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The authors have conducted a retrospective analysis based on two cases of patients with intra-tracheal pathologies who received treatment from the same surgeon at a tertiary referral center. The effective management of airways in patients with intra-tracheal lesions necessitates close collaboration between surgeons and anesthesiologists. Factors such as the size, location, rigidity of the tumor, and the remaining tracheal lumen space should be carefully considered. In situations where there is near complete obstruction of the trachea and a substantial risk of worsened respiratory function, resorting to cardiopulmonary bypass or extracorporeal membrane oxygenation is advisable. This pilot study aims at devising an algorithm for the airway management of intra-tracheal lesions, although a larger case cohort is needed to assess its applicability and effectiveness. [ABSTRACT FROM AUTHOR]

Introduction: Extra Corporeal Membrane Oxygenation (ECMO) has long been used for cardiorespiratory support in the immediate postpaediatric cardiac surgery period with a 2-3% success as per the ELSO registry. Success in recovery depends upon the optimal delivery of critical care to paediatric patients and a comprehensive healthcare team. Methodology: The survival benefit of children placed on central veno arterial (VA) ECMO following elective cardiac surgeries for congenital heart disease (n = 672) was studied in a cohort of 29 (4.3%) cases from the period of Jan 2018 to Dec 2022 in our cardiac surgical centre. Indications for placing these patients on central VA ECMO included inability to wean from cardiopulmonary bypass (CPB), low cardiac output syndrome, severe pulmonary arterial hypertension, significant bleeding, anaphylaxis, respiratory failure and severe pulmonary edema. Results: The mean time to initiation of ECMO was less than 5 h and the mean duration of ECMO support was 56 h with a survival rate of 58.3%. Amongst perioperative complications, sepsis and arrhythmia on ECMO were found to be negatively associated with survival. Improvements in the pH, PaO2 levels and serum lactate levels after initiation of ECMO were associated with survival benefits. Conclusion: The early initiation of ECMO for paediatric cardiotomies could be a beacon of hope for families and medical teams confronting these challenging situations. Improvement in indicators of adequate perfusion and ventricular recoveries like pH and serum lactate and absence of arrhythmia and sepsis are associated with good outcomes. [ABSTRACT FROM AUTHOR]

During the coronavirus disease 2019 (COVID-19) pandemic, acute kidney injury (AKI) was a common sequela of COVID-19 infection and predicted disease severity and mortality. Extracorporeal blood purification techniques involving blood filtration devices are an emerging treatment for AKI in the setting of severe COVID-19 infections. In this review, we discuss potential mechanisms for the development of AKI in COVID-19 patients as well as the various available blood filtration devices and the role they may play in managing the AKI in COVID-19 patients. A total of seven blood filters currently available were compared based on their potential in treating AKI in COVID-19 patients. Blood filtration devices show potential as an emerging treatment modality for COVID-19--induced AKI, but further clinical trials are necessary before their widespread adoption and usage. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) has been used in patients with severe acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) who fail conventional treatment. Methods: A retrospective observational study was designed in patients who underwent ECMO for severe COVID-19 ARDS in a tertiary care centre from September 2020 to July 2021. The primary outcome was to assess factors influencing clinical outcomes and survival to hospital discharge. Secondary outcomes were to assess the clinical profile and pre-ECMO features, ECMO characteristics and complications. Collected data were entered in Excel software and analysed using R software version 4.0.2 (R foundation for statistical computing, Vienna, Austria). Results: A total of 19 patients underwent ECMO. Ten patients survived and discharge. Survivors had a longer median (interquartile range [IQR]) duration (days) on ECMO, that is, 25 (7–50), compared to non-survivors, that is, 12 (1–34) (P = 0.133). We also noted that patients who survived had a longer median (IQR) duration (days) of intensive care unit (ICU) stay, that is, 41.5 (30–70), compared to non-survivors, that is, 9 (2–40) (P = 0.001). Conclusion: In our study, 52.3% of patients survived and discharge, and with ECMO outcomes for COVID-19 ARDS were at par with ECMO outcomes for non-COVID-19 ARDS despite requiring ECMO for longer duration and increased ICU length of stay. [ABSTRACT FROM AUTHOR]

A 25-year-old female was presented with acute right heart failure (aRHF) and cardiogenic shock secondary to thyrotoxicosis with concomitant acute respiratory failure. A ProtekDuo cannula was placed to provide temporary percutaneous right ventricular assistance and extracorporeal membrane oxygenation (ECMO) in venopulmonary (V-P) configuration, which provided both decompression of the right ventricle (RV) and oxygenation. With treatment of the underlying thyrotoxicosis, the RV function improved and respiratory failure resolved. She was discharged home in good condition. This case details alternative ECMO management with ProtekDuo compared to the gold standard of venoarterial (V-A) ECMO. [ABSTRACT FROM AUTHOR]

In patients with shunt-dependent physiology, early risk factor identification can facilitate the prevention of adverse outcomes. This study aims to determine a scoring system to estimate the risk for adverse outcomes after Blalock--Taussig--Thomas shunt placement. Of the 39 neonates with Blalock--Taussig--Thomas shunt placement, 10 experienced the composite outcome. The resulting risk score from clinical and hemodynamic variables attributed 1 point for each of the following: central venous pressure >7.8, serum lactate >1.8 mmol/L, renal oxygen extraction ratio >32, and vasoactive-inotrope score >8.7. A score of 0 was associated with a 0% risk of the composite outcome, a score of 1 or 2 with a 15% risk, and a score of 3 or 4 with a 60% risk. A combination of increased central venous pressure, increased serum lactate, increased renal oxygen extraction ratio, and increased vasoactive-inotrope score are highly accurately associated with the risk of cardiopulmonary arrest, need for extracorporeal membrane oxygenation, or inpatient mortality after a Blalock--Taussig--Thomas shunt in patients with shunt-dependent physiology. [ABSTRACT FROM AUTHOR]

This article describes a case study where a patient with ProtekDuo + oxygenator and Impella CP (PROpella) in biventricular failure and cardiogenic shock was reconfigured to venopulmonary-arterial (VP-A) extracorporeal membrane oxygenation (ECMO), secondary to leg ischemia. The ProtekDuo was subsequently used as double-lumen drainage cannula, returning blood into a newly percutaneously placed femoral arterial cannula, mimicking venoarterial (V-A) ECMO in VP-A configuration. The following day, an Impella 5.5 could be placed and the ProtekDuo was reconfigured back to its default venopulmonary (V-P) ECMO configuration, now again as PROpella with minimally invasive biventricular groin-free full mechanical circulatory support. However, while in VP-A, good drainage blood flows of up to 4.5 LPM could be achieved similar to the ProtekDuo forward flow. None of the lumens collapsed secondary to negative pressure in the system. Drainage through the ProtekDuo for VP-A ECMO is feasible and without complications for a 24-hour period. This new method extends the ProtekDuo's spectrum of use. [ABSTRACT FROM AUTHOR]

Ventricular septal defect (VSD) is a known complication after myocardial infarction associated with high mortality. Extracorporeal membrane oxygenation (ECMO) is being successfully used in patients with VSD as a bridge to definitive surgical repair. Although often the only possibility to stabilize hemodynamics and oxygenation, ECMO has many potential complications, carrying significant morbidity and mortality. Here, the patient presented with a postinfarct VSD on peripheral venoarterial ECMO who developed a dissection of the common iliac artery (CIA) on the 5th day after ECMO implantation. As a result, a sudden drop in ECMO flow has become evident along with high pressures in the arterial cannula. After a definitive diagnosis of a CIA lesion obstructing the blood flow was made, trans-ECMO endovascular repair of CIA was performed. Four days after endovascular repair, we encountered the same problem of decreased blood flow associated with stent kinking and were approached with another endovascular repair to re-establishing full ECMO flow. [ABSTRACT FROM AUTHOR]

The role of extracorporeal membrane oxygenation (ECMO) and its indications in stage I Norwood palliation are controversial. The decision to initiate ECMO and its timing remains difficult with no definitive cut-off points or evidence-based guidelines. It varies on a case-to-case basis. We report a case where the use of ECMO was beneficial after stage I Norwood palliation with severe ventricular dysfunction. The systemic-to-pulmonary artery shunt was kept open to balance the systemic and pulmonary circulations. Cerebral oximetry can be useful as an additional monitoring modality to guide management, monitor cerebral perfusion, and help detect cerebral steal. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support which provides cardiorespiratory support to patients with potentially reversible pathophysiological processes. ECMO has evolved over the past few decades as a standard technology for neonatal severe respiratory support. However, its use in the pediatric population has increased only since 2009. We report a case of a 9-month infant who required a prolonged (789 h) venoarterial ECMO for severe acute respiratory distress consequent to pneumonia probably secondary to aspiration. He was discharged after this prolonged ECMO run without any obvious unfavorable outcome and is neurodevelopmentally sound at a 26-month follow-up. [ABSTRACT FROM AUTHOR]

With the increasing number of critically ill patients being admitted to intensive care units (ICUs), newer techniques and treatment modalities continue to evolve for their adequate management. Thus, it has become imperative to understand existing tools and resources, and utilise or repurpose them to achieve better results that can decrease morbidity and mortality. In this writeup, we chose five areas of interest, including analgosedation, role of colloids, recent advancements in the management of respiratory failure, the role of extracorporeal membrane oxygenation, and newer antimicrobials. The role of analgosedation in the critically ill has gained importance with focus on post-ICU syndromes, and albumin has re-entered the fray as a possible repairer of the injured glycocalyx. The coronavirus disease 2019 (COVID-19) pandemic forced us to relook at various ventilator strategies and mechanical support for the failing circulation has now become more common with clear end-points. Rising microbial antibiotic resistance has opened up the research on newer antibiotics. [ABSTRACT FROM AUTHOR]

The use of ECPELLA in patients with severe lung disease may result in an unfavorable phenomenon of differential hypoxia. The simultaneous evaluation of three arterial blood samples from different arterial line (right radial artery, left radial artery, ECMO arterial line) in patients at risk of Harlequin syndrome (also called differential hypoxemia (DH)) can localize the "mixing cloud" along the aorta. Focusing the attention on the "mixing cloud" position instead of on isolated flows of Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) and Impella CP makes the decision making easier about how to modify MCSs flows according to the clinical context. Herein, we present two cases in which ECPELLA configuration was used to treat a cardiogenic shock condition and how the ECPELLA-induced hypoxia was managed. [ABSTRACT FROM AUTHOR]

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure, including refractory cardiogenic shock (CS) and cardiac arrest (CA). Few studies have assessed predictors of successful weaning (SW) from VA ECMO. This systematic review and meta-analysis aimed to identify a multiparameter strategy associated with SW from VA ECMO. PubMed and the Cochrane Library and the International Clinical Trials Registry Platform were searched. Studies reporting adult patients with CS or CA treated with VA ECMO published from the year 2000 onwards were included. Primary outcomes were hemodynamic, laboratory, and echocardiography parameters associated with a VA ECMO SW. A total of 11 studies (n=653) were included in this review. Pooled VA ECMO SW was 45% (95%CI: 39–50%, I2 7%) and in-hospital mortality rate was 46.6% (95%CI: 33–60%; I2 36%). In the SW group, pulse pressure [MD 12.7 (95%CI: 7.3–18) I2 = 0%] and mean blood pressure [MD 20.15 (95%CI: 13.8–26.4 I2 = 0) were higher. They also had lower values of creatinine [MD –0.59 (95%CI: –0.9 to –0.2) I2 = 7%], lactate [MD –3.1 (95%CI: –5.4 to –0.7) I2 = 89%], and creatine kinase [–2779.5 (95%CI: –5387 to –171) I2 = 38%]. And higher left and right ventricular ejection fraction, MD 17.9% (95%CI: –0.2–36.2) I2 = 91%, and MD 15.9% (95%CI 11.9–20) I2 = 0%, respectively. Different hemodynamic, laboratory, and echocardiographic parameters were associated with successful device removal. This systematic review demonstrated the relationship of multiparametric assessment on VA ECMO SW. [ABSTRACT FROM AUTHOR]

Background: Several studies have demonstrated the utility of methylene blue (MB) to treat vasoplegic syndrome (VS), but some have cautioned against its routine use in lung transplantation with only two cases described in prominent literature. Cystic fibrosis patients commonly have chronic infections which predispose them to a systemic inflammatory syndrome-like vasoplegic response during lung transplantation. We present 13 cystic fibrosis patients who underwent lung transplantation and received MB for vasoplegic syndrome while on cardiopulmonary bypass, with or without inhaled pulmonary vasodilator therapy. Methods: Single-center, retrospective, case series analysis of cystic fibrosis patients who underwent lung transplant and received MB for vasoplegia. We defined the primary outcome as 30-day mortality, and secondary outcomes as primary graft failure, 1-year mortality, postoperative complications, and hemodynamic response to MB. Results: MB was associated with a significant increase in mean arterial pressure (MAP) (P < 0.001) in all patients, and 84.6% (11/13) of the patients had either a decrease or no change in vasopressor requirement. No patients developed acute primary graft dysfunction and there was 100% 30-day and 1-year survival. One patient required Extracorporeal membrane oxygenation (ECMO) for hypoxemia and 69% (9/13) of the patients had evidence of postoperative right ventricular dysfunction, but no patients required a right ventricular assist device. Conclusion: This case series demonstrates the effectiveness of MB in treating vasoplegia in cystic fibrosis patients during lung transplantation, without evidence of primary graft dysfunction, 30-day or 1-year mortality. The safety of MB regarding hypoxemia and increased pulmonary vascular resistance requires further investigation. [ABSTRACT FROM AUTHOR]

A patient with a percutaneously inserted cardiopulmonary bypass cannula into the right internal jugular vein, connected to an extracorporeal membrane oxygenation (ECMO) circuit using tape, was referred for transport to our ECMO center. We describe management, quality improvement, and lessons learned. [ABSTRACT FROM AUTHOR]

A pandemic named SARS-COV2 COVID 19 affected many people's life in different ways globally. The normal life is still far away, lockdown rules have been relaxed in many countries. Morbidity and mortality increased a lot after the first wave. COVID-19 has affected medical education in a significant way. Most of the patients were asymptomatic during the second wave and some had symptoms such as myalgia, fever, and cough, which complicated to pneumonia, respiratory distress, and thromboembolic complications. There have been the development of many vaccines such as Covaxin, Pfizer--BioNTech, Covishield, Sputnik V, and Moderna, and these vaccinations have been given to frontline medical workers, people with comorbidities, aged people, etc., with high priority and then the general population. Many pregnant and peripartum women were put on Extracorporeal Membrane Oxygenation (ECMO) in severe to critical cases. A new black fungus was found in post-COVID 19 infections. It was named mucormycosis which usually affected immunocompromised people. There is a high importance in the examination of all the different epidemiological variables of all the places in all the regions across the world, to understand the mutations, and severity of the disease and also to be prepared. Many studies done on COVID-19 in first and the second wave was reviewed in detail and were compared for this review. [ABSTRACT FROM AUTHOR]

Although the routine use of alkali buffer is not recommended in patients with respiratory acidosis, some patients may benefit from its administration. A 42-year-old man was treated with venovenous extracorporeal membrane oxygenation (VV-ECMO) and continuous venovenous hemodiafiltration (CVVHDF) due to necrotizing pneumonia and emphysematous cystitis with Klebsiella pneumoniae. Although the sweep gas flow rate of the VV-ECMO was gradually reduced, he failed to wean off VV-ECMO due to respiratory acidosis, followed by tachycardia and tachypnea on the 63rd day of VV-ECMO. Therefore, we mixed sodium bicarbonate in the replacement fluid of CVVHDF for 5 days to avoid an intolerable decrease in blood pH after discontinuing the VV-ECMO sweep gas. When the serum bicarbonate concentration was >30 mmol/L and pH was maintained at >7.30 with a PCO2 of >60 mmHg, VV-ECMO was finally decannulated. Sodium bicarbonate buffer through the replacement of CVVHDF fluid facilitated VV-ECMO weaning in a patient with hypercapnic respiratory failure. [ABSTRACT FROM AUTHOR]

Objective : Our primary objective study was to evaluate the association between near-infrared spectroscopy (NIRS) and low cardiac output (LCO) in patients with single-ventricle physiology after stage 1 palliation. Methods : In this retrospective study, infants ≤6 months of age with single-ventricle physiology who underwent stage 1 palliation were included. Cerebral and renal NIRS values at various time intervals after surgery were compared between patients with low and normal cardiac output. LCO within the first 48 after surgery was defined as per the pediatric cardiac critical care consortium database. NIRS values were also compared with other adverse outcomes such as cardiac arrest, need for extracorporeal membrane oxygenation and mortality. The receiver operative characteristic curve was generated to determine an optimal cut-off NIRS value for detecting LCO. Results : Ninety-one patients with median (Interquartile range) age of 10 days (6–26) and weight of 3.3 kg (3–3.5) were included in the study. Cerebral NIRS at 1 h (41.2 vs. 49.5; P = 0.002), 6 h (44 vs. 52.2; P = 0.001), and 12 h (51.8 vs. 56; P = 0.025) was significantly lower in the grouP with LCO compared to no LCO. Cerebral NIRS at 6 h was independently associated with LCO (P = 0.018), and cerebral NIRS at 6 h ≤57% had 91% sensitivity and 72% specificity to detect LCO. Conclusions : Cerebral NIRS ≤57% at 6 h after surgery detected LCO after stage 1 palliation in single-ventricle patients. Cerebral or renal NIRS was not associated with adverse outcomes and therefore, may not be useful in predicting adverse outcomes in this population. [ABSTRACT FROM AUTHOR]

Introduction: Veno-arterial extracorporeal membrane oxygenation (ECMO) is well-recognized treatment modality for patients with refractory cardiogenic shock. Uncomplicated cannulation is a prerequisite and basis for achieving a successful outcome in ECMO. Vascular access is obtained either by surgical cut-down. Common vascular access complications are bleeding and limb ischemia.Objective: To evaluate cannulation technique, the incidence of vascular complications, and their impact on the outcome.Methods: A retrospective data analysis conducted on 95 patients receiving ECMO from 2013 to 2020 was done. The patients were divided into two groups: no vascular access complications (non-VAC group) and vascular access complications (VAC group). The groups were compared related to the hospital and ICU stays and blood transfusion.Results: The patients in both groups were demographically and clinically comparable. The Non-VAC group had 75 patients, whereas the VAC group had a total of 20 patients. The main complication observed in the VAC group was bleeding from the cannulation site which required more blood transfusion than the non-VAC group (6.8 ± 1.02 vs 4.2 ± 1.26). Limb ischemia was another complication seen in the VAC group (4.2%, n = 4). Two patients had delayed bleeding after decannulation. The overall average length of stay in the hospital was statistically similar in both the groups (22 days in the VAC group vs 18 days in the non-VAC group), but the average ICU stay was more in the VAC group compared to the non-VAC group (18 days vs 12.06 days).Conclusion: Bleeding and limb ischemia are the important vascular access site complications, which increase blood transfusion requirements, ICU stay, and overall hospital stay. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In this article, the results of severe coronavirus disease 2019 (COVID‑19) cases followed with extracorporeal membrane oxygenation (ECMO) support in a 3‑month period in the third wave when there were an increased number of cases of young patients in our intensive care unit (ICU) were presented. METHODS: The study was carried out with all COVID‑19 patients who were given ECMO support in our tertiary referral hospital ICU after obtaining the consent of the Ministry of Health Scientific Research Platform and after the approval of the local ethics committee. Patient data were obtained retrospectively from intensive care bedside follow‑up charts and computer records. The demographic and clinical characteristics of the patients were presented in average, median, and percentages. The data of the patients were evaluated and compared with the current literature. RESULTS: ECMO treatment was applied in seven patients who were followed up with severe COVID‑19 pneumonia in the last 3 months. Venovenous extracorporeal membrane oxygenation (VV‑ECMO) was applied to all patients. Five (71.5%) of seven patients were weaned from ECMO. Four (57.2%) of seven patients were discharged from the ICU and hospital in good health. While two of the patients had a cesarean section (C/S) before ECMO, one patient underwent C/S under ECMO. All three newborns were delivered via C/S and all were premature (C/S dates were 35 weeks, 32 weeks, and 27 weeks), and all were discharged from the hospital in good health. CONCLUSION: Our experience shows that ECMO in COVID‑19 patients is a lifesaving treatment option that can be successfully applied in severe acute respiratory distress syndrome cases who do not respond to conventional treatments. [ABSTRACT FROM AUTHOR]

Background and Objective: High-flow nasal cannula (HFNC), a relatively new technique in acute hypoxemic respiratory failure (AHRF), is gaining popularity in intensive care units (ICUs). Our study aims to identify the predictive factors for failure of HFNC. Materials and Methods: This is a 5-year retrospective cohort study in patients with AHRF using HFNC in an ICU of a regional hospital in Hong Kong. The primary outcome is to identify the predictive factors for failure of HFNC which is defined as escalation of treatment to noninvasive ventilation, mechanical ventilation, extracorporeal membrane oxygenation, or death. Results: Of the 124 ICU patients with AHRF, 69 (55.65%) failed in the use of HFNC. The patients failing HFNC had higher Acute physiology and Chronic Health Evaluation IV scores, lower Glasgow Coma Scale scores, lower platelet counts and serum sodium levels upon ICU admission, and higher pH on day of HFNC commencement. They had higher respiratory rates before HFNC and higher heart rates before and 1 h after HFNC. The respiratory rate-oxygenation (ROX) index which is defined as a ratio of SpO2/FiO2 to respiratory rate was significantly lower in the failure group 1 h and 12 h after HFNC. By multivariate binary logistic regression, failure of HFNC is associated with lower ROX index at 12 h after HFNC. Conclusion: ROX index at 12 h serves as a valuable tool to monitor the responsiveness to HFNC treatment. Close monitoring is required to identify patient failing using HFNC. [ABSTRACT FROM AUTHOR]

Extra corporeal membrane oxygenation (ECMO) for refractory out-of-hospital cardiac arrest (OHCA) has been shown to improve outcome in many Western countries. There are no reports of ECMO being used to support OHCA in India till date. We report a case of a young man who developed cardiac arrest (CA) while driving and was given bystander cardiac massage. He was brought to tertiary care center where an ECMO was utilized for refractory CA. The patient subsequently underwent emergency coronary artery stenting and was weaned off ECMO and ventilation. We discuss the case and highlight the role of bystander cardiopulmonary resuscitation. [ABSTRACT FROM AUTHOR]

Bleeding during cardiac surgery, liver transplant, trauma and post partum hemorrhage are often multifactorial and these factors are dynamic as new factors crop up during the course of management. Conventional tests of coagulation offer information of a part of the coagulation system and also is time consuming. Viscoelastic point of care tests (VE POCTs) like rotational thromboelastometry, thromboelastogram and Sonoclot, are based on analysis of the viscoelastic properties of clotting blood and provide information for the entire coagulation pathway. In this comprehensive review being presented here, we have examined the pros and cons of VE POCTs including clinical, cost and survival benefits. The recommendations of the various guidelines regarding use of VE POCTs in various scenarios have been discussed. The review also tried to offer suggestions as to their optimal role in management of bleeding during cardiac surgeries, extracorporeal membrane oxygenation, left ventricular assist devices, liver transplant and briefly in trauma and postpartum hemorrhage. [ABSTRACT FROM AUTHOR]

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly used in managing challenging airway and thoracic cases with complex airway manipulations. We present a case of a complex tracheal resection needing prolonged apnea times for which VV-ECMO was electively planned. Intraoperatively, the team was faced with continued oxygen desaturations during periods of apnea. With an algorithmic approach to troubleshooting hypoxemia, several factors were taken into consideration. Apneic oxygenation was applied to the open tracheal segment. Despite an open airway, the applied apneic oxygenation facilitated oxygenation to the portion of the cardiac output that was being shunted through the lungs as opposed to the VV-ECMO circuit, enabling uninterrupted completion of the surgical resection and reanastomosis. [ABSTRACT FROM AUTHOR]

Background: Lung transplantation (LT) has emerged as a definitive cure for a plethora of end‑stage lung diseases (ESLDs). With improvements in immune‑suppression protocols, the posttransplantation survival rates have gone up. Aim: The study reported the initial experience of the India’s single largest lung transplant program on clinicopathological profile, procedures, challenges encountered, and outcomes. Settings and Design: A retrospective analysis was done from data available at three centers of Institute of Heart and Lung Transplant, Gleneagles Global Hospitals across Chennai, Bengaluru, and Mumbai. Materials and Methods: A total of 132 patients underwent lung (single or bilateral) or combined heart and lung transplant between April 2017 and March 2020. All the participants had 30 days’ follow‑up. Postoperative complications, graft rejection, and 30‑day mortality were reported. Kaplan–Meier survival analysis and logistic regression analysis were performed. Statistical Analysis Used: Kaplan–Meier survival and binary logistic regression was performed. Results: Interstitial lung diseases, 65.91%, were the most common diagnosis. Bilateral LT (81.3%) was the most common type of LT performed. Grade III primary graft dysfunction was observed in 16 (12.1%). Distal airway stenosis (21.97%) was the most common complication followed by anastomotic stenosis (14.30%). Gram‑negative bacterial sepsis (52%) was the leading cause of death. Cumulative probability of survival at 1 month was 0.85 (95% confidence interval [CI] 0.80–0.92), and at 1 year, it was 0.78 (95% CI, 0.72–0.86). Conclusion: This study establishes the fact that despite multiple challenges, LT is a viable option for selected patients with ESLDs in India and should encourage early referrals to a transplant center. [ABSTRACT FROM AUTHOR]

Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery.Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients.Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients.Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days).Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers. [ABSTRACT FROM AUTHOR]

Acute respiratory distress syndrome (ARDS) and respiratory failure can occur after drowning. Some of these patients do not respond to conventional mechanical ventilation and require extracorporeal membrane oxygenation (ECMO). Patients with severe respiratory failure can also develop acute right heart failure. We describe a case of a young drowning victim who developed ARDS and subsequent right heart failure. The patient was initiated on venovenous ECMO with right atrial to pulmonary artery cannulation of ECMO using the Protek Duo (TandemLife, Pittsburgh, PA, USA). The patient recovered from his ARDS and heart failure and was successfully liberated from ECMO. We will discuss the utility of ECMO in drowning victims and the use of this unique cannulation strategy to support the right ventricle in patients with concomitant respiratory failure. [ABSTRACT FROM AUTHOR]

Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery. Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients. Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients. Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days). Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers. [ABSTRACT FROM AUTHOR]

We present a case of acute respiratory distress syndrome (ARDS) secondary to COVID-19 who required venovenous extracorporeal membrane oxygenation (V-V ECMO). Initially, a right ventricular assist device (RVAD), the ProtekDuo with an oxygenator, was placed in an outside heart center and the patient was transferred to us for ECMO management. Due to severe hypoxia, the configuration was later modified, and a 25 Fr femoral drainage cannula was inserted for venous drainage only. The arterial return tubing was spliced and using a Y-connector, arterialized blood was returned through both limbs of the ProtekDuo resulting in a significantly increased oxygenation and flow. [ABSTRACT FROM AUTHOR]

In the case of complete surgical resection of locally aggressive thyroid mass with severely compromised airways, airway management is difficult and can be considerably risky. We report a case of airway management using i-gelTM and cardiopulmonary bypass (CPB) with venoarterial extracorporeal membrane oxygenation (ECMO), which is a safe and feasible method of airway management for providing general anesthesia in a patient with a large thyroid mass. [ABSTRACT FROM AUTHOR]

Massive pulmonary embolism (PE) is one of the important emergencies that needs aggressive treatment for decreasing the risk of death. Extracorporeal membrane oxygenation (ECMO) and fibrinolysis should be considered in patients with failure in oxygenation and perfusion despite invasive mechanical ventilation and vasopressor treatment. We present the case of a 22-year-old male who underwent ECMO, systemic fibrinolysis, and cardiopulmonary resuscitation because of massive PE and subsequently developed intraperitoneal bleeding. [ABSTRACT FROM AUTHOR]

Pulmonary Alveolar Microlithiasis (PAM) is a rare autosomal recessive end stage lung condition characterized by widespread alveolar deposition of calcium microliths. It is worth emphasis india has reported 80 cases out of 1022 cases worldwide but there is no report on lung transplant and and anaesthetic management in this category of patient. This report present the anaesthetic challenge in management of first indian patient with the diagnosis of PAM, who underwent bilateral lung transplantation. Bilateral lung transplantation is one of the most challenging surgeries that require the care of a cardiothoracic anesthesiologist. Utilization of extracorporeal circulation has allowed a safer performance of this procedure in patients with severe cardiopulmonary compromise. Intraoperative management is a pivotal part of the patient's care, as it contributes to the patient's overall outcome. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although 85% of infected patients remain asymptomatic, 5% show severe symptoms such as hypoxaemic respiratory failure and multiple end organ dysfunction (MODS) requiring intensive care unit (ICU) admission with a mortality rate of about 2.8%. Since a definitive treatment is yet to be identified, preventive and supportive strategies remain the mainstay of management. Supportive measures such as oxygen therapy with nasal cannula, face mask, noninvasive ventilation, mechanical ventilation and even extreme measures such as extracorporeal membrane oxygenation (ECMO) fail to improve oxygenation in some patients. Hence, hyperbaric oxygen therapy (HBOT) has been proposed as a supportive strategy to improve oxygenation in COVID-19 patients. HBOT is known to increase tissue oxygenation by increasing the amount of dissolved oxygen in plasma. HBOT also mitigates tissue inflammation thus reducing the ill effects of cytokine storm in COVID-19 patients. Though there is limited literature available on HBOT in COVID-19 patients, considering the present need for additional supportive therapy to improve oxygenation, HBOT has been proposed as a novel supportive treatment in COVID-19 patients. [ABSTRACT FROM AUTHOR]

Zoonotic virus spill over in human community has been an intensive area of viral pathogenesis and the outbreak of Hantaan virus and severe acute respiratory syndrome coronavirus 2 (SARS CoV2) after late December 2019 caused a global threat. Hantaan virus is second to the COVID-19 outbreak in China with seven cases positive and one death. Both RNA viruses have opposite sense as in (−) for Hantaan virus and (+) for SARS CoV2 but have similarity in the pathogenesis and relevant clinical features including dry cough, high fever, shortness of breath, and SARS associated with pneumonia and certain reported cases with multiple organ failure. Although COVID-19 has global impact with high death toll, Hantaan virus has varyingly high mortality rate between 1% and 40%. Hence, there is a need to explore novel therapeutic targets in Hantaan virus due to its rapid evolution rate in its genetic makeup which governs virulence and target host cells. This review emphasizes the importance of structural and nonstructural proteins of Hantaan virus with relevant insight from SARS CoV2. The envelope glycoproteins such as Gn, Gc, and nucleocapsid protein (N) direct the viral assembly and replication in host cells. Therapeutic treatment has similarity in using ribavirin and extracorporeal membrane oxygenation but lack of efficacious treatment in both cases of SARAS CoV2 and Hantaan virus. Therefore, potential features regarding therapeutic targets for drug discovery for Hantaan viruses are discussed herewith. The conclusive description highlights that N protein is substantially involved in evoking immune response and induces symptoms and could be precursive target for drug discovery studies. [ABSTRACT FROM AUTHOR]

Pulmonary hemorrhage (PH) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been primarily reported in pediatric patients. We report a case of fatal PH during VA-ECMO for cardiogenic shock after myocardial infarction (MI). PH, in this case, was secondary to a triad of aortic insufficiency, left ventricle distension, and severe laminar mitral regurgitation. This case scenario, previously unreported in adults, illustrates the need for the echocardiographic assessment of left-sided heart valves prior to VA-ECMO initiation after MI as well as management considerations for massive PH in this context. [ABSTRACT FROM AUTHOR]

The utilization of temporary circulatory support in the form of extracorporeal membrane oxygenation (ECMO) has increased and its indications are expanding. Anesthesiologists may be involved in the care of these patients during the initiation of and weaning off from ECMO, surgical procedures with an ECMO in situ, and transfer of patients on ECMO between the operating theater and intensive care unit. This article addresses the anesthetic considerations and management for explant of veno-arterial ECMO in adults. [ABSTRACT FROM AUTHOR]

BACKGROUND: Better outcomes have been observed in patients with acute unprovoked than provoked pulmonary embolism (PE). Prognostic biomarkers were studied in heterogeneous patient population and were not verified in patients with unprovoked PE. METHODS: Patients diagnosed with unprovoked acute PE from 2010 to 2017 at Asan Medical Center, South Korea, were analyzed retrospectively. Adverse composite outcomes were defined as thrombolysis, thrombectomy, extracorporeal membrane oxygenation, or death. Venous blood samples were collected at the first visit before anticoagulant treatment. Biomarkers associated with composite outcomes were analyzed and compared with preexisting risk models. RESULTS: This study included 265 patients (48.7% male) with a median age of 66.0 (interquartile range 52.0, 75.0) years. Composite outcomes occurred in 20 (7.5%) patients. Hemoglobin, uric acid, and glucose were significantly and independently associated with adverse composite outcomes. This biomarker model showed the highest prognostic accuracy for adverse composite outcomes, with an area under the curve of 0.806 (95% confidence interval: 0.702–0.911,P < 0.001), which was significantly better than that of PE severity index (PESI) or simplified PESI, and comparable to that of the European Society of Cardiology (ESC) risk classification. CONCLUSIONS: The biomarker model including hemoglobin, uric acid, and glucose has good prognostic performance comparable to the ESC risk classification while PESI or simplified PESI score was not useful in unprovoked PE. [ABSTRACT FROM AUTHOR]

Background: Management of H1N1 viral infection-associated acute respiratory distress syndrome (ARDS) has primarily been focused on lung protective ventilation strategies, despite that mortality remains high (up to 45%). Other measures to improve survival are prone position ventilation (PPV) and extracorporeal membrane oxygenation. There is scarcity of literature on the use of prone ventilation in H1N1-associated ARDS patients. Methods: In this retrospective study, all adult patients admitted to medical intensive care unit (ICU) with H1N1 viral pneumonia having severe ARDS and requiring prone ventilation as a rescue therapy for severe hypoxemia were reviewed. The patients were considered to turn prone if PaO2/FiO2ratio was <100 cmH2O and PaCO2was >45 cmH2O; if no progressive improvement was seen in PaO2/FiO2over a period of 4 h, then patients were considered to turn back to supine. Measurements were obtained in supine (baseline) and PPV, after 30–60 min and then 4–6 hourly. Results: Eleven adult patients with severe ARDS were ventilated in prone position. Their age range was 26–59 years. The worst PaO2/FiO2ratio range on the day of invasive ventilation was 48–100 (median 79). A total of 39 PPV sessions were done, with a range of 1–8 prone sessions per patient (median three sessions). Out of the 39 PPV sessions, PaO2/FiO2ratio and PaCO2responder were 38 (97.4%) and 27 (69.2%) sessions, respectively. The median ICU stay and mechanical ventilation days were 15 (range: 3–26) and 12 (range: 2–22) days, respectively. The common complication observed due to PPV was pressure ulcer. At ICU discharge, all except two patients survived. Conclusion: PPV improves oxygenation when started early with adequate duration and should be considered in all severe ARDS cases secondary to H1N1 viral infection. [ABSTRACT FROM AUTHOR]

We present the case of a 7-week-old male infant diagnosed with anomalous left coronary artery from the pulmonary artery (ALCAPA) who underwent repair by left coronary artery reimplantation, followed by an eventful postoperative period including need for venous arterial extracorporeal membrane oxygenation and mitral valve replacement due to mitral calcification and severe insufficiency. He also required heart transplant due to severe rapidly progressive biventricular hypertrophy. The pathology examination of the explanted heart showed massive cardiomegaly. Subsequently, the infant's cardiomyopathy panel was positive for RAF1 mutation, consistent with diagnosis of a rare form of Noonan syndrome. To our knowledge, this autosomal dominant condition in association with ALCAPA has not been previously reported in the literature. [ABSTRACT FROM AUTHOR]

A tracheostomy could damage the stent and a supraglottic airway device risked aspiration.[[3]] A fibre-optic bronchoscope is essential and the best available option to ensure correct position of the tube within the stent or just above the stent. Sir, Airway stents have long been used to maintain luminal integrity of compromised airway in case of obstruction and malignancy.[[1]] The complications associated with airway stent placement are malposition, haemorrhage, airway rupture during placement, migration, impaction, formation of granulation tissue, and stent fracture.[[2]] We present here a challenging case of an airway emergency in a patient with a tracheal stent inserted for a malignancy. [Extracted from the article]

In the patients with stenotic upper respiratory airways tumor, the tracheal intubation during the surgical resection is sometimes impossible. In these situations, Extracorporeal Membrane Oxygenation appears to be an interesting temporarily alternative to ventilation to allow tumor removal. In this report the authors describe a case of successful resection of tracheal tumor in an 80-year-old female patient in which tracheal intubation was impossible. A circulatory assistance was used to perform the operation. Afterwards, tracheal intubation was easily performed for the rest of the operation. [ABSTRACT FROM AUTHOR]

The anesthetic management of patients with a mediastinal mass represent a challenge due to the potential for difficult ventilation and intubation, as well as the risk of cardiovascular collapse upon induction of general anesthesia. Different strategies and alternatives have been described. We present the case of a 70-year-old man with a right para-tracheal mass extending into the anterior mediastinum with 90% mid-tracheal lumen obstruction who was successfully managed with venous-venous extra-corporeal membrane oxygenation (ECMO) during mass debulking and tracheal stent placement. [ABSTRACT FROM AUTHOR]

Technological advances in mechanical circulatory support have enabled more patients with end‑stage heart failure to benefit from left ventricular assist devices (LVAD). Indications for LVAD implantation have evolved to include patients who are deemed unsuitable for cardiac transplantation, otherwise known as destination therapy. This case report describes such patient with multi‑organ failure who underwent LVAD insertion after nine days of extra‑corporeal membrane oxygenation, intra‑aortic balloon pump and maximal inotropic support. Strategies for perioperative management, as well as intra‑operative monitoring and interventions are discussed. [ABSTRACT FROM AUTHOR]

Influenza A (H1N1) infection has a propensity to infect an immunocompromised host (ICH). These patients experience more severe manifestations and related complications with increased mortality. Influenza A (H1N1) infection in ICH differs from non‑ICH in terms of clinical features, range of complications, radiological features, treatment response, and outcome. Radiology may show higher number of lesions but with no or minimal corresponding clinical manifestations. Coinfection with streptococci, staphylococci, and Aspergillus further increases mortality. Antiviral resistance compounds the overall picture despite optimal regimen. Use of steroids is detrimental. Extracorporeal membrane oxygenation (ECMO) is usually avoided in ICH. However, ICH groups with influenza A (H1N1) infection complicated by acute respiratory distress syndrome who have received ECMO have recorded mortality up to 61%. Nevertheless, evidence‑based recommendation on use of ECMO in ICH is lacking. Annual inactivated influenza vaccine is recommended for most ICH groups with a few exceptions and for their close contacts. Hygiene measures greatly contribute to reducing disease burden. High index of suspicion for influenza A (H1N1) infection in ICH, early antiviral therapy, and treatment of coinfection is recommended. With the threat of transmission of resistant viral strains from ICH to the community, apart from treatment, preventive measures such as vaccination and hygienic practices have a significant role. Through this review, we have attempted to identify clinical and radiological peculiarities in ICH with influenza A (H1N1) infection, treatment guidelines, and prognostic factors. Influenza A (H1N1) infection in ICH may remain clinically silent or mild. [ABSTRACT FROM AUTHOR]

The article focuses on some randomized controlled trials (RCTs) in critical care during 2018. Topics discussed include hydrocortisone which was found in one RCT to reduce the risk of death in patients with septic shock; the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS); and the use of proton pump inhibitors (PPIs) for stress ulcer prophylaxis.

Background: A common challenge in the development of laboratory clinical decision support (CDS) and laboratory utilization management (UM) initiatives stems from the fact that many laboratory tests have multiple potential indications, limiting the ability to develop context-specific alerts. As a potential solution, we designed a CDS alert that asks the ordering clinician to provide the indication for testing, using D-dimer as an exemplar. Using data collected over a nearly 3-year period, we sought to determine whether the indication capture was a useful feature within the CDS alert and whether it provided actionable intelligence to guide the development of an UM strategy. Methods: We extracted results and ordering data for D-dimer testing performed in our laboratory over a 35-month period. We analyzed order patterns by clinical indication, hospital service, and length of hospitalization. Results: Our final data set included 13,971 result-order combinations and indeed provided actionable intelligence regarding test utilization patterns. For example, pulmonary embolism was the most common emergency department indication (86%), while disseminated intravascular coagulation was the most common inpatient indication (56%). D-dimer positivity rates increased with the duration of hospitalization and our data suggested limited utility for ordering this test in the setting of suspected venous thromboembolic disease in admitted patients. In addition, we found that D-dimer was ordered for unexpected indications including the assessment of stroke, dissection, and extracorporeal membrane oxygenation. Conclusions: Indication capture within a CDS alert and correlation with result data can provide insight into order patterns which can be used to develop future CDS strategies to guide appropriate test use by clinical indication. [ABSTRACT FROM AUTHOR]

Thrombosis and systemic embolization are important complications of extracorporeal membrane oxygenation (ECMO). We present a 2.5 kg neonate born at 37.4 weeks with hypoplastic left heart supported on ECMO that developed an acute, occlusive distal aortic thrombus that was emergently managed by transcatheter Angiojet® (Boston Scientific, Boston, MA) thrombectomy. The procedure successfully restored perfusion to the lower extremities with sustained result upon 1-week follow-up. This case highlights the Angiojet® thrombectomy as a treatment option for limb- or organ-threatening acute thrombus in even the most complex ECMO patients. [ABSTRACT FROM AUTHOR]

Gastrointestinal mucormycosis involving ileum is a very rare phenomenon. We present a case of 52-year-old male, known case of diabetes mellitus requiring extracorporeal membrane oxygenation (ECMO) for H1N1 pneumonia with severe acute respiratory distress syndrome (ARDS). The patient had small bowel obstruction with impending perforation requiring emergency bowel resection and ileostomy. The resected bowel segment histopathology showed mucormycosis. He was treated with conventional Amphotericin-B and later changed to Posaconazole. The patient responded very well and was gradually weaned from ventilator and successfully discharged home. This case report highlights rare site of mucormycosis. Early diagnosis and timely intervention can reduce mortality. [ABSTRACT FROM AUTHOR]

Severe pulmonary complications associated with COVID-19 infections are a substantial source of morbidity and/or mortality. Extracorporeal membrane oxygenation (ECMO) has been shown to be a potentially useful therapy in the management of severe COVID-19 infection as a means to facilitate pulmonary recovery. Despite growing evidence to demonstrate the utility of ECMO for COVID-19 respiratory failure, little is known regarding the posthospital discharge recovery and functional status of these patients. Furthermore, concerns regarding potential long-term complications, but data are lacking. We illustrate a case of a previously healthy male, who was supported on ECMO for severe COVID-19 who demonstrated what appears to be a complete subjective and objective pulmonary recovery within a short time postdischarge. Our case provides some optimisms that critically-ill COVID-19 patients might recover completely and be able to return to functional lives. [ABSTRACT FROM AUTHOR]