Posterior Segment Findings in Patients on Extracorporeal Membrane                     Oxygenation

Purpose: Extracorporeal membrane oxygenation (ECMO) is an established treatment modality for critically ill patients with cardiopulmonary failure, yet little is known of the ocular pathology in this population. The aim of this study is to characterize the posterior segment findings of ECMO patients. Methods: This study is a retrospective analysis of 20 ECMO patients evaluated by ophthalmology from September 2012 to May 2019 at a level 1 trauma center. Comprehensive examinations assessed for intraocular pathology. Demographic data, exam findings, and mortality were analyzed. Results: The sample size consisted of 20 patients; a majority were male (75%), and mean age was 37.4 years (interquartile range, 26.75-50 years). All patients received ECMO for care of acute respiratory distress syndrome (ARDS). Average duration of ECMO therapy was 9.6 ± 6.5 days. Eleven (55%) patients had acute retinal pathology, including Purtscher-like retinopathy (20%), intraocular hemorrhage (50%), and septic chorioretinitis (bacterial or fungal, 10%). Location of hemorrhage included the retina (40%), vitreous (30%), and optic disc (15%). Sixty percent (n = 12) of patients were unable to provide a subjective history on initial assessment. Ultimately, 5 out of 20 patients (25%) died of systemic illness during their hospital stay. Conclusion: This study demonstrates high rates of retinal pathology, most commonly vitreous and/or retinal hemorrhage alongside a Purtscher-like retinopathy. This is likely secondary to complications of anticoagulation, microthrombi, septicemia, and hemodynamic instability. We found a mortality rate slightly lower than that of prior ECMO studies. Prospective studies with pre-ECMO and post-ECMO fundus photography is warranted for better understanding of these medically complex patients.

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Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team

Military Medicine ◽

10.1093/milmed/usaa215 ◽

2020 ◽

Vol 185 (11-12) ◽

pp. e2055-e2060

Author(s):

Matthew D Read ◽

Jason J Nam ◽

Mauer Biscotti ◽

Lydia C Piper ◽

Sarah B Thomas ◽

...

Keyword(s):

Critical Care ◽

Extracorporeal Membrane Oxygenation ◽

Demographic Data ◽

The United States ◽

Published Data ◽

Medical Treatment Facility ◽

Membrane Oxygenation ◽

Transport Distance ◽

Primary Indication ◽

The U.S

Abstract Introduction The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients. Materials and methods We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth. Results The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%. Conclusions Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

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Veno-arterial extracorporeal membrane oxygenation for severe fever with thrombocytopenia syndrome with fulminant myocarditis: a case report

BMC Infectious Diseases ◽

10.1186/s12879-021-06446-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Uh. Jin Kim ◽

Hyukjin Park ◽

Kye Hun Kim ◽

Dong Min Kim ◽

Seung Eun Kim ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiac Involvement ◽

Hemodynamic Instability ◽

Multiple Organ ◽

Left Ventricular ◽

Fulminant Myocarditis ◽

Hemodynamic Support ◽

Membrane Oxygenation ◽

Initial Symptoms ◽

Severe Fever

Abstract Background The clinical spectrum of severe fever with thrombocytopenia syndrome (SFTS) is wide, which can range from fever to multiple organ failure. Conservative therapy plays a key role in the treatment of SFTS. However, severe cases of SFTS, such as fulminant myocarditis, may require mechanical hemodynamic support. Case presentation This report presents a case of a 59-year old woman diagnosed with SFTS by reverse-transcription polymerase chain reaction. The patient had no initial symptoms of cardiac involvement and rapidly developed hemodynamic instability 3 days after hospitalization. She suffered from chest pain and had elevated cardiac enzymes. In the absence of atrio-ventricular conduction abnormalities, left ventricular dysfunction, and coronary artery abnormalities by coronary angiography, she was diagnosed with fulminant myocarditis. At that time, her pulse rate nearly dropped to 0 bpm and she developed near complete akinesia of the heart despite vasopressor administration. Veno-arterial extracorporeal membrane oxygenation (ECMO) was initiated with other supportive measures and she fully recovered after 21 days. Conclusions This case indicates that SFTS can cause fulminant myocarditis even without evidence of cardiac involvement at presentation. When symptoms and/or signs of acute heart failure develop in patients with SFTS, myocarditis should be suspected and the patient should be promptly evaluated. Additionally, mechanical hemodynamic support like ECMO can be a lifesaving tool in the treatment of fulminant myocarditis.

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Low cardiac output syndrome requiring extracorporeal membrane oxygenation following pericardiocentesis in an adolescent with Hodgkin Lymphoma: a case report

Perfusion ◽

10.1177/0267659120950604 ◽

2020 ◽

pp. 026765912095060

Author(s):

Toni Matic ◽

Matija Bakos ◽

Dalibor Saric ◽

Miran Cvitkovic ◽

Zrinko Salek ◽

...

Keyword(s):

Cardiac Output ◽

Pericardial Effusion ◽

Extracorporeal Membrane Oxygenation ◽

Hodgkin Lymphoma ◽

Hemodynamic Instability ◽

Low Cardiac Output Syndrome ◽

Low Cardiac Output ◽

Membrane Oxygenation ◽

Drainage Rate ◽

Large Pericardial Effusion

We present a case of a 16-year-old male with large pericardial effusion due to Hodgkin Lymphoma (HL). Shortly after drainage of pericardial effusion he developed a low cardiac output syndrome which had to be treated with extracorporeal membrane oxygenation (ECMO). This 9-day ECMO support helped the patient to recover his cardiac function, and thereafter a remission of his primary disease was successfully achieved with chemotherapy. It is a matter of discussion whether a large pericardial effusion with moderate symptoms in patients with HL should be evacuated or just observed since the effusion should ameliorate with chemotherapy. But based upon our experience in this case of hemodynamic instability due to a large effusion requiring evacuation, we propose that pericardiocentesis procedure should be performed with caution at a slow drainage rate of 0.5-1 ml/kg/hour with a maximum rate of 50 ml/hour, to help avoid the low cardiac output syndrome in patients with similar disease conditions.

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Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children

PEDIATRICS ◽

10.1542/peds.93.5.726 ◽

1994 ◽

Vol 93 (5) ◽

pp. 726-729

Author(s):

John Beca ◽

Warwick Butt

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Demographic Data ◽

Pediatric Intensive Care ◽

Organ System ◽

Severe Respiratory Failure ◽

Prism Score ◽

Membrane Oxygenation ◽

Refractory Septic Shock

Objective. To review demographic data and outcome of children who received extracorporeal membrane oxygenation (ECMO) for refractory septic shock. Method. Review of medical charts of nine children receiving ECMO for culture-proven refractory septic shock treated in a multidisciplinary pediatric intensive care unit. Results. Median age was 12 years and median weight was 45 kg. Median inotrope requirements (µg/kg per minute) before ECMO were dopamine, 15; dobutamine, 12.5; epinephrine, 4; and norepinephrine, 3.5. Four children received two inotropes concurrently, and five received three or more. All nine patients had severe respiratory failure; eight had evidence of other organ system dysfunction, with six having five or more organ system dysfunctions. Median PRISM score was 27. Median duration of ECMO was 137 hours. Within 24 hours of starting ECMO, 7 of 9 children had all inotropes stopped. Four patients died and five survived, all of whom are leading normal lives. Conclusion. In this small group of children with probably fatal septic shock, ECMO was successfully supported the circulation and 5 of the 9 children survived. We suggest that septic shock should not be considered a contra-indication to ECMO.

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A comparison of pump-controlled retrograde trial off to arterio-venous bridging for weaning from venoarterial extracorporeal membrane oxygenation†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezy485 ◽

2019 ◽

Vol 56 (2) ◽

pp. 277-284 ◽

Cited By ~ 4

Author(s):

Nischal R Pandya ◽

Michael Daley ◽

Adrian Mattke ◽

Fumiaki Shikata ◽

Kim Betts ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Stress Test ◽

Demographic Data ◽

Trial Period ◽

Inclusion Criteria ◽

Ecmo Circuit ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Va Ecmo ◽

Study Inclusion

Abstract OBJECTIVES The aim of the study is to compare a technique of pump-controlled retrograde trial off (PCRTO) to insertion of an arterio-venous (AV) bridge to conduct a trial from venoarterial extracorporeal membrane oxygenation (VA ECMO). METHODS We studied all patients who were weaned from VA ECMO using either PCRTO or AV bridging from November 2014 to April 2018. Demographic data, indications for ECMO, duration of ECMO, duration of trial period off ECMO and survival were compared between the 2 groups. RESULTS Seventy-nine patients were placed on VA ECMO from November 2014 to April 2018, of whom, 51 (65%) patients met the study inclusion criteria: 31 (61%) patients who had a trial period from VA ECMO using PCRTO and 20 (39%) patients who were weaned using an AV bridge. The indications for ECMO included cardiac (n = 16 and 11, respectively) and non-cardiac aetiologies (n = 15 and 9, respectively). There was 1 death in each group. The duration of the trial off VA ECMO was significantly shorter in the PCRTO group (median = 88.0 vs 196.6 min, P < 0.001). There were 2 conversions from PCRTO to AV bridging during the trial period off ECMO (2.9-kg neonate following a Norwood procedure and 2.2-kg patient following repair of ectopia cordis). CONCLUSIONS PCRTO is a safe, simple and reproducible approach for enabling a trial period while preserving the circuit during weaning from VA ECMO. In our study, the duration of the trial period off VA ECMO was significantly shorter in the PCRTO group. PCRTO avoids manipulation of the ECMO circuit, provides a ‘stress test’ to evaluate cardiorespiratory reserve during the trial period off ECMO, is applicable for a wide variety of cardiac and non-cardiac indications and facilitates multiple attempts at weaning from ECMO.

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Appendicostomy for Intraluminal Antibiotic Administration and Extracorporeal Membrane Oxygenation Support in Severe Hirschsprung's Enterocolitis

The American Surgeon ◽

10.1177/000313481408000913 ◽

2014 ◽

Vol 80 (9) ◽

pp. 844-845

Author(s):

Michael R. Phillips ◽

Kimberly M. Erickson ◽

William T. Adamson ◽

Sean E. McLean

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Developmentally Appropriate ◽

Male Infant ◽

Hemodynamic Instability ◽

Antibiotic Administration ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Hemorrhagic Complications ◽

Pull Through ◽

Laparoscopic Assisted

A term male infant with Hirschsprung's disease underwent an uncomplicated laparoscopic-assisted endorectal pull-through procedure. Four weeks after discharge, the patient developed severe Clostridium difficile enterocolitis with hemodynamic instability and peritonitis. Bedside laparotomy confirmed intestinal viability and accommodated an appendicostomy for antegrade vancomycin colonic irrigations. The patient required venoarterial extracorporeal membrane oxygenation for physiological support for more than six days. Transition to conventional support was successful with survival and discharge from the hospital free from hemorrhagic complications. The patient is now developmentally appropriate for his age.

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Extracorporeal Membrane Oxygenation in Patients With COVID-19: An International Multicenter Cohort Study

Journal of Intensive Care Medicine ◽

10.1177/08850666211007063 ◽

2021 ◽

pp. 088506662110070

Author(s):

Senta Jorinde Raasveld ◽

Thijs S. R. Delnoij ◽

Lars M. Broman ◽

Annemieke Oude Lansink-Hartgring ◽

Greet Hermans ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Demographic Data ◽

Invasive Mechanical Ventilation ◽

Supportive Therapy ◽

Secondary Outcome ◽

Multicenter Cohort Study ◽

Membrane Oxygenation ◽

Kaplan Meier ◽

Significant Difference

Background: To report and compare the characteristics and outcomes of COVID-19 patients on extracorporeal membrane oxygenation (ECMO) to non-COVID-19 acute respiratory distress syndrome (ARDS) patients on ECMO. Methods: We performed an international retrospective study of COVID-19 patients on ECMO from 13 intensive care units from March 1 to April 30, 2020. Demographic data, ECMO characteristics and clinical outcomes were collected. The primary outcome was to assess the complication rate and 28-day mortality; the secondary outcome was to compare patient and ECMO characteristics between COVID-19 patients on ECMO and non-COVID-19 related ARDS patients on ECMO (non-COVID-19; January 1, 2018 until July 31, 2019). Results: During the study period 71 COVID-19 patients received ECMO, mostly veno-venous, for a median duration of 13 days (IQR 7-20). ECMO was initiated at 5 days (IQR 3-10) following invasive mechanical ventilation. Median PaO2/FiO2 ratio prior to initiation of ECMO was similar in COVID-19 patients (58 mmHg [IQR 46-76]) and non-COVID-19 patients (53 mmHg [IQR 44-66]), the latter consisting of 48 patients. 28-day mortality was 37% in COVID-19 patients and 27% in non-COVID-19 patients. However, Kaplan-Meier curves showed that after a 100-day follow-up this non-significant difference resolves. Non-surviving COVID-19 patients were more acidotic prior to initiation ECMO, had a shorter ECMO run and fewer received muscle paralysis compared to survivors. Conclusions: No significant differences in outcomes were found between COVID-19 patients on ECMO and non-COVID-19 ARDS patients on ECMO. This suggests that ECMO could be considered as a supportive therapy in case of refractory respiratory failure in COVID-19.

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Short-term and intermediate outcomes of cardiogenic shock and cardiac arrest patients supported by venoarterial extracorporeal membrane oxygenation

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01674-w ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Deep Vakil ◽

Cassandra Soto ◽

Zoee D’Costa ◽

Lindsay Volk ◽

Sivaveera Kandasamy ◽

...

Keyword(s):

Cardiac Arrest ◽

Length Of Stay ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Rescue Therapy ◽

Demographic Data ◽

Primary Therapy ◽

Membrane Oxygenation ◽

Intermediate Outcomes ◽

Va Ecmo

Abstract Background Cardiogenic shock and cardiac arrest are life-threatening emergencies with high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (e-CPR) provide viable options for life sustaining measures when medical therapy fails. The purpose of this study is to determine the utilization and outcomes of VA ECMO and eCPR in patients that require emergent cardiac support at a single academic center. Methods A retrospective chart review of prospectively collected data was performed at an academic institution from January 1st, 2018 to June 30th, 2020. All consecutive patients who required VA ECMO were evaluated based on whether they underwent traditional VA ECMO or eCPR. The study variables include demographic data, duration on ECMO, length of stay, complications, and survival to discharge. Results A total of 90 patients were placed on VA ECMO for cardiac support with 44.4% (40) of these patients undergoing eCPR secondary to cardiac arrest and emergent placement on ECMO. A majority of the patients were male (n = 64, 71.1%) and the mean age was 58.8 ± 15.8 years. 44.4% of patients were transferred from outside hospitals for a higher level of care and 37.8% of patients required another primary therapy such as an Impella or IABP. The most common complication experienced by patients was bleeding (n = 41, 45.6%), which occurred less often in eCPR (n = 29, 58% vs. n = 12, 30%). Other complications included infections (n = 11, 12.2%), limb ischemia (n = 13, 14.4%), acute kidney injury (n = 17, 18.9%), and cerebral vascular accident (n = 4, 4.4%). The length of stay was longer for patients on VA ECMO (32.1 ± 40.7 days vs. 17.7 ± 18.2 days). Mean time on ECMO was 8.1 ± 8.3 days. Survival to discharge was higher in VA ECMO patients (n = 23, 46% vs. n = 8, 20%). Conclusion VA ECMO provided an effective rescue therapy in patients in acute cardiogenic shock with a survival greater than the expected ELSO guidelines of 40%. While the survival of eCPR was lower than expected, this may reflect the severity of patient’s condition and emphasizes the importance of careful patient selection and planning.

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