Activated clotting time (ACT) ranges are targeted to minimize both bleeding and clotting complications during anticoagulation for extracorporeal life support (ECLS) therapy. A change in the equipment used to measure ACT at the bedside prompted a laboratory-based method comparison study in an animal model to compare ACT results from two Hemochron machines. A retrospective, observational cohort study was undertaken to compare bleeding and clotting complications for both "eras" of Hemochron machine. The newer Hemochron Response ACT results were approximately 30 seconds longer than the outgoing Hemochron 401 results at both baseline and heparinization. This prompted a change in the clinical practice standard at the University of Michigan and a shift of the goal ACT range from 180 to 200 seconds to 210 to 230 seconds. Bleeding and clotting complications were less frequent in the Hemochron Response group, although significantly more heparin was infused during the ECLS period. Changes in equipment, which measure important physiologic variables at the bedside, need to be compared with previously established standards to ensure that patient care and safety is maintained, as demonstrated by the longer ACT results obtained with the newer Hemochron Response machine.
Adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis is associated with a poor prognosis. We hypothesized that extracorporeal life support (ECLS) may be an effective treatment option for the most severe cases of pancreatitis-induced ARDS.We reviewed 8 cases of pancreatitis-induced ARDS that were treated with ECLS at our institution. We collected data on demographics, comorbidities, hemodynamic parameters, and ventilatory support used before ECLS. Our outcome measures for this study included survival to discharge, length of ECLS run, days undergoing mechanical ventilation, days in an intensive care unit, total length of hospital stay, adjunct therapies and procedures, and complications.Overall, 5 of the 8 patients (63%) survived to discharge. Seven of the 8 patients underwent venovenous ECLS, and 1 underwent venoarterial ECLS. The overall mean length of ECLS was 9.7 ± 10.7 days. However, the mean ECLS run length in survivors was 4.3 ± 1.8 days and the longest ECLS run in a survivor was 7.25 days. Two of the 3 patients who died had very long run lengths (28.8 and 24.7 days, respectively), whereas 1 patient had a short run (2.4 days). Five of the 8 patients (63%), including all of the 3 who died, experienced a bleeding complication of some kind. Two patients required continuous venovenous hemofiltration, 1 of whom died and 1 of whom survived. Six patients underwent tracheostomy on ECLS, 1 patient already had undergone tracheostomy, and 1 patient did not undergo tracheostomy.ECLS is useful in treating severe pancreatitis-induced ARDS. Pancreatic debridement can be performed during ECLS, using a comprehensive protocol to minimize bleeding complications.
Extracorporeal life support (ECLS) is used to support patients with pulmonary alveolar proteinosis (PAP) both during acute illness and during lung lavage therapies. We report the challenges encountered while providing ECLS for respiratory failure to a 12-year-old girl with PAP who had previously received ECLS as a toddler for a prior episode of respiratory failure due to PAP. She was placed on venovenous-arterial (VVA) ECLS and subsequently switched to venovenous (VV) ECLS with drainage from the right femoral vein and reinfusion by a long cannula placed into the right atrium. Our case illustrates standard cannulation may not be possible for children requiring a second ECLS course and the importance of considering alternative modes of cannulation and ECLS support when conventional methods are not possible.
Centrifugal pumps are increasingly used for extracorporeal membrane oxygenation (ECMO) rather than roller pumps. However, shear forces induced by these types of continuousflow pumps are associated with acquired von Willebrand factor deficiency and bleeding complications. This study was undertaken to compare adverse bleeding complications with the use of centrifugal and roller pumps in patients on prolonged ECMO support. The records of all adult ECMO patients from June 2002 to 2013 were retrospectively reviewed using the University of Michigan Health System database and the Extracorporeal Life Support Organization registry, focusing on patients supported for at least 5 days. Ninety-five ECMO patients met criteria for inclusion (48 roller vs. 47 centrifugal pump). Indications included pulmonary (79%), cardiac (15%), and extracorporeal cardiopulmonary resuscitation (6%), without significant difference between the two groups. Despite lower heparin anticoagulation (10.9 vs. 13.7 IU/kg/hr) with centrifugal pumps, there was a higher incidence of nonsurgical bleeding (gastrointestinal, pulmonary, and neurological) in centrifugal pump patients (26.1 vs. 9.0 events/1,000 patient-days, p = 0.024). In conclusion, in our historical comparison, despite reduced anticoagulation, ECMO support using centrifugal pumps was associated with a higher incidence of nonsurgical bleeding. The mechanisms behind this are multifactorial and require further investigation
In Fig 6, the R&B Development should be R&D Development.Please see the correct Fig 6 here.In the Limitation subsection of Discussion, the third sentence of the first paragraph should have not been indicated.The correct first paragraph is: Up to now we can present only early results of our course and we must wait for at least some months or years to know how training in ALS impacted on clinical practice and ECMO applications.In spite of this limitation, the short-term results of developed concept in "Center of Artificial Life Support and Patient Safety" with ELSO cooperation are very promising.Moreover, having practice in ECMO applications, we are aware how important is good cooperation with many other members of medical personnel and emergency system.This course was only for physicians.Of note, during training we appeal for participants to create their own teams and to play by them role of leaders.The significant improvement in behavioral assessment, particular leader of ECMO team, gives hope for successful involvement other medical professionals.
In 2020, the Extracorporeal Life Support Organization education task force identified seven extracorporeal membrane oxygenation (ECMO) educational domains that would benefit from international collaborative efforts. These included research efforts to delineate the impact and outcomes of ECMO courses.Development of a standardized online assessment tool to evaluate the effectiveness of didactic and simulation-based ECMO courses on participants' confidence, knowledge, and simulation-based skills; participant satisfaction; and course educational benefits.We performed a prospective multicenter observational study of five different U.S. academic institution-based adult ECMO courses that met Extracorporeal Life Support Organization endorsement requirements for course structure, educational content, and objectives. Standardized online forms were developed and administered before and after courses, assessing demographics, self-assessment regarding ECMO management, and knowledge examination (15 simple-recall multiple-choice questions). Psychomotor skill assessment was performed during the course (time to complete prespecified critical actions during simulation scenarios). Self-assessment evaluated cognitive, behavioral, and technical aspects of ECMO; course satisfaction; and educational benefits.Out of 211 participants, 107 completed both pre- and postcourse self-assessment forms (97 completed both pre- and postcourse knowledge forms). Fifty-three percent of respondents were physician intensivists, with most (51%) practicing at academic hospitals and with less than 1 year of ECMO experience (50%). After the course, participants reported significant increases in confidence across all domains (cognitive, technical, and behavioral, P < 0.0001, 95% confidence interval [CI], 1.2-1.5; P < 0.0001, 95% CI, 2.2-2.6; and P = 0.002, 95% CI, 1.7-2.1, respectively) with an increase in knowledge scores (P < 0.001; 95% CI, 1.4-2.5). These findings were most significant in participants with less ECMO experience. There were also significant reductions in times to critical actions in three of the four scored simulation scenarios. The results demonstrated participants' satisfaction with most course aspects, with more than 95% expressing that courses met their educational goals.We developed and tested a structured ECMO course assessment tool, demonstrating participants' self-reported benefit as well as improvement in psychomotor skill acquisition, course satisfaction, and educational benefits. Course evaluation is feasible and potentially provides important information to improve ECMO courses. Future steps could include national implementation, addition of questions targeting clinical decision making to further assess knowledge gain, and multilanguage translation for implementation in international courses.
The veno-venoarterial (VVA) mode of extracorporeal membrane oxygenation (ECMO) is defined by having both venous and arterial reinfusion cannulas. It is purposed to improve upper body oxygenation as the venous reinfusion cannula is typically placed in the upper body. We performed a single-center retrospective review to better characterize the patients placed on this mode. Adults (n = 23) were 40.4 ± 14.7 years old and were supported with ECMO for a median of 141 (97, 253) hours, with VVA support 110 (63, 179) hours. Ten (43%) were initially cannulated VVA; reasons for conversion included cardiac failure (46%), North-South syndrome (38%), and worsening hypoxia (15%). Survival was 39% and neurological complications 13%. Pediatrics (n = 8) were 13.0 ± 2.4 years old and were supported with ECMO for a median of 258 (168, 419) hours, with VVA support 131 (98, 161) hours. One (12.5%) was initially cannulated VVA; reasons for conversion were North-South syndrome (42%), cardiac failure (29%), and worsening hypoxia (29%). Survival was 71% and neurological complications 29%. We concluded that there was neither survival advantage nor complication reduction with the VVA mode in this cohort; however, VVA does have value for unique clinical situations when conventional ECMO modes do not meet support needs.
To determine the effect of therapeutic plasma exchange on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome due to sepsis requiring extracorporeal life support.A retrospective analysis.A PICU in an academic children's hospital.Fourteen consecutive children with sepsis and multiple organ dysfunction syndrome who received therapeutic plasma exchange while on extracorporeal life support from 2005 to 2013.Median of three cycles of therapeutic plasma exchange with median of 1.0 times the estimated plasma volume per exchange.Organ Failure Index and Vasoactive-Inotropic Score were measured before and after therapeutic plasma exchange use. PICU survival in our cohort was 71.4%. Organ Failure Index decreased in patients following therapeutic plasma exchange (mean ± SD: pre, 4.1 ± 0.7 vs post, 2.9 ± 0.9; p = 0.0004). Patients showed improved Vasoactive-Inotropic Score following therapeutic plasma exchange (median [25th-75th]: pre, 24.5 [13.0-69.8] vs post, 5.0 [1.5-7.0]; p = 0.0002). Among all patients, the change in Organ Failure Index was greater for early therapeutic plasma exchange use than late use (early, -1.7 ± 1.2 vs late, -0.9 ± 0.6; p = 0.14), similar to the change in Vasoactive-Inotropic Score (early, -67.5 [28.0-171.2] vs late, -12.0 [7.2-18.5]; p = 0.02). Among survivors, the change in Organ Failure Index was greater among early therapeutic plasma exchange use than late use (early, -2.3 ± 1.0 vs late, -0.8 ± 0.8; p = 0.03), as was the change in Vasoactive-Inotropic Score (early, -42.0 [16.0-76.3] vs late, -12.0 [5.3-29.0]; p = 0.17). The mean duration of extracorporeal life support after therapeutic plasma exchange according to timing of therapeutic plasma exchange was not statistically different among all patients or among survivors.The use of therapeutic plasma exchange in children on extracorporeal life support with sepsis-induced multiple organ dysfunction syndrome is associated with organ failure recovery and improved hemodynamic status. Initiating therapeutic plasma exchange early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.
Abstract Background: The Extracorporeal Life Support Organization (ELSO) education taskforce (ELSOed) recently identified seven extracorporeal membrane oxygenation (ECMO) educational domains that would benefit from international collaborative efforts among which standardized assessments of ECMO courses was prioritized. We aimed to develop a standardized online assessment tool to evaluate the effectiveness of a comprehensive didactic and simulation-based ECMO course on participants’ gain in confidence, knowledge, and simulation-based skills. Methods: We performed a prospective multicenter observational study of five US adult ECMO courses. Standardized online assessment forms were developed and administered before and after courses, covering demographics, self-assessment regarding ECMO management, and knowledge exam (15 simple-recall multiple choice questions), while psychomotor skill assessment was performed during the course (time to complete pre-specified critical actions during simulation scenarios). Self-assessment covered cognitive, behavioral, and technical aspects of ECMO care. Results: Out of 211 participants, 107 completed both pre- and post-course forms (97 completed both pre and post-course knowledge forms). Physician-intensivists were the largest group (53%) and the majority practiced at academic hospitals (51%) and had less than 1-year of ECMO experience (50%). Post-course, participants reported significant increases in confidence across all domains (cognitive, technical, and behavioral; p<0.0001 CI:1.2-1.5, p<0.0001 CI:2.2-2.6, and p=0.002 CI:1.7-2.1, respectively) as well as an increase in knowledge scores (p<0.001, CI: 1.4-2.5). These findings were consistent for all specialties and prior ECMO experience. There were also significant reductions in the times to critical actions in 3 of the 4 scored simulation scenarios. Conclusions: We successfully developed and tested a comprehensive standardized ECMO course assessment tool, demonstrating participants’ self-reported benefit as well as improvement in both knowledge and psychomotor skill acquisition . Standardized course evaluation is feasible and potentially provides important information to improve ECMO courses. Future steps include national implementation, addition of questions targeting clinical decision making to further assess knowledge gain, and multi-language translation for implementation at international courses.
