Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience.

INTRODUCTION: To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation. METHODS: A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge. RESULTS: In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days. CONCLUSION: Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Managing patients on extracorporeal membrane oxygenation support during the COVID-19 pandemic - a proposal for a nursing standard operating procedure.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is effective in a selected critically ill patient population with promising results in refractory hypoxemia related to the novel coronavirus disease (COVID-19). However, it requires specialized clinicians and resources in advanced technology. Moreover, the COVID-19 remains an ongoing global emergency, and there is no evidence-based practice in preparedness. This article proposes an innovative and optimized nursing care protocol, the Standard Operating Procedure (SOP), that regulates safety and efficiency in using personal protective equipment (PPE) during ECMO-relevant procedures while providing ECMO therapy for patients with COVID-19. METHODS: After performing a narrative literature search, we developed a high-fidelity translational simulation scenario. It included practicing appropriate donning and doffing PPE during work organization, ECMO-related procedures, and routine daily nursing care and management of ECMO over nine hours. In addition, we held supplementary constructive debrief meetings to consult international expert in the field. RESULTS: A proposal for nursing standardized operating procedures was created, divided into categories. They included work organization, workload references, competences, infrastructural conditions, cannulation equipment, daily routine nursing care, and procedures during ECMO. CONCLUSIONS: High-fidelity medical simulation can play an important role in staff training, improvement in previously gained proficiency, and development of optimal SOP for nursing care and management during ECMO in patients with COVID-19. Optimal SOPs may further guide multidisciplinary teams, including intensive care units and interventional departments.

Using a Modified CPD Blood Bag to Store Blood from either ECMO or RRT Circuit Blood in Pediatric Patients.

By adapting a citrate phosphate dextrose (CPD) whole blood storage bag, residual blood from a renal replacement therapy (RRT) circuit can be saved in pediatric patients, decreasing in donor exposure later. The techniques used for autologous preoperative blood storage are the basis of storing the RRT circuit blood. The CPD anticoagulant has a benefit of having a commonly used reversal agent for its anticoagulant properties, i.e., calcium. Also, unlike the traditional anticoagulants used in extracorporeal membrane oxygenation (ECMO), i.e., heparin, and direct thrombin inhibitors, i.e., bivalirudin, there is no increase in anticoagulation laboratory parameters after administration. The CPD volume in the bag is reduced but keeps the original ratio the same between CPD and blood. This is accomplished by removing all CPD from the bag, adding back only the exact amount of CPD needed for the smaller amount of blood being transferred from the circuit. The RRT circuit managed at our institution uses 23 mL of CPD for 165 mL of circuit blood when stored with this technique. This calculation assumes a normal patient calcium level. This technique has been used successfully multiple times in more than 30 pediatric patients without incident for 7 years at our center. The CPD bag can also be used to store the residual blood from ECMO circuits after removal of ECMO to allow the blood to be given back to the patient at a later time by keeping the same citrate-to-blood ratio.

Incorporating the use of thromboelastographic studies when assessing bleeding patients.

This column discusses the use of thromboelastographic studies when assessing patients with bleeding disorders.

Practical Implementation of Failure Mode and Effects Analysis for Extracorporeal Membrane Oxygenation Activation.

Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.

Assessing the bleeding patient: factors affecting hemostasis and common coagulation studies.

This column discusses the factors affecting hemostasis and the common coagulation studies used to assess patients with bleeding disorders.