The Effect of Sedation on Long-Term Psychological Impairment After Extracorporeal Life Support.

OBJECTIVE: This retrospective study aimed to identify the association between long-term psychological impairment and total sedation received during venovenous extracorporeal life support (VV-ECLS) for acute respiratory failure (ARF). DESIGN: This observational retrospective study compared characteristics between patients with and without long-term psychological morbidity at long-term follow-up after VV-ECLS for ARF. SETTING: A single institutional experience in a quaternary referral academic medical center in the United States. PATIENTS: Patients who received VV-ECLS for ARF between January 1, 2015, and April 1, 2017, were identified for selection. Presence of psychiatric morbidity (anxiety and/or depression) was determined with the Hospital Anxiety and Depression Subscale battery at long-term follow-up. INTERVENTIONS: No interventions were made during this retrospective observational study. MEASUREMENTS AND MAIN RESULTS: A total of 42 patients (21 male, 21 female, median age 49 [interquartile range {IQR} 36-57]) completed a telephone interview a median of 14.6 (IQR 7.7-21.1) months after ECLS decannulation. Cohorts were defined as possessing any psychiatric morbidity (anxiety and/or depression) as defined by the Hospital Anxiety and Depression Subscale battery (n = 22 [52%]) versus no psychiatric morbidity (n = 20 [48%]) at long-term follow-up. Patients who had clinically significant psychiatric morbidity received a median of 15.0 (IQR 11.0-17.0) days of continuous intravenous sedation compared with patients who had no psychiatric morbidity, who received a median of 10.0 (IQR 6.5-13.5) days of intravenous sedation; (p = 0.02). CONCLUSIONS: This retrospective analysis identified a significant association between the presence of long-term post-VV-ECLS psychiatric symptoms and the total number of days of intravenous sedation.

Venovenous Extracorporeal Membrane Oxygenation for Patients With Return of Spontaneous Circulation After Cardiac Arrest Owing to Acute Respiratory Distress Syndrome.

OBJECTIVE: The primary objective of this study was to determine the survival to hospital discharge of patients who were treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) for respiratory failure after cardiac arrest. DESIGN: Retrospective chart review. SETTING: University-affiliated tertiary care hospitals. PARTICIPANTS: The study comprised 21 patients. INTERVENTIONS: Implementation of VV ECMO in patients with return of spontaneous circulation after cardiac arrest owing to respiratory insufficiency. MEASUREMENTS AND MAIN RESULTS: The most common etiology of arrest was pneumonia-associated acute respiratory distress syndrome (8/21 [38%]). Overall, 12/21(57%) patients survived to hospital discharge. Two of 12 (17%) patients required hemodialysis upon discharge. CONCLUSION: VV ECMO may be an appropriate alternative to venoarterial ECMO in select patients with return of spontaneous circulation after cardiac arrest owing to profound respiratory failure.

Long-Term Outcomes After Extracorporeal Life Support for Acute Respiratory Failure.

OBJECTIVE: This study aims to determine the prevalence of functional and psychological impairment in survivors of extracorporeal life support (ECLS) and assess the needs of survivors to guide development of an effective follow-up program. DESIGN: This mixed-methods outcomes study used quantitative assessment via standardized instruments (Katz Index of Independence of Activities of Daily Living [Katz ADL], the Lawton Instrumental Activities of Daily Living [Lawton IADL], Hospital Anxiety and Depression Scale, and the Post Traumatic Growth Inventory) and qualitative interview to identify challenges experienced by survivors. SETTING: A single institutional experience in an academic medical center in the United States. PATIENTS: Patient selection targeted patients who underwent veno-venous ECLS for acute respiratory failure between January 1, 2015, and April 1, 2017. Forty-two patients (21 male, 21 female; median age of 49 years; interquartile range 36-57 years) completed the interview a median of 14.6 (interquartile range 7.7-21.1) months after ECLS decannulation. INTERVENTIONS: This was an observational follow-up study for which no intervention was made. MEASUREMENTS AND MAIN RESULTS: The Katz ADL and Lawton IADL revealed high independence and functionality in 62% of patients (26 of 42). Clinically significant anxiety was present in 48% (20 of 42) of patients and depression in 26% (11 of 42). There was a correlation between the number of ADL and IADL deficiencies and depression (rho 0.61, p < 0.001) and anxiety (rho 0.29, p = 0.033) subscales of the Hospital Anxiety and Depression Scale. High levels of posttraumatic growth were noted in 50% (21 of 42) of patients. Nearly all survivors noted that a clinic designed for post-ECLS follow-up would be beneficial. Patients desired access to education, improved coordination of care, and additional mental health resources. CONCLUSIONS: This study demonstrated persistent physical and psychological impairments in survivors of ECLS. Patients consistently expressed a desire to debrief on their hospital course and receive education on possible long-term effects. Study findings suggest that structured follow-up may allow for early identification of psychological and physical impairments to improve outcomes. Future studies should focus on investigating the effect of rehabilitation and follow-up clinics in preventing these issues.

Acute Respiratory Failure Managed via Inter-Facility Transport for Extracorporeal Life Support: A 3-Year Experience.

OBJECTIVES: The objectives of this study were as follows: (1) to describe a successful design for a mobile lung rescue program, focusing on challenges and resources required to support such a program, and (2) report short-term outcomes for patients placed on venovenous extracorporeal life support (VV-ECLS) by a transferring team before inter-facility transport to a specialized extracorporeal life support (ECLS) center. DESIGN: This retrospective review and analysis used patient chart review to collect outcomes data and resource demand. SETTING: A single institutional experience in an academic center in the United States. PARTICIPANTS: Patient selection targeted the 75 patients who were placed on VV-ECLS for acute respiratory failure at an outside institution by the authors' team before transport from January 1, 2015, through December 31, 2017. INTERVENTIONS: No intervention was made. MEASUREMENTS AND MAIN RESULTS: Average time for dispatch and transfer was 4 hours and 10 minutes for ground and 3 hours and 30 minutes for air transport (p = 0.029). Demand was highest in winter, with 61% (46/75) of patients presenting from November through April, and daytime, with 73% (55/75) occurring from 8 am to 8 pm. Demand increased during the study period, with 21 patients in 2015, 24 in 2016, and 30 in 2017. Mortality was low, with 72% of patients surviving to discharge. CONCLUSIONS: Herein a successful mobile lung rescue program for transfer to a regional ECLS center is described. These findings demonstrate bed availability during high census and presence of a physician for duration of transport. These challenges can be overcome and successful implementation can be made with low mortality, supporting the development of regional ECLS centers.

Assessment of Risk of Cholera in Haiti following Hurricane Matthew.

Damage to the inferior and fragile water and sanitation infrastructure of Haiti after Hurricane Matthew has created an urgent public health emergency in terms of likelihood of cholera occurring in the human population. Using satellite-derived data on precipitation, gridded air temperature, and hurricane path and with information on water and sanitation (WASH) infrastructure, we tracked changing environmental conditions conducive for growth of pathogenic vibrios. Based on these data, we predicted and validated the likelihood of cholera cases occurring past hurricane. The risk of cholera in the southwestern part of Haiti remained relatively high since November 2016 to the present. Findings of this study provide a contemporary process for monitoring ground conditions that can guide public health intervention to control cholera in human population by providing access to vaccines, safe WASH facilities. Assuming current social and behavioral patterns remain constant, it is recommended that WASH infrastructure should be improved and considered a priority especially before 2017 rainy season.

Successful management of stuttering priapism using home self-injections of the alpha-agonist metaraminol

Low-flow priapism can result in impotence if treatment is delayed, yet patients with recurrent priapism often suffer delay before therapy. We describe management of recurrent priapism using self-administered injections of intracavernosal metaraminol (AramineÖ, Merck), a long-acting vasoconstricting amine that is considered safer than epinephrine. The patient injects as often as once daily using 5-10 mg of drug. Our patient reports rapid detumescence and has not required emergency room visits since starting injections. He denies complications. Treatment of priapism using metaraminol has been suggested in the hospital setting; however, this is the first report of successful home self-administration of the drug.

Successful management of stuttering priapism using home self-injections of the alpha-agonist metaraminol.

Low-flow priapism can result in impotence if treatment is delayed, yet patients with recurrent priapism often suffer delay before therapy. We describe management of recurrent priapism using self-administered injections of intracavernosal metaraminol (Aramine, Merck), a long-acting vasoconstricting amine that is considered safer than epinephrine. The patient injects as often as once daily using 5-10 mg of drug. Our patient reports rapid detumescence and has not required emergency room visits since starting injections. He denies complications. Treatment of priapism using metaraminol has been suggested in the hospital setting; however, this is the first report of successful home self-administration of the drug.