To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN:A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program.SETTING: An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS:Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS:Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS:Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS:There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.
The number of hospitals with veno-venous extracorporeal membrane oxygenation (VV-ECMO) capabilities is expanding. To support an ECMO program, centers must be equipped to handle associated complications such as pulmonary hemorrhage. We describe a case series of 4 patients with life-threatening pulmonary bleeding and central airway obstruction. A therapeutic approach of anticoagulation cessation coupled with cryoextraction via flexible bronchoscopy led to successful restoration of airway patency without any adverse events. A low threshold to stop anticoagulation with a strong consideration of bronchoscopy with cryotherapy for pulmonary toilet should be done in patients with pulmonary hemorrhage during VV-ECMO.
Objective : Continuous renal replacement therapy (CRRT) in patients receiving venovenous extracorporeal membrane oxygenation (VV ECMO) can be accessed via separate venous access (SVA) or directly “in-line” within the ECMO circuit. The objective of this study is to compare the efficacy and safety of SVA versus in-line configuration in patients requiring CRRT and VV ECMO. Design: A retrospective review of 16 subjects receiving CRRT while on VV ECMO support. Setting: Adult ICU at a tertiary academic medical institution. Patients: Critically ill adult subjects with severe respiratory failure undergoing percutaneous VV ECMO and CRRT. Interventions: CRRT with venous access via separate temporary hemodialysis catheter versus direct access in-line with the VV ECMO circuit. Measurements and Results: Subject demographics, ECMO cannulation configuration, duration of CRRT, oxygenator and CRRT filter lifespan, number of interruptions, and dialysis blood flow rate were recorded. Five patients received CRRT via SVA and 11 patients via in-line configuration. There was a higher mean number of days on CRRT in the in-line group (7 vs 12 days, p = 0.32). There was no significant difference in oxygenator lifespan (days) (17.1 vs 14.72, p = 0.597), CRRT filter lifespan (days) (1.68 vs 2.15 p = 0.136), or interruptions per 100 CRRT days (10 vs 11.73, p = 0.834) in SVA vs in-line groups. Percentage days with therapeutic anticoagulation (65 vs 68, p =0.859) and initial dialysis blood flow rate (300 vs 310.91 mL/min, p = 0.258) were similar between configurations. SVA was associated with frequent access site manipulation (60% of patients) and catheter site bleeding (40% of patients). Conclusions: CRRT can be delivered via SVA or in-line configuration in patients requiring VV ECMO with similar efficacy. Separate venous access for CRRT may be associated with higher rates of access associated bleeding and need for access manipulation when compared to in-line configuration.
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