Joseph E. Tonna

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

Esophageal verrucous carcinoma arising from hyperkeratotic plaques associated with human papilloma virus type 51

Esophageal verrucous carcinoma is a rare variant of esophageal squamous cell carcinoma. We report a case of esophageal verrucous carcinoma associated with human papilloma virus (HPV) type 51. The patient had long-standing dysphagia and odynophagia, and white esophageal plaques showing hyperkeratosis on biopsy. At repeat endoscopy, the esophagus was covered with verrucous white plaques and areas of nodular mucosa with white fronds, with a distal 10-cm smooth mass protruding into the lumen. Biopsies demonstrated an atypical squamoproliferative lesion but no frank malignancy. HPV type 51 DNA was detected in endoscopic biopsy specimens by polymerase chain reaction. Because the size of the lesion favored an underlying verrucous carcinoma, our patient underwent minimally invasive esophagectomy with gastric pull-up and cervical anastomosis. The pathologic diagnosis was a well-differentiated esophageal verrucous carcinoma. One year after esophagectomy, the patient feels well and is free of disease. Although HPV DNA was not detected in the cancer tissue obtained at surgery, our case suggests an association between HPV type 51 and esophageal verrucous carcinoma. The clinical evolution in this case highlights the importance of endoscopic surveillance in patients with exuberant esophageal hyperkeratosis, and of definitive surgical resection when malignancy is suspected even if frank malignancy is not demonstrated on superficial biopsies.

A case and review of noma.

History and Epidemiology Historically, noma is a disease of extreme poverty and malnourishment, reported throughout history in Asia, Europe, South America, and Africa [1,3,4]. It was described by Hippocrates [5] and found in German and Japanese concentration camps during World War II [1,6]. Infection occurs mostly in children, although it has been described in neonates, adults, and the chronically ill [3,7]. The true prevalence and incidence of noma are not fully known, because it is believed that only ,15% of patients with acute cases of the disease seek medical care [1,8]. Noma is a disease of shame, and the condition often results in forced isolation from the community and family; many children are sent to live in isolation rather than being taken to medical care [1,8–10]. In the late 1990s, the incidence of acute childhood noma was placed at 25,600 in countries bordering the Sahara [11], and worldwide at between 100,000 and 140,000 per year, primarily in sub-Saharan Africa and Asia [12]. Peak incidence is among children aged 1–4 [3,4,7]. Worldwide prevalence of those living with the sequelae of noma was placed at 770,000 in 1997 [8].

Emergency physician–performed transesophageal echocardiography for extracorporeal life support vascular cannula placement☆

INTRODUCTION There is growing interest and application of extracorporeal membrane oxygenation (ECMO) as a life-saving procedure for out-of-hospital cardiac arrest (OHCA), also called extracorporeal life support (ECLS). Extracorporeal membrane oxygenation cannulation with ongoing chest compressions is challenging, and transesophageal echocardiography (TEE) is an invaluable tool with which to guide ECMO wire guidance and cannula positioning. METHODS We describe our protocol for TEE guidance by emergency physicians in our hospital. RESULTS Of our first 12 cases of ECLS, 10 have had TEE guidance by an emergency physician with successful placement and without complication or need for repositioning. Emergency physician-performed TEE for ECLS vascular cannula placement has been both feasible and useful in our experience and warrants further study.

Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program

&NA; Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out‐of‐hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra‐arrest extracorporeal life support, including to out‐of‐hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out‐of‐hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.

Value-driven cardiac surgery: Achieving “perfect care” after coronary artery bypass grafting

Objective The objective of this study was to determine if the implementation of a value‐driven outcomes tool comprising modifiable quality and utilization metrics lowers cost and improves value of coronary artery bypass grafting (CABG) postoperative care. Methods Ten metrics were defined for CABG patients in 2 temporally separated phases. Clinical care protocols were designed and implemented to increase compliance with these metrics. Clinical outcomes and cost data were harvested from the electronic medical record using a proprietary value‐driven outcomes tool and verified by a data management team. “Perfect care” was defined as achieving all 10 metrics per patient episode. Results Over a 45‐month period, data of 467 consecutive patients who underwent isolated CABG were analyzed. “Perfect care” was successfully achieved in 304 patients (65.1%). There were no observed differences in mortality between patient groups. Linear regression analysis showed a negative correlation between percent compliance with “perfect care” and mean cost. When multivariate analysis was used to adjust for preoperative risk score, mean cost for patients with “perfect care” was 37.0% less than for those without “perfect care.” Conclusions In the context of focused institution‐specific interventions to target quality and utilization metrics for CABG care, clinical care pathways and protocols informed by innovative tools that link automated tracking of these metrics to cost data might simultaneously promote quality and decrease costs, thereby enhancing value. This descriptive study provides preliminary support for a systematic approach to define, measure, and modulate the drivers of value for cardiothoracic surgery patients.

Awake Laryngoscopy in the Emergency Department

BACKGROUND Many emergency physicians gain familiarity with the laryngeal anatomy only during the brief view achieved during rapid sequence induction and intubation. Awake laryngoscopy in the emergency department (ED) is an important and clinically underutilized procedure. DISCUSSION Providing benefit to the emergency physician through a slow, controlled, and deliberate examination of the airway, awake laryngoscopy facilitates confidence in the high-risk airway and eases the evolution to intubation, should it be required. Emergency physicians possess all the tools and skills required to effectively perform this procedure, through either the flexible endoscopic or rigid approaches. The procedure can be conducted utilizing local anesthesia with or without mild sedation, such that patients protect their airway. CONCLUSION We discuss two clinical scenarios, indications/contraindications, patient selection, and steps to performing two approaches to awake laryngoscopy in the ED.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

Purpose: Studies suggest that “on‐demand” radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied. Materials and methods: This was a quasi‐experimental, pre‐post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on‐demand basis at one time point, without controlling or monitoring behavior or providing follow‐up. Results: A total of 11,994 patient days over 18 months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11–19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0–5), duration (hours) of MV: 21.7 (IQR: 9.8–81.4) and ICU LOS (days): 2.8 (IQR: 1.8–5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89–0.96), and 0.73 (95% CI: 0.69–0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p < 0.001), then increased by about 3%/month (p = 0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re‐intubations, ICU LOS. Conclusions: In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study. HighlightsDaily chest radiography in the ICU is commonly done, despite lack of benefit.On demand radiography can be achieved pragmatically.Pragmatic intervention of on demand radiography does not adversely affect patients.

251: ANTICOAGULATION LEVELS AND BLEEDING AFTER EMERGENCY EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) in neonates and children. It is not without significant complications however, such as risk of hemorrhage. Red cell transfusions has also been independently associated with increased mortality in ECMO patients. Our hospital introduced a formal ECMO program in 2012, with guidelines on blood component transfusions. We aim to describe our transfusion practices since the program’s inception, and test the hypothesis that blood component transfusions were associated with ECMO mortality. Methods: Charts and records of all patients who underwent ECMO between January 2012 and December 2014 were reviewed. Relevant demographic data, ECMO variables and blood component volumes used were collected. Outcomes measured were ECMO and ICU survival. We analyzed categorical and continuous variables with Fisher’s exact and Wilcoxon rank-sum tests respectively. Statistical significance was taken as p < 0.05. Results: Twenty-seven ECMO runs were available for analysis. The median age was 17 months. The median duration of ECLS was 8 days and the main modality was veno-arterial. Successful de-cannulation occurred in 17 runs (63.0%), and overall ICU survival was 44.4% (12/27). Median transfusion requirements for red cells (RBC), fresh frozen plasma (FFP) and platelets were: 7.6 (4.2, 17.1), 5.9 (1.3, 9.6) and 8.0 (5.0, 11.9) ml/kg/day respectively. There was no statistical difference in hemorrhagic complications in survivors and non-survivors. RBC, FFP and platelet requirements were statistically different in survivors and non-survivors respectively [RBC: 6(3.5, 11.6) vs 15.4(7.9, 25.6) ml/kg/day, p < 0.01; FFP: 2.9(1, 6.8) vs 8.9(5.9, 18.1) ml/kg/day, p = 0.01; platelets: 6.3(4.5, 8.9) vs 12.3(8, 16.0) ml/kg/day, p < 0.01]. There was no association between duration of ECMO and volume of blood components transfused. Conclusions: While our instutition’s blood component transfusion volumes are lower than reported internationally, it is significantly associated with ECMO mortality.