cohort (46.2 [41.7, 57.3] vs. 41.5 [35.8, 52.2], p = 0.04). There were no significant differences in operative variables. CVA patients had longer initial intensive care unit (ICU) stays (316 h [251, 557] vs. 124 [85, 218], p < 0.001) and longer length of stay (22 days [17, 53] vs. 15 [11, 26], p = 0.007). CVA patients required more ICU readmissions (35% vs. 15%, p = 0.02) and had a lower rates of home discharge (35% vs. 71%, p < 0.001). Thirty-day mortality was higher in the CVA cohort (20% vs. 1.3%, p < 0.001). Overall survival was lower in the CVA cohort (log rank p = 0.044).

CONCLUSIONS

Postoperative CVA following LT was associated with longer ICU stays, more ICU readmissions, longer length of stay, and fewer home discharges. Thirty day and long-term mortality were significantly higher in the CVA group.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA.

METHODS

We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale.

RESULTS

Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26).

CONCLUSION

We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Successful Percutaneous Mechanical Suction Thrombectomy of Extracorporeal Filtration System Following Bilateral Lung Transplantation Secondary to COVID-Pneumonia

Introduction

COVID infections show increased risk of thromboembolic events. We report a case of a 43 year old male with acute Covid-19 pneumonia necessitating veno-venous ECMO and RVAD support as bridge to pulmonary transplantation. At transplant, he had thrombus along his extra-corporeal pulmonary artery cannula necessitating percutaneous mechanical thrombectomy.

Case Report

The patient presented as a transfer to our institution with COVID-19 related ARDS in refractory respiratory failure with multiple bronchopleural fistulas. Shortly after admission, veno-venous ECMO was initiated and over time was fully ECMO dependent due to extensive tissue destruction with essentially no functional lung tissue. He was converted to right internal jugular-left subclavian vein ECMO-RVAD configuration while assessing for transplantation. After 135 days of support, a suitable donor was identified and was taken for bilateral lung transplantation with ECMO/RVAD support. This was complicated by a frozen chest, massive transfusion, and primary graft dysfunction necessitating postoperative maintenance of circulatory support. Intraoperatively, a large thrombus burden was found along the pulmonary artery outflow cannula. His chest was left open at that time while his graft recovered. Three days later, a percutaneous suction thrombectomy device was inserted through his right femoral vein and under TEE guidance, he underwent suction thrombectomy of the pulmonary artery cannula clot burden (Figure 1). He was decannulated and underwent chest closure thereafter. He was anticoagulated post-operatively and has not had any further thromboembolic events.

Summary

Acute COVID-19 infection leads to a known increased risk of thromboembolic phenomena. We present an interesting approach to removal of ECMO-cannula associated thrombus in severe SARS-CoV-2 infection necessitating bilateral lung transplantation.

Recurrent images and early memories in social phobia

A recent model [Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guildford Press] suggests that a distorted image of one's public self lies at the heart of social phobia. A previous study of spontaneous imagery [Hackmann, A., Surawy, C. & Clark, D. M. (1998) Seeing yourself through others' eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy, 26, 3-12] confirmed that patients with social phobia frequently report experiencing negative, distorted, observer-perspective images when in anxiety provoking social situations. In the present study, 22 patients with social phobia were given a semistructured interview which aimed to further explore the nature of social phobic imagery. All participants were able to identify negative spontaneous images that were recurrent in the sense that their content appeared to be relatively stable over time and across different feared social situations. Most recurrent images involved several sensory modalities. Most recurrent images were linked to memories of adverse social events that clustered in time around the onset of the disorder. Taken together, the results suggest that in patients with social phobia, early unpleasant experiences may lead to the development of excessively negative images of their social selves that are repeatedly activated in subsequent social situations and fail to update in the light of subsequent, more favourable experiences. Implications of the findings for the understanding and treatment of social phobia are discussed.

Brief cognitive therapy for panic disorder: a randomized controlled trial

Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.

Brief cognitive therapy for panic disorder: a randomized controlled trial

Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.

Two psychological treatments for hypochondriasis. A randomised controlled trial

BACKGROUND

Hypochondriasis is generally considered difficult to manage. This study aimed to assess the effectiveness of cognitive therapy and to compare it with an equally credible, alternative treatment.

METHOD

Forty-eight patients with hypochondriasis were initially randomly assigned to either cognitive therapy, behavioural stress management or a no treatment waiting list control group. At the end of the waiting period, patients in the control group were randomly assigned to one of the two treatments. Assessments were at pre-, mid- and post-treatment or waiting list and at three-, six- and 12-month post-treatment follow-up.

RESULTS

Comparisons with the waiting list group showed both treatments were effective. Comparisons between the treatments showed that cognitive therapy was more effective than behavioural stress management on measures of hypochondriasis, but not general mood disturbance at mid-treatment and at post-treatment. One year after treatment patients who had received either treatment remained significantly better than before treatment, and on almost all measures the two therapies did not differ from each other.

CONCLUSIONS

Cognitive therapy is a specific treatment for hypochondriasis. Behavioural stress management is also effective but its specificity remains to be demonstrated.

Extension of the Rorschach--Hazlewood theoretical model for spin-lattice relaxation in biological systems to low frequencies

The water-biopolymer cross-relaxation model, proposed by H. E. Rorschach and C. F. Hazlewood (RH) [J. Magn. Reson. 70, 79 (1986)], explains the Larmor frequency dependence of T1 in many biological systems. However, the RH theory fails at low Larmor frequencies. In this paper, a more general version of the RH theory has been developed. This theory is valid at all frequencies. Use of the new expression for the spin-lattice relaxation rate (1/T1), earlier published experimental data in H2O/D2O bovine serum albumin, which had been measured over a wide frequency range (10 kHz to 100 MHz), were fitted over the entire frequency range. The agreement between theory and the experimental data is excellent. Theoretical expressions for the rotating-frame spin-lattice relaxation rate (1/T1(rho)) were also obtained.

Application to rat lung of the extended Rorschach-Hazlewood model of spin-lattice relaxation

The spin-lattice relaxation time T1 was measured in excised degassed (airless) rat lungs over the frequency range 6.7 to 80.5 MHz. The observed frequency dependence was fitted successfully to the water-biopolymer cross-relaxation theory proposed by H. E. Rorschach and C. F. Hazlewood (RH) [J. Magn. Reson. 70, 79 (1986)]. The rotating frame spin-lattice relaxation time T1(rho) was also measured in rat lung fragments over the frequency range 0.56 to 5.6 kHz, and the observed frequency dependence was explained with an extension of the RH model. The agreement between the theory and the experimental data in both cases is good.

Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial

OBJECTIVE

To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome.

DESIGN

Randomised controlled trial with final assessment at 12 months.

SETTING

An infectious diseases outpatient clinic.

SUBJECTS

60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome.

INTERVENTIONS

Medical care comprised assessment, advice, and follow up in general practice. Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care.

MAIN OUTCOME MEASURES

The proportions of patients (a) who achieved normal daily functioning (Karnofsky score 80 or more) and (b) who achieved a clinically significant improvement in functioning (change in Karnofsky score 10 points or more) by 12 months after randomisation.

RESULTS

Only two eligible patients refused to participate. All randomised patients completed treatment. An intention to treat analysis showed that 73% (22/30) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27% (8/30) of patients who were given only medical care (difference 47 percentage points; 95% confidence interval 24 to 69). Similar differences were observed in subsidiary outcome measures. The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy. Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone.

CONCLUSION

Adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment.

Chronic fatigue syndrome: a cognitive approach

Observations concerning the characteristics of patients who presented to a medical clinic with a principal complaint of chronic medically unexplained fatigue (Chronic Fatigue Syndrome or CFS) are described, including the cognitions (thoughts and assumptions) elicited from a sample of these patients who were treated using cognitive behavioural therapy. On the basis of these observations a cognitive theory of the aetiology of CFS is proposed. These observations have implications for the treatment of patients with CFS.

A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder

Recent studies have shown that cognitive therapy is an effective treatment for panic disorder. However, little is known about how cognitive therapy compares with other psychological and pharmacological treatments. To investigate this question 64 panic disorder patients were initially assigned to cognitive therapy, applied relaxation, imipramine (mean 233 mg/day), or a 3-month wait followed by allocation to treatment. During treatment patients had up to 12 sessions in the first 3 months and up to three booster sessions in the next 3 months. Imipramine was gradually withdrawn after 6 months. Each treatment included self-exposure homework assignments. Cognitive therapy and applied relaxation sessions lasted one hour. Imipramine sessions lasted 25 minutes. Assessments were before treatment/wait and at 3, 6, and 15 months. Comparisons with waiting-list showed all three treatments were effective. Comparisons between treatments showed that at 3 months cognitive therapy was superior to both applied relaxation and imipramine on most measures. At 6 months cognitive therapy did not differ from imipramine and both were superior to applied relaxation on several measures. Between 6 and 15 months a number of imipramine patients relapsed. At 15 months cognitive therapy was again superior to both applied relaxation and imipramine but on fewer measures than at 3 months. Cognitive measures taken at the end of treatment were significant predictors of outcome at follow-up.

Treatment of panic attacks using cognitive therapy without exposure or breathing retraining

Cognitive treatment of panic attacks is based on the hypothesis that panic results from the catastrophic misinterpretation of bodily sensations, and that changing such misinterpretations will block the occurrence of panic. The treatment normally involves an integrated set of cognitive and behavioural techniques. In a consecutive series of panic patients, a multiple baseline across subjects design was used to investigate whether a modified form of treatment involving only cognitive procedures could reduce panic attack frequency. The results provide preliminary evidence that cognitive procedures directed at changing misinterpretations of bodily sensations can reduce panic attack frequency, and also that cognitive procedures which do not target misinterpretations may not reduce panic.