Justyna Swol

Conditions and procedures for in-hospital extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR) of adult patients

The use of extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR; ECPR) has been repeatedly published as non-randomized studies, mainly case series and case reports. The aim of this article is to support physicians, perfusionists, nurses and extracorporeal membrane oxygenation (ECMO) specialists who regularly perform ECPR or are willing to start an ECPR program by establishing standards for safe and efficient ECPR procedures. This article represents the experience and recommendations of physicians who provide ECPR routinely. Based on its survival and outcome rates, ECPR can be considered when determining the optimal treatment of patients who require CPR. The successful performance of ECLS cannulation during CPR is a life-saving measure and has been associated with improved outcome (including neurological outcome) after CPR. We summarize the general structure of an ECLS team and describe the cannulation procedure and the approaches for post-resuscitation care. The differences in hospital organizations and their regulations may result in variations of this model.

Neurologic Injury in Adults Supported With Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: Findings From the Extracorporeal Life Support Organization Database

Objectives: To assess in-hospital neurologic (CNS) complications in adult patients undergoing veno-venous extracorporeal membrane oxygenation for respiratory failure. Design: Retrospective analysis of the Extracorporeal Life Support Organization’s data registry. Setting: Data reported to Extracorporeal Life Support Organization from 350 international extracorporeal membrane oxygenation centers during 1992–2015. Patients: Adults (≥ 18 yr old) supported with veno-venous extracorporeal membrane oxygenation for respiratory failure. Interventions: None. Measurements and Main Results: We included 4,988 adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure. Neurologic injury was defined as brain death, seizures, stroke, and intracranial hemorrhage occurring during extracorporeal membrane oxygenation support. We used multivariable logistic regression to explore patient and extracorporeal membrane oxygenation factors associated with neurologic injury. Median age of the study cohort was 46 (interquartile range, 32–58). Four hundred twenty-six neurologic complications were reported in 356 patients (7.1%), and included 181 intracranial hemorrhage (42.5%), 100 brain deaths (23.5%), 85 stroke (19.9%), and 60 seizure events (14.1%). In-hospital mortality was significantly higher for those with CNS complications (75.8% vs 37.8%; p < 0.001) and varied by type of CNS injury; mortality was 79.6% in patients with intracranial hemorrhage, 68.2% in patients with stroke, and 50% in patients with seizures. Pre-extracorporeal membrane oxygenation cardiac arrest, continuous veno-venous hemofiltration, and hyperbilirubinemia during extracorporeal membrane oxygenation were associated with increased odds of neurologic injury. Conclusions: Approximately 7% of adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure had neurologic injury. Intracranial hemorrhage was the most frequent type, and survival for patients with neurologic injury was poor. Future investigations should evaluate anticoagulation management as well as brain/extracorporeal membrane oxygenation interaction to reduce these life-threatening events.

Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) with pulmonary embolism in surgical patients – a case series

Background: Extracorporeal life support (ECLS) devices maintain the circulation and oxygenation of organs during acute right ventricular failure and cardiogenic shock, bypassing the lungs. A pulmonary embolism can cause this life-threatening condition. ECLS is a considerably less invasive treatment than surgical embolectomy. Whether to bridge embolectomy or for a therapeutic purpose, ECLS is used almost exclusively following failure of all other therapeutic options. Methods: From January 1, 2008 to June 30, 2014, five patients in cardiac arrest and with diagnosed pulmonary embolism (PE) were cannulated with the ECLS system. Results: PE was diagnosed using computer tomography scanning or echocardiography. Cardiac arrest was witnessed in the hospital in all cases and CPR (cardiopulmonary resuscitation) was initiated immediately. Cannulation of the femoral vein and femoral artery was always performed under CPR conditions. Right heart failure regressed during the ECLS therapy, usually under a blood flow of 4-5 L/min after 48 hours. Three patients were weaned from ECLS and one patient became an organ donor. Finally, two of the five PE patients treated with ECLS were discharged from inpatient treatment without neurological dysfunction. The duration of ECLS therapy depends on the patient’s condition. Irreversible damage to the organs after hypoxemia limits ECLS treatment and leads to futile multiorgan failure. Hemorrhages after thrombolysis and cerebral dysfunction were further complications. Conclusions: Veno-arterial cannulation for ECLS can be feasibly achieved and should be established during active CPR for cardiac arrest. In the case of PE, the immediate diagnosis and rapid implantation of the system are decisive for therapeutic success.

Veno-venous extracorporeal membrane oxygenation in obese surgical patients with hypercapnic lung failure.

In patients with a body mass index (BMI) > 35 kg/m2, or in extreme cases weighting > 250 kg, we are faced with special challenges in therapy and logistics. The aim was to analyze the feasibility of the extracorporeal membrane oxygenation (ECMO) in these patients.

Use of extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life‐threatening complications in trauma patients. Despite the implantation of a veno‐venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO2 > 90%) is not always achieved. The additive use of high‐frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life‐threatening hypoxaemia and multi‐organ failure.

Infections and Extracorporeal Membrane Oxygenation: Incidence, Therapy, and Outcome.

The objective is to assess the influence of infections and the microbiological spectrum on the general outcome of patients undergoing therapy with extracorporeal devices (ECDs), extracorporeal membrane oxygenation, extracorporeal life support, and pumpless extracorporeal lung assist. We performed a single-center, retrospective analysis of 99 patients receiving ECD. Infections requiring ECD, nosocomial infections occurring during treatment, the use of guideline-based antiinfective therapies, and patient outcomes were described and statistically analyzed. We analyzed 88 patients—survivors and nonsurvivors—and subdivided the infections into primary and nosocomial infections. The median patient age was 54.0 years, 85.2% were men, and 45 (51.1%) survived. Surviving ECD patients had a higher risk of nosocomial infection because of their prolonged hospital stay. Our results indicated that early, focused, antiinfective therapy was important to avoid severe infection complications. Infections causing sepsis and multiorgan dysfunction were negatively associated with outcome and successful weaning of ECD. The percentages and types of pathogens in the ECD cohort did not differ from the general colonization of intensive care units. Because a significant correlation between pathogens, infections, and outcome was not detected, we recommend focusing on clinical parameters to decide whether patients will benefit from ECD support.

The Effects of Propofol and Isoflurane Sedation on the Outcomes of Surgical Patients Receiving Extracorporeal Membrane Oxygenation.

This article resurrects a historical technique using a new technology by describing the results of a retrospective, observational, single-center study that investigated the effects of propofol compared with isoflurane sedation on patient outcomes after extracorporeal membrane oxygenation (ECMO). No differences in patient outcomes were observed between the propofol and isoflurane groups. Nevertheless, the results of this study might improve our understanding of the effects of sedation on patient outcomes after ECMO and provide insight into the effects of spontaneous breathing during ECMO.

Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection.

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.

Fulminant necrotizing fasciitis of the thigh, following an infection of the sacro-iliac joint in an immunosuppressed, young woman

Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient’s history revealed intravenous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.

Extremely obese patients treated with venovenous ECMO—an intensivist’s challenge

Obesity, defined according to bodymass index (BMI N 30 kg/m), is an increasing problem in theworld’s population. The proportion of extremely obese patients (BMI N 40 kg/m) in intensive care units varies between 2.8% and 6.8 %. We report on 2 surgical patients (BMI N 70 kg/m) with postoperative acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO). The first patient developed severe pneumonia with ARDS on the fourth day postsurgical intervention, and venovenous ECMO was performed. At 6-month follow-up after successful weaning from extracorporeal lung support and mechanical ventilation, the patient was well but required noninvasive ventilation. The second patient developed ARDS because of severe sepsis after treatment of necrotizing fasciitis. Extracorporeal lung support took 19 days. A sacral decubitus caused secondary sepsis and resulted in lethal multiorgan failure. These 2 case reports showed that venovenous ECMO represents a challenge for the entire intensive care unitteam and is feasible for extremely obese patients but not always successful. Obesity (bodymass index [BMI] N 30 kg/m) is an increasing problem in the world’s population. In 2014, 26% of adults worldwide were obese [1]. The proportion of extremely obese patients (BMI N 40 kg/m) in intensive care units varies between 2.8% and 6.8% [2–7]. A BMI higher than 40 kg/m seems to be associated with an increased risk of developing acute respiratory distress syndrome (ARDS) along with greater morbidity, length of stay, and duration of mechanical ventilation in the intensive care unit (ICU) [8]. However, extreme obesity is not a risk factor for hospital mortality in patients with acute lung failure and is not a contraindication for venovenous extracorporeal membrane oxygenation (vv ECMO) implantation [9,10].We report on 2 cases of surgically treated patients (BMI N 70 kg/m) with postoperative ARDS and ECMO support. The first patient was a 45-year-old man (180 cm tall, 250 kg, BMI 77 kg/m) with a distal tibial and fibular shaft fracture on the left side and an ankle fracture on the right, which were operatively treated with open reduction and internalfixation. The patient developed severe pneumonia with ARDS on the fourth day of hospitalization. Because of an episode of hypercapnia, intubation and mechanical ventilation were necessary. Hypercapnic lung failure persisted after 24 hours of mechanical ventilation, and vv ECMO was indicated. The cannulation was performed via the right femoral and jugular veins with 23F and 19F cannulae. The CardioHelp HLS (Maquet, Raststatt, Germany) was used. Recovery was prolonged by 2 episodes of intestinal bleeding, which were treated successfully with endoscopic clipping. The patient ☆ Conflict of interest: None http://dx.doi.org/10.1016/j.ajem.2015.03.065 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Ull C, et al, Extremely obese patients treated with challenge, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015 was able to be weaned off the respirator. Six months after his discharge from the hospital, hewaswell but still required noninvasive ventilation. The second patient was a 34-year-old man (180 cm tall, 287 kg, BMI 88.6 kg/m) with necrotizing fasciitis on his lower left limb, which was surgically treated with extensive debridement. The patient required hemofiltration because of acute kidney failure. Furthermore, he developed ARDS as a result of severe sepsis. Severe hypoxemia and hypercapnia occurred, and vv ECMO was indicated. The cannulation was performed via the right femoral and jugular veinswith 23F and 21F cannulae. Extracorporeal membrane oxygenation was removed 19 days after implantation. Oxygenation significantly improved, and the patient wasweaned off the respirator. A sacral decubitus caused secondary sepsis and resulted in lethal multiorgan failure. The treatment of extremely obese patients with vv ECMOposes a special challenge for intensivists. Radiological diagnostics are limited because tables have weight restrictions of 200 kg. It makes the use of a doublelumen cannulation not available. Percutaneous cannulation venovenous femoral-jugular is associated with several pitfalls: anatomical landmarks are difficult tofind, the blood vessels cannot be visualized sonographically, and at least 4 people from the ICU team help for patient positioning. Both patients were successfully weaned from ECMO and later from invasive ventilation. These case reports showed that extracorporeal lung support is a feasible treatment option for extremely obese patients with ARDS, a finding that was previously described [9,10]. After weaning from ECMO, 1 patient required noninvasive ventilation support; the other died of multiorgan failure due to secondary sepsis. It also demonstrated as well how difficult it is to make accurate predictions about the outcome of ECMO in patients with extreme obesity. Several studies tried to determine the risk factors associated with ECMO treatment. In an analysis of preoperative risk factors in cardiac ECMO, Wagner et al [11] showed a positive association between preoperative SvO2 and survival. Later, they [12] found that poor renal function before ECMO resulted in a higher mortality rate for patients with pulmonary failure. This association was seen in the second patient, who required hemofiltration because of acute kidney failure. Another study revealed a lowermortality rate in younger and nondiabetic patients who experienced cardiogenic shock [13]. Formica et al [14] identified a high blood lactate level (N3mmol/L) at 48 hours as a significant predictor of 30-day hospital mortality for patients with cardiogenic shock. A higher survival rate of younger patients and those with a normal blood lactate level after 24 hours of ECMO treatment was confirmed by Pham et al [15] in a study with 123 adults with ARDS caused by influenza A (H1N1). Those risk factors could not be found in either of the patients. The study by Rastan et al [16] was the only trial that identified obesity as a risk factor for hospital mortality in adult patients treated with ECMO for refractory postcardiotomy cardiogenic shock. venovenous extracorporeal membrane oxygenation—an intensivist’s .03.065 2 C. Ull et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx This case report supports the findings of previous studies in this regard that treatmentwith vv ECMO in extremely obese patients presents special challenges for the entire ICU team. Extreme obesity should not be seen as a contraindication for ECMO treatment, but the procedure should be performed by experienced hands.