Membrane Oxygenator Use With Biventricular Assist Device: Facilitation of Support and Lung Recovery.

We present the use of a low-resistance membrane oxygenator (Quadrox D, Maquet) in series with a pulsatile right ventricular assist device (Berlin Heart EXCOR, Berlin Heart) in a patient with biventricular support who required high-frequency oscillatory ventilation (HFOV), due to refractory acute respiratory distress syndrome associated with Cytomegalovirus pneumonia. The high mean airway pressure associated with the use of HFOV resulted in a significant negative impact on left ventricular assist device (LVAD) filling that led to a combined respiratory and metabolic acidosis and the need for vasopressor support. Oxygenator placement enabled transition to conventional ventilation and the discontinuation of vasopressor support. This case demonstrates the feasibility and safety of the use of this lung support system in patients requiring ventricular assist device (VAD) support.

Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study.

OBJECTIVES: To determine whether time to prepare IV medications for hyperkalemia varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data support the Advanced Cardiac Life Support recommended sequence. DESIGN: Prospective randomized simulation-based study. SETTING: Single pediatric tertiary medical referral center. SUBJECTS: Pediatric nurses and adult or pediatric pharmacists. INTERVENTIONS: Subjects were randomized to prepare medication doses for one of four medication sequences and stratified by one of three weight categories representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and 50 kg. Using provided supplies and dosing references, subjects prepared doses of calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with dextrose. Because insulin and dextrose are traditionally prepared and delivered together, they were analyzed as one drug. Subjects preparing medications were video-recorded for the purpose of extracting timing data. MEASUREMENTS AND MAIN RESULTS: A total of 12 nurses and 12 pharmacists were enrolled. The median (interquartile range) total preparation time for the three drugs was 9.5 minutes (6.4-13.7 min). Drugs were prepared significantly faster for larger children (50 kg, 6.8 min [5.6-9.1 min] vs 20 kg, 9.5 min [8.6-13.0 min] vs 4 kg, 16.3 min [12.7-18.9 min]; p = 0.001). Insulin with dextrose took significantly longer to prepare than the other medications, and there was no difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8-2.6] vs calcium chloride, 2.1 [1.2-3.1] vs calcium gluconate, 2.4 [2.1-3.0] vs insulin with dextrose, 5.1 min [3.7-7.7 min], respectively; p < 0.001). Forty-two percent of subjects (10/24) made at least one dosing error. CONCLUSIONS: Medication preparation for hyperkalemia takes significantly longer for smaller children and preparation of insulin with dextrose takes the longest. This study supports Pediatric Advanced Life Support guidelines to treat hyperkalemia during pediatric cardiac arrest similar to those recommended per Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; and third, insulin with dextrose).