Publications by authors named "Cara Agerstrand"

38 Publications

Pulmonary Embolism Response Team utilization during the COVID-19 pandemic.

Vasc Med 2021 Apr 4:1358863X21995896. Epub 2021 Apr 4.

Department of Cardiology, Columbia Irving Medical Center, New York, NY, USA.

Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 ( = 74) compared to the same period in 2019 ( = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1358863X21995896DOI Listing
April 2021

ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO).

ASAIO J 2021 Feb 26. Epub 2021 Feb 26.

Department of Emergency Medicine, University of Washington, USA Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, USA General ICU, University Hospital of Parma, Italy Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Italy Extracorporeal Life Support Organization Texas Children's Hospital, Baylor College of Medicine Children's Medical Center of Dallas, University of Texas Southwestern Medical Center Extracorporeal Life Support Organization, President; Children's Healthcare of Atlanta, Emory University Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA University of Michigan Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust Centre for Human & Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013 PARIS, France Department of Cardio-Thoracic Surgery - Maastricht University Medical Centre - Cardiovascular Research Institute Maastricht Maastricht, The Netherlands Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany Nemours Children's Health System Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, USA Intensive Care Unit, Alfred Health Melbourne, Victoria, Australia Critical Care ECMO service, King Saud Medical City - Ministry Of Health (MOH), Riyadh - Saudi Arabia. Fundación Cardiovascular de Colombia Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France. Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France. Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia National University Hospital, Singapore Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA.

This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001422DOI Listing
February 2021

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Crisis Standards of Care.

ASAIO J 2021 03;67(3):245-249

From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York.

The coronavirus disease 2019 (COVID-19) pandemic has placed extraordinary strain on global healthcare systems. Use of extracorporeal membrane oxygenation (ECMO) for patients with severe respiratory or cardiac failure attributed to COVID-19 has been debated due to uncertain survival benefit and the resources required to safely deliver ECMO support. We retrospectively investigated adult patients supported with ECMO for COVID-19 at our institution during the first 80 days following New York City's declaration of a state of emergency. The primary objective was to evaluate survival outcomes in patients supported with ECMO for COVID-19 and describe the programmatic adaptations made in response to pandemic-related crisis conditions. Twenty-two patients with COVID-19 were placed on ECMO during the study period. Median age was 52 years and 18 (81.8%) were male. Twenty-one patients (95.4%) had severe ARDS and seven (31.8%) had cardiac failure. Fifteen patients (68.1%) were managed with venovenous ECMO while 7 (31.8%) required arterial support. Twelve patients (54.5%) were transported on ECMO from external institutions. Twelve patients were discharged alive from the hospital (54.5%). Extracorporeal membrane oxygenation was used successfully in patients with respiratory and cardiac failure due to COVID-19. The continued use of ECMO, including ECMO transport, during crisis conditions was possible even at the height of the COVID-19 pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001376DOI Listing
March 2021

Successful Treatment of Pregnant and Postpartum Women With Severe COVID-19 Associated Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation.

ASAIO J 2021 02;67(2):132-136

Department of Pediatrics (Critical Care), Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846250PMC
February 2021

Extracorporeal Carbon Dioxide Removal in the Treatment of Status Asthmaticus.

Crit Care Med 2020 Dec;48(12):e1226-e1231

1Department of Surgery, Columbia University Irving Medical Center, New York, NY. 2Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Irving Medical Center, New York, NY. 3Department of Clinical Perfusion, New York-Presbyterian Hospital, New York, NY. 4Section of Thoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY. 5Departments of Thoracic and Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN.

Objectives: Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus.

Design: Retrospective review.

Setting: Medical ICU.

Patients: Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal.

Interventions: None.

Measurements And Main Results: Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs.

Conclusions: In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004645DOI Listing
December 2020

Ten-year outcomes of extracorporeal life support for in-hospital cardiac arrest at a tertiary center.

J Artif Organs 2020 Dec 3;23(4):321-327. Epub 2020 Oct 3.

Division of Cardiothoracic Surgery, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, 177 Fort Washington Ave, Milstein Hospital Building, 7GN-435, New York, NY, 10032, USA.

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45-72) with a median ECLS duration of 2.2 days (IQR 0.6-5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30-50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22-8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14-0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10047-020-01217-5DOI Listing
December 2020

Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry.

Lancet 2020 10 25;396(10257):1071-1078. Epub 2020 Sep 25.

Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.

Background: Multiple major health organisations recommend the use of extracorporeal membrane oxygenation (ECMO) support for COVID-19-related acute hypoxaemic respiratory failure. However, initial reports of ECMO use in patients with COVID-19 described very high mortality and there have been no large, international cohort studies of ECMO for COVID-19 reported to date.

Methods: We used data from the Extracorporeal Life Support Organization (ELSO) Registry to characterise the epidemiology, hospital course, and outcomes of patients aged 16 years or older with confirmed COVID-19 who had ECMO support initiated between Jan 16 and May 1, 2020, at 213 hospitals in 36 countries. The primary outcome was in-hospital death in a time-to-event analysis assessed at 90 days after ECMO initiation. We applied a multivariable Cox model to examine whether patient and hospital factors were associated with in-hospital mortality.

Findings: Data for 1035 patients with COVID-19 who received ECMO support were included in this study. Of these, 67 (6%) remained hospitalised, 311 (30%) were discharged home or to an acute rehabilitation centre, 101 (10%) were discharged to a long-term acute care centre or unspecified location, 176 (17%) were discharged to another hospital, and 380 (37%) died. The estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 37·4% (95% CI 34·4-40·4). Mortality was 39% (380 of 968) in patients with a final disposition of death or hospital discharge. The use of ECMO for circulatory support was independently associated with higher in-hospital mortality (hazard ratio 1·89, 95% CI 1·20-2·97). In the subset of patients with COVID-19 receiving respiratory (venovenous) ECMO and characterised as having acute respiratory distress syndrome, the estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 38·0% (95% CI 34·6-41·5).

Interpretation: In patients with COVID-19 who received ECMO, both estimated mortality 90 days after ECMO and mortality in those with a final disposition of death or discharge were less than 40%. These data from 213 hospitals worldwide provide a generalisable estimate of ECMO mortality in the setting of COVID-19.

Funding: None.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(20)32008-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518880PMC
October 2020

Right Ventricular Clot in Transit in COVID-19: Implications for the Pulmonary Embolism Response Team.

JACC Case Rep 2020 Jul 29;2(9):1391-1396. Epub 2020 May 29.

Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York.

Severe acute respiratory syndrome coronavirus 2 is associated with a prothrombotic state in infected patients. After presenting a case of right ventricular thrombus in a patient with coronavirus disease-2019 (COVID-19), we discuss the unique challenges in the evaluation and treatment of COVID-19 patients, highlighting our COVID-19-modified pulmonary embolism response team algorithm. ().
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2020.05.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259913PMC
July 2020

Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study.

Lancet 2020 08;396(10250):545-552

Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université INSERM-UMRS 1166, Institute of Cardiometabolism and Nutrition, Paris, France.

Background: Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments.

Methods: In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged ≥18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 μg/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders.

Findings: At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1·5 L/min per mvs 2·2 L/min per m, LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 μg/kg per min vs 145 μg/kg per min, lactataemia 8·9 mmol/L vs 6·5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p<0·0001 for each comparison. Survival at 90 days for patients treated with VA-ECMO was significantly higher than for controls (60% vs 25%, risk ratio [RR] for mortality 0·54, 95% CI [0·40-0·70]; p<0·0001). After propensity score weighting, ECMO remained associated with improved survival (51% vs 14%, adjusted RR for mortality 0·57, 95% CI [0·35-0·93]; p=0·0029). Lactate and catecholamine clearance were also significantly enhanced in patients treated with ECMO. Among the 49 survivors treated with ECMO, 32 who had been treated at the largest centre reported satisfactory Short Form-36 evaluated health-related quality of life at 1-year follow-up.

Interpretation: Patients with severe sepsis-induced cardiogenic shock treated with VA-ECMO had a large and significant improvement in survival compared with controls not receiving ECMO. However, despite the careful propensity-weighted analysis, we cannot rule out unmeasured confounders.

Funding: None.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(20)30733-9DOI Listing
August 2020

Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce.

Crit Care Med 2020 03;48(3):406-414

Department of Pediatrics, Division of Neonatology, Nemours Alfred I duPont Hospital for Children, Wilmington, DE.

Objectives: The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.

Design: Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication.

Setting: In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education.

Patients: None.

Interventions: None.

Measurements And Main Results: The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development.

Conclusions: Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004158DOI Listing
March 2020

Extracorporeal life support bridge for pulmonary hypertension: A high-volume single-center experience.

J Heart Lung Transplant 2019 12 12;38(12):1275-1285. Epub 2019 Sep 12.

Department of Thoracic & Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, and Biomedical Engineering, Columbia University Medical Center, New York, New York.

Background: Application of extracorporeal life support (ECLS) for advanced pulmonary hypertension (PH) is evolving and may be deployed as a bridge to transplantation (BTT) or in one of several non-BTT uses, such as bridge to recovery (BTR) to the chronic PH clinical state in the setting of an acute PH trigger, bridge through non-transplant surgery (BTNTS), or bridge post-transplantation (BPT).

Methods: We conducted a retrospective analysis of all adult patients with World Symposium on Pulmonary Hypertension Group 1, 3, 4, or 5 PH who received ECLS at Columbia University Medical Center/New York Presbyterian Hospital between January 1, 2010 and August 18, 2018. We describe patient characteristics, outcomes, and our approach to medical and surgical management of these patients.

Results: There were 98 patients with significant PH in the cohort (54 female; median age, 48 years [interquartile range, 32-58]). Of these, 44 (45%) patients with PH received ECLS as non-BTT with intent to recover back to their baseline functional state, optimize therapy, or support through a definitive surgery, including 19 BTR, 17 BTNTS, and 8 BPT, and 54 (55%) patients received ECLS as BTT. In the overall cohort, 67 (68.4%) patients received venoarterial ECLS and 31 (31.6%) received venovenous (VV) ECLS. Out of 83 patients, 52 (63%) were liberated from invasive mechanical ventilation, and 85.2% of BTT patients with PH ambulated while on ECLS. Management of PH medications was individualized, often requiring titration with use of inhaled pulmonary vasodilators increased after cannulation in non-BTT. Overall 30-day survival was 73.5%, survival to ECLS decannulation was 66.3%, and survival to hospital discharge was 54.1%. All 8 BPT patients (100%) survived to hospital discharge, 64.7% of BTNTS patients survived to hospital discharge, and 32 (59.3%) BTT patients survived to lung transplantation. Early-era use of VV-ECLS for BTT had worse survival to discharge than those initially configured with venoarterial ECLS, impacting the overall survival and leading to limited use of VV-ECLS in the current era for BPT, BTNTS, and select BTR cases.

Conclusions: ECLS instituted by a specialized, multidisciplinary team has a role in the management of advanced PH as BTT or as non-BTT (including BTR, BTNTS, and BPT). Careful selection of ECLS cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be effective strategies in managing these complex patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.healun.2019.09.004DOI Listing
December 2019

Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support.

ASAIO J 2020 06;66(6):652-656

Departments of Thoracic & Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Patients receiving extracorporeal membrane oxygenation (ECMO) often require prolonged mechanical ventilation. Providers may be reluctant to perform tracheostomies on patients during ECMO due to their tenuous clinical status and systemic anticoagulation. We report our experience with performing open and percutaneous tracheostomies on patients supported on ECMO from August 2009 to December 2017. Of the 127 patients who underwent tracheostomy during ECMO support, the median age was 42 years (interquartile range [IQR], 29-54), 99 (78%) patients had venovenous (VV) cannulation, 22 (17%) patients had venoarterial (VA) cannulation, and six (5%) patients had hybrid configurations. Percutaneous tracheostomy was performed in 110 (87%) patients. Median-activated partial thromboplastin time (aPTT) at the time of tracheostomy was 47.5 seconds (IQR, 41-57.6 seconds). The median time from ECMO initiation to tracheostomy was 7 days (IQR, 4-11 days). A total of 55 patients (43%) received packed red blood cell (pRBC) transfusions within 48 hours after tracheostomy with a median transfusion of 2 units (IQR, 1-3). There was no procedural mortality. Overall, 88 (69%) patients survived to decannulation and 74 (58%) survived to hospital discharge. Our experience with the largest published series of tracheostomies during ECMO demonstrates that excellent outcomes can be achieved without significant morbidity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001059DOI Listing
June 2020

Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation.

J Crit Care 2019 10 29;53:98-106. Epub 2019 May 29.

Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America.

Purpose: To characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure.

Materials And Methods: International, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine.

Results: Respondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04).

Conclusions: Most respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrc.2019.05.014DOI Listing
October 2019

Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort.

Am J Respir Crit Care Med 2019 10;200(8):1002-1012

INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France.

Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes. This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs. We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO Pa/Fi 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm HO), driving pressure (20 ± 7 vs. 14 ± 4 cm HO), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes. Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1164/rccm.201806-1094OCDOI Listing
October 2019

Outcomes of Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation.

Ann Thorac Surg 2019 05 18;107(5):1456-1463. Epub 2019 Feb 18.

Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. Electronic address:

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has become a critical component of caring for patients with end-stage lung disease. This study examined outcomes of patients who received ECMO as a BTT.

Methods: Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients who received ECMO as BTT at Columbia University Medical Center from April 2009 through July 2018.

Results: A total of 121 adult patients were placed on ECMO as BTT, and 70 patients (59%) were successfully bridged to lung transplantation. Simplified Acute Physiology Score II, unplanned endotracheal intubation, renal replacement therapy, and cerebrovascular accident were identified as independent predictors of unsuccessful BTT. Ambulation was the only independent predictor of successful BTT (odds ratio, 7.579; 95% confidence interval, 2.158 to 26.615; p = 0.002). Among the 64 patients (91%) who survived to hospital discharge, survival was 88% at 1 year and 83% at 3 years. Propensity matching between BTT and non-BTT lung transplant recipients did not show a significant difference in survival (log-rank = 0.53) despite significant differences in the lung allocation score (median, 92.2 [interquartile range, 89.0 to 94.2] vs 49.6 [interquartile range, 40.6 to 72.3], p < 0.01).

Conclusions: ECMO can be used successfully to bridge patients with end-stage lung disease to lung transplantation. When implemented by an experienced team with adherence to stringent protocols and patient selection, outcomes in BTT patients were comparable to patients who did not receive pretransplant support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2019.01.032DOI Listing
May 2019

A decade of interfacility extracorporeal membrane oxygenation transport.

J Thorac Cardiovasc Surg 2019 04 29;157(4):1696-1706. Epub 2018 Nov 29.

Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn. Electronic address:

Objective: Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO.

Methods: Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017.

Results: Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge.

Conclusions: Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2018.09.139DOI Listing
April 2019

Increasing Opportunity for Lung Transplant in Interstitial Lung Disease With Pulmonary Hypertension.

Ann Thorac Surg 2018 12 28;106(6):1812-1819. Epub 2018 May 28.

Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York. Electronic address:

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation for end-stage interstitial lung disease (ILD) and pulmonary hypertension (PH) has varying results based on ECMO configuration. We compare our experience using venovenous (VV) and venoarterial (VA) ECMO bridge to transplantation for ILD with PH on survival to successful transplantation.

Methods: A single-center retrospective review was done of patients with ILD and secondary PH who were placed on either VV or VA ECMO as bridge to transplantation from 2010 to 2016. Comparisons for factors associated with survival to transplantation between VV and VA ECMO strategies were made using Cox proportional hazards model. Subgroup analysis included comparisons of VV ECMO patients who remained on VV or were converted to VA ECMO.

Results: A total of 50 patients with ILD and PH were treated initially with either VV (n = 19) or VA (n = 31) ECMO as bridge to lung transplantation. Initial VA ECMO had a significantly higher survival to transplantation compared with initial VV ECMO (p = 0.03). Cox proportional hazards modeling showed a 59% reduction in risk of death for VA compared with VV ECMO (hazard reduction 0.41, 95% confidence interval: 0.18 to 0.92, p = 0.03). Patients converted from VV to VA ECMO had significantly longer survival awaiting transplant than patients who remained on VV ECMO (p = 0.03). Ambulation on ECMO before transplantation was associated with an 80% reduction in the risk of death (hazard reduction 0.20, 95% confidence interval: 0.08 to 0.48, p < 0.01).

Conclusions: Venoarterial ECMO upper body configuration for patients with end stage ILD and PH significantly improves overall survival to transplantation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2018.04.068DOI Listing
December 2018

Morbid obesity is not a contraindication to transport on extracorporeal support.

Eur J Cardiothorac Surg 2018 04;53(4):793-798

Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, USA.

Objectives: Extracorporeal membrane oxygenation (ECMO) transport has not been described in morbidly obese patients, a population that can pose significant challenges in obtaining vascular access, indexed flows and transport logistics. We sought to study the feasibility and safety of transporting obese and morbidly obese patients during extracorporeal support.

Methods: We conducted a retrospective review of all patients transported to our institution while receiving ECMO from September 2008 to September 2016. Survival to decannulation and survival to discharge were the primary outcomes. Obesity and morbid obesity were defined as a body mass index of greater than 30 kg/m2 and greater than 40 kg/m2, respectively.

Results: From 2008 to 2016, 222 patients were transported to our institution while receiving ECMO. Among these included patients, 131 were non-obese (interquartile range 22-27 kg/m2), 63 were obese (interquartile range 31-35 kg/m2) and 28 were morbidly obese (interquartile range 41-49 kg/m2), with 6 patients having a body mass index greater than 50 kg/m2 (range 52.3-79 kg/m2). Pre-ECMO arterial blood gases, disease severity indices, cannulation strategies and transport distances were similar between these 3 groups. There was no mortality of patients during transport, and survival to discharge was 66% (n = 87) in non-obese patients, 56% (n = 35) in obese patients and 82% (n = 23) in morbidly obese patients (P = 0.042). On multivariable logistic regression analysis, body mass index was not a predictor of in-hospital mortality (odds ratio 0.99, 95% confidence interval 0.95-1.03; P = 0.517).

Conclusions: Transport of morbidly obese patients receiving ECMO may be performed safely and with excellent results in the setting of a dedicated ECMO transport programme with well-established management protocols.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ejcts/ezx452DOI Listing
April 2018

Management of Surge in Extracorporeal Membrane Oxygenation Transport.

Ann Thorac Surg 2018 Feb 23;105(2):528-534. Epub 2017 Nov 23.

Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York. Electronic address:

Background: Transporting patients receiving extracorporeal membrane oxygenation (ECMO) support is safe and reliable with a dedicated program and established management protocols. As our program has grown, our teams have had to adapt to manage surges in transport volume while maintaining patient safety. We assessed the outcomes at peak use of our ECMO transport services during surges.

Methods: We conducted a single-center retrospective review of all patients transported to our institution while supported with ECMO from September 2008 to September 2016. Survival to discharge was the primary outcome. Surge patients were defined as those transported during months with at least 8 transports or patients transported within 24 hours of another patient in nonsurge months.

Results: From 2008 to 2016, 222 patients were transported to our institution while supported with ECMO. Baseline characteristics and indices of disease severity were comparable between surge and nonsurge patients. Of the 84 patients transported during surges, 59 surge patients (70%) survived to hospital discharge vs 86 (63%) of nonsurge patients (p = 0.31). Multivariable logistic regression showed that age and APACHE II (Acute Physiology and Chronic Health Evaluation) severity index score were predictors of in-hospital death (p < 0.05), but transportation during a surge was not (odds ratio, 0.91; 95% confidence interval, 0.46 to 1.80; p = 0.79).

Conclusions: Patient safety and clinical outcomes can be maintained during surges in ECMO transport volume if the ECMO program has developed plans for handling transient increases in volume and considers staff fatigue and burnout. Standardizing interhospital communication, patient selection, and management protocols are critical to maintaining quality of care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2017.07.019DOI Listing
February 2018

Awake Extracorporeal Membrane Oxygenation as Bridge to Lung Transplantation: A 9-Year Experience.

Ann Thorac Surg 2017 Aug 24;104(2):412-419. Epub 2017 Feb 24.

Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York. Electronic address:

Background: Extracorporeal membrane oxygenation (ECMO) is used as a bridge to lung transplantation, but characteristics that influence its success are poorly understood. This large, single-center experience evaluated the implementation and outcomes of ECMO in this setting.

Methods: Data were collected for patients at our institution (New York-Presbyterian Hospital/Columbia University Medical Center in New York) who received ECMO as a bridge to lung transplantation from January 1, 2007 through July 10, 2016. Data were analyzed for demographics, baseline characteristics, survival, and ECMO configuration.

Results: Seventy-two patients received ECMO as a bridge to lung transplantation. Of the 72 patients, 40 (55.6%) underwent the transplantation procedure, 37 (92.5%) survived to discharge, and 21 (84.0%) survived for 2 years. Inotropy or vasopressor support (70% vs 93.8%; p = 0.011), Simplified Acute Physiology Score (26.8 vs 30.5; p = 0.048), and ambulation (80% vs 56.2%; p = 0.030) were significantly different between the patients who underwent lung transplantation and those who did not. Patients with cystic fibrosis were more likely to have a bridge to transplantation than patients with other lung diseases (47.5% vs 25%; p = 0.050). Daily participation in physical therapy was achieved in 50 patients (69.4%).

Conclusions: This study demonstrated favorable survival in patients receiving ECMO as a bridge to lung transplantation and achieved high rates of physical therapy and avoidance of mechanical ventilation while ECMO was used in patients awaiting lung transplantation. With more than half of these patients successfully bridged to lung transplantation, we gained insight into the factors influencing patients' outcomes, including patient selection, timing of ECMO, and patient management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.11.056DOI Listing
August 2017

Reply.

Ann Thorac Surg 2017 01;103(1):361-362

Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.07.013DOI Listing
January 2017

Extracorporeal Membrane Oxygenation for Cardiopulmonary Failure During Pregnancy and Postpartum.

Ann Thorac Surg 2016 Sep 4;102(3):774-779. Epub 2016 May 4.

Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York.

Background: Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support pregnant and postpartum patients with severe cardiac or pulmonary failure, although patient management and clinical outcomes are underreported. This study represents patients who received ECMO during the peripartum period.

Methods: All pregnant or postpartum patients treated with ECMO in the medical intensive care unit between January 1, 2009, and June 30, 2015, were included in this study. Data were analyzed retrospectively. The primary objective was to characterize the circumstances and clinical characteristics of the patients who received ECMO, describe our management during pregnancy and at the time of delivery, evaluate maternal and fetal outcomes, and report bleeding and thrombotic complications.

Results: Eighteen peripartum patients were treated with ECMO during the study period; 4 were pregnant at the time of cannulation. Median age was 32.6 years, and median gestational age in pregnant patients was 32 weeks. Sixteen patients (88.9%) survived to hospital discharge. Fetal survival was 14 (77.8%) in the entire cohort and 100% in patients cannulated after fetal viability. Two patients successfully delivered on ECMO. Bleeding complications developed in 6 patients (33.3%) and were associated with disseminated intravascular coagulation. No fetal complications were attributed to ECMO.

Conclusions: ECMO can be used during pregnancy and postpartum with favorable maternal and fetal outcomes, and it outweighs the risk of bleeding or thrombotic complications when managed by an experienced, multidisciplinary team.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.03.005DOI Listing
September 2016

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study.

Intensive Care Med 2016 May 23;42(5):844-852. Epub 2016 Mar 23.

Division of Pulmonary and Critical Care, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

Purpose: The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia.

Methods: We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤50,000/μL) while on ECMO.

Results: Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β -0.85, 95 % CI -2.05 to 0.36), nor after considering and controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β -0.83, 95 % CI -1.9 to 0.25). Twenty-two subjects (22 %) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35 % for every 5-point increase in APACHE II score (OR 1.35, 95 % CI 0.94-1.94) and increased 35 % for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95 % CI 1.10-1.64).

Conclusions: Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00134-016-4312-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407307PMC
May 2016

Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation.

J Crit Care 2015 Dec 1;30(6):1190-4. Epub 2015 Aug 1.

Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, NY 10032.

Purpose: Patients receiving extracorporeal membrane oxygenation (ECMO) are at risk for thrombocytopenia including heparin-induced thrombocytopenia (HIT). The purpose of this study was to determine the frequency of suspected HIT in patients receiving ECMO and unfractionated heparin (UFH).

Materials And Methods: We conducted a retrospective review in adult patients on ECMO. Patients were included if they received ECMO for at least 5 days and concomitant UFH.

Results: There were 119 patients who met inclusion criteria. Twenty-three patients (19%) had a heparin-platelet factor 4 immunoassay performed. Patients with suspected HIT had a significantly lower platelet count within the first 3 days of ECMO, 69×10(9)/L (22-126×10(9)/L) vs 87.5×10(9)/L (63-149×10(9)/L); P=.04. The lowest platelet count on the day of HIT testing was 43×10(9)/L (26-73), representing a 71% reduction from baseline. Twenty patients (87%) had an optical density score less than 0.4, and all patients had a score less than 1.0. A functional assay was performed in 7 patients (30%), with only 1 patient having laboratory-confirmed HIT.

Conclusions: The evaluation of HIT occurred in a small percentage of patients, with HIT rarely being detected. Patients who had heparin-platelet factor 4 immunoassay testing exhibited lower platelet counts with a similar duration of ECMO and UFH exposure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrc.2015.07.030DOI Listing
December 2015

One Hundred Transports on Extracorporeal Support to an Extracorporeal Membrane Oxygenation Center.

Ann Thorac Surg 2015 Jul 23;100(1):34-9; discussion 39-40. Epub 2015 Apr 23.

Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York. Electronic address:

Background: Extracorporeal life support technology has gained acceptance as a salvage mode for patients in respiratory or cardiac failure. Patients who are sick enough to require extracorporeal membrane oxygenation (ECMO) support are often too unstable for transfer to a hospital with ECMO capabilities. We highlight the progressive development of an ECMO transport team and the manner in which it provides reliable transport with excellent outcomes.

Methods: All data were collected retrospectively from our hospital's electronic medical record. Patient outcomes are reported through April 2, 2014.

Results: Our institution began an ECMO transport program in 2008, with the initial phase involving transport of highly selected patients for short distances. With experience we refined our intake and evaluation process. We also consolidated care for ECMO patients into two intensive care units and developed a dedicated ECMO intensivist position. As the program has matured, patient selection has become more inclusive and we have extended our capabilities to include interstate and international transport. All 100 patients were successfully placed on ECMO and transported to our center. Seventy-nine patients were placed on venovenous ECMO, 19 on venoarterial ECMO, and 2 on venovenous arterial ECMO. The median transport distance was 16 miles and ranged from 2.5 to 7,084 miles.

Conclusions: Extracorporeal membrane oxygenation transport can be performed safely and reliably with excellent outcomes with a dedicated team that maintains stringent adherence to well-designed management protocols.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2015.02.037DOI Listing
July 2015

Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome.

Ann Thorac Surg 2015 Feb 10;99(2):590-5. Epub 2014 Dec 10.

Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York. Electronic address:

Background: Extracorporeal membrane oxygenation support (ECMO) typically requires multiple blood transfusions and is associated with frequent bleeding complications. Blood transfusions are known to increase morbidity and mortality in critically ill patients, which may extend to patients receiving ECMO. Aiming to reduce transfusion requirements, we implemented a blood conservation protocol in adults with severe acute respiratory distress syndrome (ARDS) receiving ECMO.

Methods: This was a retrospective study of adults receiving ECMO for ARDS after initiation of a blood conservation protocol that included a transfusion trigger of hemoglobin of less than 7.0 g/dL, use of low-dose anticoagulation targeting an activated partial thromboplastin time of 40 to 60 seconds, and autotransfusion of circuit blood during decannulation. The primary objective was to evaluate transfusion requirements during ECMO support. Clinical outcomes included survival, neurologic function, renal function, bleeding, and thrombotic complications.

Results: The analysis included 38 patients; of these, 24 (63.2%) received a transfusion while receiving ECMO. Median hemoglobin was 8.29 g/dL. A median of 1.0 units (range, 250 to 300 mL) was transfused during ECMO support over a median duration of 9.0 days, equivalent to 0.11 U/d (range, 27.5 to 33.3 mL/d). The median activated partial thromboplastin time was 46.5 seconds. Bleeding occurred in 10 patients (26.3%); severe bleeding occurred in 2 patients (5.3%). Twenty-eight patients (73.7%) survived to hospital discharge.

Conclusions: Implementation of a blood conservation protocol in adults receiving ECMO for ARDS resulted in lower transfusion requirements and bleeding complications than previously reported in the literature and was associated with comparable survival and organ recovery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2014.08.039DOI Listing
February 2015

Extracorporeal membrane oxygenation in the management of diffuse alveolar hemorrhage.

ASAIO J 2015 Mar-Apr;61(2):216-8

From the *Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and †Division of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.

Extracorporeal membrane oxygenation (ECMO) may be used to support patients with severe hypoxemic respiratory failure refractory to conventional mechanical ventilation. However, because systemic anticoagulation is generally required to maintain circuit patency, severe bleeding is often seen as a contraindication to ECMO. We describe our center's experience with four patients who received ECMO for refractory hypoxemic respiratory failure due to diffuse alveolar hemorrhage (DAH), a condition for which anticoagulation is typically contraindicated, and provide a review of the literature. The mean age was 35.8 ± 16.4 years. The mean pre-ECMO PaO2 to FIO2 ratio was 52.3 ± 9.4 mm Hg. All patients were treated with continuous infusions of heparin with a goal-activated partial thromboplastin time between 40 and 60 seconds (mean, 47.4 ± 11.6 seconds). All four subjects (100%) survived to decannulation, and three subjects (75%) survived to discharge. The results from this case series, along with previously published data, suggest that ECMO is a reasonable management option for patients with DAH-associated severe, refractory hypoxemic respiratory failure. This is especially true in the era of modern ECMO technology where lower levels of anticoagulation are able to maintain circuit patency while minimizing bleeding risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000000183DOI Listing
April 2016

Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: a single-center experience.

ASAIO J 2014 Nov-Dec;60(6):635-42

From the *Division of Cardiothoracic Surgery, Department of Surgery and †Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York.

Use of extracorporeal membrane oxygenation (ECMO) in adults has surged in recent years. Typical configurations are venovenous (VV), which provides respiratory support, or venoarterial (VA), which provides both respiratory and circulatory support. In patients supported with VV ECMO who develop hemodynamic compromise, an arterial limb can be added (venovenous-arterial ECMO) to provide additional circulatory support. For patients on VA ECMO who develop concomitant respiratory failure in the setting of some residual cardiac function, an oxygenated reinfusion limb can be added to the internal jugular vein (venoarterial-venous ECMO) to improve oxygen delivery to the cerebral and coronary circulation. Such hybrid configurations can provide differential support for various forms of cardiopulmonary failure. We describe 21 patients who ultimately received a hybrid configuration at our institution between 2012 and 2013. Eight patients (38.1%) died during ECMO support, four patients (19.0%) died after decannulation but before hospital discharge, and nine patients (42.9%) survived to hospital discharge. Our modest survival rate is likely related to the complexity and severity of illness of these patients, and this relative success suggests that hybrid configurations can be effective. It serves patients well to maintain a flexible and adaptable approach to ECMO configurations for their variable cardiopulmonary needs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000000139DOI Listing
July 2015

Extracorporeal membrane oxygenation transport after traumatic aortic valve injury.

ASAIO J 2014 May-Jun;60(3):353-4

From the *Department of General Surgery, Columbia University Medical Center, New York, NY; †Department of Pulmonary, Allergy, and Critical Care Medicine, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY; and ‡Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY.

Traumatic injury to the aortic valve is an uncommon clinical entity. Rarer still is the transport of such a patient using extracorporeal membrane oxygenation (ECMO) to a specialized ECMO center for definitive repair. We present a case of traumatic rupture of the aortic valve complicated by severe acute respiratory distress syndrome with interhospital transport using ECMO and subsequent aortic valve replacement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000000068DOI Listing
December 2014