Michael S. Firstenberg

Central line complications.

Central venous access is a common procedure performed in many clinical settings for a variety of indications. Central lines are not without risk, and there are a multitude of complications that are associated with their placement. Complications can present in an immediate or delayed fashion and vary based on type of central venous access. Significant morbidity and mortality can result from complications related to central venous access. These complications can cause a significant healthcare burden in cost, hospital days, and patient quality of life. Advances in imaging, access technique, and medical devices have reduced and altered the types of complications encountered in clinical practice; but most complications still center around vascular injury, infection, and misplacement. Recognition and management of central line complications is important when caring for patients with vascular access, but prevention is the ultimate goal. This article discusses common and rare complications associated with central venous access, as well as techniques to recognize, manage, and prevent complications.

Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies

BackgroundFollowing the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently “rescue” a significant proportion of those affected.DiscussionHere we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices.SummarySince the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.

Neurologic complications in patients receiving extracorporeal membrane oxygenation for influenza H1N1: Morbid but not futile

Objectives: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for severe acute cardiac and respiratory distress. Management of complications, such as embolic strokes and intracranial hemorrhage, is essential during such treatment. However, the incidences of these complications as well as clinical outcomes have not been previously examined within a population with a homogenous disease process. Methods: Using de-identified clinical data submitted to the Extracorporeal Life Support Organization, we analyzed cases in which patients were treated with ECMO during the 2009 H1N1 pandemic. This data were examined with a specific focus on neurologic complications. Results: Twenty-two of the 248 patients experienced a confirmed neurological event. Patients with neurologic events were older, more acidotic, and had a higher prior incidence of cardiopulmonary arrest before ECMO therapy. There was also showed an increased incidence of cardiac arrhythmia, hyperbilirubinemia, and severe leukopenia as well as lower rates of successful weaning from ECMO and survival to discharge. Overall, within the patient population treated with ECMO, neurologic complications are not uncommon, and such patients exhibit greater morbidity and mortality. Conclusions: Thus, aggressive neurological assessment before and during ECMO could prove very useful in guiding clinical decisions with respect to further or ongoing therapies. The findings from this study will hopefully improve patient selection for ECMO therapy as well as clinical outcomes for this critically ill patient population. The following core competencies are addressed in this article: Patient care, Systems-based practice, Interpersonal skills and communication.

Tissue plasminogen activator and pulmozyme for postoperative-retained hemothorax: A safe alternative to postoperative re-exploration

Successful treatment of traumatic hemothoraces is imperative to reduce morbidity and mortality among patients. Treatment modalities range from more conservative to invasive measures, including antibiotic therapy, thoracostomy tube placement, video-assisted thoracoscopic surgery, or thoracotomy. Various studies have documented success in using fibrinolytics such as tissue plasminogen activator (tPA) in conjunction with deoxyribonuclease administered through a chest tube to resolve a hemothorax. The optimal dose and frequency of fibrinolytic therapy have not yet been determined although most studies report administering therapy two times a day for 3 days. We report a successful case of a one-time dose of fibrinolytic therapy through thoracostomy tube which could support that a single dose may be ideal and sufficient enough to resolve a hemothorax. We also performed this in the acute postoperative period, which has not been well studied, and believe fibrinolytic therapy can be safe to use in this setting.

Delayed pacemaker lead perforations: Why unusual presentations should prompt an early multidisciplinary team approach

Our first case is an 84-year-old female diagnosed with sick sinus syndrome. She underwent implantation of dual chamber permanent pacemaker without complications. On the 8th day status-postimplantation, she returned to the emergency department (ED) with moderately severe left anterior chest pain and significant ecchymosis. She was given an initial diagnosis of shingles and discharged. Two days later, she returned to the ED with increasing chest pain, dyspnea, nausea, and vomiting. Lead migration and cardiac perforation was confirmed by chest X-ray and computed tomography (CT), respectively. She was taken to the operating room (OR) for lead repositioning, and she was discharged the next day. Our second case is a 64-year-old female with a diagnosis of 2:1 high-grade third-degree atrioventricular block. A dual chamber permanent pacemaker system was implanted without initial complication. Five days after implantation, she presented to the ED following an episode of syncope due to hypotension (67/46), shortness of breath, left flank pain, and fatigue. The initial diagnosis was sepsis. A chest CT was obtained, noting lead perforation and hemothorax. The patient was taken to the OR for lead repositioning.

Neurologic Issues in Patients Receiving Extracorporeal Membrane Oxygenation Support

Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for patients experiencing acute severe cardiac and/or respiratory failure. Unfortunately, despite noteworthy improvements in patient selection, technology, and multidiscipli‐ nary team management, significant complications are still common. The most dramatic and potentially severe complications are neurologic. However, the incidence of neurologic complications (i.e. embolic stroke, intracerebral hemorrhage, seizures, and anoxic injuries) has not been completely defined. Unfortunately, brain death and neurologic injuries are significant causes of morbidity and mortality for patients requiring an ECMO support. Critical to the management of patients requiring ECMO is a broader understanding of neurologic monitoring along with the clinical assess‐ ment and management of neurologic events. It is important to evaluate and potential‐ ly intervene early in the event of a neurologic problem to minimize its clinical significance. Hopefully, with a better understanding of the pathophysiology, diagnos‐ tic and therapeutic tools, and prevention strategies, the true incidence of neurologic complications can be understood and minimized.

The 11th annual INDO-US world congress of academic emergency medicine, “Synergizing science to sustain systems“, a level one international meeting, all india institute of medical sciences, New Delhi, India, september 30 to october 4, 2015

The Annual INDO-US World Congress of Academic Emergency Medicine (WoCAEM) continues to be Indias premier level one conference encompassing emergency care, trauma management, cutting edge critical care, and the corresponding component of translational science. The 2015 Summit provided additional high profile sessions on burn care, cardiovascular, and cerebrovascular topics, as well as environmental and disaster medicine. Competitive faculty selection ensures a high-quality educational experience. In addition to extensive didactic sessions, the WoCAEM incorporated outstanding small group learning and state-of-the-art simulation experiences in thematic blocks. The WoCAEM Leadership Council is pleased to report on the most recent conference that took place from September 30 to October 4 in New Delhi, India. We hope that this report, in addition to serving as a historical record, will generate additional interest regarding the meeting among potential faculty and attendees alike. The following core competencies are addressed in this article: Medical knowledge, patient care, communication and interpersonal skills, system based practice.