Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries.

Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.

Extracorporeal membrane oxygenation line-associated complications: in vitro testing of cyanoacrylate tissue adhesive and securement devices to prevent infection and dislodgement.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) delivers cardiac and/or respiratory support to critically ill patients who have failed conventional medical therapies. If the large-bore cannulas used to deliver ECMO become infected or dislodged, the patient consequences can be catastrophic. ECMO cannula-related infection has been reported to be double the rate of other vascular devices (7.1 vs 3.4 episodes/1000 ECMO days respectively). The aim of this study was to assess the ability of cyanoacrylate tissue adhesive (TA) to inhibit bacterial growth at the ECMO cannulation site, and the effectiveness of TA and securement devices in securing ECMO cannulas and tubing. METHODS: This in vitro study tested the (1) antimicrobial qualities of TA against standard transparent dressing with ECMO cannula; (2) chemical compatibility between cannula, TA and removal agent; (3) pull-out strength of transparent dressing and TA at the cannula insertion site; and (4) pull-out strength of adhesive bandage and commercial sutureless securement devices (SSDs) on circuit tubing. Fisher's exact test was used to evaluate differences in bacterial growth observed between the transparent dressing and TA groups. Data from mechanical testing were analysed using one-way ANOVA, followed by Tukey's multiple comparison test or t test as appropriate. Statistical significance was defined as p < 0.05. RESULTS: No bacterial growth occurred under TA-covered cannulas compared with transparent dressing-covered cannulas (p = 0.002). Compared to plates lacking TA or transparent dressing, growth was observed at the insertion point and under the dressing in the transparent dressing group; however, no growth was observed in the TA group (p = 0.019). TA did not weaken the cannulas; however, the TA removal agent did after 60 min of exposure, compared with control (p < 0.01). Compared with transparent dressing, TA increased the pull-out force required for cannula dislodgement from the insertion point (p < 0.0001). SSDs significantly increased the force required to remove the tubing from the fixation points compared with adhesive bandage (p < 0.01). CONCLUSIONS: Our findings suggest that the combined use of TA at the cannula insertion site with a commercial device for tubing securement could provide an effective bedside strategy to prevent or minimise infection and line dislodgement.

Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI ≥30: a randomised controlled trial.

PURPOSE: Patients with a body mass index (BMI) ≥30 kg/m(2) experience more severe atelectasis following cardiac surgery than those with normal BMI and its resolution is slower. This study aimed to compare extubation of patients post-cardiac surgery with a BMI ≥30 kg/m(2) onto high-flow nasal cannulae (HFNC) with standard care to determine whether HFNC could assist in minimising post-operative atelectasis and improve respiratory function. METHODS: In this randomised controlled trial, patients received HFNC or standard oxygen therapy post-extubation. The primary outcome was atelectasis on chest X-ray. Secondary outcomes included oxygenation, respiratory rate (RR), subjective dyspnoea, and failure of allocated treatment. RESULTS: One hundred and fifty-five patients were randomised, 74 to control, 81 to HFNC. No difference was seen between groups in atelectasis scores on Days 1 or 5 (median scores = 2, p = 0.70 and p = 0.15, respectively). In the 24-h post-extubation, there was no difference in mean PaO2/FiO2 ratio (HFNC 227.9, control 253.3, p = 0.08), or RR (HFNC 17.2, control 16.7, p = 0.17). However, low dyspnoea levels were observed in each group at 8 h post-extubation, median (IQR) scores were 0 (0-1) for control and 1 (0-3) for HFNC (p = 0.008). Five patients failed allocated treatment in the control group compared with three in the treatment group [Odds ratio 0.53, (95 % CI 0.11, 2.24), p = 0.40]. CONCLUSIONS: In this study, prophylactic extubation onto HFNC post-cardiac surgery in patients with a BMI ≥30 kg/m(2) did not lead to improvements in respiratory function. Larger studies assessing the role of HFNC in preventing worsening of respiratory function and intubation are required.

Outcomes of the first 30 cases of an adult extracorporeal membrane oxygenation program: strategies to manage the "learning curve" and implications for intensive care unit risk adjustment models.

BACKGROUND: We established an adult extracorporeal membrane oxygenation (ECMO) service for cardiorespiratory support in April 2009. Complex therapies may show a learning curve and volume-outcome relationship. OBJECTIVES: To describe our model of care, casemix and outcomes for the first 30 cases together with unique features of this service and potential strategies to manage the learning curve. METHODS: Data were obtained from the intensive care unit database, medical record and minutes of multidisciplinary ECMO review meetings. RESULTS: The model of care was based heavily on that used at an experienced ECMO centre following Extracorporeal Life Support Organization guidelines. ECMO was established as an ICU-managed, multidisciplinary service with collaboration from other specialties using standardised policies and procedures, staff training and formal case review. A specific budget was allocated to training and education and a clinical perfusionist was present on site for the first 10 cases. Seventeen patients received venoarterial (VA) and 13 received venovenous (VV) ECMO. Median duration of ECMO was 7 days for VA and 15 days for VV ECMO. Median ICU stay was 22 days. Twenty patients were referred from 13 hospitals throughout Queensland. Hospital mortality was 47% for VA ECMO and 15% for VV ECMO. The unique features of this service are the use of a Levitronix CentriMag system as well as the Rotaflow system, and the use of extended daily haemodiafiltration using the Fresenius 4008s ARrT plus connected into the ECMO circuit. The clinical implications of conducting plasma exchange and sustained low-efficiency dialysis via direct ECMO circuit connection using the Fresenius ARrT machine, and using a second system for ECMO support, were notable challenges. CONCLUSION: Satisfactory outcomes were achieved using an ICU-based multidisciplinary approach with a broadly based education strategy with additional clinical perfusionist support to manage the learning curve.