[Show abstract][Hide abstract] ABSTRACT: Approximately 7% of patients with status asthmaticus (SA) die each year despite maximal pharmacological therapy and Introduction mechanical ventilator (MV) support. The use of extracorporeal membrane oxygenation (ECMO) in patients with asthma is uncommon (Table 1). We describe a patient with life-threatening SA with persistent respiratory acidosis and hemodynamic instability who was successfully supported with ambulatory, low blood flow veno-venous (VV)-ECMO. A 36-year-old man, active smoker with moderate persistent asthma was admitted to intensive care unit for SA. On Case Presentation: lung exam, he had limited air movement and diffuse wheezing. Chest radiograph showed bilateral hyperinflation without infiltration. Initial arterial blood gas (ABG) showed pH=7.39, PaCO2=38mmHg, PaO2=62mmHg. Despite being on intravenous methylprednisolone, magnesium sulfate, subcutaneous terbutaline, continuous bronchodilator and heliox therapy, he developed worsening hypercapnia and required intubation. He was placed on volume-controlled ventilation, respiratory rate (RR) =14/minute, tidal volume (TV) =520 mL, positive end-expiratory pressure (PEEP) =5cmH O and fractional inspired of oxygen (FiO2) =0.4. Due to severe bronchospasm, worsening 2 auto-PEEP and high peak inspiratory pressure (PIP=50cmH O), he was paralyzed and started on ketamine infusion. We allowed permissive 2 hypercapnia, adjusted TV and RR, continued sodium bicarbonate infusion to maintain optimal pH and minimize auto-PEEP. However, he continued to have respiratory acidosis, difficult ventilation (pH=7.15, PaCO2=71mmHg, PIP=71mmHg), and developed worsening shock, lactic acidosis and renal failure. Within 20 hours after admission, he was placed on VV-ECMO with a 27 French double-lumen catheter in the right internal jugular vein. ECMO flow was maintained between 2-2.5liters/minute, sweep gas flow of 2liters, which resulted in adequate ventilation (PaCO =45-50mmHg), improvement in auto-PEEP and PIP. The patient was maintained on lung rest ventilation 2 (TV=6mL/kg, RR=10/min, FiO2=0.45) for additional 24 hours. Vasopressors and paralytics were discontinued within 6 hours of ECMO initiation. On day3, despite having severe bronchoconstriction and high PIP, he was alert and successfully extubated to room air, while continuing ECMO support. During the next two days, the patient participated in physical therapy and ambulated over 800 feet/day without complications. ECMO was discontinued on day5 and he was discharged home on day8 in good condition. ECMO may be used safely in patients with severe asthma or SA who require MV. In addition to discontinuing ventilator Discussion: support, low blood flow ECMO allows patients to receive physical rehabilitation and ambulate while awaiting resolution of bronchospasm. Studies are needed to determine if ECMO use can reduce morbidity or mortality in patients with SA that require MV.
[Show abstract][Hide abstract] ABSTRACT: Mortality of severe ARDS remains high. Once conventional mechanical ventilation fails, alternative modes of therapy are used, most of which have limited evidence to support their use. No definitive guidelines exist for management of these patients with alternate modalities of treatment. We conducted a cross-sectional national survey of 302 adult critical care training programs in the United States to understand the current preferences of intensivists regarding the use of different therapies for severe ARDS, including the use of ECMO. A total of 381 responses were received: 203 Critical Care faculty, 174 Critical Care trainees. APRV was the initial choice of treatment reported by most when conventional mechanical ventilation strategy failed followed by inhaled nitric oxide and prone positioning. ECMO availability was reported by 80% of the respondents at their institutions. Most respondents (83%) would consider ECMO in patients who fail optimal mechanical ventilation strategies and the majority (60%) believed that ECMO use can facilitate lung protective ventilation, but few favored its use as a first line modality. The majority of respondents reported limited knowledge of ECMO and desired specific ECMO education during training.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 04/2015; Publish Ahead of Print(5). DOI:10.1097/MAT.0000000000000245 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hepatopulmonary syndrome (HPS) is a rare complication of liver cirrhosis that may result in refractory hypoxemia even after liver transplantation. ECMO has been rarely used after liver transplantation or in patients with HPS.
We present a patient with HPS who underwent liver transplantation and developed refractory hypoxemia requiring postoperative ECMO support at our institution. During our review of literature we found nine reports of ECMO use for cardiorespiratory failure after liver transplant in the past.
Our patient had persistent intrapulmonary shunting and developed severe respiratory failure after liver transplant. Additionally, the patient was found to have an atrial septal defect (ASD) and required percutaneous closure while receiving ECMO support. Literature review suggests that survival among these patients who were supported with ECMO after liver transplant was 50% and catastrophic bleeding complications were described in only one report.
With careful selection of post-liver transplant patients and judicious management of anticoagulation, ECMO can be safely instituted in this cohort.
The International journal of artificial organs 03/2015; 38(3). DOI:10.5301/ijao.5000399 · 0.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hemolysis is a common complication of extracorporeal membrane oxygenation (ECMO) support and is associated with increased mortality. Frequent monitoring of markers of hemolysis is performed at ECMO centers. We report two cases of spurious hemolysis caused by hypertriglyceridemia in patients undergoing ECMO support. Critically ill patients, including those receiving ECMO, may be at risk of developing medication-induced hypertriglyceridemia. The interference of lipids with the measurement of plasma free hemoglobin, a marker of hemolysis, should be recognized. Our cases highlight the importance of investigating hypertriglyceridemia as part of the assessment of unexplained hemolysis in patients supported with ECMO.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Pulmonary veno-occlusive disease (PVOD) is an uncommon cause of pulmonary arterial hypertension (PAH). However, unlike PAH, treatment options for PVOD are usually quite limited. The impact of the lung allocation score on access to transplantation for PVOD patients, and the clinical course of these patients, have not been well-described. Methods: Patients with a diagnosis of PVOD and PAH registered on the United Network for Organ Sharing wait list for transplantation from May 4, 2005-May 3, 2013 were included. Lung transplantation was the primary outcome measure. Multivariable analyses were performed to determine the odds of dying or receiving a lung transplant after listing. Survival was compared using Kaplan-Meier and competing risks methods. Results: Of 12,251 patients listed for lung transplantation, 49 with PVOD and 647 with PAH were identified. There were no significant differences in the lung allocation score between PVOD and PAH patients at listing, transplant, or wait list removal for death/ too sick for transplant. By 6 months, 22.6% of PVOD patients had been removed from the wait list due to death, compared to 11.0% of PAH patients (Chi square p=0.03). PVOD patients who died or were considered too sick for transplant were removed from the waiting list sooner after listing (22 vs. 105 days, p=0.08). There was no difference in the proportion of PVOD and PAH patients transplanted (50.0% vs. 47.6%, p=0.60). Conclusion: In the lung allocation score era, PVOD patients may be at higher risk for death while on the transplant waiting list. After wait list registration, close monitoring for disease progression is advised.
[Show abstract][Hide abstract] ABSTRACT: Background
Donor to recipient lung size matching at lung transplantation (LTx) can be estimated by the predicted total lung capacity (pTLC)ratio (donor pTLC/recipient pTLC).
We aimed to determine whether the pTLC-ratio is associated with the risk of primary graft dysfunction (PGD) after bilateral LTx (BLT).
We calculated the pTLC-ratio for 812 adult BLTs from the Lung Transplant Outcomes Group between 3/2002-12/2010. Patients were stratified by pTLC-ratio>1.0 ("oversized") and pTLC-ratio≤1.0 ("undersized"). PGD was defined as any ISHLT grade 3 PGD within 72 hours of reperfusion (PGD 3). We analyzed the association between risk factors and PGD using multivariable conditional logistic regression. As transplant diagnoses can influence the size matching decisions and also modulate the risk for PGD, we performed pre-specified analyses by assessing the impact of lung size mismatch within diagnostic categories.
In univariate analyses oversizing was associated with a 39% lower odds of PGD3 (OR 0.61, 95% CI, p=0.003). In a multivariate model accounting for center effects and known PGD risks, oversizing remained independently associated with a decreased odds of PGD3 (OR 0.58, 95% CI 0.38-0.88, p=0.01). The risk adjusted point estimate was similar for the non-COPD diagnoses groups (OR 0.52, 95%CI 0.32-0.86, p=0.01); however there was no detected association within the COPD group (OR 0.72, 95% CI 0.29-1.78, p=0.5).
Oversized allografts are associated with a decreased risk of PGD3 after BLT; this effect appears most apparent in non-COPD patients.
The Journal of Heart and Lung Transplantation 09/2014; 34(2). DOI:10.1016/j.healun.2014.09.030 · 6.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Extracorporeal membrane oxygenation (ECMO) use during pregnancy and the post-partum period is thought to be associated with an increased risk for maternal or fetal bleeding complications. We present our recent institutional experience in managing pregnant and post-partum patients with ECMO. We also performed a literature review of modern use of ECMO in pregnant and post-partum patients utilizing Pubmed and Embase databases. ECMO was used for severe cardiopulmonary failure due to multiple conditions. Based on published reports, overall maternal and fetal survival on ECMO were 80% and 70%, respectively. Mild to moderate vaginal bleeding was reported in a few cases, with rare occurrences of catastrophic post-partum hemorrhage. There was no consensus on an optimal anticoagulation strategy in these patients, though most preferred to keep anticoagulation at lower therapeutic levels. We conclude that ECMO, in well-selected pregnant and post-partum patients, appears to be safe and associated with low risk of maternal and fetal complications.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 09/2014; 61(1). DOI:10.1097/MAT.0000000000000154 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Guillain-Barré syndrome (GBS) has been described after solid organ and bone marrow transplantation mostly due to viral infections and possibly calcineurin inhibitors. Incidence after bone marrow transplant is 0.3-0.7%, though incidence in other transplants is not well known. We present the first description of tacrolimus associated GBS in lung transplant recipients in the English language literature. The pathophysiology of tacrolimus-induced polyneuropathy is not known, but some have hypothesized that tacrolimus induces an inflammatory phenomenon by differential effects on T cell subsets. Diagnosis of association may be challenging and requires high index of suspicion. The optimal treatment of GBS-associated with tacrolimus after lung transplantation is unknown, although drug discontinuation may result in improvement in some patients, while some reports suggest that the use of IVIG and/or plasmapheresis may be helpful and safe in organ transplant recipients with severe symptoms.
[Show abstract][Hide abstract] ABSTRACT: Regional citrate anticoagulation (RCA) is used as an anticoagulant for continuous renal replacement therapy (CRRT). A systemic calcium (Ca2+) infusion is required to replace Ca2+ lost in the effluent. The shortage of intravenous Ca2+ in the United States has limited RCA use. We describe a continuous veno-venous hemofiltration (CVVH) protocol with RCA using 2.2% anticoagulant citrate dextrose formula-A (ACD-A) and a commercial dialysate containing Ca2+ 1.5 mmol/l (N × Stage) as post-filter replacement fluid (RF), without need for Ca2+ infusion.
We prospectively evaluated five patients on CRRT who had at least three episodes of filter clotting within 24 h. Patients were switched to CVVH using ACD-A infused pre-blood pump and titrated to achieve a post-filter ionized calcium (iCa2+) level <0.5 mmol/l. The Ca2+ -containing dialysate was delivered post-filter as RF.
Steady state mean serum chemistries were: Na+: 140.8 ± 2.3 meq/l, K+: 4.2 ± 0.4 meq/l, HCO3-: 30.9 ± 3.7 meq/l, pH: 7.42 ± 0.07, CO2: 47.9 ± 8.3 mmHg, total Ca2+: 8.08 ± 1.09 mg/dL. Post-filter iCa2+ ranged 0.27-0.36 mmol/l, and patient iCa2+ ranged 0.81-1.24 mmol/l. Mean post-filter RF rate: 3086 ± 164 ml/h, mean ACD-A rate: 298 ± 21 ml/h. Mean blood flow rate: 200 ± 17 ml/min, mean filtration fraction: 39.6 ± 7.2%. Mean effluent flow rate: 38.6 ± 6.7 ml/kg/h (range 28.7-55.8). Mean filter survival was 7 h without anticoagulation, compared to 42.6 h in the ACD-A group (p<0.0001).
In this pilot study, CVVH using ACD-A for RCA and a Ca2+ -containing RF was safely and effectively used without a continuous Ca2+ infusion. This protocol is a promising solution for maintaining effective CRRT when intravenous calcium is in short supply.
The International journal of artificial organs 04/2014; DOI:10.5301/ijao.5000323 · 0.96 Impact Factor