Disinfection of needleless connectors for catheters in one second using a hand-held UV device.

BACKGROUND: The standard of care for disinfecting needleless connectors (NCs) of central venous catheters includes alcohol-containing caps or up to a 15-second scrub with alcohol or chlorhexidine. Due to the clinical impact and high cost of treating Central line-associated bloodstream infections (CLABSI), reducing the incidence of CLABSI is a priority for public health and of the Centers for Disease Control. Alcohol-containing caps have been demonstrated to disinfect external NC surfaces, but not the internal surface. Ultraviolet light (UV-C) is a strategy for disinfection of NC internal and external surfaces. METHODS: Four clinically relevant bacteria (Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa) and Candida albicans were inoculated on NCs. Disinfection efficacy was measured after exposure to one second of 285 nm UV-C light at 48 mW/cm2 in a proprietary handheld device and UV-C transparent NC or standard of care. Disinfection of internal and external surfaces of NC inoculated with S aureus using alcohol caps, and UV-C was also compared. RESULTS: A 4-log reduction in colony forming units (CFUs) on the interior and exterior surfaces of the UV-transparent NC of clinically relevant pathogens was observed with UV-C light at this power for 1 second. DISCUSSION: We demonstrated the efficacy of UV-C for the disinfection of NCs in one second using the UV-C device in benchtop studies. CONCLUSIONS: This device holds promise for reducing CLABSI, and clinical studies are planned.

Acute kidney injury in patients before and after extracorporeal membrane oxygenation (ECMO) - Retrospective longitudinal analysis of the hospital outcomes.

PURPOSE: Acute Kidney Injury (AKI) occurs in up to 85% of patients managed by ECMO support. Limited data are available comparing the outcomes among patients who develop AKI before and after ECMO initiation. METHODS: A retrospective longitudinal observational study was performed on all adult patients placed on ECMO from January 2000 to December 2015 at our institution. Longitudinal multivariate logistic regressional analysis was performed to identify the variables that are associated with the outcome measures (post-ECMO AKI and in-hospital mortality). RESULTS: A total of 329 patients were included in our analysis in which AKI occurred in 176 (53%) and 137 (42%) patients before and after ECMO, respectively. In the multivariate analysis, increasing age, pre-existing chronic kidney disease (CKD), increasing bilirubin, decreasing fibrinogen, and use of LVAD had significant association with post-ECMO AKI. In-hospital mortality was seen in 128 out of 176 (73%) patients in the pre-ECMO AKI group and 32 out of 137 (42%) in the post-ECMO AKI group. In the multivariate analysis, age, interstitial lung disease, pre-ECMO AKI, and post-ECMO RRT requirement were independently associated with mortality. CONCLUSION: AKI before ECMO initiation and the need for RRT post-ECMO are independently associated with poor patient survival.

Survival-to-Hospital Discharge in Neonates With Congenital Heart Disease Supported With Prolonged Extracorporeal Membrane Oxygenation.

Factors that determine early outcomes in neonates with congenital heart disease (CHD) supported with prolonged venoarterial extracorporeal membrane oxygenation (ECMO) are not known and contemporary multicenter data are limited. This Extracorporeal Life Support Organization registry-based retrospective cohort study included all neonates (age ≤28 days) with CHD supported with venoarterial ECMO >7 days at 111 centers in the United States from January 2011 to December 2020. The primary outcome was survival-to-hospital discharge, and the secondary outcome was ECMO survival (successful decannulation before hospital discharge or death). Of the 2,155 total ECMO runs, 948 neonates received prolonged ECMO (gestational age [mean ± SD] 37.9 ± 1.8 weeks; birth weight 3.1 ± 0.6 kg; ECMO duration 13.6 ± 11.2 days). The ECMO survival rate was 51.6% (489 of 948), and the survival-to-hospital discharge rate was 23.9% (226 of 948). Body weight at ECMO (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.44 to 0.78/kg), gestational age (OR 0.89, 95% CI 0.79 to 1.00 per week), risk-adjusted congenital heart surgery-1 score (OR 1.22, 95% CI 1.04 to 1.45), and pump flow at 24 hours (OR 1.11, 95% CI 1.04 to 1.18 per 10 ml/kg/min) were significantly associated with survival-to-hospital discharge. Pre-ECMO mechanical ventilation duration, time to extubation after ECMO decannulation, and length of stay were inversely associated with hospital survival. Patient-specific (higher body weight and gestational age) and CHD-related (lower risk-adjusted congenital heart surgery-1 score) attributes are associated with better outcomes in neonates who receive prolonged venoarterial ECMO. Further elucidation of the factors associated with reduced survival to discharge in ECMO survivors is needed.

Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience.

INTRODUCTION: To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation. METHODS: A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge. RESULTS: In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days. CONCLUSION: Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Peripherally inserted central catheters inserted with current best practices have low deep vein thrombosis and central line-associated bloodstream infection risk compared with centrally inserted central catheters: A contemporary meta-analysis.

BACKGROUND: Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines. METHODS: Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006-2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line-associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle-Ottawa and Cochrane Risk of Bias scales. RESULTS: Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line-associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30-0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47-2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients (p = 0.064). Patient outcomes favored peripherally inserted central catheters. CONCLUSION: When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.

Same-Day Versus Non-Simultaneous Extracorporeal Membrane Oxygenation Support for In-Hospital Cardiac Arrest Complicating Acute Myocardial Infarction.

BACKGROUND: Although extracorporeal membrane oxygenation (ECMO) is used for hemodynamic support for in-hospital cardiac arrest (IHCA) complicating acute myocardial infarction (AMI), there are limited data on the outcomes stratified by the timing of initiation of this strategy. METHODS: Adult (>18 years) AMI admissions with IHCA were identified using the National Inpatient Sample (2000-2017) and the timing of ECMO with relation to IHCA was identified. Same-day vs. non-simultaneous ECMO support for IHCA were compared. Outcomes of interest included in-hospital mortality, temporal trends, hospitalization costs, and length of stay. RESULTS: Of the 11.6 million AMI admissions, IHCA was noted in 1.5% with 914 (<0.01%) receiving ECMO support. The cohort receiving same-day ECMO (N = 795) was on average female, with lower comorbidity, higher rates of ST-segment-elevation AMI, shockable rhythm, and higher rates of complications. Compared to non-simultaneous ECMO, the same-day ECMO cohort had higher rates of coronary angiography (67.5% vs. 51.3%; p = 0.001) and comparable rates of percutaneous coronary intervention (58.9% vs. 63.9%; p = 0.32). The same-day ECMO cohort had higher in-hospital mortality (63.1% vs. 44.5%; adjusted odds ratio 3.98 (95% confidence interval 2.34-6.77); p < 0.001), shorter length of stay, and lower hospitalization costs. Older age, minority race, non-ST-segment elevation AMI, multiorgan failure, and complications independently predicted higher in-hospital mortality in IHCA complicating AMI. CONCLUSIONS: Same-day ECMO support for IHCA was associated with higher in-hospital mortality compared to those receiving non-simultaneous ECMO support. Though ECMO-assisted CPR is being increasingly used, careful candidate selection is key to improving outcomes in this population.

Using a Modified CPD Blood Bag to Store Blood from either ECMO or RRT Circuit Blood in Pediatric Patients.

By adapting a citrate phosphate dextrose (CPD) whole blood storage bag, residual blood from a renal replacement therapy (RRT) circuit can be saved in pediatric patients, decreasing in donor exposure later. The techniques used for autologous preoperative blood storage are the basis of storing the RRT circuit blood. The CPD anticoagulant has a benefit of having a commonly used reversal agent for its anticoagulant properties, i.e., calcium. Also, unlike the traditional anticoagulants used in extracorporeal membrane oxygenation (ECMO), i.e., heparin, and direct thrombin inhibitors, i.e., bivalirudin, there is no increase in anticoagulation laboratory parameters after administration. The CPD volume in the bag is reduced but keeps the original ratio the same between CPD and blood. This is accomplished by removing all CPD from the bag, adding back only the exact amount of CPD needed for the smaller amount of blood being transferred from the circuit. The RRT circuit managed at our institution uses 23 mL of CPD for 165 mL of circuit blood when stored with this technique. This calculation assumes a normal patient calcium level. This technique has been used successfully multiple times in more than 30 pediatric patients without incident for 7 years at our center. The CPD bag can also be used to store the residual blood from ECMO circuits after removal of ECMO to allow the blood to be given back to the patient at a later time by keeping the same citrate-to-blood ratio.

Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000 to 2014.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data. METHODS: Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization. RESULTS: In ≈9 million AMI admissions, ECMO was used in 2962 (<0.01%) and implanted a median of 1 day after admission. ECMO was used in 0.5% and 0.3% AMI admissions complicated by cardiogenic shock and cardiac arrest, respectively. ECMO was used more commonly in admissions that were younger, nonwhite, and with less comorbidity. ECMO use was 11× higher in 2014 as compared with 2000 (odds ratio, 11.37 [95% CI, 7.20-17.97]). Same-day percutaneous coronary intervention was performed in 23.1%; intra-aortic balloon pump/percutaneous LVAD was used in 57.9%, of which 30.3% were placed concomitantly. In-hospital mortality with ECMO was 59.2% overall but decreased from 100% (2000) to 45.1% (2014). Durable LVAD and cardiac transplantation were performed in 11.7% as an exit strategy. Of the hospital survivors, 40.8% were discharged to skilled nursing facilities. Older age, male sex, nonwhite race, and lower socioeconomic status were independently associated with higher in-hospital mortality with ECMO use. CONCLUSIONS: In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO.

Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations.

OBJECTIVE: To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology. PATIENTS AND METHODS: We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation. RESULTS: Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death. CONCLUSION: For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.

Anticoagulation Management during First Five Days of Infant-Pediatric Extracorporeal Life Support.

Anticoagulation during infant-pediatric extracorporeal life support (ECLS) has been a topic of study for many years, but management of anticoagulation is still only partially understood. Adequate anticoagulation during ECLS is imperative for successful outcomes and understanding the individual variables that play part is crucial for properly implementing anticoagulation management strategies. The purpose of our study was to compare the relationships between the variables of activated partial thromboplastin time (aPTT), activated clotting time, international normalized ratio, bleeding, thrombus formation, kaolin + heparinase thromboelastograph alpha angle, kaolin thromboelastograph reaction time (KTEG R-time), heparin dose rates (HDR), antithrombin (AT), anti-Xa, bivalirudin dose rate, argatroban dose rate, interventions, and transfusions. We hypothesized that the relationship between measures of anticoagulation would be influenced by the AT levels, and a therapeutic aPTT (60-80 seconds) could be achieved by increasing, or maintaining, the overall AT above a specific threshold for infant-pediatric patients on ECLS. Thirty-five infant-pediatric patients underwent ECLS between January 2013 and January 2016. The median age was 39 days with an average weight of 3.9 ± 4.3 kg. ECLS parameters collected at least every 24 hours for the first five ECLS days. Parameters recorded by retrospective chart review were analyzed using linear regression and receiver operator characteristic (ROC) analysis. We were unable to report a significant correlation between optimal aPTT and HDR at various AT levels. However, ROC analysis suggested that to maintain an aPTT above 60 seconds, an AT threshold of 42% or higher was observed when the HDR was >12 U/kg/h ROC analysis also determined that no thrombus was associated with an aPTT >64 seconds and decreased bleeding was associated with a KTEG R-time below 30 minutes. Based on these findings, we report multiple correlations that may help develop future standardized infant-pediatric ECLS anticoagulation protocols.

Practical Implementation of Failure Mode and Effects Analysis for Extracorporeal Membrane Oxygenation Activation.

Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.

Granulocyte colony-stimulating factor significantly decreases density of hippocampal caspase 3-positive nuclei, thus ameliorating apoptosis-mediated damage, in a model of ischaemic neonatal brain injury.

OBJECTIVES: Ischaemic brain injury is a major complication in patients undergoing surgery for congenital heart disease, with the hippocampus being a particularly vulnerable region. We hypothesized that neuronal injury resulting from cardiopulmonary bypass and associated circulatory arrest is ameliorated by pretreatment with granulocyte colony-stimulating factor (G-CSF), a cytokine and an anti-apoptotic neurotrophic factor. METHODS: In a model of ischaemic brain injury, 4 male newborn piglets were anaesthetized and subjected to deep hypothermic circulatory arrest (DHCA) (cooled to 18°C, DHCA maintained for 60 min, rewarmed and recovered for 8-9 h), while 4 animals received G-CSF (34 µg/kg, intravenously) 2 h prior to the DHCA procedure. At the end of each experiment, the animals were perfused with a fixative, the hippocampus was extracted, cryoprotected, cut and the brain sections were immunoprocessed for activated caspase 3, a pro-apoptotic factor. Immunopositive neuronal nuclei were counted in multiple counting boxes (440 × 330 µm) centred on the CA1 or CA3 hippocampal regions and their mean numbers compared between the different treatment groups and regions. RESULTS: G-CSF pretreatment resulted in significantly lower counts of caspase 3-positive nuclei per counting box in both the CA1 [52.2 ± 9.3 (SD) vs 61.6 ± 8.4, P < 0.001] and CA3 (41.2 ± 6.9 vs 60.4 ± 16.4, P < 0.00002) regions of the hippocampus as compared to DHCA groups. The effects of G-CSF were significant for pyramidal cells of both regions and for interneurons in the CA3 region. CONCLUSIONS: In an animal model of ischaemic brain injury, G-CSF reduces neuronal injury in the hippocampus, thus potentially having beneficial effect on neurologic outcomes.

Congenital diaphragmatic hernia: outcomes of neonates treated at Mayo Clinic with and without extracorporeal membrane oxygenation.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long-term comorbid conditions. AIMS: Our aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution. METHODS: We performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow-up. RESULTS: Thirty-eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver-up vs liver-down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01-0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20-73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO. CONCLUSION: The overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

Coagulation Parameter Thresholds Associated with Non-Bleeding in the Eighth Hour of Adult Cardiac Surgical Post-Cardiotomy Extracorporeal Membrane Oxygenation.

Excessive bleeding and allogeneic transfusion during adult post-cardiotomy venoarterial extracorporeal membrane oxygenation (ECMO) are potentially harmful and expensive. Balancing the inhibition of clotting and distinguishing surgical from non-surgical bleeding in post-operative period is difficult. The sensitivity of coagulation tests including Thromboelastography(®) (TEG) to predict chest tube drainage in the early hours of ECMO was examined with the use of receiver-operating characteristics (ROC). The results are useful to incorporate in clinical evidence-based algorithms to guide management decisions. In the eighth hour of ECMO, 26 of the 53 adult patients (49%) studied were identified as non-bleeders (less than 2.0 mL/kg/h). All had experienced various types of cardiac surgical procedures. Fifty-two percent were female and the group was 54 ± 19 (mean ± 1 SD) years old. The coagulation parameter threshold with the maximum sensitivity and specificity to predict non-bleeding at 8 hours on ECMO was the kaolin plus heparinase TEG maximum amplitude (KH-TEG MA) at a significant ROC threshold (t) > 50 mm. The activated partial thromboplastin time (aPTT) t < 49 seconds, KH-TEG alpha-angle t > 51°, and the kaolin activated clotting time (ACT) t < 148 seconds were sensitive predictors of non-bleeders. The whole-blood KH-TEG MA was superior to the plasma-based aPTT or International Normalization Ratio (INR) to predict bleeding in the eighth hour of ECMO. Using coagulation laboratory thresholds that predict non-bleeding can begin a process of identifying patients earlier that are likely to bleed. Awareness of these parameter thresholds may improve care through patient protection from unnecessary transfusion and prolonging the life of the ECMO circuit. An algorithm incorporating the ROC thresholds was created to help recognize surgical bleeding to minimize unnecessary transfusions.

Use of Extracorporeal Membrane Oxygenation for the Treatment of Influenza-Induced Acute Respiratory Distress Syndrome in Immunocompromised Adults.

Influenza infection in the adult immunocompromised hosts can have severe presentations and rapid progression to lower respiratory tract infection requiring mechanical ventilation, and it even can progress to acute respiratory distress syndrome. Little is known about the role of extracorporeal membrane oxygenation for management in this setting. We present a review of the current literature on the subject.

Derivation and Validation of a Search Algorithm to Retrospectively Identify CRRT Initiation in the ECMO Patients.

BACKGROUND: The role of extracorporeal membrane oxygenation (ECMO) in refractory cardiorespiratory failure is gaining momentum with recent advancements in technology. However, the need for dialysis modes such as continuous renal replacement therapy (CRRT) has also increased in the management for acute kidney injury. Establishing the exact timing of CRRT initiation in these patients from the electronic medical record is vital for automated data extraction for research and quality improvement efforts. OBJECTIVES: We aimed to derive and validate an automated Electronic Health Records (EHR) search strategy for CRRT initiation in patients receiving ECMO. METHODS: We screened 488 patients who received ECMO and a total of 213 patients underwent CRRT. We evaluated random 120 patients, 60 for derivation and 60 for validation cohorts. Following implementation of eligibility criteria, the algorithm was derived in 55 out of 120 ECMO/CRRT patients. The search algorithm was developed using first-time chart entry of 'access pressure drop' at CRRT initiation. The algorithm was then validated in an independent subset of 52 patients from the same time period. The overall agreement between electronic search algorithm and a comprehensive manual medical record review in the derivation and validation subsets, using 'access pressure drop' as the reference standard, was compared to assess CRRT initiation time. RESULTS: In the derivation subset (N=55), the automated electronic search strategy achieved an excellent agreement with manual search (κ =0.99, 54 were identified electronically, and 55 upon manual review). There was no time difference observed in 49/54(89%) patients, while in the remaining 5 (9%) patients time difference was within 15 minutes. In the validation cohort (N=52), agreement was 100 % (κ = 1.0, both methods identified 52 patients). Out of 52 patients, 47 (90%) had no time difference between the methods, for the remaining 5 (10%) patients, differences were within 15 minutes. CONCLUSIONS: The use of an electronic search strategy resulted in determining an accurate CRRT initiation time among ECMO patients.

Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease.

BACKGROUND: Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover. METHODS: We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013. RESULTS: During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors. CONCLUSIONS: Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.