Venoarterial extracorporeal membrane oxygenation is an effective management strategy for massive pulmonary embolism patients.

OBJECTIVE: Treatment of massive pulmonary embolism (MPE) is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institution's pulmonary embolism response team experience using VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from MPE. METHODS: From March 2017 to July 2019 we retrospectively reviewed 17 consecutive patients at our institution with MPE who were placed on VA-ECMO for initial hemodynamic stabilization. RESULTS: The mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All patients had evidence of profound shock with a mean initial lactate of 8.95 mmol/L, a mean pH of 7.10, and a mean serum creatinine of 1.78 mg/dL. Seventeen of 17 cannulations (100%) were performed percutaneously, with 41% (n = 7) of patients placed on VA-ECMO while awake and using local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 of 17 patients (76%), with causes of death resulting from anoxic brain injury (n = 2), septic shock (n = 1), and cardiopulmonary resuscitation-induced hemorrhage from liver laceration (n = 1). In survivors, 12 of 13 patients (92%) were discharged without evidence of neurologic insult. The median duration of the VA-ECMO run for survivors was 86 hours (range, 45-218 hours). In survivors, the median length of time from ECMO cannulation to lactate clearance (<2.0 mmol/L) was 10 hours and the median length of time from ECMO cannulation to freedom from vasopressors was 6 hours. Three of 13 patients (23%) required concomitant percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction, with the remaining survivors (77%) receiving VA-ECMO and anticoagulation alone as definitive therapy for their MPE. The median intensive care and hospital length of stay for survivors was 9 and 13 days, respectively. CONCLUSIONS: VA-ECMO was effective at salvaging highly unstable patients with MPE. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. The majority of survivors required ECMO and anticoagulation alone for definitive therapy of their MPE.

Resident guideline development to standardize intensive care unit care delivery: a competency-based educational method.

PURPOSE: We developed a system of resident-driven, evidence-based standardization of care in our trauma-surgical intensive care unit (TSICU). Our main purposes are to improve patient care and outcomes and to help the residents develop practical competency in practice-based learning and improvement and in systems-based practice. DEVELOPMENT OF THE ACTIVITY: Since October 2006, each rotating TSICU resident has chosen a topic to research the available evidence and has developed a guideline, which the resident then presents to the TSICU faculty and residents for discussion, amendments, and acceptance or reevaluation. EVALUATION COMPONENT: Evaluation of proposed guidelines is based on the quality of information presented in support of the recommendations. Ultimately, acceptance of a guideline requires consensus among the TSICU faculty. Immediate feedback is given to the presenting resident by the faculty. The residents evaluate the program via a Web-based evaluation tool. PROPOSED OUTCOME MEASURES: We have qualitative data from residents that indicate this experience is positive. We are developing a tool to use both qualitative and quantitative means to evaluate resident, faculty, and nursing staff satisfaction with the process. We will use our clinical database to evaluate whether improved patient outcomes have resulted from standardization of care. IMPLEMENTATION DATES AND EXPERIENCE TO DATE: We implemented this methodology in October 2006 and have thus far implemented 20 guidelines and 2 standardized order sets. CONCLUSION AND OR NEXT STEPS: We believe competency is achieved and demonstrated by actively participating in a process such as development of care guidelines. Researching and developing standardized guidelines for our TSICU seems to be an effective and practical way for residents to use multiple sources for practice-based learning and improvement. It also requires the resident to advocate for quality patient care and optimal patient care systems. We plan to use outcome and qualitative data to validate this method.