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BACKGROUND: Extracorporeal membrane oxygenation (ECMO) outcomes in small centers are commonly considered less favorable than in large-volume centers. New ECMO protocols and procedures were established in our regional community hospital system as part of a cardiogenic shock initiative. This retrospective study aims to evaluate the outcomes of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in a community hospital system with cardiac surgery capability and assess whether protocol optimization and cannulation standards result in comparable outcomes to larger centers whether the outcomes of this new ECMO program at the community hospital setting were comparable to the United States averages. METHODS: Our regional system comprises five hospitals with 1500 beds covering southwestern New Jersey, with only one of these hospitals having cardiac surgery and ECMO capability. In May 2021, the new ECMO program was initiated. Patients were screened by a multidisciplinary call, cannulated by our ECMO team, and subsequently treated by the designated team. We reviewed our cardiac ECMO outcomes over two years, from May 2021 to April 2023, in patients who required ECMO due to cardiogenic shock or as a part of extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS: A total of 60 patients underwent cardiac ECMO, and all were VA ECMO, including 18 (30%) patients who required ECPR for cardiac arrest. The overall survival rate for our cardiac ECMO program turned out to be 48% (29/60), with 50% (22/42) in VA ECMO excluding ECPR and 39% (7/18) in the ECPR group. The hospital survival rate for the VA ECMO and ECPR groups was 36% (15/42) and 28% (5/18), respectively. The ELSO-reported national average for hospital survival is 48% for VA ECMO and 30% for ECPR. Considering these benchmarks, the hospital survival rate of our program did not significantly lag behind the national average. CONCLUSIONS: With protocol, cannulation standards, and ECMO management optimized, the VA ECMO results of a community hospital system with cardiac surgery capability were not inferior to those of larger centers.
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Leg ischemia is a potential complication of percutaneous left ventricular assist device (Impella CP®) placement. To avoid leg ischemia in at-risk patients, a distal perfusion catheter (DPC) should be placed. In utilizing a passive distal perfusion system from the contralateral femoral artery, we optimized blood flow to the distal limb mitigating leg ischemia. A 65-year-old female with dilated cardiomyopathy complicated by hemodynamic instability was placed on an Impella CP via the right femoral artery. A DPC was placed to the right distal femoral artery and connected to the wire re-access port of the Impella CP. Despite this, the leg became ischemic shortly after admission to the ICU. A contralateral femoral arterial line was placed in standard fashion, and it was connected to the DPC while the wire re-access port was capped. Shortly after placement of the new DPC system, the right lower extremity distal pulses returned, and distal leg ischemia was resolved. Another patient, a 67-year-old male with acute myocardial infarction, was placed on an Impella CP via the left femoral artery for cardiogenic shock. His hemodynamics continued to deteriorate, requiring initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) via the right femoral artery and vein with associated DPC placement. Shortly after the initiation of VA ECMO, the Impella CP-related extremity (left leg) became ischemic. A left femoral DPC was placed and connected to the side port of the right femoral arterial cannula. After initiation of the additional DPC system, the left leg ischemia resolved. Distal leg ischemia with Impella CP is not a rare event. Utilization of a DPC to Impella CP may decrease the morbidity of limb malperfusion.
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Patients with novel coronavirus 2019 (COVID-19) may develop acute respiratory distress syndrome (ARDS) and require extracorporeal membrane oxygenation (ECMO) support. Currently there is no specific treatment for COVID-19 available; thus, for patients with severe ARDS, the respiratory condition needs to improve while on ECMO support. Here we present a multidisciplinary team approach to the care of a patient with COVID-related ARDS requiring three months of veno-venous (VV) ECMO which lead to recovery. A 35-year-old male was transferred to us with ARDS due to COVID-19 infection with a lactate 13.7 mmol/L and an arterial-blood gas oxygenation of 75 mmHg on maximum ventilator settings. He was placed on VV ECMO during which he developed pneumonia, bacteremia, and pneumothoraces; however, his other organ functions were preserved. During his time in the Intensive Care Unit (ICU), multiple subspecialist teams participated in his care including physicians, pharmacists, nurses, nutritionists, case management, and social work. The VV ECMO was weaned off after 91 days of support, after which he had a prolonged hospital course due to inflammatory bowel disease, and aspiration pneumonia. CT scan performed six weeks prior to discharge showed mild improvement in diffuse airspace opacities superimposed on extensive chronic cystic changes. He was eventually discharged to a rehabilitation facility 68 days after ECMO removal. He was then seen in our outpatient pulmonary clinic one month and our Post-Intensive Care Syndrome clinic three months after discharge on two liters of nasal cannula oxygen. Pulmonary function testing done at this time demonstrated severe restrictive lung disease and severely reduced diffusion capacity. This case highlights the need for multidisciplinary collaboration among hospital teams to ensure success and patient survival in the setting of COVID ARDS. In those COVID ARDS patients with intact renal, metabolic, hematologic, and cardiovascular function, ECMO should be strongly considered.
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High-frequency oscillatory ventilation (HFOV) may assist in the prevention of volutrauma for high-risk patients with acute respiratory distress syndrome (ARDS) during venovenous extracorporeal membrane oxygenation (VV ECMO). In combined VV ECMO and HFOV, we noted that increased intrathoracic pressure contributed to shunt formation in the dual-lumen Avalon® cannula (Maquet, Rastatt, Germany). A 51-year-old female with ARDS secondary to aspiration pneumonia was placed on VV ECMO using a single Avalon cannula. By ECMO Day 16, she became unable to ventilate due to elevated peak airway pressures, even with low tidal volume ventilation and an otherwise stable VV ECMO course. HFOV was introduced to minimize ventilator-induced lung injury. Shortly after HFOV started, the patient desaturated, and consequently, the fraction of inspired oxygen (FiO2) was increased to 100%. We noted that a flash of bright red, oxygenated blood was flowing retrograde in the Avalon cannula at the same rate as the beat of the oscillator, while the patient's ECMO flow rate, arterial blood gas, and blood pressure all remained stable. The ECMO flow was increased above 5.5 L/min and the resolution of the retrograde shunt through the Avalon cannula was immediately observed. Concurrent use of HFOV with VV ECMO using an Avalon cannula may result in a shunt that becomes visible with arterial O2 saturations nearing 100%. Due to pressure differences between the venous and arterial lumens of the Avalon cannula, increasing the ECMO flow rate appeared to decrease this shunting effect caused by elevated intrathoracic pressure.
