Harrison T. Pitcher

Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography.

BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been used for profound cardiogenic shock to bridge to decision, ventricular assist device(s) (VADs), or transplant. To assess ventricular function and volume status along with hemodynamics during ECMO weaning, we developed a standardized weaning protocol, guided by a miniaturized transesophageal echocardiography probe designed for continuous hemodynamic monitoring (hemodynamic transesophageal echocardiography [hTEE]). We reviewed our experience with this weaning protocol with hTEE guidance to assess if we could predict patient outcomes. METHODS During the academic year of 2011, hTEE-guided ECMO weaning was performed in 21 patients on VA ECMO. Left and right ventricular function and volume status were assessed by continuous hTEE, while attempting to wean ECMO after a standardized protocol. The clinical outcomes, management, and positive predictive value of the device were investigated and analyzed for this cohort of patients. RESULTS Of the 21 patients, 6 (29%) had left and right ventricular recovery and underwent optimal medical therapy or revascularization for underlying coronary artery disease; 7 (33%) had nonrecoverable left and right ventricular function; and 8 (38%) had right ventricular recovery without improvement of the left ventricular function. These 8 patients underwent left VAD placement; none subsequently developed profound right ventricular failure. The positive predictive value for ventricular recovery by hTEE was 100% using our standardized ECMO weaning protocol (95% confidence interval, 73%-100%). CONCLUSIONS The hTEE-guided ECMO weaning protocol accurately predicted the ability to wean ECMO to decision. This protocol can be applied by cardiac intensivists as a part of standard bedside intensive care unit assessment.

Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure.

Background: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. Methods: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. Results: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. There were no instances of dehiscence, infection or sepsis related to interventions. Anticoagulation was stopped six hours before and restarted 24 hours after major interventions, with no thrombotic or neurologic complications. All patients weaned off ECMO were discharged. Conclusions: ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in this high-risk population.

Perioperative use of the imacor hemodynamic transesophageal echocardiography probe in cardiac surgery patients: initial experience.

Echocardiography is the standard to assess heart function although obtaining transesophageal echocardiography (TEE) on an emergent basis may be limited by its availability. A transoral miniaturized hemodynamic TEE (hTEE) probe (ImaCor Inc.) was developed to provide direct visualization of the heart, and we hypothesized that the probe could provide hemodynamic information useful for patient management. Data from 2011 to 2012 was retrospectively collected. Four hundred ninety patients were treated in the cardiovascular intensive care unit of which 61 underwent hTEE monitoring and were divided into three groups: patients on extracorporeal membrane oxygenation (ECMO) (n = 25), ventricular assist device (VAD) (n = 6), and others (n = 30). Patient charts were reviewed to investigate the indications for the use of hTEE, findings, and the interventions performed. The indications for probe insertion were hemodynamic instability (n = 32), ECMO weaning (n = 10), VAD alarm (n = 1), tamponade (n = 14), pulmonary embolism (n = 2), and intra-aortic balloon pump wean (n = 2). In all 61 cases, we were successfully able to diagnose and treat the etiology of instability based on the hTEE findings. Utilization of the hTEE probe successfully diagnosed and aided therapy in all patients with hemodynamic instability refractory to initial therapy and provides a valuable tool to aid clinicians in the management of postoperative hemodynamics.

Can procalcitonin differentiate infection from systemic inflammatory reaction in patients on extracorporeal membrane oxygenation

Anne Keogh, Eugene Kotlyar, Emily Granger and Phillip Spratt in the care of these patients and for allowing the study to be performed. C.S.H. has received research funding and travel support unrelated to the current project from HeartWare, Inc. None of the other authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

Feasibility of diagnosis of postcardiotomy tamponade by miniaturized transesophageal echocardiography

BACKGROUND Pericardial tamponade after cardiac surgery is a critical diagnosis that can be difficult to diagnose using conventional cardiac monitoring. Transesophageal echocardiography can provide comprehensive information to make the diagnosis but is not always available, whereas transthoracic echocardiography has its utility limited because of the body habitus or other surgical effects. New monitoring devices, miniaturized hemodynamic transesophageal echocardiography (hTEE), which allows point of care assessment of cardiac filling and functions, may aid in diagnosis of postcardiotomy tamponade. METHODS From May 2011 to July 2013, 21 patients underwent hTEE to rule out pericardial tamponade for clinical suspicion of tamponade after open heart surgery. The hTEE images were reviewed, and the patient outcomes were analyzed. RESULTS Nine patients showed no evidence of pericardial collection and did not require reexploration. Two patients showed a presence of small hematoma without ventricular compression and also did not undergo exploration. Ten patients were positive for pericardial tamponade (effusion or hematoma with ventricular compression); eight of these cases underwent emergent surgical exploration. Of the two patients who did not undergo immediate reoperation, one was managed by chest tube manipulation and the other patient underwent subsequent surgical exploration after his extensive coagulopathy was corrected by medical treatment. CONCLUSIONS The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE based on our limited experience. We avoided unnecessary explorations while concomitantly made prompt diagnosis in emergent situations. The hTEE device was a valuable tool in hemodynamic management in the intensive care unit, allowing rapid evaluations.

Vascular site hemostasis in percutaneous extracorporeal membrane oxygenation therapy.

Bleeding is a well described complication of percutaneous extracorporeal membrane oxygenation support (ECMO). In an effort to prevent ongoing percutaneous-cannula blood loss, we tried multiple methods to achieve hemostasis and obtained the best results with QuikClot ® Combat Gauze TM (Z-Medica Corp, Wallingford, CT). This product is made of kaolin, white alumina silicate clay, which initiates activation of the intrinsic clotting cascade. We reviewed our experience in 21 ECMO patients and found 5 patients who required 17 applications of QuikClot ® Combat Gauze TM to percutaneous catheter insertion sites and demonstrated a significant reduction in both localized bleeding complications and the need for blood transfusion. QuikClot Combat Gauze TM , used for the dual purpose of a dressing and hemostatic agent, is a simple valuable method to control pericatheter bleeding in the ECMO population with demonstrated cost savings and clinical utility.

Adult extracorporeal membrane oxygenation and gastrointestinal bleeding from small bowel arteriovenous malformations: A novel treatment using spiral enteroscopy

Hemorrhagic complications on extracorporeal membrane oxygenation (ECMO) are common because of the need for anticoagulation to maintain the oxygenator and circuitry. Gastrointestinal (GI) bleeding is reported to occur in 3% to 6% of patients receiving ECMO, requiring frequent transfusions and multiple diagnostic and therapeutic interventions. Multiple transfusions can result in volume overload, coagulopathies, and infections leading to significant morbidity and mortality. We present the first published case of GI bleeding from an arteriovenous malformation (AVM) treated with a novel therapy termed ‘‘spiral enteroscopy’’ while the patient remained on venoarterial ECMO.

Recurrent orthostatic syncope due to left atrial and left ventricular collapse after a continuous-flow left ventricular assist device implantation

Left ventricular assist devices (LVADs) have become an established treatment for patients with advanced heart failure as a bridge to transplantation or for permanent support as an alternative to heart transplantation. Continuous-flow LVADs have been shown to improve outcomes, including survival, and reduce device failure compared with pulsatile devices. Although LVADs have been shown to be a good option for patients with end-stage heart failure, unanticipated complications may occur. We describe dynamic left atrial and left ventricular chamber collapse related to postural changes in a patient with a recent continuous-flow LVAD implantation.

Extracorporeal Membrane Oxygenation Management: Techniques to Liberate from Extracorporeal Membrane Oxygenation and Manage Post–Intensive Care Unit Issues

Extracorporeal membrane oxygenation (ECMO) is a life-saving technique when patients require pulmonary and/or cardiac support for days to weeks for recovery, bridge to decision, or transplantation. Due to complications associated with ECMO, it is best to stay on ECMO as little time as necessary. Foremost is weaning from ECMO, but the post-ECMO period recapitulates the entire field of critical care. Identified issues include (1) potential for systemic inflammatory response syndrome post-decannulation; (2) post-ECMO complications, such as deep vein thrombosis, wounds, renal failure, and stroke; (3) delirium; (4) posttraumatic stress disorder; (5) rehabilitation; and (6) end of life.

Issues in the Intensive Care Unit for Patients with Extracorporeal Membrane Oxygenation

The care of patients on extracorporeal corporeal oxygenation support takes a coordinated effort among the team of nurses, midlevel providers, perfusionists, respiratory therapists, pharmacists, and physicians. Attention on the details of the circuitry and its interactions with the patient, the resolution of the disease process and the ongoing plan of care, and unique issues in the intensive care unit are crucial for success.