The Role of Palliative Care Consultation in Withdrawal of Life-Sustaining Treatment among ICU Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): A Retrospective Case-Control Study.

Background: Extracorporeal membrane oxygenation (ECMO) has extended the survivability of critically ill patients beyond their unsupported prognosis and has widened the timeframe for making an informed decision about the goal of care. However, an extended time window for survival does not necessarily translate into a better outcome and the sustaining treatment is ultimately withdrawn in many patients. Emerging evidence has implicated the determining role of palliative care consult (PCC) in direction of the care that critically ill patients receive. Objective: To evaluate the impact of PCC in withdrawal of life-sustaining treatment (WOLST) among critically ill patients, who were placed on venovenous ECMO (VV-ECMO) at the intensive care unit (ICU) of a tertiary care hospital. Methods: In a retrospective observational study, electronic medical records of 750 patients admitted to the ICU of our hospital between January 1, 2015, and October 31, 2021, were reviewed. Data was collected for patients on VV-ECMO, for whom WOLST was withdrawn during the ICU stay. Clinical characteristics and the underlying reasons for WOLST were compared between those who received PCC (PCC group) and those who did not (non-PCC group). Results: A total of 95 patients were included in our analysis, 63 in the PCC group and 32 in the non-PCC group. The average age of the study population was 48.8 ± 12.6 years, and 64.2% were male. There was no statistically significant difference between the two groups in terms of demographics or clinical characteristics at the time of ICU admission. The average duration of ICU stay and VV-ECMO were 14.1 ± 19.9 days and 9.4 ± 16.6 days, respectively. The number of PCC visits was correlated with the length of ICU stay. The average duration of ICU stay (40.3 ± 33.2 days vs 27.8 ± 19.3 days, P = .05) and ECMO treatment (31.9 ± 27 days vs 18.6 ± 16.1 days, P = .01) were significantly longer in patients receiving PCC than those not receiving PCC. However, the frequency of life sustaining measures or the underlying reasons for WOLST did not significantly differ between the two groups (P > .05). Conclusion: Among ICU patients requiring ECMO support, longer duration of ICU stay and treatment with a higher number of life-sustaining measures seemed to be correlated with the number of PCC visits. The underlying reasons for WOLST seem not to be affected by PCC.

Changes in end-tidal carbon dioxide and volumetric carbon dioxide as predictors of volume responsiveness in hemodynamically unstable patients.

OBJECTIVE: The purpose of this study was to determine whether changes in PETCO2 and exhaled CO2 (VCO2) can predict fluid responsiveness after a preload challenge. DESIGN: A retrospective review of prospectively recorded data. SETTING: A medical intensive care unit of a university-affiliated tertiary care hospital. PARTICIPANTS: Mechanically ventilated patients undergoing a preload challenge. INTERVENTIONS: In the authors' intensive care unit, fluid responsiveness is determined by a passive leg raising (PLR) maneuver and/or a 500-mL crystalloid challenge. An increase in the stroke volume index >10% as measured by a NICOM bioreactance cardiac output monitor (Cheetah Medical, Inc, Vancouver, WA) is used to determine fluid responsiveness. PETCO2 and volumetric capnography (VCO2) were monitored via a combined CO2 and flow sensor capnostat (Respironics NM3 Monitor; Philips Healthcare, Eindhoven, Netherlands). Patients were mechanically ventilated with tidal volumes controlled at 8 mL/kg, allowing for consistent minute ventilation. MEASUREMENTS AND MAIN RESULTS: During the study period, 44 challenges (10 PLR and 34 fluid boluses) were performed on 34 patients. There were 24 (54%) positive "fluid" responses. PETCO2 increased by 5.9% ± 7.6% in the responders compared with 1.4% ± 4.4% in the nonresponders (p = 0.02). Similarly, VCO2 increased by 11.0% ± 8.6% in the responders compared with 0.8% ± 5.6% in the nonresponders (p = 0.001). The area under the receiver operating characteristic curve was 0.67 (95% confidence interval, 0.48-0.80) for PETCO2 and 0.79 (95% confidence interval, 0.63-0.89) for VCO2. PETCO2 and VCO2 were predictive of fluid responsiveness only in those patients without underlying lung disease. The stroke volume variation was 15.8 ± 3.7 in the responders compared with 13.6 ± 4.8 in the nonresponders (p = 0.15). CONCLUSIONS: Dynamic changes in PETCO2 and VCO2 may be used as adjunctive indicators of fluid responsiveness in patients without underlying lung disease.

Top Ten Tips Palliative Care Clinicians Should Know About Working With Adults Receiving Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is an invasive intervention that is both resource- and labor-intensive. It can also be emotionally challenging for all involved. Palliative care (PC) clinicians can support adult patients, families, surrogate decision makers, and the interdisciplinary team (IDT) throughout ECMO, starting at the time of ECMO initiation through discontinuation and to bereavement in the event of a patient's death. In addition to knowing the basics of ECMO circuitry, indications to start ECMO, and the complex decision points throughout treatment, PC clinicians must understand the critical need for specialist and IDT coordination when discussing prognosis and resuscitation, clarifying goals of care, and identifying future treatment options. Not only are PC clinicians' skills needed to manage symptoms and psychosocial needs but also during end-of-life care, which can often be rapid and requires team consensus to ensure a smooth clinical process with continuous family support. While using their expert communication skills to conduct frequent family meetings, ideally starting within one week of ECMO initiation and weekly thereafter, PC clinicians offer a consistent presence and "big picture" perspective for patients and families, while other members of the IDT may rotate regularly. PC clinicians will also be called on to assist members of the IDT to debrief about the understandable moral and emotional distress they may experience while providing care for patients receiving ECMO and their families.

The effect of APRV ventilation on ICP and cerebral hemodynamics.

BACKGROUND: Airway pressure release ventilation (APRV) is an alternative approach to the low-tidal volume "open-lung" ventilation strategy. APRV is associated with a higher mean airway pressure than conventional ventilation and has therefore not been evaluated in patients with acute neurological injuries. METHODS: Case report. RESULTS: We report a patient with severe progressive hypoxemia following a subarachnoid hemorrhage who was converted from pressure-controlled mechanical ventilation to APRV. This change in ventilatory mode was associated with a significant improvement in oxygenation and alveolar ventilation with an associated increase in cerebral blood flow and a negligible increase in intracranial pressure. CONCLUSION: APRV may safely be applied to neurocritically ill patients, and that this mode of ventilation may increase cerebral blood flow without increasing intracranial pressure.

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial.

BACKGROUND: Transfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients. METHODS: We conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7-9.49 g/dL, 9.5-11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL. RESULTS: The use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7-9.49 g/dL. CONCLUSIONS: This pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.

Fungal Pneumonia in Patients with Hematologic Malignancy and Hematopoietic Stem Cell Transplantation.

Fungal pneumonias cause unacceptable morbidity among patients with hematologic malignancies (HM) and recipients of hematopoietic stem cell transplantation (HSCT). The high incidence of fungal pneumonias in HM/HSCT populations arises from their frequently severe, complex, and persistent immune dysfunction caused by the underlying disease and its treatment. The cytopenias, treatment toxicities, and other immune derangements that make patients susceptible to fungal pneumonia frequently complicate its diagnosis and increase the intensity and duration of antifungal therapy. This article addresses the host factors that contribute to susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of fungal pneumonia in patients with HM/HSCT.

Prolonged Venovenous Extracorporeal Membrane Oxygenation in a Patient With Acute Respiratory Distress Syndrome.

A 30 year-old Hispanic man with no significant previous medical history presented with refractory hypoxemia after flu-like symptoms. Because of progressive hypoxemia despite appropriate ventilator strategies, venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated for severe acute respiratory distress syndrome (ARDS). His course was complicated at our hospital by subarachnoid hemorrhage, right ventricular failure, multiple pneumothoraces, and significant deconditioning. He was able to be weaned off VV-ECMO after 193 days and was ambulatory at discharge from the hospital.

The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients.

BACKGROUND: The clinical assessment of intravascular volume status and volume responsiveness is one of the most difficult tasks in critical care medicine. Furthermore, accumulating evidence suggests that both inadequate and overzealous fluid resuscitation are associated with poor outcomes. The objective of this study was to determine the predictive value of passive leg raising (PLR)- induced changes in stroke volume index (SVI) as assessed by bioreactance in predicting volume responsiveness in a heterogenous group of patients in the ICU. A secondary end point was to evaluate the change in carotid Doppler fl ow following the PLR maneuver. METHODS: During an 8-month period, we collected clinical, hemodynamic, and carotid Doppler data on hemodynamically unstable patients in the ICU who underwent a PLR maneuver as part of our resuscitation protocol. A patient whose SVI increased by . 10% following a fluid challenge was considered a fluid responder. RESULTS: A complete data set was available for 34 patients. Twenty-two patients (65%) had severe sepsis/septic shock, whereas 21 (62%) required vasopressor support and 19 (56%) required mechanical ventilation. Eighteen patients (53%) were volume responders. The PLR maneuver had a sensitivity of 94% and a specificity of 100% for predicting volume responsiveness (one false negative result). In the 19 patients undergoing mechanical ventilation, the stroke volume variation was 18.0% 5.1% in the responders and 14.8% 3.4% in the nonresponders ( P 5 .15). Carotid blood fl ow increased by 79% 32% after the PLR in the responders compared with 0.1% 14% in the nonresponders ( P , .0001). There was a strong correlation between the percent change in SVI by PLR and the concomitant percent change in carotid blood fl ow ( r 5 0.59, P 5 .0003). Using a threshold increase in carotid Doppler fl ow imaging of 20% for predicting volume responsiveness, there were two false positive results and one false negative result, giving a sensitivity and specificity of 94% and 86%, respectively. We noted a significant increase in the diameter of the common carotid artery in the fluid responders. CONCLUSIONS: Monitoring the hemodynamic response to a PLR maneuver using bioreactance provides an accurate method of assessing volume responsiveness in critically ill patients. In addition, the study suggests that changes in carotid blood fl ow following a PLR maneuver may be a useful adjunctive method for determining fluid responsiveness in hemodynamically unstable patients.