Assuntos
Tomada de Decisão Clínica/ética , Tomada de Decisão Clínica/métodos , Oxigenação por Membrana Extracorpórea/ética , Oxigenação por Membrana Extracorpórea/métodos , Seleção de Pacientes/ética , Análise Custo-Benefício , Ética Médica , Oxigenação por Membrana Extracorpórea/economia , Oxigenação por Membrana Extracorpórea/mortalidade , Humanos , Qualidade de Vida , Fatores de TempoRESUMO
Although no consensus exists on whether extracorporeal membrane oxygenation (ECMO) support is an indication for solid-organ transplantation other than heart and lung, this practice continues to be limited. We present a case of a 55-year-old man who was placed on venoarterial ECMO (VA-ECMO) during orthotopic heart transplantation (OHT) because of acute graft failure. Twenty-four hours later, the patient underwent deceased-donor renal transplantation (DDRT) while on VA-ECMO and had no complications. On post-DDRT day 2 (post-OHT day 3), the patient was successfully decannulated from VA-ECMO and ultimately discharged home. This case highlights the potential successful use of ECMO support during solid-organ transplantation other than heart and lung and the importance of trained providers and tailored anticoagulation. To the authors' knowledge, this is the first report of perioperative ECMO use during kidney transplantation after recent heart transplantation.
RESUMO
OBJECTIVE: To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients. METHODS: Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients. RESULTS: After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohen's κ of 0.745 [95% CI, 0.385-1.0; P < .01]) in the diagnosis of shock when compared to experienced intensivists. CONCLUSIONS: Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.
Assuntos
Ecocardiografia/normas , Educação Médica Continuada , Estado Terminal , Currículo , Humanos , Unidades de Terapia Intensiva , Estudos Longitudinais , Estudos ProspectivosRESUMO
Training adult learners to use ultrasound in clinical practice relies on the ability of the learner to apply visuospatial concepts to the anatomy of the human body. We describe a visuospatial trainer that replicates the housing of an ultrasound transducer, through which a linear laser projects light in the same plane and orientation as the ultrasonic sound waves. We use this trainer in combination with a porcine heart dissection laboratory to teach bedside cardiac ultrasound and transthoracic echocardiography (TTE). Off-the-shelf components, including an on/off switch, a laser, and 2 ampere batteries are connected in series and placed inside the 3-dimensional (3D)-printed housing. The trainer's laser emission projects a red line that visually represents the ultrasound's field. Learners project the laser against a porcine or human heart in the orientation of the TTE window they wish to obtain and then dissect the heart in that plane, allowing for visualization of how grayscale images are obtained from 3D structures. Previous research has demonstrated that visuospatial aptitude is correlated with ultrasound procedural performance. We present this trainer and educational method as a specific training intervention that could enhance the visuospatial ability of the ultrasound learner. This visuospatial trainer and educational method present a novel process for enhancing learner understanding of 2-dimensional ultrasound images as they relate to 3D structures. Having a clear understanding of how images are generated in cross section may translate into more proficient adaptation of cardiac ultrasound and TTE.
Assuntos
Coração/diagnóstico por imagem , Impressão Tridimensional , Ultrassom/educação , Ultrassonografia/instrumentação , Animais , Humanos , Modelos Animais , SuínosAssuntos
Hipóxia/diagnóstico por imagem , Complicações Intraoperatórias/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Ultrassonografia de Intervenção/métodos , Humanos , Hipóxia/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Pulmão/cirurgiaRESUMO
Ornithine transcarbamylase (OTC) deficiency is well known for its diagnosis in the neonatal period. Presentation often occurs after protein feeding and manifests as poor oral intake, vomiting, lethargy progressing to seizure, respiratory difficulty, and eventually coma. Presentation at adulthood is rare (and likely underdiagnosed); however, OTC deficiency can be life-threatening and requires prompt investigation and treatment. Reports and guidelines are scarce due to its rarity. Here, we present a 59-year-old woman with a past history of irritable bowel syndrome who underwent a reparative operation for rectal prolapse and enterocele. Her postoperative course was complicated by a bowel perforation (which was repaired), prolonged mechanical ventilation, tracheostomy, critical illness myopathy, protein-caloric malnutrition, and altered mental status. After standard therapy for delirium failed, further investigation showed hyperammonemia and increased urine orotic acid, ultimately leading to the diagnosis of OTC deficiency. This case highlights the importance of considering OTC deficiency in hospitalized adults, especially during the diagnostic evaluation for altered mental status.
Assuntos
Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Ecocardiografia/métodos , Veias Jugulares/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Adulto , Catéteres/efeitos adversos , Desenho de Equipamento/efeitos adversos , Desenho de Equipamento/instrumentação , Feminino , Humanos , Veias Jugulares/cirurgiaRESUMO
A 58-year-old man with medical history of thrombocytopenia was admitted to an outside hospital for a 6-day history of worsening dyspnoea requiring mechanical ventilator support. He was transferred to our institution for extracorporeal membrane oxygenation (ECMO) given his refractory hypoxaemia. On arrival, H1N1 influenza virus was confirmed and all measures to improve oxygenation were ineffective. Thus, the decision was made to start venovenous (VV)-ECMO. Although a low baseline platelet count was recognised (60-70×109/L), a sudden further decrease occurred (30×109/L) and platelet transfusion was initiated. A substantial increase in the pressure across the ECMO oxygenator was identified, and the diagnosis of type II heparin-induced thrombocytopenia was suspected and confirmed. Heparin was discontinued, the oxygenator was exchanged and argatroban was used for anticoagulation. After 28â days on VV-ECMO support, the decision was made to withdraw organ support in conjunction with the patient and family wishes.
Assuntos
Dispneia/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Heparina/efeitos adversos , Oxigenadores/efeitos adversos , Trombocitopenia/induzido quimicamente , Anticoagulantes/efeitos adversos , Falha de Equipamento , Oxigenação por Membrana Extracorpórea/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Trombocitopenia/sangueRESUMO
Giant cell myocarditis (GCM) is a rare and commonly fatal form of fulminant myocarditis. During the acute phase, while immunosuppressive therapy is initiated, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is commonly used as a bridge to heart transplantation or recovery. Until recently, conventional transesophageal echocardiography and transthoracic echocardiography were the tools available for hemodynamic assessment of patients on this form of mechanical circulatory support. Nevertheless, both techniques have their limitations. We present a case of a 54-year-old man diagnosed with GCM requiring VA-ECMO support that was monitored under a novel miniaturized transesophageal echocardiography (hTEE) probe recently approved for 72 hours of continuous hemodynamic monitoring. Our case highlights the value of this novel, flexible, and disposable device for hemodynamic monitoring, accurate therapy guidance, and potential VA-ECMO weaning process of patients with this form of severe myocarditis.