Stuart Gillon

A Retrospective Observational Case Series of Low-Flow Venovenous Extracorporeal Carbon Dioxide Removal Use in Patients with Respiratory Failure.

We aimed to describe the use of venovenous extracorporeal carbon dioxide removal (ECCO2R) in patients with hypercapnic respiratory failure. We performed a retrospective case note review of patients admitted to our tertiary regional intensive care unit and commenced on ECCO2R from August 2013 to February 2015. Fourteen patients received ECCO2R. Demographic data, physiologic data (including pH and partial pressure of carbon dioxide in arterial blood [PaCO2]) when starting ECCO2R (t = 0), at 4 hourly intervals for the first 24 hours, then at 24 hour intervals until cessation of ECCO2R, and overall outcome were recorded. Patients are reported separately depending on whether the indication for ECCO2R was an exacerbation of chronic obstructive pulmonary disease (COPD; n = 5), or acute respiratory distress syndrome (ARDS) and persisting hypercapnoea (n = 9). Patients were managed with ECCO2R (Hemolung, ALung Inc, Pittsburgh, PA). Median duration of ECCO2R was 5 days. Four complications related to ECCO2R were reported, none resulting in serious adverse outcomes. Ten patients were discharged from intensive care unit (ICU) alive. A statistically significant improvement in pH (p = 0.012) was demonstrated. Our observational series of ECCO2R shows that this technique can be safely used to achieve therapeutic goals in patients requiring lung protection, and in COPD, in line with current publications in this area.

Retrospective Observational Review of Percutaneous Cannulation for Extracorporeal Membrane Oxygenation.

Cannulation is a potentially complex event in the conduct of venovenous extracorporeal membrane oxygenation (VV-ECMO) for patients with severe respiratory failure. The purpose of this article is to describe our approach to cannulation and its complications. A single-center, retrospective, observational cohort, electronic note review study of patients commenced on VV-ECMO for severe respiratory failure. We identified 348 cannulae placed in 179 patients commenced on VV-ECMO from December 2011 to March 2015. All cannulations were successful. There were no deaths related to cannulation, and complications included one arterial injury, one cardiac tamponade, two cases of venous insufficiency, and five cannula site infections. Percutaneous cannulation for VV-ECMO can be achieved with a high degree of success and low complication rate by intensivists using ultrasound and fluoroscopic guidance.

Perioperative Extracorporeal Membrane Oxygenation to Facilitate Lung Resection After Contralateral Pneumonectomy.

A 75-year-old man previously underwent pneumonectomy for lung cancer. He subsequently had colorectal adenocarcinoma, and resection of metastases from his remaining lung was performed. Venovenous extracorporeal membrane oxygenation was used for perioperative respiratory support to facilitate intraoperative deflation of the remaining lung and optimization of the surgical field. Venovenous extracorporeal membrane oxygenation was continued postoperatively, allowing immediate extubation, thus avoiding strain on suture lines. Advantages, and potential risks, of venovenous extracorporeal membrane oxygenation for thoracic surgery are discussed.

CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is an advanced form of organ support indicated in selected cases of severe cardiovascular and respiratory failure. Echocardiography is an invaluable diagnostic and monitoring tool in all aspects of ECMO support. The unique nature of ECMO, and its distinct effects upon cardio-respiratory physiology, requires the echocardiographer to have a sound understanding of the technology and its interaction with the patient. In this article, we introduce the key concepts underpinning commonly used modes of ECMO and discuss the role of echocardiography. Case A 38-year-old lady, with no significant past medical history, was admitted to her local hospital with group A Streptococcal pneumonia. Rapidly progressive respiratory failure ensued and, despite intubation and maximal ventilatory support, adequate oxygenation proved impossible. She was attended by the regional severe respiratory failure service who established her on veno-venous (VV)-ECMO for respiratory support. Systemic oxygenation improved; however, significant cardiovascular compromise was encountered and echocardiography demonstrated a severe septic cardiomyopathy (ejection fraction <15%, aortic velocity time integral 5.9 cm and mitral regurgitation dP/dt 672 mmHg/s). Her ECMO support was consequently converted to a veno-veno-arterial configuration, thus providing additional haemodynamic support. As the sepsis resolved, arterial ECMO support was weaned under echocardiographic guidance; subsequent resolution of intrinsic respiratory function allowed the weaning of VV-ECMO support. The patient was liberated from ECMO 7 days after hospital admission.

Acceptance and transfer to a regional severe respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors and outcomes

The use of extracorporeal membrane oxygenation for respiratory failure is high risk and resource intensive. In England, five centres provide this service and patients who are referred have four possible outcomes: declined transfer due to perceived futility; accepted in principle but remain at the referring centre with ongoing surveillance; retrieved using conventional ventilation; or retrieved on extracorporeal support. The decision‐making process leading to these outcomes has not previously been examined. We evaluated referrals to one centre and identified factors associated with each decision outcome. Five hundred and sixty‐four patients were analysed from January 2012 to October 2015. One hundred and fifty‐seven patients were declined; multivariate analysis demonstrated associated factors to be: age (odds ratio (95% confidence interval) 1.05 (1.04–1.07)); immunocompromise (4.95 (2.58–9.67)); lactate (1.11 (1.01–1.22)); duration of ventilation (1.08 (1.04–1.14)); and cardiac failure (3.22 (1.04–10.51)). Factors associated with the decision to retrieve an accepted patient were: plateau pressure (1.05 (1.01–1.10)); ratio of arterial oxygen partial pressure to fractional inspired oxygen (0.89 (0.85–0.93)); partial pressure of carbon dioxide in arterial blood (1.13 (1.03–1.25)); and the absence of non‐pulmonary infection (0.31 (0.15–0.61)). Only pH was independently associated with the decision to transfer on extracorporeal support (0.020 (0.002–0.017)). Six‐month survival in the declined, non‐retrieved, conventionally retrieved and extracorporeal‐retrieved groups was 16.6%, 71.1%, 76.7% and 72.1%, respectively, substantially supporting the decision‐making model. Survival in the accepted group exceeds that reported previously. However, a proportion of those declined do survive and some remotely managed patients die. This suggests the approach does not account for some important survival‐determining factors.

In a financially driven quest for antibiotic stewardship, does intensive care hold the key?

One message has permeated acute medical specialties like no other in the last decade: sepsis kills and early intervention—in particular administration of appropriate antibiotics—saves lives. The work of the Surviving Sepsis Campaign, the Sepsis Trust, and related groups in the dissemination of this information is to be applauded; their efforts have undoubtedly improved clinical practice and prevented countless deaths. The need for early antibiotics in severe sepsis is not in question. But the potential implications of unchecked antimicrobial therapy, for both individual and population, must be recognized and addressed. In England, the bio-ethical basis for rationalizing antibiotic use has been compounded by financial pressure: new government targets threaten hospitals with loss of income if they fail to curtail the use of broad-spectrum antibiotics. In this editorial, we explore the implications of these new targets and discuss how intensive care units (ICU) may offer the greatest gain in the quest for antibiotic stewardship. For the individual, antibiotics pose many risks including renal and hepatic toxicity, rash, allergic reaction, and Clostridium difficile infection. For the health-care system, antibiotics account for a significant proportion of the pharmaceutical budget [1]. Of greatest significance, however, is the population-wide risk of resistant microorganisms. The increasing use of broad-spectrum antibiotics correlates with the rise in bacterial resistance to previously effective antimicrobial agents. As a consequence, international bodies recommend the widespread implementation of antibiotic stewardship [2]. This process, in practical terms, means early identification or exclusion of bacterial infection, the avoidance or cessation of antibiotics in the absence of infection, and – when antibiotics are administered – the delivery of a short but effective course [3]. The United Kingdom has a track record of using top-down interventions to improve patient outcomes and modify clinician behavior. Highly publicized methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile outbreaks in the late 1990s and early 2000s prompted a strong organizational response from the British Government and National Health Service. Mandatory reporting, infection reduction targets, and the elevation of responsibility for infection control to the level of the executive board were enforced by legislation (Health Act 2006; Health and Social Care Act 2008). In the years that followed, the incidence of MRSA bacteremia and Clostridium difficile fell by 85% and 53%, respectively [4]. Whilst a clear causative relationship can never be firmly established, it is on the background of this perceived success that the United Kingdom has approached the issue of antibiotic resistance and stewardship. The Commissioning for Quality and Innovation (CQUIN) framework is an initiative intended to ‘deliver clinical quality improvements and drive transformational change’ [5]. The venture operates by offering financial incentive for the attainment of specific quality targets (known as CQUINs): a proportion of funding for a given health-care provider is dependent upon the attainment of these targets. Every year, a number of both national and local CQUINs are agreed upon. One of four national CQUINs for the year 2016/17 relates to antibiotic stewardship [5]. This promotes reduction in antibiotic use (as measured by defined daily dose) across secondary care organizations with particular focus upon carbapenems and piperacillin-tazobactam. All health-care providers—regardless of case mix and existing resistance patterns—are asked to achieve a 1% reduction in total antibiotic use and a 1% reduction in the utilization of carbapenems and piperacillintazobactam; there is an added requirement to review all antibiotic prescriptions within 72 h and that historical antibiotic consumption data will be provided. For a large, acute healthcare provider such as ours, attainment of these targets is worth nearly £1 million in a year; the incentive to implement antibiotic stewardship is large. Certain aspects of this target are problematic. Firstly, the 1% reduction is arbitrary and does not take into account appropriateness of antibiotic prescription. Secondly, the prescribing baseline against which UK hospitals are compared is the financial year 2013–14. Antibiotic use has been rising year upon year: between 2013 and 2014 alone it increased by 2.4% [6]. When the annual increase in antibiotic prescribing is considered, a reduction in 2016 prescribing to 1% below 2013/14 levels is, in real terms, a cut of more than a 5%. Thirdly, in previous centrally driven infection control initiatives, attainment of targets by individual hospitals was followed by more ambitious aims in subsequent years. It is not inconceivable that a similar approach will be adopted in

Intracardiac Right-to-Left Shunt Impeding Liberation From Veno-Venous Extracorporeal Membrane Oxygenation: Two Case Studies.

Objectives: Veno-venous extracorporeal membrane oxygenation is an increasingly used form of advanced respiratory support, but its effects on the physiology of the right heart are incompletely understood. We seek to illustrate the impact of veno-venous extracorporeal membrane oxygenation return blood flow upon the right atrium by considering the physiologic effects during interatrial shunting. Patients: Two veno-venous extracorporeal membrane oxygenation patients in whom an extracorporeal membrane oxygenation induced right-to-left interatrial shunt appears to have created a barrier to liberation from extracorporeal support. Conclusions: Veno-venous extracorporeal membrane oxygenation return flow generates a high-pressure jet that has potential to exert focal pressure upon the intra-atrial septum. In patients with potential for interatrial flow, this may lead to a right-to-left shunt, which becomes physiologically apparent only when sweep gas flow is ceased.