James K. Wu Md

Triple setup airway—simultaneous oropharyngeal, surgical, and ECMO preparation

Extracorporeal membrane oxygenation is increasingly used in the intensive care unit for refractory cardiopulmonary diseases [1]. There has been little application at this time of its use in the emergency department (ED) and none for its use in high-risk airways. We present a case of a patient with supraglottitis and large parapharyngeal abscesses causing an unstable airway that would be difficult to manage with traditional “double setup” (oropharyngeal and surgical) methodology. We highlight the potential use of extracorporeal membrane oxygenation in the management of her airway. Extracorporeal membrane oxygenation (ECMO) is used in intensive care medicine for treating refractory cardiopulmonary diseases. While traditionally, ECMO has been used to support patients suffering from ARDS, there has been increased interest in exploring the use of EMO for various diseases [1,2]. For instance, the use of ECMO as a bridge to treatment and recovery in cardiac arrest has been studied [1,3,4]. Additionally, reports have appeared in the literature concerning the use of ECMO in severe accidental hypothermia [5,6]. There are few documented reports of ECMObeing used for difficult airways and none specifically in the ED [7–9]. We report a case of ECMO as a management option in the ED for a woman with extensive parapharyngeal abscesses. A 58-year-old woman with a history of GERD presented to the ED complaining of throat pain. She had previously been seen at an urgent care facility three days prior, and diagnosed with viral pharyngitis. Her symptoms worsened, which prompted her ED visit. On arrival, she complained of fevers, chest tightness, neck swelling and dysphagia. Initial vitals included blood pressure, 106/58 mmHg; pulse, 77 beats/minute; temperature, 96.7°F; respirations, 14; and oxygen saturation, 100%. The patient was awake and alert. She had mild pharyngeal erythema, a midline uvula and no obvious peritonsillar swelling or abscess. Remarkable blood chemistries measured: WBCs, 19.2 (4-10.0 thou/cmm) with left shift; and creatinine, 1.32 (0.53-1.20 mg/dL). A CT of the patients neck with contrast showed extensive supraglottic edema with narrowing of the airway at the level of the false vocal cords (Figs. 1,2). In addition, there were multiple abscesses in the neck with extension into the retropharynx and mediastinum. She was treated with broad-spectrum antibiotics and steroids. Definitive surgical care was anticipated to be difficult. While the patient was not in acute airway obstruction at that time, the rapid progression of this disease raised the possibility of an imminent airway collapse. ☆ The authors have no outside support information, conflicts or financial interest to

Durability, Reliability, Viability: 48 Year-survival of a Starr–Edwards Mitral Valve

We report a case of 67 year-old female with a 48-year survival of a Starr-Edwards valve at mitral position. The patient underwent Starr-Edwards mitral valve replacement at age of 19 years for mitral stenosis secondary to severe rheumatic valve disease. The patient had experienced a progressive decline in her functional status with increasing dyspnoea on exertion over a two-week period to eventual development of severe shortness of breath at rest prior to hospitalisation. Transoesophageal echocardiogram revealed severe para-prosthetic and intravalvular mitral valve regurgitation. The patient underwent explantation of Starr-Edwards valve and replacement with a mechanical prosthesis. Our case details the longest reported survival of a Starr-Edwards prosthetic valve at mitral area.

Incidence of nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation

INTRODUCTION Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for developing nosocomial infections owing to their underlying disease process along with numerous invasive monitoring devices. METHODS We retrospectively analyzed the rate, type, pathogens, outcomes, and risk factors of nosocomial infections that developed during adult patients on ECMO at our institution from 2012-2015. RESULTS Compared to current ELSO reported adult nosocomial infections rate of 20.5%, we report our rate of 26% (CI 17.2%-34.7%). No significant differences were observed in mortality (42.3% vs. 36.5%; p=0.598), and presence of either antibiotics prior to ECMO (57.7% vs. 56.7%; p=0.934) or culture-proven infection prior to ECMO (19.2% vs. 32.4%; p=0.201). Patients who developed nosocomial infections had longer duration of ECMO (13 vs. 5 days; p<0.001), longer length of stay (36.5 vs. 18.5 days; p=0.004), and more days on ventilator (29 vs. 12.5; p=0.002). Duration of ECMO (OR=1.20, 95% CI 1.02-1.39; p=0.020) and duration of ECMO greater than 10 days (OR=14.65, 95% CI 1.81-118.78; p=0.012) were independent risk factors for developing nosocomial infections. However, there was no difference in mortality when duration of ECMO >10 days was compared with ≤10 days (28.5% vs. 43.1%; p=0.154). CONCLUSION Nosocomial infections have no effect on survival in adult ECMO patients. Presence of either antibiotics or infection prior to ECMO has no effect on developing nosocomial infections while on ECMO. Duration of ECMO longer than 10 days is a major risk factor for developing nosocomial infection.

Extracorporeal Membrane Oxygenation (ECMO) for Hypothermic Cardiac Deterioration: A Case Series

Accidental hypothermia can lead to untoward cardiac manifestations and arrest. This report presents a case series of severe accidental hypothermia with cardiac complications in three emergency patients who were treated with extracorporeal membrane oxygenation (ECMO) and survived after re-warming. The aim of this discussion was to encourage more clinicians to consider ECMO as a re-warming therapy for severe hypothermia with circulatory collapse and to prompt discussion about decreasing the barriers to its use. Niehaus MT , Pechulis RM , Wu JK , Frei S , Hong JJ , Sandhu RS , Greenberg MR . Extracorporeal membrane oxygenation (ECMO) for hypothermic cardiac deterioration: a case series. Prehosp Disaster Med. 2016;31(5):570-571.