Verticalization Therapy for Acute Respiratory Distress Syndrome Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation.

Persistent hypoxemia during veno-venous extracorporeal membrane oxygenation (VV-ECMO) for supporting acute respiratory distress syndrome (ARDS) patients is a clinical challenge for intensive care medical providers. Prone positioning is an effective strategy to treat persistent hypoxemia; however, placing a patient in a prone position is resource intensive with significant risks to the patient. We present a patient with severe ARDS receiving VV-ECMO who underwent verticalization therapy and subsequently recovered pulmonary function.

Preoperative Anemia and Risk for Perioperative Neurocognitive Dysfunction in Cardiac Surgery Patients: A Retrospective Analysis.

OBJECTIVES: To evaluate whether there is a relationship between preoperative anemia and domain-specific cognitive performance in patients undergoing cardiac surgery. DESIGN: Retrospective analysis of data collected from a randomized study. SETTING: Tertiary care university hospital. PARTICIPANTS: A total of 436 patients age ≥55 years undergoing cardiac surgery. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological testing was performed before and one month after surgery, using a standard battery. Individual Z-scores calculated from the mean and standard deviation of tests at baseline were combined into domain-specific scores. Anemia (hemoglobin <130 g/L for men, <120 g/L for women) was present in 41% of patients. Preoperative anemia had little impact on preoperative cognition. There were no differences in the change in cognitive performance one month after surgery from baseline between patients with and without preoperative anemia. However, in a sensitivity analysis using multiple imputation for missing cognitive test scores, significant associations were observed between preoperative anemia and change in postoperative processing speed (p = 0.016), change in executive function (p = 0.049), and change in fine motor speed (p = 0.016). Nadir hemoglobin during cardiopulmonary bypass, which was lower in anemic than nonanemic patients, was associated with decrements in performance on tests of verbal fluency (p = 0.007), processing speed (p = 0.042), and executive function (p = 0.10) one month after surgery but not delayed neurocognitive recovery (p = 0.06). CONCLUSIONS: Preoperative anemia may be associated with impairment of selective cognitive domains after surgery. Any effect of preoperative anemia may have on cognition after surgery might be related to lower nadir hemoglobin during cardiopulmonary bypass.

Institution of prothrombin complex concentrate protocols is associated with a reduction in plasma administration at a Tertiary Care Hospital.

STUDY OBJECTIVE: Explore how the introduction of 4-factor prothrombin complex concentrates (4F-PCC) protocols for reversing anticoagulation and the treatment of critical bleeding influenced blood product utilization. DESIGN: A retrospective analysis of the utilization rate of plasma and 4F-PCC from September 2012 through December 2018. SETTING: Blood bank and pharmacy records of a single large tertiary care medical center. PATIENTS: Admitted patients except obstetric during the study period (n = 283,319). INTERVENTION: Five institutional protocols providing guidelines for 4F-PCC administration were deployed over a 3-year period. MEASUREMENTS: The utilization rate of plasma and 4F-PCC was the primary outcome and analyzed using an interrupted time series analysis. Utilization of platelets and cryoprecipitate as well as the impact of the intervention on the service prescribing the blood products were evaluated as secondary outcomes. Data were evaluated using a segmented time series regression. RESULTS: When adjusted for seasonality, the monthly rate of plasma administration was 24.7 ± 2.0 units per 100 admissions in the 6-month period prior to the 1st intervention (May-October 2013) and decreased to 9.9 ± 2.2 units per 100 admissions in the same six-month period following the 5th intervention (May-October 2018), median difference - 14.5, 95% CI -16.0 to -13.2, P < 0.001. During the 6-month period prior to the 1st intervention (May-October 2013) the monthly rate of 4-F PCC use was 1.2 ± 0.8 doses per 1000 admissions and increased to 2.8 ± 1.0 doses per 1000 admissions 6-months following the 5th intervention (May-October 2018), median difference 1.6, 95% CI 0.3 to 1.9, P = 0.014. The monthly utilization of platelets was decreased and cryoprecipitate slightly increased following the implementation of the PCC protocols. CONCLUSIONS AND RELEVANCE: Our findings demonstrate that establishing institutional protocols for the use of 4F-PCC to reverse the effects of anticoagulation and to treat critical bleeding with associated coagulopathy was associated with reduced plasma utilization.

Extracorporeal Membrane Oxygenation Can Successfully Support Patients With Severe Acute Respiratory Distress Syndrome in Lieu of Mechanical Ventilation.

OBJECTIVES: Extracorporeal membrane oxygenation is increasingly used in the management of severe acute respiratory distress syndrome. With extracorporeal membrane oxygenation, select patients with acute respiratory distress syndrome can be managed without mechanical ventilation, sedation, or neuromuscular blockade. Published experience with this approach, specifically with attention to a patient's respiratory drive following cannulation, is limited. DESIGN: We describe our experience with three consecutive patients with severe acute respiratory distress syndrome supported with right jugular-femoral configuration of venovenous extracorporeal membrane oxygenation without therapeutic anticoagulation as an alternative to lung-protective mechanical ventilation. Outcomes are reported including daily respiratory rate, vital capacities, and follow-up pulmonary function testing. RESULTS: Following cannulation, patients were extubated within 24 hours. During extracorporeal membrane oxygenation support, all patients were able to maintain a normal respiratory rate and experienced steady improvements in vital capacities. Patients received oral nutrition and ambulated daily. At follow-up, no patients required supplemental oxygen. CONCLUSIONS: Our results suggest that venovenous extracorporeal membrane oxygenation can provide a safe and effective alternative to lung-protective mechanical ventilation in carefully selected patients. This approach facilitates participation in physical therapy and avoids complications associated with mechanical ventilation.

Prognostic value of postoperative proteinuria in cardiac surgery: a pilot study.

BACKGROUND: Proteinuria is a non-specific marker of inflammation that may reflect the glomerular component of systemic capillary leak. The objective of this pilot study was to determine if postoperative proteinuria is associated with adverse outcomes following cardiac surgery with cardiopulmonary bypass. METHODS: Eligible patients were individuals undergoing cardiac surgery with cardiopulmonary bypass who did not have severe pre-existing renal dysfunction. Urine was collected after induction of anesthesia (baseline) and two to four hours after arrival to the intensive care unit (ICU). Proteinuria was measured as random protein creatinine ratio in g.mol(-1). Adverse events were defined a priori as prolonged ICU stay (> or = 90th percentile) and organ dysfunction. The relationship between proteinuria and adverse events was assessed by bivariate (Chi-square or Fisher's exact tests) and multivariable (multiple logistic regression) analyses. RESULTS: The study included 197 (of 243 eligible) patients. Postoperative proteinuria (protein creatinine ratio > or = 30 g.mol(-1)) was associated with prolonged (> or = four days) ICU stay [odds ratio (OR) 7.0; 95% confidence interval (CI) 2.8-17.1] and organ dysfunction (OR 3.9; CI 1.9-8.1). After adjustment for confounders, proteinuria was associated with a 3.2-fold increase in the odds of both prolonged ICU stay (CI 1.1-9.7) and organ dysfunction (CI 1.4-7.0). CONCLUSIONS: Proteinuria two to four hours after cardiac surgery with cardiopulmonary bypass may be a useful marker for systemic capillary leak and adverse postoperative events. Large prospective studies are needed to confirm these findings.