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Extracorporeal membrane oxygenation (ECMO) circuit failure is a well known complication of ECMO support. Little is documented in the literature. Retrospective review of all patients underwent ECMO support and experienced circuit failure events in our two institutions between Jan 2012 and Dec 2018. Seven hundred forty-six patients were supported by ECMO, among these 400 venovenous ECMO (VV-ECMO), 289 patients treated with venoarterial ECMO (VA-ECMO) and 57 with VA-ECMO for ECPR. The mean support time was 161.9±2.13hours (ranged from 5 -1493 hours). Overall, 539 (72.3%) patients were separated of ECMO, among these 434 (58.2%) patients were discharged from the hospital. Eighty (10.7%) circuits needed total or partial circuit change, the total circuit was changes in 46 patients, among these 34 cases due to clotting, 5 circuits were changed due to circuit compatibility of patients transferred of outside hospital. Four circuits were changed due to large air in the circuit not amenable to simple suctioning maneuvers, 2 due to circuit tube fracture and one had mechanical pump failure. Major clotting needed total or partial circuit change occurred in 68 circuits, amongst these circuit was changed in 34 patients, Oxygenator only was changed in 30 circuits. the bladder only was changed in 4 circuits due to clotting. 46 (67.4%) major clotting needed circuit change occurred after 2 weeks of support, 17 occurred during the second week, and only 5 occurred in the first week. Air in the circuit was encountered in 13 cases, majority (9 cases) was amenable to simple suctioning maneuvers. ECMO circuit failure occurs frequently. Major clotting needing partial or total circuit change are the most common complications, followed by air in the circuit, followed by circuit incompatibility in transferred patients. While majority of circuit clotting occur after 2 weeks, it rarely occurs in the first week. [ABSTRACT FROM AUTHOR]

The management of massive pulmonary embolism with hemodynamic instability remains challenging with high mortality rate, Using Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is used in general as salvage therapy. Here we report a single center experience. Medical records of all patients who underwent VA-ECMO support for massive pulmonary emboli and presented with cardiogenic shock and severe right ventricle dysfunction between January 2015-December 2018 were retrospectively reviewed. All patients who continue to have signs of right ventricle strain after 3 days of VA-ECMO support underwent surgical embolectomy. Thirty-nine patients were identified; one patient underwent Surgical Embolectomy removal 4 days after support. The remaining 38 included, there were 22 (58%) males. Median age was 58 years (range 17-88), the mean support time was 4 days (range 1-10). Overall, 29 (76%) patients were successfully separated off ECMO, 3 patients underwent comfort care measures due to severe neurologic injury. Twenty (53%) patients were discharged from the hospital, 3 with mild or moderate right ventricle dysfunction, nineteen patients were alive after 6 months follow up all have normalized right ventricle function. Ten patients from the series received E-CPR at the time of initiation, 4 (40%) were separated from ECMO and three were discharged home. 28 patients underwent catheter-based therapy prior to ECMO or while on support, 5 received angiovac debulking prior to ECMO support. The major ECMO complications included 3 patients with vascular injury from ECMO placement and 3 with irreversible neurological injury and PA catheter rupture. VA-ECMO support is an effective method of support for patients with massive PE and hemodynamic instability. It could be used as a first line of treatment in selected patients or could be used to stabilize the patient as bridge to alternative treatment. [ABSTRACT FROM AUTHOR]

The management of massive pulmonary embolism with hemodynamic instability and needs cardiopulmonary resuscitation (CPR) remains challenging with high mortality rate. Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is used in general as salvage therapy. Here we report a single center experience. Medical records of all patients who underwent VA-ECMO support for massive pulmonary emboli and presented with cardiogenic shock between January 2015-December 2018 were retrospectively reviewed. Thirty-nine patients were identified, amongst these ten patients received ECMO while performing CPR at the time of initiation, 6 patients were males. Median age was 50 years (range 17-73), the mean BMI was 36.7 (range 20.5-57.8), the mean support time was 4 days (range 0-10), The mean hospitals stay was 12 days (range 0-39 days), One patient underwent surgical embolectomy and successfully separated of ECMO. Overall 4 patients were successfully separated off ECMO, one was transitioned to VV ECMO then successfully separated one developed a large stroke after ECMO separation and underwent comfort care measures and 3 patients were discharged from the hospital, and they were alive in 6 months follow up. ECPR support for cardiac support for massive pulmonary emboli has bad survival outcomes comparable to the left sided ECPR, ECPR might be an acceptable method of support to stabilize the patient before proceeding with Surgical embolectomy if right ventricle continue to show signs of failure. [ABSTRACT FROM AUTHOR]

Poor prognostic significance of elevated serum lactate in patients who are started on ECMO support is widely known. Typically, serial lactate measurements are obtained. our primary objective was to study the predictive utility of lactate measured at different points of time. We performed a retrospective chart review with collection of clinical and laboratory data. Lactic acid was collected before initiating ECMO support and then on day 1, 3, 5, and 10 while on ECMO. Outcomes were defined as survival to weaning and survival to discharge.Comparison of these lactate levels to identify which one is superior in predicting outcomes was performed using the Hanley and McNeil method as implemented in the MedCalc software. Out of total of 238 patients who received VA ECMO, 129 (54.2%) survived ECMO and 98 (41.2%) were discharged alive. Patient successfully weaned from ECMO had a significantly lower lactic acid level pre-ECMO (P=0.001), at day 1 (P<0.001), day 3 (P<0.001) and day 5 (P=0.001), compared with those who were not successfully weaned. Also, patients who were discharged alive had significantly lower lactic acid pre-ECMO (P=0.007), at day 1 (P<0.001), day 3 (P=0.001) and day 5 (P=0.001), compared with those who died in-hospital. We have investigated the association of magnitude in reduction of lactic acid from pre-ECMO to day 1 and pre-ECMO to day 3 on study outcomes. There was no association between the magnitude of reduction of lactate from pre-ECMO to day 1 on successful ECMO weaning (P=0.121) and discharge alive (P=0.127). Similarly, there was no association between the magnitude of reduction of lactate from pre-ECMO to day 3 (P=0.418) on successful ECMO weaning and discharge alive (P=0.671). Day 3 lactic acid was superior to pre-ECMO lactic acid (P=0.007), lactic acid reduction from pre-ECMO to day 1 (P=0.0125), and from pre-ECMO to day 3 (P=0.0313). The reduction of lactic acid from pre-ECMO to day 1, and pre-ECMO to day 3 was not superior to any absolute value at either pre-ECMO, days 1 or 3. With regards to discharge alive, lactic acid at ECMO day 3 is superior to pre-ECMO lactic acid (P=0.0385), lactic acid reduction from pre-ECMO to day 1 (P=0.0177) and from pre-ECMO to day 3 (P=0.0361). The absolute level of lactic acid while on ECMO support is more important for prognosis that a pre-ECMO level or the magnitude of decline from pre-ECMO to on-ECMO level. [ABSTRACT FROM AUTHOR]