Gail Faulkner

Aspirin and bleeding peptic ulcers in the elderly.

A case-control study was performed to determine whether aspirin confers a similar risk of bleeding from gastric or duodenal ulcers in the elderly as non-aspirin, non-steroidal anti-inflammatory drugs. The intake of analgesics in 230 patients with bleeding ulcers aged 60 and over and in hospital and community controls matched for age and sex was examined. Those who had taken aspirin were between two and three times more likely to be admitted to hospital with bleeding ulcers. This increased risk was not accounted for by aspirin taken for indigestion or by concurrent use of non-aspirin, non-steroidal anti-inflammatory drugs. A similar effect was not seen for paracetamol. When aspirin and other non-steroidal anti-inflammatory drugs were considered together the overall risk attributed to the drugs suggested that these drugs may be responsible for over a third of admissions for bleeding peptic ulcers in the elderly.

Five-year experience with mobile adult extracorporeal membrane oxygenation in a tertiary referral center.

INTRODUCTION Mobile extracorporeal membrane oxygenation (ECMO) is reserved for critically unstable patients who may not otherwise survive transfer to the ECMO center. We describe our experience with mobile ECMO. METHODS We retrospectively reviewed adult patients between 2010 and 2014 who were referred for ECMO support and were too unwell for conventional transfer. They were cannulated at their referring center by our team and subsequently transported back to our hospital on ECMO. RESULTS A total of 102 patients were put on ECMO by our team. Of 102 patients, 95 (93%) were managed by venovenous ECMO, and 7 (7%), by venoarterial ECMO. The average distance traveled was 195 miles (SD, ±256.8; range, 3.6-980). Transportation was via road in 77 cases (77%), by air in 22 cases (22%), and in 3 cases (3%) a combination of road and air was used. A double-lumen Avalon cannula was used in 72 patients (70%). One patient had a ventricular tachycardia arrest during cannulation but was successfully resuscitated. There was no mortality or major complications during transfer. CONCLUSION The use of mobile ECMO in adult patients is a safe modality for transfer of critically unwell patients. We have safely used double-lumen cannulas in most of these patients.

Panton-Valentine leukocidin expressing Staphylococcus aureus pneumonia managed with extracorporeal membrane oxygenation: Experience and outcome

Objective:Panton-Valentine leukocidin expressing Staphylococcus aureus pneumonia, an infection that affects predominantly young people, has a mortality rate of >70% despite aggressive conventional management. Little information is available on the management of patients with Panton-Valentine leukocidin expressing S. aureus pneumonia with extracorporeal membrane oxygenation support. As a large extracorporeal membrane oxygenation center, we reviewed our experience and outcomes with Panton-Valentine Leukocidin expressing S. aureus pneumonia. Data Sources:Locally held register of all extracorporeal membrane oxygenation patients at Glenfield Hospital. Study Selection:Retrospective study including all patients with sputum-positive Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation support at a single extracorporeal membrane oxygenation center. Data Synthesis:On review of our database held from September 1989 until date, there were four patients with sputum-confirmed Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation. Refractory hypoxemia and/or uncompensated hypercapnia despite optimal conventional management were the indications for extracorporeal membrane oxygenation. After varying periods on extracorporeal membrane oxygenation with appropriate antibiotic and ancillary care, all four patients were discharged home. Conclusions:Panton-Valentine leukocidin expressing S. aureus pneumonia can cause severe, necrotizing pneumonia associated with acute respiratory distress syndrome, which can be particularly challenging to manage. Extracorporeal membrane oxygenation support permits low pressure lung ventilation, avoiding barotrauma to lungs made friable by Panton-Valentine leukocidin expressing S. aureus infection. Although this is a small number of patients, the results are encouraging.

Pump controlled retrograde trial off from VA-ECMO.

We describe our novel technique of Pump Controlled Retrograde Trial Off that relies on the retrograde flow to maintain circuit integrity and allow a longer trial off from venoarterial extracorporeal membrane oxygenation support without circuit clot formation or significant patient hemodynamic compromise. This technique avoids the insertion of an arteriovenous bridge and the need to clamp the circuit. We present data on five neonatal patients who were trialled off using this method.

The use of extracorporeal membrane oxygenation in neonates with severe congenital diaphragmatic hernia: a 26-year experience from a tertiary centre†.

OBJECTIVES Neonates with severe congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation (ECMO) have a high rate of mortality. There is controversy regarding optimal time of surgical intervention. We present our data over a 26‐year period. METHODS We analysed data from our Extracorporeal Life Support Organization registry forms between 1989 and 2015, in order to determine the factors affecting survival outcome for repair of congenital diaphragmatic hernia with ECMO as a bridge to surgery and/or recovery. RESULTS Ninety‐eight neonates with congenital diaphragmatic hernia requiring ECMO were identified. In‐hospital mortality was 32%. The overall mortality (47.9%) in our study was seen up to 7 months, after this point there was no mortality. There was no difference in survival in patients repaired using pre‐, intra‐ or postoperative ECMO (P = 0.65). Requiring haemofiltration at any point was significantly associated with reduced survival [hazard ratio 2.7 (95% confidence interval 1.5‐4.9); P = 0.01] as was the presence of neurological complications [hazard ratio 3.7 (95% confidence interval 1.6‐8.5); P = 0.003]. Age, Apgar score, mode of delivery, side, associated cardiac comorbidities, pH, partial pressure of carbon dioxide, partial pressure of oxygen, oxygen saturations, bicarbonate, high‐frequency oscillatory ventilation, mode of ECMO, inhaled nitric oxide, pulmonary complications and bleeding were not associated with any survival difference. CONCLUSIONS We believe that all neonates with severe diaphragmatic hernia should be given the option of ECMO if clinically indicated. Provided these patients survive the initial postoperative period, they go on to have a sustained survival benefit. Long‐term cost analysis and morbidity need to be taken into account to determine the true effect of ECMO on congenital diaphragmatic hernia.

Safety and outcomes of mobile ECMO using a bicaval dual-stage venous catheter

There is little published data on the safety and effectiveness of mobile (inter-hospital) extracorporeal membrane oxygenation (ECMO) in adults, particularly focusing on the cannulation strategy. We sought to study the outcomes of patients cannulated with a bicaval dual lumen catheter needing mobile compared with conventional ECMO. Specifically, we evaluated the safety of using this cannulation strategy during initiation, in transport and overall performance. Multivariate adjustment was performed to report on adjusted 6 month survival as well as complications and performance from cannulation and the ECMO run. A total of 170 consecutive patients (44 mobile ECMO, 126 conventional ECMO) with severe hypoxemic respiratory failure were included in our cohort from 2010 to 2014. Improved in-hospital survival and adjusted lower 6 month mortality favored the mobile ECMO group (86% vs. 79%; odds ratio [OR] 0.24 [0.07–0.69]). Performance of ECMO and complications were similar between the two groups. There were no serious ECMO cannulation-related complications reported during cannulation and on transport. We conclude that the use of bicaval dual lumen catheters instituted with fluoroscopy guidance at referral sites is safe and should be considered in mobile ECMO patients. Furthermore, mobile ECMO is associated with an unexpected mortality benefit in severely hypoxemic patients. Further prospective study is needed to elucidate this finding.