Josh Malo

Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: History, current applications, and future directions

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.

Critical care ultrasound training: A survey of US fellowship directors

PURPOSE The purpose of this study is to describe the current state of bedside ultrasound use and training among critical care (CC) training programs in the United States. MATERIALS AND METHODS This was a cross-sectional survey of all program directors for Accreditation Council for Graduate Medical Education accredited programs during the 2012 to 2013 academic year in CC medicine, surgical CC, pulmonary and critical care, and anesthesia CC. Availability, current use, and barriers to training in CC ultrasound were assessed. RESULTS Sixty of 195 (31%; 95% confidence interval [CI], 24%-38%) program directors responded. Most of the responding programs had an ultrasound system available for use (54/60, 90%; 95% CI, 79%-96%) and identified ultrasound training as useful (59/60, 98%; 95% CI, 91%-100%) but lacked a formal curriculum (25/60, 42%; 95% CI, 29%-55%) or trained faculty (mean percentage of faculty trained in ultrasound: pulmonary and critical care, 25%; surgical CC, 33%; anesthesia CC, 20%; CC medicine, 7%), and relied on informal teaching (45/60, 77%; 95% CI, 62%-85%). Faculty with expertise (53/60, 88%; 95% CI, 77%-95%), simulation training (60/60, 100%; 95% CI, 94%-100%), establishing and meeting required number of examinations (47/60, 78%; 95% CI, 66%-88%), and regular review sessions (49/60, 82%; 95% CI, 70%-90%) were identified as necessary to improve ultrasound training. Most responding programs (32/35 91%; 95% CI, 77%-98%) without a formal curriculum plan to create one in the next 5 years. CONCLUSIONS This study identified deficiencies in current training, suggesting a need for a formal curriculum for bedside ultrasound training in CC fellowship programs.

Neuromuscular Blockade Improves First-Attempt Success for Intubation in the Intensive Care Unit. A Propensity Matched Analysis

RATIONALE The use of neuromuscular blocking agents (NMBAs) has been shown to be valuable in improving successful tracheal intubation in the operating room and emergency department. However, data on NMBA use in critically ill intensive care unit (ICU) patients are lacking. Furthermore, there are no data on NMBA use with video laryngoscopy. OBJECTIVES To evaluate the effect of NMBA use on first-attempt success (FAS) with tracheal intubation in the ICU. METHODS Single-center observational study of 709 consecutive patients intubated in the medical ICU of a university medical center from January 1, 2012 to June 30, 2014. Data were collected prospectively through a continuous quality improvement program on all patients intubated in the ICU over the study period. Data relating to patient demographics, intubation, and complications were analyzed. We used propensity score (propensity to use an NMBA) matching to generate 5,000 data sets of cases (failed first intubation attempts) matched to controls (successful first attempts) and conditional logistic regression to analyze the results. MEASUREMENTS AND MAIN RESULTS There were no significant differences in patient demographics, except median total difficult airway characteristics were higher in the non-NMBA group (2 vs. 1, P < 0.001). There were significant differences in the sedative used between groups and the operator level of training. More patients who were given NMBAs received etomidate (83 vs. 35%) and more patients in the non-NMBA group received ketamine (39 vs. 9%) (P < 0.001). The FAS for NMBA use was 80.9% (401/496) compared with 69.6% (117/168) for non-NMBA use (P = 0.003). The summary odds ratio for FAS when an NMBA was used from the propensity matched analyses was 2.37 (95% confidence interval, 1.36-4.88). In the subgroup of patients intubated with a video laryngoscope, propensity-adjusted odds of FAS with the use of an NMBA was 2.50 (1.43-4.37; P < 0.001). There were no differences in procedurally related complications between groups. CONCLUSIONS After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of FAS at intubation in the ICU with the use of an NMBA. This improvement in FAS is seen even with the use of a video laryngoscope.

Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis

RATIONALE Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited. OBJECTIVES To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit. METHODS We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding. MEASUREMENTS AND MAIN RESULTS A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008). CONCLUSIONS Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit

Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first‐attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single‐center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first‐attempt failures and first‐attempt successes. First‐attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7‐27.0% vs. 13.3%; 95% CI, 8.0‐18.8%). In logistic regression analysis of the entire 906‐patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64‐4.20), airway edema (OR, 2.85; 95% CI, 1.48‐5.45), and obesity (OR, 1.59; 95% CI, 1.08‐2.32) were significantly associated with first‐attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60‐4.64), cervical immobility (OR, 3.34; 95% CI, 1.28‐8.72), and airway edema (OR, 3.10; 95% CI, 1.42‐6.70) were associated with first‐attempt failure. Conclusions: In this single‐center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first‐attempt failure, when intubation was performed with video laryngoscopy in an ICU.

154: REASON FOR FAILED ATTEMPTS AT LARYNGOSCOPY DIFFERS BETWEEN VIDEO AND DIRECT LARYNGOSCOPES

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) at initiation of ECMO and PELOD score at initiation of ECMO, revealed that a state of fluid overload during the entire ECMO run increased the odds of death during ECMO therapy (OR=8.5, p = 0.04). Conclusions: A state of fluid overload during ECMO therapy increased mortality while on ECMO. Efforts should be taken to minimize a patient’s net fluid balance while receiving ECMO therapy.

1061: DURATION OF MECHANICAL VENTILATION AND PATIENT OUTCOMES FOR EXTRACORPOREAL MEMBRANE OXYGENATION

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: For patients with severe acute respiratory distress syndrome (ARDS), venovenous extracorporeal membrane oxygenation (VV-ECMO) is sometimes used to support oxygenation and allow time for lung rest. However, duration of pre-ECMO mechanical ventilation has been associated with increased mortality for patients who receive VV-ECMO and as such, prolonged mechanical ventilation has been suggested as a relative contraindication for VV-ECMO support. This study was conducted to examine the relationship between duration of preECMO mechanical ventilation and mortality for patients who received VV-ECMO therapy for ARDS. Methods: A retrospective, observational study of adult patients admitted to the ICU at an academic medical center for VV-ECMO between January 01, 2015 and July 1, 2017. Demographics, comorbidities, lab values and ventilator settings were extracted from the medical record along with outcomes such as length of stay and in-hospital mortality. Patients cannulated for ECMO more than 7 days after the initiation of mechanical ventilation were classified as the late initiation group. Results: A total of 23 patients were treated with VV-ECMO therapy during the study period. Of these, eight underwent late initiation (median ventilator days 14.5 days, IQR 10–20.5), and 15 were early initiation (median 2.0 days, IQR 0–4.0, p < 0.01). There was no difference between groups in survival to discharge (50% vs 67%, p = 0.66) however cases in which ECMO was initiated later were associated with longer duration of ECMO (median 40.5 (IQR 15.5–55.5) vs 9 days (IQR 4.012.0), p < 0.01), total duration of mechanical ventilation (median 58.5 (IQR 53.5–72.0) vs 20 days (IQR 6.0–27.0), p < 0.01), and hospital length of stay (61.5 (IQR 55.0–74.5) vs 35 days (IQR 30.0-46.0), p < 0.01). Conclusions: These data suggest that late initiation of VV-ECMO for ARDS is associated with longer duration of recovery but a similar mortality as patients initiated early. Thus the relative contraindication should be reconsidered, and a prospective study is needed to delineate which patients stand to benefit from VVECMO therapy for ARDS.

1097: EVALUATION OF THE RESP SCORE FOR SURVIVAL PREDICTION IN VENOVENOUS ECMO

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Checklists are simple and effective measures with the potential to reduce errors having a cumulative effect amid dynamic medical environment. However, adoption of checklist in hospital settings is sub-optimal. Various factors like perceived workload and effectiveness contribute to poor compliance. The objective of this study was to identify the effect of a pager alert to the provider on checklist use and compliance. Methods: Single center, retrospective observational study of providers’ use of checklist in a mixed ICU in an academic tertiary care center in Rochester over a period of 8 months. Providers were encouraged to complete a daily rounding checklist for all patients in the ICU using a dashboard accessible on all PCs. In order to enhance compliance, a pager alert was sent to providers for patients identified as high risk using an algorithm calculating prediction scores(APPROVE) for prolonged respiratory failure or death. We compared the checklist compliance rates pre and postimplementation of the pager alert. Results: The unit had a total of 1806 cases during the period (927 pre/879 post.) of which 1114 (492 pre/622 post.) checklists were completed. 45% (419/927) and 33% (288/879) cases during the pre and post period were identified as high risk. The unit compliance changed from 53% (492/927) to 71% (622/879) (p < 0.001). Checklist completion for high risk pool changed from 25% (104/419) to 78% (222/288)(p < 0.001) after the intervention. Checklist compliance for low risk decreased from 76% (388/508) to 68% (400/591)(p = 0.001) Conclusions: A pager alert system introduction was associated with improved checklist completion for high risk patients admitted to the ICU while the checklist compliance for low risk patients decreased. Though simple by design, completion of a checklist is hindered primarily by time restriction during patient care. Sending a pager alert reminder to the providers for high risk cases can be a useful method to help providers identify the cases and use a checklist to improve outcomes.

174: FIRST ATTEMPT SUCCESS AT INTUBATION IS ASSOCIATED WITH A LOWER ODDS OF ADVERSE EVENTS IN THE ICU.

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) and acetaminophen were the most common offending drugs causing bradycardia (propofol 32.1% and fentanyl 12.5%) and increased aspartate transaminase (acetaminophen 5.8%). Of the probable/definite ADRs, fentanyl, insulin, and dextrose were the most common offending drugs causing hyperglycemia (fentanyl 24.6% and dextrose 4.3%) and hypokalemia (insulin 18.8%). Conclusions: ADRs in patients undergoing TH after cardiac arrest are common. Select agents should be used judiciously and monitored closely in this setting as a result of the possibility of ADRs.