Simulation versus live tissue training randomised trial for ECMO proficiency: is one better than the other?

Introduction: Extracorporeal membrane oxygenation (ECMO) is a classic low-volume high-risk procedure that requires just in time and/or refresher training through animal or simulation modalities. This manuscript evaluated the performance of ECMO personnel trained with both modalities to determine which is better suited for ECMO skills training. Methods: Participants (physicians, nurses and respiratory/medical technicians) completed a series of ECMO scenarios with synthetic tissue cannulation task trainer as well as a live tissue model. Objective performance quality was based on task completion using a validated ECMO skills assessment tool. Results: Thirty-eight individuals completed this study. Participants completed individual scenario tasks 3 min faster using the simulator (26 min vs 29 min; p=0.03). No differences were seen in percentage of individual tasks completed. In the group scenarios, participants completed a higher percentage of critical tasks using the simulator (97%) versus the animal model (91%; p=0.05), but no differences were seen in task completion times. Additionally, no differences were seen in either lab-based or participants' prelab cognitive scores. Conclusions: Regardless of their self-assessment or experience, participants' objective performances were similar among both animal and simulation labs. Task completion times were quicker with simulation model. The distinction between simulation versus animal model may be less important as both demonstrate benefit in development of and/or maintaining skill competency. In the era of questioning the need for and costs of live tissue training, expanding the role of simulation may achieve similar training goals.

Vitamin D deficiency at birth among military dependants in Hawai'i.

Vitamin D has long been known to be essential in bone mineralization as well as calcium and phosphate regulation. An increasing body of literature suggests that Vitamin D is also key in many other areas to include immune function, brain development, prevention of autoimmune disease, and prevention of certain types of cancers. Studies also suggest that, with decreased sun exposure due to concern for skin cancer risk, much of the world's population is becoming increasingly deficient in vitamin D. Our hypothesis was that vitamin D deficiency exists, and can be detected, even in sunny climates such as the state of Hawai'i. To test this hypothesis, eighty-six cord blood samples were collected in the process of routine clinical testing. These samples were tested for 25-hydroxy vitamin D via liquid chromatography mass spectroscopy. Percent deficiency (<20ng/mL) and insufficiency (20-31.9ng/mL) were determined by statistical analysis. Forty-six percent (n=37) of cord blood samples tested were deficient in vitamin D; 47 percent (n=38) of samples had insufficient 25-OH vitamin D. Only 7 percent (n=6) of samples showed vitamin D concentrations at the recommended levels. A vast majority of military dependents in Hawai'i have less than optimal vitamin D levels at birth. Further investigation of vitamin D supplementation during pregnancy is required to optimize vitamin D status at birth. We conclude that a vast majority of military dependents in Hawai'i have less than optimal vitamin D levels at birth supporting the recommendation for supplementation in this population.

Correlation of brain tissue oxygen tension with cerebral near-infrared spectroscopy and mixed venous oxygen saturation during extracorporeal membrane oxygenation.

The aim of this prospective, animal study was to compare brain tissue oxygen tension (PbtO(2)) with cerebral near infrared spectroscopy (NIRS) and mixed venous oxygen saturation (SVO(2)) during venoarterial extracorporeal membrane oxygenation (VA ECMO) in a porcine model. This was accomplished using twelve immature piglets with surgically implanted catheters placed in the superficial cerebral cortex to measure brain PbtO(2) and microdialysis metabolites. The NIRS sensor was placed overlying the forehead to measure cerebral regional saturation index (rSO(2)i) while SVO(2) was measured directly from the ECMO circuit. Animals were placed on VA ECMO followed by an initial period of stabilization, after which they were subjected to graded hypoxia and recovery. Our results revealed that rSO(2)i and SVO(2) correlated only marginally with PbtO(2) (R(2)=0.32 and R(2)=0.26, respectively) while the correlation between rSO(2)i and SVO( 2) was significantly stronger (R(2)=0.59). Cerebral metabolites and rSO(2)i were significantly altered during attenuation of PbtO( 2), p<0.05). A subset of animals, following exposure to hypoxia, experienced markedly delayed recovery of both rSO(2)i and PbtO( 2) despite rapid normalization of SVO(2). Upon further analysis, these animals had significantly lower blood pressure (p=0.001), lower serum pH (p=0.01), and higher serum lactate (p=0.02). Additionally, in this subgroup, rSO(2)i correlated better with PbtO(2) (R(2)=0.76). These findings suggest that, in our ECMO model, rSO(2)i and SVO( 2) correlate reasonably well with each other, but not necessarily with brain PbtO(2) and that NIRS-derived rSO(2)i may more accurately reflect cerebral tissue hypoxia in sicker animals.

A 22-year experience in global transport extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Transport extracorporeal membrane oxygenation (ECMO) is currently available at 12 centers. We report a 22-year experience from the only facility providing global transport ECMO. Indications for transport ECMO include lack of ECMO services, inability to transport conventionally, inability to wean from cardiopulmonary bypass, extracorporeal cardiopulmonary resuscitation, and need to move a patient on ECMO for specialized services such as organ transplantation. METHODS: Retrospective database review of children undergoing inhouse and transport ECMO from 1985 to 2007. RESULTS: Sixty-eight children underwent transport ECMO. Fifty-six were transported on ECMO into our facility. The remaining 12 were moved between 2 outside locations. Ground vehicles and fixed-wing aircraft were used. Distance transported was 8 to 7500 miles (13-12070 km), mean 1380 miles (2220 km). There were 116 inhouse ECMO runs. No child died during transport. Survival to discharge after transport ECMO was 65% (44/68) and, for inhouse ECMO, was 70% (81/116). CONCLUSIONS: Transport ECMO is feasible and effective, with survival rates comparable to inhouse ECMO. We have used transport ECMO to help children at non-ECMO centers with pulmonary failure who have not improved with inhaled nitric oxide and high-frequency ventilation. We have also transported a child after extracorporeal cardiopulmonary resuscitation, which may represent an emerging indication for transport ECMO. Transport ECMO often is the only option for children too unstable for conventional transport or those already on ECMO and requiring a specialized service at another facility, such as organ transplantation.

Impact of room air resuscitation on early growth response gene-1 in a neonatal piglet model of cerebral hypoxic ischemia.

Early growth response gene-1 (Egr-1) is up-regulated by hypoxia-ischemia (HI) and reactive oxygen species (ROS) in adult animals, functioning as a master switch in inflammation and thrombogenesis. We hypothesized that resuscitation from HI with 100% O2 would result in greater Egr-1 expression, ROS, and cell death (CD) in the brains of newborn piglets than 21% O2. Two control groups breathed 21% O2 for 1 h followed by 21% or 100% O2 for 1 h. Two HI groups underwent carotid artery occlusion and breathed 8-12% O2 for 1 h followed by occlusion release and 21% or 100% O2 for 1 h. Brain Egr-1 mRNA and protein were analyzed via quantitative PCR and Western blot. CD and ROS were measured by fluorescence microscopy. Egr-1 mRNA expression increased throughout the brain in response to HI with regional heterogeneity, but protein levels did not. Resuscitation with 100% oxygen did not cause any additional Egr-1 mRNA, Egr-1 protein, CD, or ROS production as compared with 21% oxygen. There was no difference in physiologic recovery after HI with room air compared with 100% O2 resuscitation. However, 100% O2 administration was associated with increased CD in the brainstem independent of HI. Therefore, 100% O2 may have been toxic to some brainstem cells and potentially have significance in long-term neurologic sequelae seen after neonatal HI/resuscitation. Egr-1 protein levels may be tightly regulated in an attempt to diminish neurotoxicity or to enhance plasticity at this stage of development.