Arthur J. Boujoukos

Initial Experience With Single Cannulation for Venovenous Extracorporeal Oxygenation in Adults

PURPOSE Historically, venovenous extracorporeal membrane oxygenation has required dual cannulation. A single-venous cannulation strategy may facilitate implantation and patient mobilization. Here we present our early experience with a single cannulation technique. DESCRIPTION Review of venovenous extracorporeal membrane oxygenation support using internal jugular vein insertion of the Avalon elite bicaval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA) in 11 consecutive patients with severe respiratory failure. EVALUATION Adequate oxygenation was obtained in all patients: 115 mm Hg PaO(2) (median), 53 to 401 mm Hg (range). Median time of support was 78 hours (range, 3 to 267 hours). No mortality was directly related to the cannulation strategy. There were three nonfatal cannulation-related events. Two patients had proximal cannula displacement requiring repositioning. One patient suffered an acute thrombosis of the cannula. CONCLUSIONS Our series supports single-venous cannulation in venovenous extracorporeal membrane oxygenation as a promising technique. It may be an excellent alternative to current cannulation strategies in patients requiring prolonged support and specifically for those considered for a bridge-to-lung transplantation.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant: Midterm Outcomes

BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used occasionally as a bridge to lung transplantation. The impact on mid-term survival is unknown. We analyzed outcomes after lung transplant over a 19-year period in patients who received ECMO support. METHODS From March 1991 to October 2010, 1,305 lung transplants were performed at our institution. Seventeen patients (1.3%) were supported with ECMO before lung transplant. Diagnoses included retransplantation (n = 6), pulmonary fibrosis (n = 6), cystic fibrosis (n = 4), and chronic obstructive pulmonary disease (n = 1). Fifteen patients underwent double lung transplant, one patient had single left lung transplant and one patient had a heart-lung transplant. Venovenous and venoarterial ECMO were implanted in eight and nine cases, respectively. Median duration of support was 3.2 days (range, 1 to 49 days). Mean patient follow-up was 2.3 years. RESULTS Thirty-day, 1-year, and 3-year survivals were 81%, 74%, and 65%, respectively, for the supported patients and 93%, 78%, and 62% in the control group (p = 0.56). Two-year survival was not affected by ECMO type, with survival of five out of nine patients supported by venoarterial ECMO vs seven out of eight patients supported by venovenous ECMO (p = 0.17). At 1- year follow-up, allograft function for the ECMO-supported patients did not differ from the control group (forced expiratory volume in one second, 2.35 L vs 2.09 L, p = 0.39) (forced vital capacity, 3.06 L vs 2.71 L, p = 0.34). CONCLUSIONS Extracorporeal membrane oxygenation as a bridge to lung transplantation is associated with higher perioperative mortality but acceptable mid-term survival in carefully selected patients. Late allograft function did not differ in patients who received ECMO support before lung transplant from those who did not receive ECMO.

Preoperative risk models for minimally invasive coronary bypass: A preliminary study

OBJECTIVE Available risk assessment models are designed for standard coronary artery bypass grafting. We hypothesized that minimally invasive coronary bypass could improve on predicted outcome in extremely high-risk patients (Parsonnet score > 20%) by the current risk models. METHODS From September 1996 to September 1997, 27 consecutive extremely high-risk patients underwent minimally invasive coronary bypass. Seventeen patients were male; age was 73 +/- 12 years, and 63% of patients were older than 75 years. Left ventricular ejection fraction was 33.7% +/- 15% and 63% had an ejection fraction of less than 35%. The predicted 30-day mortality according to the System 97 model was 25.6% +/- 11.3%. The Parsonnet risk score was 36.2% +/- 11%; the predicted length of stay in the hospital was 15.3 +/- 3 days. The predicted risk of stroke according to the Multicenter Perioperative Stroke Risk Index was 22.3% +/- 11.7%. RESULTS Minimally invasive coronary bypass was isolated in 20 patients and integrated with angioplasty and stenting in 7 patients. The observed 30-day mortality was 0% (P < .01 vs predicted): at an average follow-up of 10.8 +/- 4.1 months, 26 patients (96.3%) are alive without angina; one patient with acquired immunodeficiency syndrome died on postoperative day 40 of acute pancreatitis. No patient had a stroke or neurologic deficit (P < .01 vs predicted). Patency of internal thoracic artery anastomosis was confirmed by angiography in all 27 patients. No patient required reoperation. Eighteen patients (67%) were extubated in the operating room. The observed length of hospital stay after minimally invasive coronary bypass was 3.8 +/- 2.6 days (P < .01 vs predicted). CONCLUSION On the basis of our results on a relatively small series of patients, we suggest that risk models geared for standard coronary bypass grafting may not be appropriate for minimally invasive coronary bypass.

ECMO support for adult patients with acute respiratory failure.

The authors analyzed factors that may influence the outcome of adult patients with respiratory failure who were treated with ECMO. Between December 1990 and July 1995, the authors used ECMO to support 33 patients (age range, 17-56 years) with respiratory failure from adult respiratory distress syndrome (ARDS; n = 9), primary graft failure after lung transplantation (n = 16), late graft failure after lung transplantation (n = 5), and miscellaneous reasons (n = 3). Twenty (61%) patients were successfully weaned from ECMO, and 13 (39%) survived to hospital discharge. Venoarterial ECMO was used in 46% of survivors, compared with 60% of nonsurvivors (p = 0.43). The time on mechanical support before ECMO and the duration on ECMO for survivors and nonsurvivors was 2.9 +/- 1.8 days vs 5.0 +/- 1.3 days (p = 0.35), and 6.5 +/- 1.8 days vs 5.7 +/- 1.1 days (p = 0.68), respectively. Compared with the nonsurvivors, survivors had higher PF ratios (PaO2/FIO2; 104 +/- 33 vs 81 +/- 8, p = 0.43) before ECMO was initiated, although the differences were not significant. Among the patients who received ECMO for primary graft failure, 75% were weaned from ECMO, and 56% survived to discharge. ECMO is beneficial for adult patients with respiratory failure, especially those with primary graft failure after lung transplantation.

Successful Management of Secondary Aortoesophageal Fistula

Aortoesophageal fistula is a rare complication after thoracic aortic aneurysm repair. Six previously reported cases of aortoesophageal fistula management have been uniformly fatal. We present our successful management and review the literature of this topic.

Geographic Access to High Capability Severe Acute Respiratory Failure Centers in the United States

Objective Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States. Design Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008–2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims. Setting Nonfederal acute care hospitals in the United States. Measurements and Main Results We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air. Conclusions Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.

Discharge Outcome in Adults Treated With Extracorporeal Membrane Oxygenation

BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used for critically ill patients when conventional treatments for cardiac or respiratory failure are unsuccessful. OBJECTIVES To describe patient and treatment characteristics and discharge outcome for ECMO patients, determine which characteristics are associated with good (survival) versus poor (death before hospital discharge) outcomes, and compare characteristics of patients with cardiac versus respiratory failure indicating ECMO. METHODS Single-center, retrospective review of all adult patients treated with ECMO from 2005 through 2009. RESULTS A total of 212 patients received ECMO for cardiac (n = 126) or respiratory (n = 86) failure. Mean age was 51 (SD, 14.5) years; support duration was 135 (SD, 149) hours. Survival to discharge was 33% overall; 50% for respiratory indication and 21% for cardiac indication patients. Patients with poor outcomes were older (53 vs 47 years, P = .007), more likely to require cardiovascular support before ECMO (99% vs 91%; P = .02), and had more transfusions (48 vs 24 units, P = .005) and complications (99% vs 87%; P < .001) than did patients with good outcomes. For cardiac patients, older age was associated with poor outcome (poor, 55 vs good, 48 years; P = .01). For respiratory patients, poor outcome was associated with more ventilator days before ECMO (poor, 6 vs good, 3; P = .01), higher peak inspiratory pressure (poor, 39 vs good, 35 cm H2O; P = .02), and lower pulmonary compliance (poor, 19 vs good, 25 mL/cm H2O; P = .008). CONCLUSIONS Patients with respiratory indications for ECMO experienced better survival than did cardiac patients. Increasing age was associated with poor outcome. Complications, regardless of ECMO indication, were common and associated with poor outcome.

Ave, CESAR, morituri te salutant! (Hail, CESAR, those who are about to die salute you!)

Article details Evidence-Based Medicine Journal Club Edited by: Eric B Milbrandt. University of Pittsburgh Department of Critical Care Medicine

Isolation of Aspergillus in three 2009 H1N1 influenza patients

Please cite this paper as: Adalja et al. (2011) Isolation of Aspergillus in three 2009 H1N1 influenza patients. Influenza and Other Respiratory Viruses 5(4), 225–229

The diagnostic challenge of a tracheal tear with a double-lumen endobronchial tube: massive air leak developing from the mouth during mechanical ventilation

The case of a 78 year-old woman who underwent a right lower lobectomy using a 35-French, left-sided, double-lumen endobronchial tube (DLET) is presented. Multiple adjustments were needed for the DLETs proper placement. At the end of surgery, sudden loss of tidal volume with a large air leak from the patients mouth was noted. Fiberoptic bronchoscopic examination through the DLET was negative. Rupture of the tracheal cuff was suspected, and the DLET was replaced with a single-lumen tube. In the intensive care unit, the massive air leak from the mouth recurred during mechanical ventilation. Nasal fiberoptic bronchoscopic examination showed a longitudinal laceration of the membranous portion of the trachea extending from the subglottic area to the orifice of the right bronchus. Surgical repair of the tear was performed.