Schears, Gregory J.

Background and objectivesExtracorporeal membrane oxygenation (ECMO) is a method of life support for either isolated cardiac failure or respiratory failure, with or without cardiac failure. When used for hemodynamic support, the ECMO circuit presents a non‐endothelialized, artificial surface to blood inciting an inflammatory response which activates haemostatic pathways. Anticoagulation may complicate a pre‐existing coagulopathy and/or inadequate surgical hemostasis of varying severity. There is no standardized method to achieve and monitor anticoagulation or guide transfusion therapy during ECMO. We tested the hypothesis that institutions across the world conduct similar management of anticoagulation and transfusion during adult ECMO support.MethodsThis is a descriptive, self‐reporting cross‐sectional survey of anticoagulation and transfusion practice for patients age 18 or older on ECMO. This 38 multiple‐choice question survey was sent to 166 institutions, internationally, utilizing adult ECMO. About 32·4% (54) of institutions responded. Responses were anonymously collected. Descriptive analyses were calculated.ResultsOur findings indicate there appears to be a significant practice variation among institutions regarding anticoagulation and transfusion during adult ECMO support.DiscussionThe lack of standard practices among institutions may reflect a paucity of data regarding optimal anticoagulation and transfusion for patients requiring ECMO. Standardized protocols for anticoagulation and transfusion may help increase quality of care for and reduce morbidity, mortality and cost to patients and healthcare centres. Further study is required for standardized, high quality care.

SummaryBackgroundCongenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long‐term comorbid conditions.AimsOur aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution.MethodsWe performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow‐up.ResultsThirty‐eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver‐up vs liver‐down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01–0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20–73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO.ConclusionThe overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

Abstract Objectives: To compare thromboelastography (TEG) tracings obtained from fresh and citrated whole-blood samples in patients on extracorporeal membrane oxygenation (ECMO) or after cardiopulmonary bypass and in healthy volunteers. Methods: Samples of fresh and citrated whole blood were analyzed for 25 patients and 4 healthy volunteers. Thromboelastography analysis was performed in both plain and heparinase cups. Results: In 5 of 6 patients on ECMO, use of citrated samples resulted in apparent partial or complete heparin reversal. In TEG tracings from patients following cardiopulmonary bypass, there was a slight hypercoagulable appearance in the citrated sample. No differences were noted between fresh and citrated samples from healthy volunteers whose blood was spiked with heparin. Conclusions: In some patients on ECMO, use of samples collected in sodium citrate tubes for TEG analysis results in significant artifacts, which could lead to heparin overdosing in these patients.

SummaryObjectivesIn pediatric patients vascular access is often more difficult than in adults because of the smaller size of the vessels and the inability of the patient to cooperate without deep sedation or general anesthesia. Therefore Ultrasound has already become an invaluable tool for vascular access, but the full potential of ultrasound has yet to be fully realized. Improvements in image quality and a better understanding of optimal insertion techniques continue to help clinicians safely and efficiently place catheters with fewer complications.Methods and TechniqueThe probes used for the vascular access are mainly linear and convex type. Higher‐ frequency ultrasound provides a vivid image; however, the signals are remarkably attenuated. Therefore, the choice of the probe with appropriate frequency is essential. As blood vessels are relatively easily identified with ultrasound, ultrasound‐guided vascular access does not require as sharp images as ultrasound‐guided nerve block. For pediatric vascular access, the linear probe with 5–15 MHz, 2–5 cm depth is ideal and adequate for almost all cases. Ultrasound‐guided vascular access has two main approaches: ‘long‐axis’ or ‘in‐plane approach’ and ‘short‐axis’ or ‘transverse approach’. The long‐axis approach visualizes the vessel along the insertion pathway and is commonly used to monitor the entire approach of the needle into the vessel. The short‐axis approach is easier to show the positional relationship and depth of target vessels, but it is much harder to follow the needle tip within the tissues.ConclusionThe use of ‘real‐time’ ultrasound has been shown to increase first insertion success, reduce access time, have a higher overall success, and reduce arterial puncture. As the technology continues to improve the use of ultrasound will become as ubiquitous as the lines themselves.

Abstract Over the last two decades, our understanding of the pathogenesis of central line associated blood steam infections has improved significantly. Also, increased attention has been focused on reducing healthcare worker exposure to infectious agents. Best practice protocols have been developed to eliminate unnecessary morbidity, mortality and costs associated with these infections and exposures. Adoption of these best practices has been incomplete and non-compliance is a major factor preventing our infectious complication rates from reaching zero. Getting at the root cause of noncompliance is complex. Online surveys are uniquely positioned to help understand the human factors contributing to non-compliance. This article reviews some of the pros and cons associated with the use of online surveys. Using several relevant recent examples, this article explores how these surveys can be used to identify those factors that create barriers to compliance. By better understanding all the issues involved with non-compliance, we will be able to create strategies and engineer products to improve best practice protocol compliance and reduce the human factor contribution to our patient's infectious complications.

Advances in extracorporeal life support have expanded indications for use extending beyond patients undergoing cardiac surgery. The approach to cannulation in patients requiring extracorporeal membrane oxygenation should be individualized and based on the specific clinical scenario in which the need arises. Adherence to proper techniques of vessel visualization, exposure, and cannulation along with accurate placement of cannulae will optimize flows and minimize complications in this setting. Patients in need of mechanical circulatory support require input from a multidisciplinary team approach with systematic clinical evaluation to optimize outcome. If hemodynamics do not initially permit the successful separation from mechanical support, then a systematic search for potentially reversible patient and/ or pump related factors should be undertaken. The success of this therapy is predicated on patient selection, a multidisciplinary team approach in the intensive care unit, adherence to precise technical principles, and repeated patient evaluation.

The technical evolution of extracorporeal membrane oxygenation (ECMO) coincides with the vast improvement in intensive care medicine of the past 4 decades. Extracorporeal circulatory technology substitutes for acutely failed cardiac or pulmonary function until these organs regain sustainable function through goal-oriented intensive care practice. The technology has been validated to improve survival in select patients who would otherwise have 100% mortality. This is by far the most complex life-sustaining technology employed and thus can contribute significant risks such that the decision to institute ECMO requires prompt risk and benefit analysis. Delaying the institution of ECMO may cause irreversible pulmonary and cardiac injuries in addition to other organs. Therefore, the optimal time of initiating ECMO support is crucial to the survival of a critically ill patient.