Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies.
Adult; Adult/*therapy; Cannulation; ECMO; Equipment Design; Extracorporeal Membrane Oxygenation/*adverse effects/instrumentation/*methods; Humans; Respiratory distress syndrome; Respiratory Distress Syndrome; Veno-venous
BACKGROUND: Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected. DISCUSSION: Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices. SUMMARY: Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.
Tulman David B; Stawicki Stanislaw P; Whitson Bryan A; Gupta Saarik C; Tripathi Ravi S; Firstenberg Michael S; Hayes Don Jr; Xu Xuzhong; Papadimos Thomas J
BMC anesthesiology
2014
2014
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1186/1471-2253-14-65" target="_blank" rel="noreferrer noopener">10.1186/1471-2253-14-65</a>
Cardiac arrest is a predictor of difficult tracheal intubation independent of operator experience in hospitalized patients.
Academic Medical Centers – Washington; Adult; Aged; Cardiopulmonary Resuscitation/*methods; Chi Square Test; Clinical Competence; Confidence Intervals; Data Analysis Software; Direct laryngoscopy; Female; Heart Arrest; Heart Arrest/*therapy; Hospitalization; Hospitals; Human; Humans; In-hospital cardiac arrest; Intratracheal/*methods; Intubation; Laryngoscopy/*methods; Logistic Models; Logistic Regression; Male; Middle Age; Middle Aged; Multivariate Analysis; Odds Ratio; Retrospective Studies; T-Tests; University; Video-Assisted Surgery/methods; Videolaryngoscopy; Washington
BACKGROUND: Placement of advanced airways has been associated with worsened neurologic outcome in survivors of out-of-hospital cardiac arrest. These findings have been attributed to factors such as inexperienced operators, prolonged intubation times and other airway related complications. As an initial step to examine outcomes of advanced airway placement during in-hospital cardiac arrest (IHCA), where immediate assistance and experienced operators are continuously available, we examined whether cardiopulmonary resuscitation efforts affect intubation difficulty. Additionally, we examined whether or not the use of videolaryngoscopy increases the odds of first attempt intubation success compared with traditional direct laryngoscopy. METHODS: The study setting is a large urban university-affiliated teaching hospital where experienced airway managers are available to perform emergent intubation for any indication in any out-of-the-operating room location 24 hours a day, 7 days-a-week, 365 days-a-year. Intubations occurring in all adults \textgreater18 years-of-age who required emergent tracheal intubation outside of the operating room between January 1, 2008 and December 31, 2012 were examined retrospectively. Multivariate logistic regression was used to estimate the odds of difficult intubation during IHCA compared to other emergent non-IHCA indications with adjustment for a priori defined potential confounders (body mass index, operator experience, use of videolaryngoscopy versus direct laryngoscopy, and age). RESULTS: In adjusted analyses, the odds of difficult intubation were higher when taking place during IHCA (OR=2.63; 95% CI 1.1-6.3, p=0.03) compared to other emergent indications. Use of video versus direct laryngoscopy for initial intubation attempts during IHCA, however, did not improve the odds of success (adjusted OR = 0.71; 95% CI 0.35-1.43, p = 0.33). CONCLUSIONS: Difficult intubation is more likely when intubation takes place during IHCA compared to other emergent indications, even when experienced operators are available. Under these conditions, direct laryngoscopy (versus videolaryngoscopy) remains a reasonable first choice intubation technique.
Khandelwal Nita; Galgon Richard E; Ali Marwan; Joffe Aaron M
BMC anesthesiology
2014
1905-7
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1186/1471-2253-14-38" target="_blank" rel="noreferrer noopener">10.1186/1471-2253-14-38</a>