An International Survey of Extracorporeal Membrane Oxygenation Education and Credentialing Practices.

Background: The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly over the past decades because of evolving indications, advances in circuit technology, and encouraging results from modern trials. Because ECMO is a complex and highly invasive therapy that requires a multidisciplinary team, optimal education, training, and credentialing remain a challenge. Objective: The primary objectives of this study were to investigate the prevalence and application of ECMO education and ECMO practitioner credentialing at ECMO centers globally. In addition, we explored differences among education and credentialing practices in relation to various ECMO center characteristics. Methods: We conducted an observational study of ECMO centers worldwide using a survey querying participants in two major domains: ECMO education and ECMO practitioner credentialing. Of note, the questionnaire included ECMO program characteristics, such as type and size of hospital and ECMO experience and volume, to explore the association with the two domains. Results: A total of 241 (32%) of the 732 identified ECMO centers responded to the survey, representing 41 countries across the globe. ECMO education was offered at 221 (92%) of the 241 centers. ECMO education was offered at 105 (98.0%) high-ECMO volume centers compared with 136 (87.5%) low-ECMO volume centers (P = 0.005). Credentialing was established at 101 (42%) of the 241 centers. Credentialing processes existed at 52 (49.5%) high-ECMO volume centers compared with 51 (37.5%) low-ECMO volume centers (P = 0.08) and 101 (49.3%) Extracorporeal Life Support Organization centers compared with 1 (2.7%) non-Extracorporeal Life Support Organization center (P < 0.001). Conclusion: We found significant variability in whether ECMO educational curricula are offered at ECMO centers. We also found fewer than half of the ECMO centers surveyed had established credentialing programs for ECMO practitioners. Future studies that assess variability in outcomes among centers with and without standardized educational and credentialing practices are needed.

Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction.

BACKGROUND: Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. METHODS: We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. RESULTS: We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% confidence interval: -7.6% to -1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). CONCLUSIONS: Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.

Mechanical Circulatory Support Devices in the Elderly.

As the field of mechanical circulatory support (MCS) continues to advance and resuscitation protocols are being refined, elderly patients previously not considered for MCS are now being supported. MCS devices can broadly be classified based on the duration of support into temporary or durable devices. Although mortality is higher in the elderly, carefully selected patients, MCS support can be valuable and lead to excellent recovery. Age itself should not preclude patients from being candidates for MCS because we must not restrict the progress of science in medicine for any age.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation.

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

Mechanical circulatory support devices in geriatric patients: more than just age.

PURPOSE OF REVIEW: The use of mechanical circulatory support (MCS) devices, such as left ventricular assist device and extracorporeal membrane oxygenation in the elderly have been rapidly increasing in various clinical settings over the past two decades. This review briefly summarizes recent literature on the role and outcomes of such mechanical circulatory support devices use in the elderly. RECENT FINDINGS: Elderly patients are receiving increasing number of LVADs with improved survival and quality-of-life outcomes, despite multiple comorbidities. ECMO is a viable option in elderly patients but they have a higher risk of mortality after both VA ECMO and VV ECMO support. However, comorbidities, clinical presentation and timing of ECMO initiation seems to have a greater impact on prognosis than for younger patients. SUMMARY: MCS device use continue to rise in the elderly population. Meticulously selected elderly patients could be successfully supported with MCS devices with favorable outcomes and acceptable mortality and complication rate.

Bedside troubleshooting during venovenous extracorporeal membrane oxygenation (ECMO).

In this review, we discuss common difficulties that clinicians may encounter while managing patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO). ECMO is an increasingly important tool for managing severe respiratory failure that is refractory to conventional therapies. Its overall goal is to manage respiratory failure-induced hypoxemia and hypercarbia to allow "lung rest" and promote recovery. Typically, by the time VV-ECMO is initiated, the patient's pulmonary condition requires conventional ventilator settings that are detrimental to lung recovery or that exceed the remaining functional lung's ability to maintain acceptable physiological conditions. Standard mechanical ventilation can activate inflammation and worsen the pulmonary damage caused by the underlying disease, leading to ventilator-induced lung injury. In contrast, VV-ECMO facilitates lung-protective ventilation, decreasing further ventilator-induced lung injury and allowing lung recovery. Such lung-protective ventilation seeks to avoid barotrauma (by monitoring transpulmonary pressure), volutrauma (by reducing excessive tidal volume to promote lung rest), atelectotrauma [by maintaining adequate positive end-expiratory pressure (PEEP)], and oxygen toxicity (by decreasing ventilator oxygen levels when PEEP is adequate). ECMO for adult respiratory failure was associated with overall survival of 62% in 2018, according to the Extracorporeal Life Support Organization (ELSO) January 2019 registry report. Difficulties that may arise during VV-ECMO require timely diagnosis and optimal management to achieve the most favorable outcomes. These difficulties include ventilation issues, hypoxemia (especially as related to recirculation or low ECMO-flow-to-cardiac-output ratio), sepsis, malfunctioning critical circuit components, lack of clarity regarding optimal hemoglobin levels, hematological/anticoagulation complications, and right ventricular (RV) dysfunction. A culture of safety should be emphasized to optimize patient outcomes. A properly functioning team-not only the bedside clinician, but also nurses, perfusionists, respiratory therapists, physical therapists, pharmacists, nutritionists, and other medical specialists and allied health personnel-is vital for therapeutic success.

Extracorporeal membrane oxygenation as rescue therapy for severe hypoxemic respiratory failure.

Extracorporeal membrane oxygenation (ECMO) has been used for more than 50 years as salvage therapy for patients with severe cardiopulmonary failure refractory to conventional treatment. ECMO was first used in the 1960s to treat hypoxemic respiratory failure in newborns. On the basis of its success in that population, ECMO began to be used in the early 1970s to treat adult hypoxemic respiratory failure. However, outcomes for adults were, somewhat perplexingly, quite poor. By the 1980s, use of ECMO for severe hypoxemia was rare outside of the pediatric population. ECMO technology, however, continued to evolve and improve. Multiple case reports and small series describing ECMO use as rescue for adults with severe hypoxemia from various lung pathologies have appeared in the literature over the past three decades. Adult respiratory distress syndrome (ARDS) is often the final common pathway of various pathologies affecting adults and causing hypoxemic respiratory failure. It is prevalent in intensive care units throughout the world and has, since it was first described in 1967, carried a high mortality. No specific therapy for ARDS has been found, and current care is supportive, primarily by mechanical ventilation. Results from recent randomized controlled trials, however, suggest that ECMO may have a place in the treatment of these patients. This article reviews these studies and recommends adding severe ARDS to the list of established indications for ECMO in patients with hypoxemic respiratory failure.