Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock-A six-year service evaluation.

Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA-ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial-ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra-aortic balloon counterpulsation on the intensive care unit. 30-day, hospital discharge, 1-year and 2-year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4-9 [1-35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA-ECMO. We suggest postoperative VA-ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

Perioperative Extracorporeal Cardiopulmonary Resuscitation: The Defibrillator of the 21st Century?: A Case Report.

Veno-arterial-extracorporeal membrane oxygenation (ECMO) for cardiopulmonary resuscitation (ECMO-CPR) has been recommended by new resuscitation guidelines in the United Kingdom. Our recently established yet unfunded ECMO-CPR service has thus far treated 6 patients, with 3 making a good recovery. One patient suffered a catastrophic perioperative complication through glycine absorption and we are in no doubt that she would not have survived without ECMO. We argue for a pragmatic approach to funding of ECMO-CPR because observational evidence suggests superiority over traditional resuscitation and there exists major methodological and ethical barriers to randomized controlled studies. We also call for high-quality observational evidence in the perioperative setting.

Extracorporeal membrane oxygenation in severe respiratory failure resulting from burns and smoke inhalation injury.

Extracorporeal membrane oxygenation (ECMO) is one of the most frequent forms of extracorporeal life support (ECLS) and can be used as rescue therapy in patients with severe respiratory failure resulting from burns and/or smoke inhalation injury. Experience and literature on this treatment option is still very limited, consequently results are varied. We report a retrospective analysis of our experience with veno-venous (VV) ECMO in burn patients. All five patients, three male and two female (age: 28-37 years) had flame type burns and smoke inhalation injury. Their Murray scores ranged between 3.25 and 3.75, and their revised Baux scores between 62 and 102. The mean pre-ECMO conventional ventilation time was 7.4days (3-13). The mean ECMO duration was 18days (8-35). Three patients were cannulated with dual lumen, two with separate cannulae. One oxygenator had to be changed due to technical issues and two patients needed two parallel oxygenators. Four patients had renal replacement therapy. All patients needed vasoconstrictor support, antibiotics and packed red blood cells (5-62 units). Three had steroid treatment. All five patients were successfully weaned from ECMO. One patient died later from multi-organ failure in the ICU, the other four patients survived. VV-ECMO is a useful rescue intervention in patients with burns related severe respiratory failure. Patients in our institution benefit from having both burns and ECMO centres with major expertise in the field under one roof. The results from this small cohort are encouraging, although more cases are needed to draw more robust conclusions.

Postcardiotomy VA-ECMO for refractory cardiogenic shock.

Postcardiotomy cardiogenic shock (PCCS) is a rare but catastrophic syndrome that can occur following separation from cardiopulmonary bypass or at any time during the immediate postoperative course. The management of PCCS varies between clinicians, institutions and countries. The available evidence to guide this practice is limited. In their systematic review and meta-analysis, Khorsandi and colleagues report a synthesis of case-series pertinent to the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for PCCS. Whilst we acknowledge the potential survival benefit for carefully selected patients for what is ordinarily a condition with high mortality, we wish to comment on several aspects of the study in the context of its application to clinical practice.

Prophylaxis against atrial fibrillation after cardiac surgery: effective, but not routinely used--a survey of cardiothoracic units in the United kingdom.

OBJECTIVE: To establish whether international recommendations on chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients are implemented locally in cardiothoracic units in the United Kingdom; to determine which drugs are being used, how long they are given, and whether outcomes are monitored. DESIGN: Survey of local cardiothoracic center guidelines. SETTING: Postal and telephone survey. PARTICIPANTS: Senior anesthesiologists and critical care staff in all 37 public cardiothoracic units in the United Kingdom. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Results were obtained from all contacted cardiothoracic units. Five units (14%) have local guidelines for chemoprophylaxis against atrial fibrillation in place. All use ß-antagonists as their primary prophylactic drugs; only one unit uses amiodarone as a secondary prophylactic drug. Duration of prophylactic treatment varies, from 5 days to 6 weeks postoperatively. Thirty-two units (86%) have no local guidelines for chemoprophylaxis in place. CONCLUSION: Chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients remains underused, despite its effectiveness and recommendations for its routine use by several international organizations. Departmental guidelines help to ensure routine use, but this survey shows that so far only a minority of cardiothoracic units in the United Kingdom have implemented such guidelines. Awareness of the advantages of routine prophylaxis against atrial fibrillation should be improved and departmental prescribing policies encouraged.