Alternative venous access sites for dual-lumen extracorporeal membrane oxygenation cannulation.

OBJECTIVES: Dual-lumen cannulas for veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support are typically inserted in the right internal jugular vein (RIJV); however, some scenarios can make this venous route inaccessible. This multicentre case series aims to evaluate if single-site cannulation using an alternative venous access is safe and feasible in patients with an inaccessible RIJV. METHODS: We performed a multi-institutional retrospective analysis including high-volume ECMO centres with substantial experience in dual-lumen cannulation (DLC) (defined as >10 DLC per year). Three centres [Freiburg (Germany), Toronto (Canada) and Vienna (Austria)] agreed to share their data, including baseline characteristics, technical ECMO and cannulation data as well as complications related to ECMO cannulation and outcome. RESULTS: A total of 20 patients received alternative DLC for respiratory failure. Cannula insertion sites included the left internal jugular vein (n = 5), the right (n = 7) or left (n = 3) subclavian vein and the right (n = 4) or left (n = 1) femoral vein. The median cannula size was 26 (19-28) French. The median initial target ECMO flow was 2.9 (1.8-3.1) l/min and corresponded with used cannula size and estimated cardiac output. No procedural complications were reported during cannulation and median ECMO runtime was 15 (9-22) days. Ten patients were successfully bridged to lung transplantation (n = 5) or lung recovery (n = 5). Ten patients died during or after ECMO support. CONCLUSIONS: Alternative venous access sites for single-site dual-lumen catheters are a safe and feasible option to provide veno-venous ECMO support to patients with inaccessible RIJV.

Colorectal cancer community engagement: a qualitative exploration of American Indian voices from North Dakota.

BACKGROUND: American Indians (AI) in North Dakota present with higher rates of advanced-stage disease for screening detectable colorectal cancers and have lower overall baseline colorectal cancer screening rates than non-AIs. We sought to identify the perceived barriers and facilitators for the engagement with colorectal cancer prevention within North Dakota tribal communities. METHODS: Twelve semi-structured interviews were carried out across four tribal reservation communities in the state of North Dakota with American Indian adults between the ages of 30 and 75 years. We utilized purposive sampling to ensure maximum variation in age, sex, and tribal community until data saturation was achieved. The interviews were transcribed, and thematic analysis was carried out to identify consistent themes rooted within the data. Ethical approval was gained for this project from all relevant institutional review boards. RESULTS: Four main themes were identified as barriers for the engagement with colorectal cancer prevention, including: colorectal cancer screening barriers, focused on other health problems, lack of colorectal cancer tailored health promotion, and socio-cultural factors affecting colorectal cancer prevention. Three main themes were identified as facilitators for the engagement with colorectal cancer prevention, including: reasons for getting colorectal cancer screening, role of culture, and getting out into the community. CONCLUSION: There is need for more community-rooted, strengths-based approaches to colorectal cancer prevention activities in AI communities in North Dakota. Socio-cultural factors, such as the use of storytelling, and the use of traditional knowledge have been demonstrated to be an important element of consideration for colorectal cancer tribal community engagement and prevention planning in the state.

Protamine Test Dose: Impact on Activated Clotting Time and Circuit Integrity.

BACKGROUND: Recurrent observation of clot in the cardiopulmonary bypass circuit after the administration of a protamine test dose (PTD) prompted concern over the effects of PTDs on patient activated clotting times (ACTs). METHODS: Data were prospectively collected on 120 patients who had cardiopulmonary bypass while undergoing a variety of cardiac surgical procedures from July to October 2018 at the Toronto General Hospital, Toronto, Canada. ACTs were documented before cardiopulmonary bypass termination, after PTDs, and after protamine full doses. Statistical analysis was completed using a paired t test. RESULTS: The average PTD was calculated to be 36 ± 21 mg or 11% ± 7% of the full protamine dose of 367 ± 153 mg. This "test" dose ranged from 1% to 67% of full dose depending on the anesthetist. Post-PTD ACTs were widely variable. On average, there was a 40% ± 25% drop from the last ACT during cardiopulmonary bypass (650 ± 155 seconds) to the ACT after PTD (376 ± 153 seconds) (P < .0001). In fact, 81% ± 5% of the patients' post-PTD ACTs were lower than the institutional ACT standard of 480 seconds for safe cardiopulmonary bypass initiation. CONCLUSIONS: Regardless of the PTD, there is no reliable way to predict how a patient's ACT will respond to a PTD. Clot formation is possible and circuit integrity is at risk when pump suction devices are continuously in use during PTD administration. Therefore, the study investigators strongly recommend that the direct recovery of mediastinal shed blood into the pump circuit be discontinued before any amount of protamine is administered to the patient.