Erik Abel

Extracorporeal membrane oxygenation for complex multiorgan system trauma.

With growing experience, the indications for salvage extracorporeal membrane oxygenation continue to expand. We describe a successful application of extracorporeal support in a polytrauma patient presenting with profound hypothermia, respiratory failure, and whom was later found to have an intracranial hemorrhage. We advocate the role of salvage therapy even in patients with complex pathophysiology despite perceived relative or absolute contraindications to extracorporeal support.

Fulminant Neisseria meningitidis: role for extracorporeal membrane oxygenation.

Invasive meningococcal disease is often associated with complications of septic shock and central nervous system dysfunction. Extracorporeal membrane oxygenation is more commonly being used for respiratory failure and sepsis, but neurologic injury and potential coagulopathy are often considered relative contraindications. We report a successful case of complicated Neisseria meningitidis septic shock with disseminated intravascular coagulopathy requiring extracorporeal support.

Delayed Malignant Hyperthermia After Routine Coronary Artery Bypass

Malignant hyperthermia is a rare but well-described hypermetabolic disorder of skeletal muscle that can be potentially fatal if untreated. In our patient, malignant hyperthermia developed several minutes after discontinuation of the known triggering agent after an uncomplicated coronary revascularization. This case illustrates the dramatic presentation and successful management of a rare disease with a rare onset.

Development and implementation of a nurse-driven, sliding-scale nomogram for bivalirudin in the management of heparin-induced thrombocytopenia

PURPOSE A simplified dosing nomogram to assist nurses in adjusting the rate of i.v. bivalirudin administration in cases of heparin-induced thrombocytopenia (HIT) is described. SUMMARY To facilitate the availability of bivalirudin [corrected] as an alternative direct thrombin inhibitor (DTI) for patients with HIT at The Ohio State University Wexner Medical Center (OSUWMC), a team of clinical pharmacists developed a nomogram designed to simplify infusion dosage adjustments by nurses. In contrast to bivalirudin nomograms requiring patient-specific, percentage-based dose adjustments, the nomogram developed at OSUWMC specifies fixed adjustments (0.005 or 0.01 mg/kg/hr) according to the current activated partial thromboplastin time (aPTT) value relative to aPTT goals. During pilot testing over three years, the nomogram was used to guide dosage adjustments in 65 adult patients receiving continuous infusions of bivalirudin for suspected or confirmed HIT in intensive care units. Overall, the use of the nomogram resulted in adequate anticoagulation, with 53.7% of all measured aPTT values in the target range; 30.5% of aPTT values were below target, and 15.8% of values were above target. The median time to steady state was 11.0 hours (range, 5.0-31.8 hours), and bleeding rates were consistent with those reported in the literature. Nurse adherence to the nomogram was 100%, and no dosing errors occurred during a total of 487 dosage changes. Based on the pilot study results, the nomogram was refined to improve initial dosing for patients with creatinine clearance values of >30 mL/min; other refinements were made to enhance the safety of bivalirudin therapy for HIT in patients with severe renal impairment. CONCLUSION A nurse-driven, sliding-scale nomogram for bivalirudin therapy in patients with HIT provided a simple dosing protocol and resulted in a high rate of adherence by nurses.

Superior vena cava bypass with cryopreserved ascending aorta allograft.

Initially superior vena cava obstruction is typically managed by an endovascular approach. However, in some patients, particularly those in whom angioplasty and stenting is not technically possible, or those who have recurrent disease after previous endovascular repair, an open surgical approach may be indicated. Conduit choices for caval reconstruction are less than ideal; hence we describe a case using a cryopreserved aortic allograft.

Emergent Pulmonary Embolectomy and Advanced Glioblastoma Multiforme

Pulmonary emboli are frequent causes of morbidity and mortality in patients with brain tumors. Treatment options are limited in these complex patients. We report a case of successful acute pulmonary embolectomy in a patient with an advanced brain cancer.

Nonconvective forces: a critical and often ignored component in the echocardiographic assessment of transvalvular pressure gradients.

Echocardiography is routinely used to assess ventricular and valvular function, particularly in patients with known or suspected cardiac disease and who have evidence of hemodynamic compromise. A cornerstone to the use of echocardiographic imaging is not only the qualitative assessment, but also the quantitative Doppler-derived velocity characteristics of intracardiac blood flow. While simplified equations, such as the modified Bernoulli equation, are used to estimate intracardiac pressure gradients based upon Doppler velocity data, these modified equations are based upon assumptions of the varying contributions of the different forces that contribute to blood flow. Unfortunately, the assumptions can result in significant miscalculations in determining a gradient if not completely understood or they are misapplied. We briefly summarize the principles of fluid dynamics that are used clinically with some of the inherent limitations of routine broad application of the simplified Bernoulli equation.

Temporary Extracorporeal Circulatory Support and Pulmonary Embolectomy for Catastrophic Amniotic Fluid Embolism

Amniotic fluid embolism is usually a life-threatening complication of an otherwise healthy pregnancy. Medical management of the coagulopathy and cardiovascular collapse is challenging and is often unsuccessful. We present a case and advocate the use of temporary circulatory support and pulmonary embolectomy in what would otherwise have been a fatal scenario.

Shortness of Breath: Pulmonary Embolism, Ischemic Heart Failure, or Both? The Role of Concomitant Surgery

We present a case of a patient who underwent successful concomitant surgical management of his massive pulmonary embolism and severe multivessel coronary disease. His presentation with shortness of breath prompted a comprehensive evaluation, which revealed both problems. This experience emphasizes the importance of considering both problems, because treating one but not the other could be catastrophic.

Aortic Rupture in a Heart Transplant Patient Following Recent Blunt Aortic Trauma

Abstract  We report a case of a patient who developed an aortic dissection with rupture. This presumably was a delayed injury following blunt thoracic trauma and highlights that concerns for aortic pathology even in this patient population.