Extracorporeal life support in trauma: Indications and techniques.

BACKGROUND: Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma. METHODS: The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion. RESULTS: A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia. CONCLUSION: The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Spontaneous resolution and the role of endoscopic surgery in the treatment of primary obstructive megaureter: a review of the literature.

The megaureter accounts for almost a quarter of all urinary tract dilations diagnosed in utero and is the second leading cause of hydronephrosis in newborns, following pyeloureteral junction obstruction. The current standard treatment for progressive or persistent, symptomatic primary obstructive megaureter is ureteral anti-reflux reimplantation, which can be associated with ureteral remodeling or plication. Due to the associated morbidity, postoperative recovery challenges, and the complications that may arise from the open surgical approach, there has been a natural inclination towards validating new minimally invasive techniques. This study reviews the literature, extracting data from three major international databases, from 1998 to 2022. Out of 1172 initially identified articles, only 52 were deemed eligible, analyzing 1764 patients and 1981 renal units. Results show that 65% of cases required surgical intervention, with minimally invasive techniques constituting 56% of these procedures. High-pressure endoscopic balloon dilation was the preferred endourologic technique. The degree of ureterohydronephrosis is considered one of the factors indicating the need for surgery. There is an inverse relationship between the diameter of the ureter and the likelihood of spontaneous resolution. Conditions such as renal hypoplasia, renal dysplasia, or ectopic ureteral insertion strongly indicate a poor prognosis. Endoscopic surgical techniques for treating primary obstructive megaureter can be definitive, firstline treatment options. In selected cases, they might be at least as effective and safe as the open approach, but with advantages like quicker recovery, fewer complications, shorter hospital stays, and reduced costs.

Premortem anticoagulation timing and dose in donation after circulatory death: multicentre study of associations with graft function.

BACKGROUND: In controlled donation after circulatory determination of death (DCD), it is common to administer premortem heparin to potential donors. This practice remains controversial because there is limited evidence for it and there is the possibility of inducing hemorrhage. To our knowledge, no previous studies have assessed the effects of heparin timing and dose on graft function. METHODS: We performed a multicentre cohort study of consecutive DCD donors and the recipients of their organs. Anticoagulation administration was considered early if given near the time of withdrawal of life-sustaining measures and late if delayed until the onset of donor hypoxemia (oxygen saturation < 70%) or hypotension (systolic blood pressure < 60 mm Hg or mean blood pressure < 50 mm Hg). The anticoagulation dose was considered high if it was 300 units/kg or greater. RESULTS: Donor anticoagulation data were available for 301 kidney, 75 liver and 46 lung recipients. Heparin was administered in 92% of cases and was most commonly withheld in donors with cerebrovascular causes of death (p = 0.01). Administration was late in 59% and the dose was low in 27%. Among kidney recipients, there were no significant differences in need for dialysis, glomerular filtration rate over the first year after transplantation or graft survival on the basis of whether or not the donor received heparin, the timing of heparin administration or the dose of heparin. Among liver recipients, alkaline phosphatase concentrations over the first year were significantly higher among recipients who received organs from donors to whom lower doses of heparin had been administered. CONCLUSION: Premortem heparin is widely used in DCD cases, but there is variability in timing and dose, which was not associated with kidney outcomes in this study. Donor anticoagulation may have a greater impact in preventing biliary complications following liver transplantation.

Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial.

PURPOSE: Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers. METHODS: Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures. RESULTS: Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04). CONCLUSIONS: Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.

Purulent pericarditis in a patient with rheumatoid arthritis treated with etanercept and methotrexate.

Purulent pericarditis is rarely seen in this post-antibiotic era. We report a case of spontaneous purulent pericarditis in a patient with rheumatoid arthritis being treated with etanercept, a tumour necrosis factor-alpha (TNF-alpha) antagonist, and methotrexate, an immunosuppressant. Both are disease-modifying anti-rheumatic drugs. We discuss the pathophysiology of purulent pericarditis and the recent literature on the infectious complications of TNF-alpha antagonists.