Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation.

BACKGROUND: Nontuberculous mycobacteria (NTM) commonly colonize municipal water supplies and cause healthcare-associated outbreaks. We investigated a biphasic outbreak of Mycobacterium abscessus at a tertiary care hospital. METHODS: Case patients had recent hospital exposure and laboratory-confirmed colonization or infection with M. abscessus from January 2013 through December 2015. We conducted a multidisciplinary epidemiologic, field, and laboratory investigation. RESULTS: The incidence rate of M. abscessus increased from 0.7 cases per 10000 patient-days during the baseline period (January 2013-July 2013) to 3.0 cases per 10000 patient-days during phase 1 of the outbreak (August 2013-May 2014) (incidence rate ratio, 4.6 [95% confidence interval, 2.3-8.8]; P < .001). Thirty-six of 71 (51%) phase 1 cases were lung transplant patients with positive respiratory cultures. We eliminated tap water exposure to the aerodigestive tract among high-risk patients, and the incidence rate decreased to baseline. Twelve of 24 (50%) phase 2 (December 2014-June 2015) cases occurred in cardiac surgery patients with invasive infections. Phase 2 resolved after we implemented an intensified disinfection protocol and used sterile water for heater-cooler units of cardiopulmonary bypass machines. Molecular fingerprinting of clinical isolates identified 2 clonal strains of M. abscessus; 1 clone was isolated from water sources at a new hospital addition. We made several water engineering interventions to improve water flow and increase disinfectant levels. CONCLUSIONS: We investigated and mitigated a 2-phase clonal outbreak of M. abscessus linked to hospital tap water. Healthcare facilities with endemic NTM should consider similar tap water avoidance and engineering strategies to decrease risk of NTM infection.

A change in anticoagulation monitoring improves safety, reduces transfusion, and reduces costs in infants on cardiopulmonary bypass.

BACKGROUND: An immature coagulation system coupled with the hypothermia and hemodilution associated with cardiopulmonary bypass (CPB) in infants makes the activated clotting time (ACT) an ineffective monitor for anticoagulation in this population. The Medtronic HMS Plus Hemostasis Management System (HMS; Medtronic, Inc., Minneapolis, MN, USA) is shown to decrease thrombin generation and blood product requirements. AIM: We conducted a quality improvement initiative to test our hypothesis that the use of HMS results in reduced incidence of subtherapeutic ACT values, blood product usage, and operating room time for infants undergoing cardiac surgery. METHODS: Fifty consecutive patients weighing <10 kg having cardiac surgery requiring CPB had anticoagulation managed by the HMS. Data were compared to that of 50 consecutive patients weighing <10 kg having cardiac surgery who had their anticoagulation monitored by the ACT alone. Comparisons between categorical variables were performed with chi-square tests. Comparisons between continuous variables were performed with the Wilcoxon rank-sum test. Statistical significance was defined as two-tailed P value < 0.05. RESULTS: The HMS group had a 61% decrease in incidence of ACT values <480 s and elimination of ACT values < 400 s at any time on bypass. The HMS group received fewer blood products and spent fewer minutes in the operating room after protamine administration, translating to fewer donor exposures and a savings of $403 in transfusion costs and $440 in operating room time costs. CONCLUSION: Our findings highlight the benefits of individualized heparinization for pediatric patients undergoing CPB with a monitored heparinization system.

Development of a collaborative program to provide extracorporeal membrane oxygenation for adults with refractory hypoxemia within the framework of a pandemic.

OBJECTIVE: We report the process used to rapidly develop a collaborative adult respiratory extracorporeal membrane oxygenation program as a response to caring for young adult patients with refractory hypoxemia in the setting of the pH1N1 pandemic. DESIGN: Interdisciplinary response of a complex medical system to a public health crisis. PATIENTS, INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS: After the successful use of extracorporeal membrane oxygenation in young adults with pH1N1-induced acute respiratory distress syndrome refractory to conventional therapies, an adult venovenous extracorporeal membrane oxygenation program was implemented over an 8-wk period. Implementation of this program involved a number of key steps that were crucial in the development process, including administrative and institutional support, multidisciplinary leadership and collaboration, extensive interdisciplinary educational initiatives, and substantial technical modifications. CONCLUSIONS: In the setting of the pH1N1 influenza pandemic, an adult respiratory extracorporeal membrane oxygenation program was successfully developed to complement an established neonatal-pediatric program. This program expansion integrated all of the necessary components involved in the development process from start to finish and confirms that a healthcare system can respond very quickly and successfully to an urgent healthcare need.

Cardiopulmonary Bypass Strategy for a Cyanotic Child With Hemoglobin SC Disease.

Hemoglobin SC (HbSC) disease is a hemoglobinopathy that may produce sickling under conditions of hypoxemia, dehydration, and acidosis. We present a case of HbSC disease and tricuspid atresia, type IB. We describe management by cardiopulmonary bypass CPB using exchange transfusion at initiation of bypass and fractionation of collected blood, allowing platelet and plasma apheresis, as an option for patients unable to undergo this procedure off pump.

Circuit oxygenator contributes to extracorporeal membrane oxygenation-induced hemolysis.

Hemolysis can occur as a consequence of extracorporeal membrane oxygenation (ECMO) and is associated with increased mortality and morbidity. Shear stress generated by flow through the circuit and oxygenator is believed to cause ECMO-induced hemolysis. We hypothesize that either a smaller dimension oxygenator or an in-line hemofilter will increase ECMO-associated hemolysis. Circuits were configured with a Quadrox-D Adult oxygenator (surface area 1.8 m), Quadrox-iD Pediatric oxygenator (surface area 0.8 m), or Quadrox-D Adult oxygenator with an in-line hemofilter (N = 4) and ran for 6 hours. Samples were collected hourly from the ECMO circuit and a time-based hemolysis control. Plasma hemoglobin levels were assayed. Circuit-induced hemolysis at each time point was defined as the change in plasma hemoglobin standardized to the time-based hemolysis control. Plasma hemoglobin increased with the use of the smaller dimension pediatric oxygenator as compared with the adult oxygenator when controlling for ECMO run time (p = 0.02). Furthermore, there was a greater pressure gradient with the smaller dimension pediatric oxygenator (p < 0.05). Plasma hemoglobin did not change with the addition of the in-line hemofilter. The use of a smaller dimension pediatric oxygenator resulted in greater hemolysis and a higher pressure gradient. This may indicate that the increased shear forces augment ECMO-induced hemolysis.

Bridge to transplant with extracorporeal membrane oxygenation followed by HeartWare ventricular assist device in a child.

A 10-year-old boy was admitted with dilated cardiomyopathy. Before scheduled implantation of a HeartWare ventricular assist device, he experienced a cardiac arrest and required extracorporeal membrane oxygenation for both cardiac and pulmonary support. After 4 days of extracorporeal membrane oxygenation and 126 days of support on the HeartWare ventricular assist device, he underwent successful cardiac transplantation. He is doing well 6 months after transplantation.

Active rehabilitation during extracorporeal membrane oxygenation as a bridge to lung transplantation.

BACKGROUND: Patients with end-stage lung disease often progress to critical illness, which dramatically reduces their chance of survival following lung transplantation. Pre-transplant deconditioning has a significant impact on outcomes for all lung transplant patients, and is likely a major contributor to increased mortality in critically ill lung transplant recipients. The aim of this report is to describe a series of patients bridged to lung transplant with extracorporeal membrane oxygenation (ECMO) and to examine the potential impact of active rehabilitation and ambulation during pre-transplant ECMO. METHODS: This retrospective case series reviews all patients bridged to lung transplantation with ECMO at a single tertiary care lung transplant center. Pre-transplant ECMO patients receiving active rehabilitation and ambulation were compared to those patients who were bridged with ECMO but did not receive pre-transplant rehabilitation. RESULTS: Nine consecutive subjects between April 2007 and May 2012 were identified for inclusion. One-year survival for all subjects was 100%, with one subject alive at 4 months post-transplant. The 5 subjects participating in pre-transplant rehabilitation had shorter mean post-transplant mechanical ventilation (4 d vs 34 d, P = .01), ICU stay (11 d vs 45 d, P = .01), and hospital stay (26 d vs 80 d, P = .01). No subject who participated in active rehabilitation had post-transplant myopathy, compared to 3 of 4 subjects who did not participate in pre-transplant rehabilitation on ECMO. CONCLUSIONS: Bridging selected critically ill patients to transplant with ECMO is a viable treatment option, and active participation in physical therapy, including ambulation, may provide a more rapid post-transplantation recovery. This innovative strategy requires further study to fully evaluate potential benefits and risks.

State of the art: strategies for extracorporeal membrane oxygenation in respiratory failure.

Extracorporeal membrane oxygenation (ECMO) is an important rescue therapy for patients with cardiac and/or respiratory failure, with a growing body of literature supporting its use. Despite widespread use of ECMO, there remains a paucity of data on optimal management strategies for ECMO patients. Management of ECMO patients involves an understanding of the complex interaction between this technology and the critically ill patients being supported. ECMO providers typically rely on a combination of consensus guidelines and institutional experience to make management decisions. Substantial controversy continues to exist regarding many elements of ECMO management, including seemingly straightforward decisions such as the initial implementation of this technology. In addition, there are multiple providers involved in the management of ECMO patients who must be co-ordinated for this supportive therapy to be most effective. This manuscript provides an overview of current techniques for treating respiratory ECMO patients.

Technological advances in extracorporeal membrane oxygenation for respiratory failure.

Extracorporeal membrane oxygenation (ECMO) for neonatal and pediatric cardiac and/or respiratory failure is well established, and its use for adult respiratory failure is rapidly increasing. Management strategies developed over the past 30 years coupled with significant recent technological advances have led to improved ECMO survival. These new technologies are expanding the potential applications for ECMO in exciting ways, including new patient populations and the ability to make ECMO mobile for both intra- and inter-hospital transport. In this article, we highlight some of the recent technological advances and their impact on the utilization of ECMO in increasingly diverse patient populations.