Novel weaning assessment for veno-arteriovenous to veno-venous extracorporeal membrane oxygenation using pump-controlled retrograde trial off.

INTRODUCTION: Pump-controlled retrograde trial off (PCRTO) is described as an effective weaning strategy for veno-arterial extracorporeal membrane oxygenation (ECMO) in the guidelines. Contrastingly, there is no established weaning strategy for veno-arteriovenous (V-AV) ECMO. We report a novel application of PCRTO in a patient undergoing V-AV ECMO. CASE REPORT: A 49-year-old man had pneumonia and a history of kidney transplantation. Two days after intubation, respiratory failure progressed and veno-venous (V-V) ECMO was introduced. On day 7 after ECMO, the configuration was changed to V-AV ECMO owing to septic cardiomyopathy due to suspected cholangitis. On day 15, with partial haemodynamic improvement and persistent respiratory failure, PCRTO was performed; the patient was safely returned to V-V ECMO. DISCUSSION: In patients undergoing V-AV ECMO, PCRTO could have the potential to accurately simulate decannulation of the arterial cannula. CONCLUSION: This novel weaning strategy could be considered in patients undergoing V-AV ECMO.

Safety of Supraclavicular Approach for Dual-Lumen Catheter Placement in Veno-Venous Extracorporeal Membrane Oxygenation: A Case Report.

In veno-venous extracorporeal membrane oxygenation (V-V ECMO), the dual-lumen catheter (DLC) facilitates mobility, reduces recirculation, and mitigates the risk of infection. The right internal jugular vein (IJV) is the most common site for DLC insertion. Still, it is often unavailable for various reasons, including local infection, hematoma, or thrombus. A 64-year-old male patient with mantle lymphoma, which was in remission after autogenous blood transplantation, suffered lung damage and refractory pneumothorax from coronavirus disease 2019 (COVID-19) and required V-V ECMO treatment initiated on day 39. The patient was unable to be weaned off V-V ECMO due to uncontrolled high serum carbon dioxide (CO2) concentration and required long-term V-V ECMO treatment for more than 80 days. DLC placement was necessary to implement aggressive rehabilitation, reduce puncture site-induced infections, and reduce recirculation. On day 119, a supraclavicular approach was used for DLC placement under fluoroscopic guidance using ultrasound guidance because a thrombus in the right IJV prevented the DLC insertion at a usual puncture site. Rehabilitation was safely performed at a higher intensity than preoperatively of DLC insertion. Overall, the DLC catheter was maintained for more than 30 days until the patient died due to septic shock by an unknown focus on day 150, with no complications such as bleeding or infection. This case report highlights the significance of using the supraclavicular approach for DLC placement in V-V ECMO in cases where IJV is not possible due to thrombus presence. In conclusion, the supraclavicular approach is safe and feasible for V-V ECMO insertion as an alternative to the IJV.

Combined use of veno-venous extracorporeal membrane oxygenation and asynchronous independent lung ventilation after thoracic surgery for lung abscess.

We used independent lung ventilation (ILV) during veno-venous extracorporeal membrane oxygenation (V-V ECMO) after lung abscess surgery in a patient with severe hypoxia and air leak. ILV can be effective in V-V ECMO as unilateral lung air leak.

Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study).

AIM: To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. METHODS: This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. RESULTS: Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. CONCLUSIONS: ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.

Pump-controlled retrograde trial off for weaning from venoarterial extracorporeal membrane oxygenation in an adult patient with pulmonary embolism.

Background: Although pump-controlled retrograde trial off (PCRTO) is a practical method for weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO), its advantages and safety for patients with pulmonary embolism are not yet reported. Case Presentation: A 62-year-old man with coronavirus disease 2019 experienced sudden cardiac arrest, and VA-ECMO was introduced. After confirming a massive acute pulmonary embolism, unfractionated heparin treatment was initiated. On day 6, the patient was confirmed stable with a flow rate of 1.0 L/min. However, decannulation led to cardiac arrest and reintroduction of VA-ECMO. After further treatment, a residual thrombus was observed, and pulmonary arterial pressure remained high. On day 23, ECMO was decannulated successfully after a weaning test with PCRTO, which simulated ECMO withdrawal by generating a partial arteriovenous shunt. Conclusion: PCRTO is a feasible weaning strategy and can be considered for patients with uncertain cardiorespiratory recovery.

Venovenous Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis: Starting without Systemic Anticoagulation.

Regarding extracorporeal membrane oxygenation (ECMO) support against hemorrhagic conditions, there seems to be a dilemma when deciding between maintaining the circuit patency by systemic anticoagulation and increasing the risk of bleeding. We herein report two cases of diffuse alveolar hemorrhage (DAH) caused by myeloperoxidase (MPO) anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) successfully treated with venovenous (VV)-ECMO support, both initially started without systemic anticoagulation. Under anticoagulation-free ECMO management, we should consider the shortcomings of frequent circuit exchange and hemorrhagic diathesis related to circuit-induced disseminated intravascular coagulation (DIC).

Reconfiguration from veno-arterial to veno-arterio-venous extracorporeal membrane oxygenation for massive pulmonary embolism.

Differential hypoxia may occur after the initiation of femorofemoral veno-arterial extracorporeal membrane oxygenation (VA ECMO) if cardiac function improves while severe respiratory failure is still present, one of the most difficult problems encountered during VA ECMO. Reconfiguration to veno-arterio-venous ECMO (V-AV ECMO) is one of several methods of dealing with differential hypoxia. V-AV ECMO requires triple cannulation and careful management of the reinjection flow, but the risk of bleeding is lower than in a surgical procedure, such as central ECMO or a subclavian artery graft. Herein, we reported a patient with a massive pulmonary embolism who received VA ECMO, which was reconfigured to V-AV ECMO 3 days later when differential hypoxia occurred. A drainage cannula was newly inserted via the right internal jugular vein, and an existing drainage cannula was used for reinjection after repositioning it caudally. V-AV ECMO is an effective and feasible treatment for differential hypoxia despite the paucity of the procedure to date.

Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: a case series.

AIM: An early tracheostomy is often considered for patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO). However, there is no consensus on the timing of a tracheostomy in patients on VV-ECMO for coronavirus disease 2019 (COVID-19). The present report described the optimal timing of tracheostomy for these patients. METHOD: The present study was a single-center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV-ECMO treatment in our center between January 1, 2020 and December 31, 2020. RESULTS: All the patients received a percutaneous dilatational tracheostomy, which was performed during VV-ECMO in four patients. Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1-14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D-dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV-ECMO, and no complication was observed. Eight patients were deeply sedated during VV-ECMO to prioritize lung rest and prevent infecting the healthcare workers. CONCLUSION: In the present study, patients who underwent a tracheostomy during VV-ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID-19, it should be performed after weaning off VV-ECMO to protect the safety of the healthcare workers concerned.