Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure.

INTRODUCTION: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients. METHODS: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls. RESULTS: After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes. CONCLUSIONS: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.

Venoarterial Extracorporeal Membrane Oxygenation After Autologous Stem Cell Transplantation With Pancytopenia: JACC Patient Care Pathways.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure. By providing circulatory support, VA-ECMO gives treatments time to reach optimal efficacy or may be used as a bridge to a more durable mechanical solution for patients with acute cardiopulmonary failure. It is commonly used when a readily reversible etiology of decompensation is identified with very strict inclusion criteria for extracorporeal cardiopulmonary resuscitation use. We present a unique case in which VA-ECMO/extracorporeal cardiopulmonary resuscitation was used after cardiac arrest with pulseless electrical activity in a patient with recurrent lymphoma of the left thigh with recent autologous stem cell transplant.

Venoarterial Extracorporeal Membrane Oxygenation After Autologous Stem Cell Transplantation With Pancytopenia: JACC Patient Care Pathways.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure. By providing circulatory support, VA-ECMO gives treatments time to reach optimal efficacy or may be used as a bridge to a more durable mechanical solution for patients with acute cardiopulmonary failure. It is commonly used when a readily reversible etiology of decompensation is identified with very strict inclusion criteria for extracorporeal cardiopulmonary resuscitation use. We present a unique case in which VA-ECMO/extracorporeal cardiopulmonary resuscitation was used after cardiac arrest with pulseless electrical activity in a patient with recurrent lymphoma of the left thigh with recent autologous stem cell transplant.

Percutaneous Pulmonary Artery Cannulation to Treat Acute Secondary Right Heart Failure While on Veno-venous Extracorporeal Membrane Oxygenation.

Right heart failure (RHF) is a common, yet difficult to manage, complication of severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) that is associated with increased mortality. Reports of the use of percutaneous mechanical circulatory support devices for concurrent right heart and respiratory failure are limited. This series describes the percutaneous cannulation of the pulmonary artery for conversion from veno-venous to veno-pulmonary artery return ECMO in 21 patients who developed secondary RHF. All patients cannulated between May 2019 and September 2021 were included. Either a 19 or 21 French venous cannula was placed percutaneously into the pulmonary artery via the internal jugular or subclavian vein, providing a total of 821 days of support (median 23 [4-71] days per patient) with flows up to 6 L/min. Five patients underwent cannulation at the bedside, with the remainder performed in the cardiac catheterization laboratory. Pulmonary artery cannulation occurred after 12 [8.5-23.5] days of ECMO support. Vasoactive infusion requirements decreased significantly within 24 hours of pulmonary artery cannula placement (p = 0.0004). Nonetheless, 75% of these patients expired after a median of 12 [4-63] days of support, with three patients found to have had significant pericardial effusions peri-arrest. This cannulation technique may be an effective alternative to veno-arterial ECMO cannulation or the placement of a dual-lumen cannula for the treatment of RHF.

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients. MATERIALS AND METHODS: We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth. RESULTS: The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%. CONCLUSIONS: Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

Preclinical models for the study of Barrett's carcinogenesis.

Barrett's esophagus (BE) is clinically significant, as it is the only known precursor lesion for esophageal adenocarcinoma. To develop improved therapies for the treatment of BE, a greater understanding of the disease process at the molecular genetic level is needed. However, achieving a greater understanding will require improved preclinical models so that the disease process can be more closely studied and novel therapies can be tested. Our concise review highlights progress in the development of preclinical models for the study of BE and identifies the most suitable model in which to test novel therapies.

Dexmedetomidine as a Rescue Therapy for Emergence Delirium in Adults: A Case Series.

Emergence delirium (ED) in adult patients encountered in the postanesthesia care unit (PACU) is not well studied; nor are ED treatment strategies. Similar to delirium in the intensive care unit, ED in the PACU can result in serious complications. We describe 3 cases of ED in the PACU in patients with a history of posttraumatic stress disorder who were successfully treated with dexmedetomidine. Although likely utilized more frequently in recent years, the use of dexmedetomidine in the PACU for treatment of ED is not established in the literature. Further research regarding treatment of ED in adults is necessary, allowing for optimization of patient care and improvement in patient outcomes.