Tracheostomy as a bridge to spontaneous breathing and awake-ECMO in non-transplant surgical patients.

AIMS: The tracheostomy is a frequently used procedure for the respiratory weaning of ventilated patients allows sedation free ECLS use in awake patient. The aim of this study is to assess the possibility and highlight the benefits of lowering the impact of sedation in surgical non-transplant patients on ECLS. The specific objective was to investigate the use of tracheostomy as a bridge to spontaneous breathing on ECLS. METHODS AND RESULTS: Of the 95 patients, 65 patients received a tracheostomy, and 5 patients were admitted with a tracheostoma. One patient was cannulated without intubation, one is extubated during ECLS course after 48 hours. 4 patients were extubated after weaning and the removal of ECLS. 19 patients died before the indication to tracheostomy was given. CONCLUSION: Tracheostomy can bridge to spontaneous breathing and awake-ECMO in non-transplant surgical patients. The "awake ECMO" strategy may avoid complications related to mechanical ventilation, sedation, and immobilization and provide comparable outcomes to other approaches for providing respiratory support.

Thirteen years of oxcarbazepine exposures reported to US poison centers: 2000 to 2012.

OBJECTIVES: Oxcarbazepine (OXC) is a 10-keto analogue of carbamazepine used in patients with partial and secondary generalized seizures. We evaluated ingestions of OXC reported to US poison centers for adverse effects from supratherapeutic doses and/or overdose. METHOD: Retrospective analysis of data reported to National Poison Data System from single-substance OXC ingestions between January 2000 and December 2012. RESULTS: There were 18,867cases with a mean of 1451 exposures/year. The patients were predominantly adults with 5464 exposures in children <6 years (29%). The most commonly reported clinical effects were drowsiness (n = 4703, 25%), vomiting (n = 1559, 8%), tachycardia (n = 590, 3%), agitated (n = 342, 1.8%), hypotension (n = 178, 0.9%), electrolyte disturbance (n = 153, 0.8%), coma (n = 156, 0.8%), and seizures (n = 121, 0.6%). There were 176 patients with a major effect of which 31 involved were children and 1728 (9%) patients with moderate effects of which 300 involved were children. Five deaths were reported in adults. Intentional exposure (e.g. suicide) was the reason for exposure in 68% of patients with major effects and in all fatalities. Fifty-three percent of adults and 38% of children were managed in a health-care facility (HCF). HCF utilization levels remained consistent. DISCUSSION: Severe outcomes appear to be infrequent (<1%). Unlike other anticonvulsants OXC does not appear to be proconvulsant in overdose. CONCLUSION: Serious outcomes for OXC overdoses are unlikely in the pediatric patient. With only mild symptoms likely, observation at home may be appropriate for the majority of cases. In the adult population there appears to be few neurologic and cardiovascular complications even in the intentional exposure.

Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) with pulmonary embolism in surgical patients - a case series.

BACKGROUND: Extracorporeal life support (ECLS) devices maintain the circulation and oxygenation of organs during acute right ventricular failure and cardiogenic shock, bypassing the lungs. A pulmonary embolism can cause this life-threatening condition. ECLS is a considerably less invasive treatment than surgical embolectomy. Whether to bridge embolectomy or for a therapeutic purpose, ECLS is used almost exclusively following failure of all other therapeutic options. METHODS: From January 1, 2008 to June 30, 2014, five patients in cardiac arrest and with diagnosed pulmonary embolism (PE) were cannulated with the ECLS system. RESULTS: PE was diagnosed using computer tomography scanning or echocardiography. Cardiac arrest was witnessed in the hospital in all cases and CPR (cardiopulmonary resuscitation) was initiated immediately. Cannulation of the femoral vein and femoral artery was always performed under CPR conditions. Right heart failure regressed during the ECLS therapy, usually under a blood flow of 4-5 L/min after 48 hours. Three patients were weaned from ECLS and one patient became an organ donor. Finally, two of the five PE patients treated with ECLS were discharged from inpatient treatment without neurological dysfunction. The duration of ECLS therapy depends on the patient's condition. Irreversible damage to the organs after hypoxemia limits ECLS treatment and leads to futile multiorgan failure. Hemorrhages after thrombolysis and cerebral dysfunction were further complications. CONCLUSIONS: Veno-arterial cannulation for ECLS can be feasibly achieved and should be established during active CPR for cardiac arrest. In the case of PE, the immediate diagnosis and rapid implantation of the system are decisive for therapeutic success.

Use of extracorporeal membrane oxygenation in an awake patient after a major trauma with an incidental finding of tuberculosis.

We report the use of extracorporeal membrane oxygenation (ECMO) in a trauma patient with an incidental finding of open tuberculosis (TB). Sedation was reduced during extracorporeal support and awake veno-venous ECMO was successfully performed. Subsequently, accidental cannula removal caused major blood loss which required the administration of cardiopulmonary resuscitation (CPR). Our case report demonstrates that the incidental finding of open TB is an important hint for differential diagnosis and that it should still be considered in high-income countries. In addition, awake ECMO appears to be a feasible therapeutic option in non-transplant patients, although the described case demonstrates that patient compliance and nursing care are important for therapeutic success to avoid complications, for example, inadvertent decannulation.

Veno-venous extracorporeal membrane oxygenation therapy of a severely injured patient after secondary survey.

Thoracic injury following a major trauma can be life threatening. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) can be used as a support to mechanical ventilation when acute respiratory distress syndrome is present. We report the case of an 18-year-old male driver who strayed from the road and fell 15 m into a backyard by landing on the roof of its car. The injury severity score was 51 for his pattern of injuries (hemopneumothorax left, sternum fracture, pneumothorax right, pneumomediastinum, intracerebral bleeding, scalping injury occipital, fracture of the ninth thoracic vertebral body, and complete paraplegia). The patient was transferred to our hospital 12 hours after the accident. As we started the secondary survey, the patient was cannulated for vv-ECMO due to deterioration in his oxygenation status. We implanted a double-lumen cannula (Avalon31F catheter, right internal jugular vein) during fluoroscopy. The patient developed posttraumatic systemic inflammatory response syndrome, which began to resolve after 72 hours, and he started breathing spontaneously. After 7 days, he was weaned from vv-ECMO and recovered in a rehabilitation facility. The use of vv-ECMO therapy in cases of major trauma has become a rescue strategy. The use of vv-ECMO was performed without anticoagulation because of his traumatic brain injury and severe spinal cord injury.

Veno-venous extracorporeal membrane oxygenation in obese surgical patients with hypercapnic lung failure.

BACKGROUND: In patients with a body mass index (BMI) > 35 kg/m(2) , or in extreme cases weighting > 250 kg, we are faced with special challenges in therapy and logistics. The aim was to analyze the feasibility of the extracorporeal membrane oxygenation (ECMO) in these patients. METHODS: We report 12 adult patients [10 male, 2 female; mean age 56.7 (34-74) years; mean BMI 47.9 (35-88.6) kg/m(2) ] with acute lung failure treated with veno-venous ECMO from 1 January 2009 to 30 June 2013. All patients were cannulated percutaneously into the right internal jugular vein and one of the femoral veins at the bedside. RESULTS: The mean time to ECMO after admission to the intensive care unit (ICU) was 2 days (0-10), and the mean ECMO run time was 9 days (4 h-20 days). Lung failure occurred in the contexts of wound infection (two patients), anaphylactic shock (one patient), major trauma (one patients) and pneumonia after surgery (four patients), and respiratory failure in abdominal sepsis (four patients). The mean time in the ICU was 31 days (0-89), and the mean time at the hospital was 38 days (0-101). Three patients died on the system because of multiorgan failure; nine patients were weaned from ECMO (75%); and six were patients discharged from the ICU and from the hospital (survival rate 50%). CONCLUSIONS: ECMO in obese patients is feasible and life saving. Therefore, a percutaneous cannulation remains feasible. The goals of the ECMO therapy include early spontaneous breathing, tracheotomy, rapid reduction of sedation and adequate analgesia. Rehabilitation includes nutritional therapy, as well as psychiatric therapy and bariatric surgery, as perspectives for the future.

Surgical extraction after thrombosis around the Avalon dual lumen cannula.

The use of a dual lumen cannula (DLC) for venovenous extracorporeal membrane oxygenation (ECMO) has several advantages and reports of complications are rare. We present a case of thrombosis around and inside the Avalon Elite™ bicaval DLC (Avalon Laboratories, Rancho Dominguez, CA, US), for which simple removal by retraction was impossible. A 30-year-old man had experienced an unstable C6/7 fracture with spinal contusion and haematoma in the spinal canal with incomplete neurological paraplegia and thoracic trauma. He developed acute respiratory failure due to posttraumatic systemic inflammatory response syndrome and venovenous extracorporeal membrane oxygenation (ECMO) support was indicated. The cannulation was performed with an Avalon Elite™ cannula (31Fr) in the right jugular vein under fluoroscopy. After 18 days of ECMO therapy, despite the continuous administration of heparin (400iu/h), ECMO was discontinued because of the formation of a massive thrombus in the oxygenator. At that time, the patient's haemodynamic and respiratory parameters were stable, and we were able to induce a rapid weaning from ECMO. The surgical removal of the cannula became necessary and was performed using a small neck incision without complications. We report this case to emphasise that any resistance encountered during an attempt to extract the Avalon Elite™ cannula may cause serious complications. In such cases, surgical removal must be considered.

Use of extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threatening complications in trauma patients. Despite the implantation of a veno-venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO(2) > 90%) is not always achieved. The additive use of high-frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life-threatening hypoxaemia and multi-organ failure. We report on a 26-year-old female (Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz-Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz-Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen (FiO(2) ) was significantly reduced. The pelvic fracture was treated non-operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days.

State of the art in neuroprotection during acute type A aortic dissection repair.

Temporary (TND) or permanent neurologic dysfunctions (PND) represent the main neurological complications following acute aortic dissection repair. The aim of our experimental and clinical research was the improvement and update of the most common neuroprotective strategies which are in present use. HYPOTHERMIC CIRCULATORY ARREST (HCA): Cerebral metabolic suppression at the clinically most used temperatures (18-22°C) is less complete than had been assumed previously. If used as a 'stand-alone' neuroprotective strategy, cooling to 15-20°C with a jugular SO(2) ≥ 95% is needed to provide sufficient metabolic suppression. Regardless of the depth of cooling, the HCA interval should not exceed 25 min. After 40 min of HCA, the incidence of TND and PND increases, after 60 min, the mortality rate increases. ANTEGRADE SELECTIVE CEREBRAL PERFUSION (ASCP): At moderate hypothermia (25-28°C), ASCP should be performed at a pump flow rate of 10ml/kg/min, targeting a cerebral perfusion pressure of 50-60mmHg. Experimental data revealed that these conditions offer an optimal regional blood flow in the cortex (80±27ml/min/100g), the cerebellum (77±32ml/min/100g), the pons (89±5ml/min/100g) and the hippocampus (55±16ml/min/100g) for 25 minutes. If prolonged, does ASCP at 32°C provide the same neuroprotective effect? CANNULATION STRATEGY: Direct axillary artery cannulation ensures the advantage of performing both systemic cooling and ASCP through the same cannula, preventing additional manipulation with the attendant embolic risk. An additional cannulation of the left carotid artery ensures a bi-hemispheric perfusion, with a neurologic outcome of only 6% TND and 1% PND. NEUROMONITORING: Near-infrared spectroscopy and evoked potentials may prove the effectiveness of the neuroprotective strategy used, especially if the trend goes to less radical cooling. CONCLUSION: A short interval of HCA (5 min) followed by a more extended period of ASCP (25 min) at moderate hypothermia (28°C), with a pump flow rate of 10ml/kg/min and a cerebral perfusion pressure of 50 mmHg, represents safe conditions for open arch surgery.

TNFalpha-induced GM-CSF release from human airway smooth muscle cells depends on activation of an ET-1 autoregulatory positive feedback mechanism.

BACKGROUND: There is an urgent need to inhibit endothelin-1 (ET-1) induced chronic inflammatory processes in early stages of lung diseases in order to prevent untreatable irreversible stages often accompanied by lung fibrosis and pulmonary hypertension. Nothing is known about the airway inflammation-inducing and/or maintaining role of ET-1 in human airway smooth muscle cells (HASMCs). OBJECTIVE: ET-1 and granulocyte-macrophage colony-stimulating factor (GM-CSF) expression in response to tumour necrosis factor alpha (TNFalpha) and ET-1 stimulation was investigated, and the impact of mitogen-activated protein kinase (MAPK) pathways in this context was studied. To elucidate the anti-inflammatory properties of the dual endothelin receptor antagonist bosentan that targets both endothelin receptor subtypes A (ET(A)R) and B (ET(B)R), its effect on the TNFalpha/ET-1/GM-CSF network was investigated. METHODS: ET-1 and GM-CSF expression and activation of MAPKs were investigated via quantitative reverse transcription-PCR (RT-PCR), western blotting and ELISA. MAIN RESULTS: Both TNFalpha and ET-1 activated p38(MAPK) and extracellular signal-regulated kinase (ERK)-1/-2 signalling. ET-1 expression was induced by TNFalpha and by ET-1 itself. Both effects were inhibited by bosentan and by specific ET(A)R or p38(MAPK) blockade. ET-1- and TNFalpha-induced GM-CSF expression were both reduced by bosentan as well as by specific inhibition of either ET(A)R, ET(B)R, p38(MAPK) or ERK-1/-2. CONCLUSION: TNFalpha activates an ET(A)R- and p38(MAPK)-dependent ET-1 autoregulatory positive feedback loop to maintain GM-CSF release from HASMCs. Since bosentan impairs ET-1 autoregulation and TNFalpha-induced ET-1 release, as well as TNFalpha- and ET-1-induced GM-CSF release, the present data suggest therapeutic utility for bosentan in treating particularly the early stages of chronic inflammatory airway diseases.

Case of left atrial metastasis of a sarcomatoid carcinoma.

Metastatic tumor involvement of the heart may occur with all types of primary neoplasms. Right atrial cardiac metastases following vena cava extension from renal cell carcinoma are well recognized, while a left atrial appearance is extremely rare. We report on a patient who developed a left atrial mass originating from the lower right pulmonary vein after successful resection of a renal cell carcinoma with sarcomatoid areas by right-sided nephrectomy. To our knowledge, this is the first described case of this type of pancytokeratin-expressing tumor in the literature so far.

Postocardiotomy failure after Ross operation: implantation of intravascular flow pump through pulmonary autograft.

We report a case of a patient with severe aortic stenosis, who underwent replacement of the aortic valve as a Ross procedure. Postoperatively the patient suffered postcardiotomy failure. Despite prolonged reperfusion and other methods of circulatory support, the patient could not be weaned from cardiopulmonary bypass (CPB). Therefore, an Impella intravascular flow pump was implanted, which is technically easy and has good weaning attributes. For implantation, a vascular prosthesis was sewn to the ascending aorta and the microaxial flow pump was placed under echocardiographic guidance across the pulmonary autograft into the left ventricle. With this support, the patient could be weaned from CPB. The report evaluates the Impella microaxial hemopump as a device that is technically easy to implant with no injury to the pulmonary autograft in patients after Ross operation. Surgeons should consider the device as a short-term support in borderline indications.

Preischemic iloprost application for improvement of graft preservation: which route is superior in experimental pig lung transplantation: inhaled or intravenous?

BACKGROUND: Optimal allograft protection is essential in lung transplantation to reduce postoperative organ dysfunction. Although intravenous prostanoids are routinely used to ameliorate reperfusion injury, the latest evidence suggests a similar efficacy of inhaled prostacyclin. Therefore, we compared donor lung-pretreatment using inhaled lioprost (Ventavis) with the commonly used intravenous technique. METHODS: Five pig lungs were each preserved with Perfadex and stored for 27 hours without (group 1) or with (group-2, 100 prior aerosolized of iloprost were (group 3) or iloprost (IV). Following left lung transplantation, hemodynamics, Po(2)/F(i)o(2), compliance, and wet-to-dry ratio were monitored for 6 hours and compared to sham controls using ANOVA analysis with repeated measures. RESULTS: The mortality was 100% in group 3. All other animals survived (P < .001). Dynamic compliance and PVR were superior in the endobronchially pretreated iloprost group as compared with untreated organs (P < .05), whereas oxygenation was comparable overall W/D-ratio revealed significantly lower lung water in group 2 (P = .027) compared with group 3. CONCLUSION: Preischemic alveolar deposition of iloprost is superior to IV pretreatment as reflected by significantly improved allograft function. This strategy offers technique to optimize pulmonary preservation.

Antegrade selective cerebral perfusion--how to proceed?

Aortic surgery still carries a high risk of brain damage that dominates postoperative morbidity and mortality. The concept and advantages of antegrade selective cerebral perfusion, which allows for numerous variations in its implementation, have been clearly seen for more than a decade now, but the preferred way of positioning remains unanswered. Ideal perfusion during ascending aorta/arch surgery should allow the easy implementation of selective antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion during dissections.

Selective cerebral perfusion via right axillary artery direct cannulation for aortic arch surgery.

BACKGROUND: The risk of neurological complications is still a life-threatening event for patients undergoing proximal aortic arch or total aortic arch surgery. To prevent these complications, axillary artery cannulation and antegrade selective cerebral perfusion were utilized. We compared the effects of using hypothermic circulatory arrest (HCA) alone or with selective cerebral perfusion (SCP/AX) via right side axillary artery direct cannulation. METHODS: 120 patients, mean age 61 +/- 12 years (range 26 - 80), underwent proximal aortic or total aortic arch replacement between 1999 and 2004; 46 were female. We retrospectively compared the results of the two patient groups comparable for preoperative risk factors: 71 pts were operated using HCA beginning in 1999 and 49 pts using HCA/SCP via axillary artery direct cannulation since 2002. The indication for surgery was an aortic aneurysm in 80 (67 %) patients and aortic dissection in 36 (30 %) patients. The groups were well matched with regard to median age (60 vs. 62 yrs), urgency (emergent/urgent 36 vs. 44 %; elective 64 vs. 65 %), and several other known risk factors ( p = ns). RESULTS: Overall in-hospital mortality was 13 %: 10 % with HCA vs. 6 % with SCP/AX. Permanent neurological dysfunction occurred in 10 % with HCA vs. 6 % with SCP/AX. Transient neurological dysfunction (TND) in patients surviving without stroke was lower with SCP/AX (10 %) than with HCA (17 %) ( p = ns). Mean duration of HCA was 28 +/- 12 min when isolated HCA was used, and significantly shorter with 21 +/- 6 min when the combination of SCP/AX ( p = 0.03) was used. Mean duration of CPB was 202 +/- 55 min with HCA vs. 192 +/- 50 min with SCP/AX ( p = ns). Comparison of the groups who had comparable preoperative risk factors showed a trend towards lower in-hospital mortality, stroke and TND rates, a significant reduction in cardiac ( p = 0.034), infectious ( p = 0.025) and bleeding complications ( p = 0.04) in SCP/AX compared with HCA, as well as a significantly shorter duration of hospitalization ( p = 0.046) and shorter ICU stay ( p = ns). CONCLUSION: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By reducing embolic risk, as well as the duration of HCA, SCP with axillary artery direct cannulation may be the optimal technique for averting cerebral events, reducing complications, and shortening hospital stays following aortic arch repair.

Right ventricular assist device implantation--a new transcutaneous approach.

The necessity for a secondary right heart assist device (RVAD) is a disastrous complication in left ventricular assist device (LVAD) support with respect to both complications and outcome. We have developed a new technique for inflow and outflow cannulation via a transcutaneous cannula in the femoral vein and a prosthesis-supported arterial cannula into the pulmonary artery, which does not necessitate rethoracotomy for device explantation. In addition to the simplified RVAD removal this transcutaneous approach may reduce the complications in patients requiring RVAD support.

Bland-White-Garland syndrome. Surgical treatment using a minimal-invasive approach.

We report the surgical treatment of a Bland-White-Garland syndrome (BWG-syndrome) of adult type in a 61-year old female patient. Coronary catheterization revealed an anomalous origin of the left coronary artery from the trunk of the pulmonary artery. Based on excellent collateral perfusion of the artery from the right coronary artery, ligation near its origin from the pulmonary artery was attempted via a minimally-invasive approach. No saphenous vein bypass was implanted, no reimplantation of the anomalous vessel in the aorta was performed. The patient recovered uneventfully without signs of ischemia. Appearance of BWG-syndrome in adults is very rare, especially without symptoms of myocardial ischemia. The different modalities of the treatment of these syndromes in adult patients are often debated. In this case, closure without revascularisation appeared to be appropriate.

Changes in regional cerebral blood flow under hypothermic selective cerebral perfusion.

OBJECTIVE: Currently the most frequently used perfusion technique during aortic arch surgery to prevent cerebral damage is hypothermic selective cerebral perfusion (SCP). Changes in cerebral blood flow (CBF) are known to occur during these procedures. We investigated regional changes of CBF under conditions of SCP in a porcine model. METHODS: In this blinded study, twenty-three juvenile pigs (20 - 22 kg) were randomized after cooling to 20 degrees C on CPB. Group I (n = 12) underwent SCP for 90 minutes, while group II (n = 11) underwent total body perfusion. Fluorescent microspheres were injected at seven time-points to calculate total and regional CBF. Hemodynamics, intracranial pressure (ICP), cerebrovascular resistance (CVR) and oxygen consumption were assessed. Tissue samples from the neocortex, cerebellum, hippocampus and brain stem were taken for a microsphere count. RESULTS: CBF decreased significantly (p = 0.0001) during cooling, but remained at significantly higher levels with SCP than with CPB throughout perfusion (p < 0.0001) and recovery (p < 0.0001). These findings were similar among all regions of the brain, certainly at different levels. Neocortex CBF decreased 50%, whereas brain stem and hippocampus CBF decreased by only 25 % during total body perfusion. All four regions showed 10 - 20% less CBF in the post-CPB period. CBF during SCP did not fall by more than 20% in any analysed region. The hippocampus turned out to have the lowest CBF, while the neocortex showed the highest CBF. CONCLUSION: SCP improves CBF in all regions of the brain. Our study characterizes the brain specific hierarchy of blood flow during SCP and total body perfusion. These dynamics are highly relevant for clinical strategies of perfusion.