Thomas Tribble

Reducing Skin Breakdown in Patients Receiving Extracorporeal Membranous Oxygenation

This article describes three strategies a cardiovascular-thoracic intensive care unit implemented to decrease the rate of hospital-acquired pressure ulcers in patients on extracorporeal membranous oxygenation support. These strategies include increased staff awareness of physiologic factors placing a critically ill patient on extracorporeal support at increased risk for development of pressure ulcers, development of a turning guideline and a skin care bundle, and use of coaching by a clinical nurse specialist to promote pressure ulcer prevention.

Safety of Nurse-Led Ambulation for Patients on Venovenous Extracorporeal Membrane Oxygenation

Purpose: Venovenous extracorporeal membrane oxygenation (VV ECMO) is an effective therapy in patients with acute lung injury and end-stage lung disease. Although immobility increases the risk of complications, ambulation of patients on VV ECMO is not the standard of care in many institutions. Staff concerns for patient safety remain a barrier to ambulation. In this case series, we present our experience utilizing a nurse-driven ambulatory VV ECMO process to safely rehabilitate patients. Methods: We retrospectively reviewed all VV ECMO cases at our institution between January 1, 2011, and November 1, 2013. Inclusion criteria for this study required patients to be cannulated in the right internal jugular vein and ambulated while on VV ECMO. Results: During the period from January 1, 2011, to November 1, 2013, 18 patients (mean age 49 ± 15 years, 12 male) were ambulated while on ECMO. Eight received a transplant and survived to discharge. Of the remaining patients, 4 were successfully weaned from VV ECMO and 6 died following decisions by the family to withdraw care. The mean duration of VV ECMO support was 18 ± 16 days with the maximum duration being 61 days. All patients received physical therapy, range of motion at the bedside, and ambulated in the hospital. There were no patient falls, decannulations, or any other complications related to ambulation. Conclusion: The adoption of a nurse-driven program to ambulate patients on VV ECMO is safe and may reduce other complications associated with immobility.

Developing an Extracorporeal Membrane Oxygenation Program

The development of a successful extracorporeal membrane oxygenation (ECMO) program requires an institutional commitment and the multidisciplinary cooperation of trained specialty personnel from nursing, internal medicine, anesthesiology, pulmonology, emergency medicine, critical care, and surgery and often pediatrics as well. The specialized training necessary to cultivate an integrated team capable of providing life-saving ECMO cannot be underestimated. The development of a successful ECMO program is best suited to a tertiary medical center that is centrally/regionally located and capable of financially supporting the level of expertise required as well as managing the programs overall cost effectiveness.

Increased blood transfusion and its impact in patients having tracheostomy while on extracorporeal membrane oxygenation

Introduction: Tracheostomy has been utilized in combination with venovenous extracorporeal membrane oxygenation (VV-ECMO) to enable early spontaneous breathing and minimize sedation requirements. Tracheostomy has been previously reported to be safe in patients supported on VV-ECMO; however, the impact of tracheostomy on blood loss in VV-ECMO patients is unknown. Methods: We analyzed VV-ECMO patients with and without tracheostomy over a 5-year period. In order to avoid other potential sources of blood loss not related to tracheostomy or ECMO-related blood loss, patients who underwent a recent surgery prior to ECMO or during ECMO (other than tracheostomy) were excluded. Results: Sixty-three patients meeting the inclusion criteria were identified (tracheostomy n=30, non-tracheostomy n=33). Tracheostomy patients were found to require more daily transfusions of red blood cells (RBC) (0.47 [0.20-1.0] vs. 0.23 [0.06-0.40] units/day, p=0.02) and total blood products (0.60 [0.32-1.0] vs. 0.31 [0.10-0.50] units/day, p=0.01). Conclusions: These results suggest that tracheostomy while on VV-ECMO predisposes patients to increased transfusion burden. Based on previous research, this increased transfusion burden could potentially be linked to increased complications and mortality.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock: a retrospective analysis based on the etiology of shock

Background We performed a retrospective analysis to evaluate the efficacy of VA-ECMO support in cardiogenic shock based on various etiologies.

Emergent percutaneous therapy for left ventricular assist device retrograde flow

With the number of heart transplants being performed each year stagnating due to lack of donors the left ventricular assist device (LVAD) patient population will continue to grow. As more and more patients are living longer with LVADs, either as a bridge to transplant or destination therapy, we will continue to see an increased number of complications related to assist device therapy. One of the common challenges physicians face are patients who suffer from both bleeding and thrombotic complications. When bleeding complications occur anticoagulation is usually reduced or discontinued and then the thrombosis risk increases. Once a pump thrombosis occurs there are limited percutaneous treatment strategies available, especially in the setting of a recent bleeding event. Surgical exchange is the only definitive therapy and that can be a high risk and difficult operation. Turning off an LVAD may become necessary, as it did in our case, but that can lead to significant retrograde flow through the device and rapid patient decline. A prompt percutaneous therapy is needed to stabilize these patients.

OUTCOMES OF VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION

Venoarterial extracorporeal membrane oxygenation (VA ECMO) can provide circulatory support with or without gas exchange. We performed a retrospective analysis of patients who were supported with VA ECMO to analyze outcomes based on the etiology of cardiogenic shock. We reviewed the records of

DRIVELINE FRACTURES IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES: A STUDY OF CLINICAL COURSE AND OUTCOMES

Mechanical circulatory support with left ventricular assist devices (LVAD) has greatly improved outcomes in patients with heart failure. However, despite positive results, complications exist. This study investigates the prevalence, clinical course, management, and outcomes of patients with LVAD