Discharge outcome in adults treated with extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is used for critically ill patients when conventional treatments for cardiac or respiratory failure are unsuccessful. OBJECTIVES: To describe patient and treatment characteristics and discharge outcome for ECMO patients, determine which characteristics are associated with good (survival) versus poor (death before hospital discharge) outcomes, and compare characteristics of patients with cardiac versus respiratory failure indicating ECMO. METHODS: Single-center, retrospective review of all adult patients treated with ECMO from 2005 through 2009. RESULTS: A total of 212 patients received ECMO for cardiac (n = 126) or respiratory (n = 86) failure. Mean age was 51 (SD, 14.5) years; support duration was 135 (SD, 149) hours. Survival to discharge was 33% overall; 50% for respiratory indication and 21% for cardiac indication patients. Patients with poor outcomes were older (53 vs 47 years, P = .007), more likely to require cardiovascular support before ECMO (99% vs 91%; P = .02), and had more transfusions (48 vs 24 units, P = .005) and complications (99% vs 87%; P < .001) than did patients with good outcomes. For cardiac patients, older age was associated with poor outcome (poor, 55 vs good, 48 years; P = .01). For respiratory patients, poor outcome was associated with more ventilator days before ECMO (poor, 6 vs good, 3; P = .01), higher peak inspiratory pressure (poor, 39 vs good, 35 cm H2O; P = .02), and lower pulmonary compliance (poor, 19 vs good, 25 mL/cm H2O; P = .008). CONCLUSIONS: Patients with respiratory indications for ECMO experienced better survival than did cardiac patients. Increasing age was associated with poor outcome. Complications, regardless of ECMO indication, were common and associated with poor outcome.

Extracorporeal membrane oxygenation as a bridge to lung transplant: midterm outcomes.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is used occasionally as a bridge to lung transplantation. The impact on mid-term survival is unknown. We analyzed outcomes after lung transplant over a 19-year period in patients who received ECMO support. METHODS: From March 1991 to October 2010, 1,305 lung transplants were performed at our institution. Seventeen patients (1.3%) were supported with ECMO before lung transplant. Diagnoses included retransplantation (n = 6), pulmonary fibrosis (n = 6), cystic fibrosis (n = 4), and chronic obstructive pulmonary disease (n = 1). Fifteen patients underwent double lung transplant, one patient had single left lung transplant and one patient had a heart-lung transplant. Venovenous and venoarterial ECMO were implanted in eight and nine cases, respectively. Median duration of support was 3.2 days (range, 1 to 49 days). Mean patient follow-up was 2.3 years. RESULTS: Thirty-day, 1-year, and 3-year survivals were 81%, 74%, and 65%, respectively, for the supported patients and 93%, 78%, and 62% in the control group (p = 0.56). Two-year survival was not affected by ECMO type, with survival of five out of nine patients supported by venoarterial ECMO vs seven out of eight patients supported by venovenous ECMO (p = 0.17). At 1- year follow-up, allograft function for the ECMO-supported patients did not differ from the control group (forced expiratory volume in one second, 2.35 L vs 2.09 L, p = 0.39) (forced vital capacity, 3.06 L vs 2.71 L, p = 0.34). CONCLUSIONS: Extracorporeal membrane oxygenation as a bridge to lung transplantation is associated with higher perioperative mortality but acceptable mid-term survival in carefully selected patients. Late allograft function did not differ in patients who received ECMO support before lung transplant from those who did not receive ECMO.

Isolation of Aspergillus in three 2009 H1N1 influenza patients.

OBJECTIVES: To describe the association of Aspergillus with influenza. DESIGN/SETTING/SAMPLE: Three case reports of ICU patients with influenza complicated by the isolation of Aspergillus species are described and a review of the literature on the topic was performed. CONCLUSIONS: Severe influenza cases can be complicated by Aspergillus infection.

The diagnostic challenge of a tracheal tear with a double-lumen endobronchial tube: massive air leak developing from the mouth during mechanical ventilation.

The case of a 78 year-old woman who underwent a right lower lobectomy using a 35-French, left-sided, double-lumen endobronchial tube (DLET) is presented. Multiple adjustments were needed for the DLET's proper placement. At the end of surgery, sudden loss of tidal volume with a large air leak from the patient's mouth was noted. Fiberoptic bronchoscopic examination through the DLET was negative. Rupture of the tracheal cuff was suspected, and the DLET was replaced with a single-lumen tube. In the intensive care unit, the massive air leak from the mouth recurred during mechanical ventilation. Nasal fiberoptic bronchoscopic examination showed a longitudinal laceration of the membranous portion of the trachea extending from the subglottic area to the orifice of the right bronchus. Surgical repair of the tear was performed.

Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults.

PURPOSE: Historically, venovenous extracorporeal membrane oxygenation has required dual cannulation. A single-venous cannulation strategy may facilitate implantation and patient mobilization. Here we present our early experience with a single cannulation technique. DESCRIPTION: Review of venovenous extracorporeal membrane oxygenation support using internal jugular vein insertion of the Avalon elite bicaval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA) in 11 consecutive patients with severe respiratory failure. EVALUATION: Adequate oxygenation was obtained in all patients: 115 mm Hg PaO(2) (median), 53 to 401 mm Hg (range). Median time of support was 78 hours (range, 3 to 267 hours). No mortality was directly related to the cannulation strategy. There were three nonfatal cannulation-related events. Two patients had proximal cannula displacement requiring repositioning. One patient suffered an acute thrombosis of the cannula. CONCLUSIONS: Our series supports single-venous cannulation in venovenous extracorporeal membrane oxygenation as a promising technique. It may be an excellent alternative to current cannulation strategies in patients requiring prolonged support and specifically for those considered for a bridge-to-lung transplantation.

Lung and heart-lung transplantation at the University of Pittsburgh: 1982-2002.

The University of Pittsburgh lung transplantation program began in 1982 and through 2002 we have performed 576 lung and 101 heart-lung transplants. One-, 3- and 5-year survival rates over the past decade have been 77%, 62% and 55%, respectively, comparing favorably to ISHLT registry outcomes of 73%, 57% and 46%. We continue to utilize a very thorough evaluation process but have been flexible and aggressive with potential recipients with regard to age, coronary artery disease and disease state (eg., scleroderma). Despite worldwide progress in the field of lung transplantation, many difficulties remain. The limited number of lungs deemed acceptable for transplantation continues to hinder application to a greater number of patients. Our efforts in this regard have focused on cooperation with our OPO in education and detailed donor management protocols. Chronic rejection also remains a major difficulty frequently leading to death. Recent work utilizing aerosol cyclosporine in patients with established chronic rejection suggests that this therapy may prolong life. We are also hopeful that recently initiated therapies utilizing T-cell induction strategies may contribute to further improvement in outcomes.