In view of the variations in survival and costs in ECMO patients, further studies should aim to delineate patient populations that benefit from early initiation of ECMO.
Extracorporeal membrane oxygenation in patients with heart transplant graft failure had the best outcome. In patients who had cardiac arrest, prolonged CPR > 30 minutes was associated with very high mortality. Paradoxically, patients with EF > 35% had a higher mortality than patients with EF < 35%, likely reflecting patients with diastolic heart failure or noncardiac causes necessitating ECMO. For transplant candidates, direct bridge from ECMO to transplant could achieve a very good outcome.
Extracorporeal membrane oxygenation (ECMO) provides lifesaving hemodynamic and respiratory support to neonatal and pediatric patients with a variety of congenital or acquired cardiopulmonary defects. Successful ECMO support requires close collaboration among multiple services, including critical care medicine, perfusion, and transfusion medicine services. Neonatal and pediatric ECMO patients require significant transfusion support, both at the time of cannulation and after the ECMO circuit has been established, often with little advance notice. Thus a number of communication and logistic issues must be addressed through a multidisciplinary approach to ensure both good patient outcome and judicious use of resources. In this article, we describe our protocol for transfusion support for ECMO and potential ECMO patients, which was developed to address a number of issues, including identifying and stratifiying ECMO candidate patients, streamlining the ordering and communication processes, and improving blood product turnaround times and availability. Additional measures of quality improvement are also discussed. As the number of centers performing ECMO procedures remains high, we believe that our experience may be of interest to our colleagues in transfusion medicine and critical care.
Summary:
Infections involving thoracic aortic grafts are difficult to treat and have devastating consequences. The traditional approaches to surgical management include aggressive debridement with graft explantation and replacement. Despite treatment, the reported morbidity and mortality rates are high. The purpose of this study was to present our experience with an innovative approach to aortic graft salvage in the setting of sternal wound infection using antibiotic impregnated polymethylmethacrylate beads followed by definitive wound closure with flap coverage. A retrospective review identified patients with surgical wounds after aortic graft or cardiac valve placement over a 7-year period at a single institution. Patients were treated using an algorithm consisting of repeated surgical debridement and placement of antibiotic beads followed by flap coverage after suppression of the infection. A total of 20 patients were treated for surgical wounds, including 19 sternal and one thoracotomy wound. Culture positive surgical site infections were documented in 16 patients. One patient required a bead exchange before definitive closure. There were no in-hospital mortalities. All but two patients achieved successful infection suppression and wound closure with flap coverage. The use of antibiotic beads with serial debridement and flap closure may offer a valid option for aortic graft salvage in the setting of infected sternal wounds in the appropriate patient population. The proposed algorithm showed that patients may be successfully treated, and their infection suppressed without the need for graft removal. Mortality rates were lower from those previously reported in the literature.
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