Diagnosis of inadvertent cannulation of the azygos vein during cardiopulmonary bypass.

Cardiac surgery with cardiopulmonary bypass demands diligence and attention to detail to prevent neurologic injury. Arterial and venous cannulae are used to facilitate cardiopulmonary bypass. The assessment of adequate decompression of the venous circulation is an essential duty of the cardiac surgical team. Modalities for the assessment of adequate regional venous drainage are limited, however communication between the team and increased awareness of certain pathologic states can be useful. These modalities include cerebral oximetry and superior vena caval pressure monitoring, which were employed during a case with bicaval venous cannulation. Malposition of the superior vena cava cannula was detected after a series of events alerted the team that superior vena cava drainage may be compromised.

Use of an extracorporeal membrane oxygenation circuit as a bridge to salvage a major upper-extremity replant in a critically ill patient.

Major replantation of the upper extremity is defined as replantation at or above the level of the wrist. Selection of appropriate candidates is complex and requires consideration of many patient- and injury-associated factors including patient age, associated injuries, patient desire, mechanism of injury, ischemia time, wound condition, and presence of multiple-level injury. With respect to age, younger patients, especially children, are deemed to have a distinct advantage over more elderly patients due to improved nerve regeneration, and many advocate making every effort to replant this population. The risks of major upper-extremity replantation are significant and include bleeding, depletion of coagulation factors, secondary infection, and sepsis. As a result, major systemic illness and significant associated injuries are accepted as contraindications to limb salvage in this patient population. Herein we describe the use of an extracorporeal membrane oxygenation (ECMO) circuit as a potential bridge for short-term preservation of the extremity in a young patient with an acute, concomitant systemic illness. In the authors' opinion, use of ECMO perfusion is a viable means of maintaining extremity perfusion over hours or even days and may lead to broadened replant criteria in patients with associated injuries.