Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: How Long Is Too Long?

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) in adults with respiratory failure has steadily increased during the past decade. Recent literature has demonstrated variable outcomes with the use of extended ECMO. The purpose of this study is to evaluate survival to hospital discharge in patients with extended ECMO runs compared with patients with short ECMO runs at a tertiary care ECMO referral center. We retrospectively reviewed all patients on VV ECMO for respiratory failure between August 2014 and February 2017. Bridge to lung transplant, post-lung transplant, and post-cardiac surgery patients were excluded. Patients were stratified by duration of ECMO: extended ECMO, defined as >504 hours; short ECMO as ≤504 hours. Demographics, pre-ECMO data, ECMO-specific data, and outcomes were analyzed. One hundred and thirty-nine patients with respiratory failure were treated with VV ECMO. Overall survival to discharge was 76%. Thirty-one (22%) patients had extended ECMO runs with an 87% survival to discharge. When compared with patients with short ECMO runs, there was no difference in median age, body mass index (BMI), body surface area (BSA), partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) (P/F), and survival to discharge. However, time from intubation to cannulation for ECMO was significantly longer in patients with extended ECMO runs. (p = 0.008). Our data demonstrate that patients with extended ECMO runs have equivalent outcomes to those with short ECMO runs. Although the decision to continue ECMO support in this patient population is multifactorial, we suggest that time on ECMO should not be the sole factor in this challenging decision.

Single-Center Experience With Venovenous ECMO for Influenza-Related ARDS.

OBJECTIVES: This study was designed to determine whether venovenous extracorporeal membrane oxygenation (VV ECMO) reduced mortality in patients with influenza-related acute respiratory distress syndrome (ARDS). DESIGN: A retrospective cohort study was performed. Baseline characteristics of participants were compared and Kaplan-Meier survival analysis was used to compare survival at last medical center follow-up. Cox proportional hazards modeling also was performed to test for univariate associations between salient variables and mortality. SETTING: A single-center ECMO referral university hospital. PARTICIPANTS: All patients admitted with influenza-related ARDS during the 2015 to 2016 influenza season. INTERVENTIONS: Mechanical ventilation alone versus mechanical ventilation and ECMO cannulation. MEASUREMENTS AND MAIN RESULTS: A total of 26 patients with influenza-related ARDS were included in the cohort. Thirteen patients were treated with VV ECMO while 13 were not. Twelve of the ECMO patients and 8 of the non-ECMO patients were transferred from outside hospitals. Patients treated with ECMO were younger and had less hypertension and diabetes mellitus. There was no difference in baseline sequential organ failure assessment score between the 2 groups. In-hospital mortality for ECMO patients was 15.4% versus 46.7% for patients not treated with ECMO. Survival at last medical center follow-up was better in patients treated with ECMO (p = 0.02). Age, highest blood carbon dioxide level, and treatment without ECMO were all associated with increased mortality. CONCLUSIONS: Influenza-related ARDS has a high mortality rate and patients treated only with mechanical ventilation have worse outcome than those managed with VV ECMO. More liberal use of ECMO should be considered in patients with influenza-related ARDS.

Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country.

PURPOSE: Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low- and middle-income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele-intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images. MATERIALS AND METHODS: Nine Haitian non-physician health care workers received a 20-minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non-physicians to ultrasound five anatomic sites. The tele-intensivist evaluated the image quality and clinical utility of performing tele-ultrasound in a LMIC. RESULTS: The intensivist agreed (defined as "agree" or "strongly agree" on a five-point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time. CONCLUSIONS: Non-physicians can feasibly obtain high-quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers.

Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine.

PURPOSE: Remote telementored ultrasound (RTMUS) systems can deliver ultrasound (US) expertise to regions lacking highly trained bedside ultrasonographers and US interpreters. To date, no studies have evaluated the quality and clinical utility of US images transmitted using commercially available RTMUS systems. METHODS: This prospective pilot evaluated the quality of US images (right internal jugular vein, lung apices and bases, cardiac subxiphoid view, bladder) obtained using a commercially available iPad operating FaceTime software. A bedside non-physician obtained images and a tele-intensivist interpreted them. All US screen images were simultaneously saved on the US machine and captured via a FaceTime screen shot. The tele-intensivist and an independent US expert rated image quality and utility in guiding clinical decisions. RESULTS: The tele-intensivist rated FaceTime images as high quality (90% [69/77]) and could comfortably make clinical decisions using these images (96% [74/77]). Image quality did not differ between FaceTime and US images (97% (75/77). Strong inter-rater reliability existed between tele-intensivist and US expert evaluations (Spearman's rho 0.43; P<.001). CONCLUSION: An RTMUS system using commercially available two-way audiovisual technology can transmit US images without quality degradation. For most anatomic sites assessed, US images acquired using FaceTime are not inferior to those obtained directly with the US machine.