Robert Loveridge

Extracorporeal membrane oxygenation for refractory hypoxemia after liver transplantation in severe hepatopulmonary syndrome: A solution with pitfalls

According to a recent publication by Nayyar et al., severe hypoxemia after liver transplantation (LT) in patients with hepatopulmonary syndrome (HPS) is not uncommon. According to a review of the literature and the authors’ local institutional experience, the prevalence could be as high as 12% with a mortality rate of 45%. Very severe preoperative hypoxemia, defined as a partial pressure of oxygen 50 mm Hg, and the presence of anatomical shunts were identified as predictors of this complication. Among the possible treatment strategies, the authors reported the use of inhaled vasodilator agents and systemic vasoconstrictors such as methylene blue to improve ventilation perfusion matching. The effectiveness of specific rescue ventilation strategies such as high-frequency oscillatory techniques and ventilation in the prone position remains unproven. We would like to propose another potentially beneficial treatment and bridging strategy: venovenous (V-V) extracorporeal membrane oxygenation (ECMO). Long-term ECMO support in this population after transplantation, solely for treating refractory shunt, has thus far not been reported in adults. Cannulation for ECMO after LT can also pose a significant challenge that depends on the configuration used. We have used ECMO in 6 patients (5 adults and 1 child) before and after LT since December 2012. Three patients required extracorporeal cardiac support, whereas the other 3 patients underwent V-V ECMO for hypoxemic respiratory failure. Ethical approval for the reporting of anonymous data was given by the South East London Research Ethics Committee.

Improving critical care discharge summaries: a collaborative quality improvement project using PDSA

Abstract Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called ‘iMobile’ is being provided at King’s College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from Kings Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

Portopulmonary hypertension: Improved detection using CT and echocardiography in combination

AbstractObjectivesTo establish the relationship between CT signs of pulmonary hypertension and mean pulmonary artery pressure (mPAP) in patients with liver disease, and to determine the additive value of CT in the detection of portopulmonary hypertension in combination with transthoracic echocardiography.MethodsForty-nine patients referred for liver transplantation were retrospectively reviewed. Measured CT signs included the main pulmonary artery/ascending aorta diameter ratio (PA/AAmeas) and the mean left and right main PA diameter (RLPAmeas). Enlargement of the pulmonary artery compared to the ascending aorta was also assessed visually (PA/AAvis). CT measurements were correlated with right-sided heart catheter-derived mPAP. The ability of PA/AAvis combined with echocardiogram-derived right ventricular systolic pressure (RVSP) to detect portopulmonary hypertension was tested with ROC analysis.ResultsThere were moderate correlations between mPAP and both PA/AAmeas and RLPAmeas (rs = 0.41 and rs = 0.42, respectively; p < 0.005). Compared to transthoracic echocardiography alone (AUC = 0.59, p = 0.23), a diagnostic algorithm incorporating PA/AAvis and transthoracic echocardiography-derived RVSP improved the detection of portopulmonary hypertension (AUC = 0.8, p < 0.0001).ConclusionsCT contributes to the non-invasive detection of portopulmonary hypertension when used in a diagnostic algorithm with transthoracic echocardiography. CT may have a role in the pre-liver transplantation triage of patients with portopulmonary hypertension for right-sided heart catheterisation.Key Points• CT signs correlate with right-sided heart catheter data in portopulmonary hypertension • CT adds to the transthoracic echocardiography detection of portopulmonary hypertension • CT may have a complementary role in pre-liver transplantation triage

Extracorporeal Membrane Oxygenation and Pediatric Liver Transplantation – “A step too far?” Results of a single center experience

Extracorporeal membrane oxygenation (ECMO) is an established rescue therapy for refractory hypoxemia. More recently, a potential role has emerged in the context of adult orthotopic liver transplantation (OLT), both as a preoperative or intraoperative emergency rescue technique to facilitate transplantation itself, or to enable recovery from severe acute respiratory failure in the postoperative period. Within the pediatric population, the published evidence of the use of ECMO in liver transplantation is limited to isolated case reports. Here we present a small series of 3 pediatric patients in whom venovenous (VV) ECMO was used to either facilitate emergency liver transplantation (ELT) in the context of preoperative refractory hypoxemia, or assist during postoperative severe respiratory failure unresponsive to conventional therapy. Ethics approval for the reporting of anonymous data was given by the South East London Research Ethics Committee.

Tracking failure to rescue in the future hospital.

We describe the development of a scoring tool, based around the main ‘failure to rescue’ modes [1, 2], that can be used to identify and track the quality of care given to patients with acute clinical deterioration on the ward. Between February and May 2014, the notes of all patients admitted

Nowhere else to turn? building a case for equity of access to VV ECMO in the UK for complex multi-system patients

In the UK, VV ECMO is only commissioned [[1]] for specific patients - the list of perceived contra-indications is long which prevents some patients having access to this rescue technique. Recognising this, the National Peer Review Programme stated that there may be cases “who might benefit from ECMO support who also require super-specialist services” - these may lack equity of access to commissioned resources.