Background-Venovenous extracorporeal membrane oxygenation (ECMO) is increasingly being used for acute respiratory distress syndrome and as a bridge to lung transplantation. After initiation of venovenous ECMO, systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis. Here, we investigated whether venovenous ECMO can be administered without continuous systemic anticoagulation administration for patients with acute respiratory distress syndrome.Methods-This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through February 2019. Overall, 38 patients received low levels of continuous systemic anticoagulation (AC + ) whereas the subsequent 36 patients received standard venous thromboprophylaxis (AC −). Published Extracorporeal Life Support Organization guidelines were used for the definition of outcomes and complications.Results-Overall, survival was not different between the two groups (P = .58). However, patients in the AC + group had higher rates of gastrointestinal bleeding (28.9%, vs AC− group 5.6%; P < .001). The events per patient-day of gastrointestinal bleeding was 0.00025 in the AC− group and 0.00064 in the AC+ group (P < .001). In addition, oxygenator dysfunction was increased in the AC + group (28.9% and 0.00067 events per patient-day, vs AC− 11.1% and 0.00062 events per patient-day; P = .02). Furthermore, the AC+ group received more transfusions: packed red blood cells, AC+ group 94.7% vs AC− group 55.5% (P < .001); fresh frozen plasma, AC+ 60.5% vs AC − 16.6% (P = .001); and platelets, AC+ 84.2% vs AC− 27.7% (P < .001). There was no circuit thrombosis in either groups throughout the duration of ECMO support.Conclusions-Our results suggest that venovenous ECMO can be safely administered without continuous systemic anticoagulation therapy. This approach may be associated with reduced bleeding diathesis and need for blood transfusions.

Background Veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) support is increasingly used in the management of COVID‐19‐related acute respiratory distress syndrome (ARDS). However, the clinical decision‐making to initiate V‐V ECMO for severe COVID‐19 still remains unclear. In order to determine the optimal timing and patient selection, we investigated the outcomes of both COVID‐19 and non‐COVID‐19 patients undergoing V‐V ECMO support. Methods Overall, 138 patients were included in this study. Patients were stratified into two cohorts: those with COVID‐19 and non‐COVID‐19 ARDS. Results The survival in patients with COVID‐19 was statistically similar to non‐COVID‐19 patients ( p = .16). However, the COVID‐19 group demonstrated higher rates of bleeding ( p = .03) and thrombotic complications ( p < .001). The duration of V‐V ECMO support was longer in COVID‐19 patients compared to non‐COVID‐19 patients (29.0 ± 27.5 vs 15.9 ± 19.6 days, p < .01). Most notably, in contrast to the non‐COVID‐19 group, we found that COVID‐19 patients who had been on a ventilator for longer than 7 days prior to ECMO had 100% mortality without a lung transplant. Conclusions These findings suggest that COVID‐19‐associated ARDS was not associated with a higher post‐ECMO mortality than non‐COVID‐19‐associated ARDS patients, despite longer duration of extracorporeal support. Early initiation of V‐V ECMO is important for improved ECMO outcomes in COVID‐19 ARDS patients. Since late initiation of ECMO was associated with extremely high mortality related to lack of pulmonary recovery, it should be used judiciously or as a bridge to lung transplantation.

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Blood stream infection (BSI) is a potentially lethal complication in patients receiving extracorporeal membrane oxygenation (ECMO). It may be particularly common in patients with veno-venous ECMO due to their long hospitalization in the intensive care unit. Given that these patients have concurrent indwelling central venous catheters (CVC), it is unclear whether the ECMO circuit, CVC, or both, contribute to BSI. This study evaluated the risk factors associated with BSI in patients receiving veno-venous ECMO in a single institution study of 61 patients from 2016 through 2019. All ECMO catheters and the circuit oxygenator fluid were aseptically collected and analyzed for microorganisms at the time of decannulation. New BSI was diagnosed in 15 (24.6%) patients and increased mortality by threefold. None of the ECMO catheters or oxygenator fluid were culture positive. BSI increased with CVC use of over 8 days and was significantly lowered when CVC were exchanged by day 8 compared with patients with exchanges at later points (15.0% vs. 42.8%, p = 0.02). Median length of CVC use in the BSI-negative and BSI-positive group were 6.3 ± 5.0 and 9.4 ± 5.1, respectively (p = 0.04). In summary, BSI is a potentially lethal complication in patients receiving ECMO. Indwelling CVC, not the ECMO circuitry, is the likely contributor for BSI, and exchanging CVC by day 8 can reduce the incidence of BSI.

Background Shorter length of stay (LOS) is a welcome consequence of optimized perioperative care. However, accelerated hospital discharge may have unintended consequences. Before implementing an institutional enhanced recovery after surgery protocol, we evaluated the safety of shorter LOS and compared outcomes of patients with shorter LOS (LOS ≤ 3 days) to those with longer LOS (LOS > 3 days). Methods We identified all patients undergoing elective cardiac surgery with cardiopulmonary bypass between July 2004 and June 2017. Transcatheter approaches, ventricular assist devices, transplants, and traumas were excluded. Patients were divided into two cohorts, one with shorter hospitalizations (LOS ≤ 3 days) and one with longer hospitalizations (LOS > 3 days). Propensity score matching (PSM) was performed and differences between the two groups were compared. Results A total of 5,987 patients (63.0 ± 13.8 years old, 34% female) were identified and 131 (2.2%) patients were LOS ≤ 3 days; median STS Risk score was 1.2 (0.6–2.4). PSM resulted in a total of 478 patients (357 LOS > 3 and 121 LOS ≤ 3 days); median STS Risk score was 0.4 (0.3–0.9). LOS ≤ 3 days had lower rates of postoperative atrial fibrillation (2% vs. 19%; p < .001) and major in‐hospital complications (0% vs. 9%; p = .001); however, 30‐day readmissions (8% LOS ≤ 3 vs. 6% LOS > 3 days; p = .66) and mortality rates (0% vs. 0%) were comparable between the two groups. Conclusion LOS ≤ 3 days was associated with less postoperative atrial fibrillation and fewer major in‐hospital complications. LOS ≤ 3 days was not associated with rehospitalization or mortality. Shorter LOS after elective cardiac surgery appears to be a safe practice with favorable outcomes, especially in low operative risk patients.

Burden and Consequences,'' 1 both resident applicants and program directors make a tremendous investment of time and money to match positions for graduate medical education. This comes at the price of making the fourth year of medical school increasingly dedicated to securing such graduate medical education positions rather than learning. For the resident, the process usually involves completing multiple applications, securing subinternship ''audition'' rotations, and traveling plus interviewing at multiple programs. For the training programs, this usually means interviewing 30 to 40 almostindistinguishable applicants for 1 or 2 integrated positions. In cardiothoracic surgery, because we have more than one available training track (integrated and traditional), this forces the applicants to hedge bets and apply to both integrated thoracic residencies as well as traditional general surgery residencies, potentially compounding the application problem.