Venovenous extracorporeal membrane oxygenation for respiratory failure refractory to high frequency percussive ventilation.

BACKGROUND: High frequency percussive ventilation (HFPV) has demonstrated improvements in gas exchange, but not in clinical outcomes. OBJECTIVES: We utilize HFPV in patients failing conventional ventilation (CV), with rescue venovenous extracorporeal membrane oxygenation (VV ECMO) reserved for failure of HFPV, and we describe our experience with such a strategy. METHODS: All adult patients (age >18 years) placed on HFPV for failure of CV at a single institution over a 10-year period were included. Those maintained on HFPV were compared to those that failed HFPV and required VV ECMO. Survival was compared to expected survival after upfront VV ECMO as estimated by VV ECMO risk prediction models. RESULTS: Sixty-four patients were placed on HFPV for failure of CV over a 10-year period. After HFPV initiation, the P/F ratio rose from 76mmHg to 153.3mmHg in the 69 % of patients successfully maintained on HFPV. The P/F ratio only rose from 60.3mmHg to 67mmHg in the other 31 % of patients, and they underwent rescue ECMO with the P/F ratio rising to 261.6mmHg. The P/F ratio continued to improve in HFPV patients, while it declined in ECMO patients, such that at 24 h, the P/F ratio was greater in HFPV patients. The strongest independent predictor of failure of HFPV requiring rescue VV ECMO was a lower pO2 (p = .055). Overall in-hospital survival (59.4 %) was similar to that expected with upfront ECMO (RESP score: 57 %). CONCLUSIONS: HFPV demonstrated significant and sustained improvements in gas exchange and may obviate the need for ECMO and its associated complications.

Managing patients on extracorporeal membrane oxygenation support during the COVID-19 pandemic - a proposal for a nursing standard operating procedure.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is effective in a selected critically ill patient population with promising results in refractory hypoxemia related to the novel coronavirus disease (COVID-19). However, it requires specialized clinicians and resources in advanced technology. Moreover, the COVID-19 remains an ongoing global emergency, and there is no evidence-based practice in preparedness. This article proposes an innovative and optimized nursing care protocol, the Standard Operating Procedure (SOP), that regulates safety and efficiency in using personal protective equipment (PPE) during ECMO-relevant procedures while providing ECMO therapy for patients with COVID-19. METHODS: After performing a narrative literature search, we developed a high-fidelity translational simulation scenario. It included practicing appropriate donning and doffing PPE during work organization, ECMO-related procedures, and routine daily nursing care and management of ECMO over nine hours. In addition, we held supplementary constructive debrief meetings to consult international expert in the field. RESULTS: A proposal for nursing standardized operating procedures was created, divided into categories. They included work organization, workload references, competences, infrastructural conditions, cannulation equipment, daily routine nursing care, and procedures during ECMO. CONCLUSIONS: High-fidelity medical simulation can play an important role in staff training, improvement in previously gained proficiency, and development of optimal SOP for nursing care and management during ECMO in patients with COVID-19. Optimal SOPs may further guide multidisciplinary teams, including intensive care units and interventional departments.

ECMO During a Pandemic: A COVID-19 Quality Improvement Process.

Extracorporeal membrane oxygenation is a modified form of cardiopulmonary bypass and a complex adult critical care therapy. No evidence appears to exist on sustaining relevant quality nursing standards during a pandemic. The aim for this quality improvement process was to address nursing provision in real time related to extracorporeal membrane oxygenation in a pandemic, providing fundamentals for future readiness. The Ishikawa fishbone diagram and a Plan-Do-Study-Act cycle were methods used. Process changes included implementation of a communication algorithm, an alternative nursing care model, increased nursing staffing and leadership visibility, use of perfusion services for nursing task support, and minimized nursing documentation. Changes applied were successful. We recommend increasing nursing staffing volume and support resources, applying a communication algorithm, and minimizing documentation requirements. These strategies are generalizable to other clinical nursing areas in similar pandemics or disasters.

Extubation during extracorporeal membrane oxygenation in adults: An international qualitative study on experts' opinions.

BACKGROUND: Extracorporeal membrane oxygenation in adults (adult-ECMO), a modification of cardiopulmonary bypass is increasingly used. Liberation from mechanical ventilation, or extubation, during adult-ECMO remains a challenge. OBJECTIVES: This study aimed to understand expert perceptions of the reasonableness of extubation during adult-ECMO and the usefulness of an extubation clinical practice guideline (ECPG). METHODS: Homogeneous purposive sampling, focus groups, and interviews with a discussion guide, and direct content, thematic analysis were used. RESULTS: Fourteen volunteers participated with different educational levels (79% Doctor of Medicine, 14% Registered Nurse, 7% Nurse Practitioner), from high-volume ECMO centers of various annual ECMO runs (50% 30-49 ECMO/year, 36% 50-99 ECMO/year, 14% >100 ECMO/year) worldwide (64% North America, 21% South America, 7% Europe, 7% Asia). Seven themes were identified: paucity of evidence, mindsets towards using an ECPG, barriers, criteria and benefits of extubation, culture towards extubation and vision of the future. Participants recommended aiming for extubation based on patient selection, and a standardized extubation approach with an ECPG or team decision-making. CONCLUSION: Application of adult-ECMO is expanding, during which extubation remains difficult. Experts recommend two methods of a standardized extubation approach.

Pharmacokinetics and Extracorporeal Membrane Oxygenation in Adults: A Literature Review.

Extracorporeal membrane oxygenation is a rapidly emerging treatment for respiratory or cardiac failure and is used as a bridge to recovery, transplant, or destination therapy. Adult patients receiving extracorporeal membrane oxygenation also receive significant amounts of pharmacotherapy. Although the body of literature on extra-corporeal membrane oxygenation in general is extensive, only a few publications focus on pharmacokinetic changes related to extracorporeal membrane oxygenation in adults. Understanding pharmacokinetics in adult patients receiving extracorporeal membrane oxygenation is important to correctly select and dose medications in this patient population. This article reviews published studies of the effects of extracorporeal membrane oxygenation on pharmacokinetics in adults.