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The incidence of brain death/death by neurologic criteria (BD/DNC) among all hospital deaths in the US is approximately 2.06% or 15,000-20,000 cases annually. This article reviews the latest guidelines for adult and pediatric BD/DNC. Although there have not been many changes to the guidelines over the years, BD/DNC guideline updates maintain consistency in determining BD/DNC. [ABSTRACT FROM AUTHOR]

BACKGROUND: Waitlist mortality (WM) remains elevated in pediatric heart transplantation. Allocation policy is a potential tool to help improve WM. This study aims to identify patients at highest risk for WM to potentially inform future allocation policy changes. METHODS: The Pediatric Heart Transplant Society database was queried for patients <18 years of age indicated for heart transplantation between January 1, 2010 to December 31, 2021. Waitlist mortality was defined as death while awaiting transplant or removal from the waitlist due to clinical deterioration. Because WM is low after the first year, analysis was limited to the first 12 months on the heart transplant list. Kaplan-Meier analysis and log-rank testing was conducted to compare unadjusted survival between groups. Cox proportional hazard models were created to determine risk factors for WM. Subgroup analysis was performed for status 1A patients based on body surface area (BSA) at time of listing, cardiac diagnosis, and presence of mechanical circulatory support. RESULTS: In total 5974 children met study criteria of which 3928 were status 1A, 1012 were status 1B, 963 were listed status 2, and 65 were listed status 7. Because of the significant burden of WM experienced by 1A patients, further analysis was performed in only patients indicated as 1A. Within that group of patients, those with smaller size and lower eGFR had higher WM, whereas those patients without congenital heart disease or support from a ventricular assist device (VAD) at time of listing had decreased WM. In the smallest size cohort, cardiac diagnoses other than dilated cardiomyopathy were risk factors for WM. Previous cardiac surgery was a risk factor in the 0.3 to 0.7 m2 and >0.7 m2 BSA groups. VAD support was associated with lower WM other than in the single ventricle cohort, where VAD was associated with higher WM. Extracorporeal membrane oxygenation and mechanical ventilation were associated with increased risk of WM in all cohorts. CONCLUSIONS: There is significant variability in WM among status-1A patients. Potential refinements to current allocation system should factor in the increased WM risk we identified in patients supported by extracorporeal membrane oxygenation or mechanical ventilation, single ventricle congenital heart disease on VAD support and small children with congenital heart disease, restrictive cardiomyopathy, or hypertrophic cardiomyopathy. [ABSTRACT FROM AUTHOR]

Skin tears are a major problem for patients and the health care professionals who treat them. Although opinions on their prevalence differ, it is estimated that they are encountered more frequently than pressure sores but are overlooked. Recommendations based on strong evidence were presented for the prevention and treatment of skin tears as classified by the International Skin Tear Advisory Panel. This case series includes the clinical status of 3 patients who developed skin tears while receiving care in the hospital, and the corrective and preventive practices related to skin tears. This article will contribute to raising the awareness of health care professionals in predicting, preventing, evaluating, and treating skin tears. [ABSTRACT FROM AUTHOR]

Background: Determining appropriate extracorporeal membrane oxygenation (ECMO) candidacy ensures appropriate utilization of this costly resource. The current ECMO survival prediction scores do not consider clinician assessment of patient viability. This study compared clinician prediction of survival to hospital discharge versus prediction scores. Objectives: The aim of this study was to compare clinician prediction of patients' survival to hospital discharge versus prognostic prediction scores (Respiratory ECMO Survival Prediction [RESP] or Survival After Veno-Arterial ECMO [SAVE] score) to actual survival. Methods: This was an observational descriptive study from January 2020 to November 2021 conducted with interviews of nurses, perfusionists, and physicians who were involved during the initiation of ECMO within the first 24 hours of cannulation. Data were retrieved from the medical record to determine prediction scores and survival outcomes at hospital discharge. Accuracy of clinician prediction of survival was compared to the RESP or SAVE prediction scores and actual survival to hospital discharge. Results: Accurate prediction of survival to hospital discharge for veno-venous ECMO by nurses was 47%, 64% by perfusionists, 45% by physicians, and 45% by the RESP score. Accurate predictions of patients on veno-arterial ECMO were correct in 54% of nurses, 77% of physicians, and 14% by the SAVE score. Physicians were more accurate than the SAVE score, P =.021, and perfusionists were significantly more accurate than the RESP score, P =.044. There was no relationship between ECMO specialists' years of experience and accuracy of predications. Conclusion: Extracorporeal membrane oxygenation clinicians may have better predictions of survival to hospital discharge than the prediction scores. Further research is needed to develop accurate prediction tools to help determine ECMO eligibility. [ABSTRACT FROM AUTHOR]

This article discusses the value of serial assessments and the challenges of observational research in the context of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with out-of-hospital cardiac arrest (OHCA). It highlights three large randomized controlled trials that evaluated the effect of ECPR on survival, each with different findings. The article then introduces a new study that examines the added value of serial lactate measurements for outcome prediction among adult patients undergoing ECPR after OHCA. The study finds that increased lactate clearance is associated with higher survival rates and more favorable neurological outcomes. However, the study has limitations, such as not incorporating arterial oxygen tension (Pao2) into the analysis, which may have influenced the results. Overall, the study emphasizes the importance of serial assessments and post-resuscitation care in improving outcomes for ECPR patients. [Extracted from the article]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve neurologically favorable survival in patients with refractory out-of-hospital cardiac arrest (OHCA) caused by shockable rhythms. Further refinement of patient selection is needed to focus this resource-intensive therapy on those patients likely to benefit. This study sought to create a selection model using machine learning (ML) tools for refractory cardiac arrest patients undergoing ECPR. DESIGN: Retrospective cohort study. SETTING: Cardiac ICU in a Quaternary Care Center. PATIENTS: Adults 18-75 years old with refractory OHCA caused by a shockable rhythm. METHODS: Three hundred seventy-six consecutive patients with refractory OHCA and a shockable presenting rhythm were analyzed, of which 301 underwent ECPR and cannulation for venoarterial extracorporeal membrane oxygenation. Clinical variables that were widely available at the time of cannulation were analyzed and ranked on their ability to predict neurologically favorable survival. INTERVENTIONS: ML was used to train supervised models and predict favorable neurologic outcomes of ECPR. The best-performing models were internally validated using a holdout test set. MEASUREMENTS AND MAIN RESULTS: Neurologically favorable survival occurred in 119 of 301 patients (40%) receiving ECPR. Rhythm at the time of cannulation, intermittent or sustained return of spontaneous circulation, arrest to extracorporeal membrane oxygenation perfusion time, and lactic acid levels were the most predictive of the 11 variables analyzed. All variables were integrated into a training model that yielded an in-sample area under the receiver-operating characteristic curve (AUC) of 0.89 and a misclassification rate of 0.19. Out-of-sample validation of the model yielded an AUC of 0.80 and a misclassification rate of 0.23, demonstrating acceptable prediction ability. CONCLUSIONS: ML can develop a tiered risk model to guide ECPR patient selection with tailored arrest profiles. [ABSTRACT FROM AUTHOR]

Cardiogenic shock (CS) is a complex and dreadful condition for which effective treatments remain unclear. The concerningly high mortality rate of CS emphasizes a need for developing effective therapies to reduce its mortality and reverse its detrimental course. This article aims to provide an updated and evidence-based review of the pathophysiology of CS and the related pharmacotherapeutics with a special focus on vasoactive and inotropic agents. [ABSTRACT FROM AUTHOR]

The use of diaries is known to reduce post-intensive care syndrome in the intensive care unit (ICU) for survivors and families. Studies are needed to explore nurses' experience with diaries. Although the diaries are written for the patient, the diary entries may be helpful for the nurse as well. Research has shown that ICU diaries fill in significant memory gaps and aid in the resolution of delusional memories. However, there is a shortage of knowledge about the nurses' experience of writing caring notes in diaries. The purpose of this research was to explore the extracorporeal membrane oxygenation (ECMO) nurses' experience of writing caring notes in diaries during the patients' ICU stay. This is a descriptive phenomenological qualitative research study using semi-structured interviews. A one-on-one interview was performed, audiotaped, and transcribed. Three investigators analyzed the data for themes, subcategories, and indicators. A purposive sample of 15 specialty-trained ECMO nurses participated in the study. Three themes emerged from the study relating to the nurse, family, and patient, including positive and negative aspects of writing in the diary and barriers. The vast majority (88%) of 340 comments answered during the interviews were positive. Overall, nurses found the diaries to be beneficial to the nurse, family, and patient. Diary writing may help nurses get back to the core of why we do what they do. Understanding the nurses' experience may help to improve communication and family satisfaction while optimizing dairy programs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (ECMO). How the right heart (the right ventricle and pulmonary artery) affect survival during venoarterial ECMO is unknown. We aimed to identify the relationship between right heart function with mortality and the duration of ECMO support. Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization Registry between 2010 and 2022 were queried. Right heart function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for modified Society for Cardiovascular Angiography and Interventions stage, age, sex, and concurrent clinical data (ie, pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. RESULTS: A total of 4442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; nonsurvivors were more likely to be older, have a worse Society for Cardiovascular Angiography and Interventions stage, and have longer pre-ECMO endotracheal intubation times (P<0.05 for all) than survivors. Increasing PAPP from pre-ECMO to on-ECMO time (ΔPAPP) was associated with reduced mortality per 2 mm Hg increase (odds ratio, 0.98 [95% CI, 0.97-0.99]; P=0.002). Higher on-ECMO PAPP was associated with mortality reduction across quartiles with the greatest reduction in the third PAPP quartile (odds ratio, 0.75 [95% CI, 0.63-0.90]; P=0.002) and longer time on ECMO per 10 mm Hg (beta, 15 [95% CI, 7.7-21]; P<0.001). CONCLUSIONS:' Early on-ECMO right heart function and interval improvement from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of right heart metrics into risk prediction models should be considered. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to investigate the current use and impact of pulmonary artery catheters (PACs) in patients with cardiogenic shock (CS) who underwent Impella support. DESIGN: This was a prospective multicenter observational study between January 2020 and December 2021 that registered all patients with drugrefractory acute heart failure and in whom the placement of an Impella 2.5, CP, or 5.0 pump was attempted or successful in Japan. SETTING: Cardiac ICUs in Japan. PATIENTS: Between January 2020 and December 2021, a total of 3112 patients treated with an Impella were prospectively enrolled in the Japan registry for percutaneous ventricular assist device (J-PVAD). Among them, 2063 patients with CS were divided into two groups according to the PAC use. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the 30-day mortality, and the secondary endpoints were hemolysis, acute kidney injury, sepsis, major bleeding unrelated to the Impella, and ventricular arrhythmias within 30 days. PACs were used in 1358 patients (65.8%) who underwent an Impella implantation. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) was significantly higher in the patients with PACs than in those without. Factors associated with PAC use were the prevalence of hypertension, out-of-hospital cardiac arrest, New York Heart Association classification IV, the lesser prevalence of a heart rate less than 50, and the use of any catecholamine. The primary and secondary endpoints did not significantly differ according to the PAC use. Focusing on the patients with VA-ECMO use, the 30-day mortality and hemolysis were univariately lower in the patients with PACs. CONCLUSIONS: The J-PVAD findings indicated that PAC use did not have a significant impact on the short-term outcomes in CS patients undergoing Impella support. Further prospective studies are required to explore the clinical implications of PAC-guided intensive treatment strategies in these patients. [ABSTRACT FROM AUTHOR]

The article discusses the use of extracorporeal cardiopulmonary resuscitation (ECPR) for adult patients in cardiac arrest. It emphasizes the importance of patient selection for ECPR and discusses controversies surrounding its implementation. The text also highlights the need for rapid cannulation and the potential benefits of automated mechanical compressions before ECPR. The document provides a comprehensive list of references and citations related to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, as well as a list of references specifically related to ECPR for out-of-hospital cardiac arrest. These resources can be valuable for library patrons conducting research on these topics. [Extracted from the article]

OBJECTIVES: To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. DESIGN: Retrospective observational cohort study. SETTING: Adult patients in the Extracorporeal Life Support Organization registry. PATIENTS: Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. CONCLUSIONS: Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cardiolipin is a mitochondrial-specific phospholipid that maintains integrity of the electron transport chain (ETC) and plays a central role in myocardial ischemia/reperfusion injury. Tafazzin is an enzyme that is required for cardiolipin maturation. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use to provide hemodynamic support for acute myocardial infarction has grown exponentially, is associated with poor outcomes, and is under active clinical investigation, yet the mechanistic effect of VA-ECMO on myocardial damage in acute myocardial infarction remains poorly understood. We hypothesized that VA-ECMO acutely depletes myocardial cardiolipin and exacerbates myocardial injury in acute myocardial infarction. METHODS: We examined cardiolipin and tafazzin levels in human subjects with heart failure and healthy swine exposed to VAECMO and used a swine model of closed-chest myocardial ischemia/reperfusion injury to evaluate the effect of VA-ECMO on cardiolipin expression, myocardial injury, and mitochondrial function. RESULTS: Cardiolipin and tafazzin levels are significantly reduced in the left ventricles of individuals requiring VA-ECMO compared with individuals without VA-ECMO before heart transplantation. Six hours of exposure to VA-ECMO also decreased left ventricular levels of cardiolipin and tafazzin in healthy swine compared with sham controls. To explore whether cardiolipin depletion by VA-ECMO increases infarct size, we performed left anterior descending artery occlusion for a total of 120 minutes followed by 180 minutes of reperfusion in adult swine in the presence and absence of MTP-131, an amphipathic molecule that interacts with cardiolipin to stabilize the inner mitochondrial membrane. Compared with reperfusion alone, VA-ECMO activation beginning after 90 minutes of left anterior descending artery occlusion increased infarct size (36±8% versus 48±7%; P<0.001). VA-ECMO also decreased cardiolipin and tafazzin levels, disrupted mitochondrial integrity, reduced electron transport chain function, and promoted oxidative stress. Compared with reperfusion alone or VA-ECMO before reperfusion, delivery of MTP-131 before VA-ECMO activation reduced infarct size (22±8%; P=0.03 versus reperfusion alone and P<0.001 versus VA-ECMO alone). MTP-131 restored cardiolipin and tafazzin levels, stabilized mitochondrial function, and reduced oxidative stress in the left ventricle. CONCLUSIONS: We identified a novel mechanism by which VA-ECMO promotes myocardial injury and further identify cardiolipin as an important target of therapy to reduce infarct size and to preserve mitochondrial function in the setting of VA-ECMO for acute myocardial infarction. [ABSTRACT FROM AUTHOR]

The article discusses the impact of the COVID-19 pandemic on critical care and the relationship between surge conditions and mortality. A study conducted in the Netherlands found that as COVID-19 hospitalizations increased, the number of patients in the ICU with non-COVID conditions decreased. There was also a small but clear relationship between surge conditions and mortality, indicating the strain on healthcare resources and its impact on patient safety. The study highlights the need to consider the risks of deferred surgeries and the quality of care provided during high caseloads. ICUs worldwide are facing strain due to capacity and staffing issues, which has highlighted the risk of mortality. However, there is limited understanding of the factors that impact patient outcomes. There is a need for better data and research definitions to define ICU care beyond just location. Using markers of patient acuity and interventions such as pressors and mechanical ventilation can help assess the risk. It is important to capture changes in staffing and training levels. Data lakes with patient data could be used to identify safety risks, but they are often not coupled with temporal data or hospital information. Healthcare should follow the aviation industry's example and agree to submit essential information to a third party to shape our understanding of the relationship between strain and safety. At the bedside, proactive evaluation of risk mitigation can be done through tests of change, such as new staffing models and smart technology. A surge index could be developed to predict and compare strain across hospitals. ICU care should focus on preventing adverse outcomes associated with infections and pressure [Extracted from the article]

OBJECTIVES: This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES: Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION: All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION: Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS: The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS: Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN: Retrospective multicenter cohort study. SETTING: Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS: Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time (p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis (p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS: ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability). [ABSTRACT FROM AUTHOR]

OBJECTIVES: Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR. DESIGN: Retrospective multicenter registry study. SETTING: Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II). PATIENTS: Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001). CONCLUSIONS: SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation (CPR) is increasingly used in children suffering cardiac arrest after cardiac surgery. However, its efficacy in promoting survival has not been evaluated. We compared survival of pediatric cardiac surgery patients suffering in-hospital cardiac arrest who were resuscitated with extracorporeal CPR (E-CPR) to those resuscitated with conventional CPR (C-CPR) using propensity matching. DESIGN: Retrospective study using multicenter data from the American Heart Association Get With The Guidelines-Resuscitation registry (2008-2020). SETTING: Multicenter cardiac arrest database containing cardiac arrest and CPR data from U.S. hospitals. PATIENTS: Cardiac surgical patients younger than 18 years old who suffered in-hospital cardiac arrest and received greater than or equal to 10 minutes of CPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 1223 patients, 741 (60.6%) received C-CPR and 482 (39.4%) received E-CPR. E-CPR utilization increased over the study period (p < 0.001). Duration of CPR was longer in E-CPR compared with C-CPR recipients (42 vs. 26 min; p < 0.001). In a propensity score matched cohort (382 E-CPR recipients, 382 C-CPR recipients), E-CPR recipients had survival to discharge (odds ratio [OR], 2.22; 95% CI, 1.7-2.9; p < 0.001). E-CPR survival was only higher when CPR duration was greater than 18 minutes. Propensity matched analysis using patients from institutions contributing at least one E-CPR case (n = 35 centers; 353 E-CPR recipients, 353 C-CPR recipients) similarly demonstrated improved survival in E-CPR recipients compared with those who received C-CPR alone (OR, 2.08; 95% CI, 1.6-2.8; p < 0.001). CONCLUSIONS: E-CPR compared with C-CPR improved survival in children suffering cardiac arrest after cardiac surgery requiring CPR greater than or equal to 10 minutes. [ABSTRACT FROM AUTHOR]

The article discusses the use of machine learning algorithms to predict clinical outcomes in patients with cardiac arrest who are supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). The study found that patients who achieved return of spontaneous circulation (ROSC) and were in refractory cardiogenic shock had better outcomes with VA ECMO. However, there are limitations to the study, including the lack of diversity in the patient population and the specific characteristics of the high-volume VA ECMO center where the study was conducted. The authors emphasize the need for further research and ethical considerations in the use of VA ECMO. [Extracted from the article]

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES: Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION: Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta- Analysis checklist. DATA EXTRACTION: Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS: Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS: ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR. [ABSTRACT FROM AUTHOR]

The article explores the use of left ventricular (LV) unloading devices in combination with extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest. The authors present a meta-analysis of observational studies and find that using an LV unloading device may reduce mortality but also increase complications. However, more scientific evidence is needed to establish guidelines for the use of LV unloading devices in cardiac arrest. The article also discusses the challenges of conducting randomized clinical trials in this context and emphasizes the importance of well-trained teams and timely interventions. Ethical considerations and the impact on quality of life are also addressed. Further research is needed to determine which patients would benefit from LV unloading in ECPR and to understand the ethical implications of mechanical cardiac support devices. [Extracted from the article]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES: A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION: Selection includes original research, review articles, and guidelines. DATA EXTRACTION: Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS: We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/Co2, and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS: Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field. [ABSTRACT FROM AUTHOR]

The use of fetoscopic endoluminal tracheal occlusion in severe left-sided congenital diaphragmatic hernia may improve morbidity but did not reduce overall mortality in a North American cohort. OBJECTIVE: To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed. METHODS: We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients. RESULTS: Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014). CONCLUSION: In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%). [ABSTRACT FROM AUTHOR]

OBJECTIVES: Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. DATA SOURCES: Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. STUDY SELECTION: Studies that included more than three patients supported with V-PA ECMO were included. DATA EXTRACTION: Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. DATA SYNTHESIS: We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. CONCLUSIONS: V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To estimate the maternal survival and live-birth rates in pregnant women with acute respiratory distress syndrome (ARDS) secondary to critical corona-virus disease 2019 (COVID-19) who are treated with extracorporeal membrane oxygenation (ECMO) by performing a systematic review and meta-analysis. DATA SOURCES: From database inception through August 2023, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials. Studies reporting maternal survival and live-birth rates in pregnant women with critical COVID-19 undergoing ECMO were included. METHODS OF STUDY SELECTION: Two reviewers separately ascertained studies, obtained data, and evaluated study quality. Summary estimates of maternal survival and live-birth rates were measured, and 95% CIs were calculated. TABULATION, INTEGRATION, AND RESULTS: Nine retrospective case series and 12 retrospective cohort studies were identified with 386 pregnant women with critical COVID-19 who underwent ECMO. Studies evaluated women that were treated from January 2020 to October 2022. Four studies were from the United States; three were from Turkey; two were from France; two were from Israel;and one each was from Columbia, Germany, Italy, Kuwait, Poland, Republic of Srpska, the United Arab Emirates, the United Kingdom, a consortium from Belgium, France, Switzerland, and an international registry. The pooled estimate of the maternal survival rate among pregnant patients who were initiated on ECMO was 75.6% (95% CI, 66.0-84.1%, I²=72%). The pooled estimate of the live-birth rate among pregnant patients who were initiated on ECMO was 83.7% (95% CI, 76.8-89.6%, 153 neonates, I²=11%). When the case series and cohort studies were examined separately, the results were similar. CONCLUSION: Among pregnant women with acute respiratory distress syndrome attributable to critical COVID-19 who were managed with ECMO, maternal survival and live-birth rates were high. [ABSTRACT FROM AUTHOR]

The article discusses the use of extracorporeal cardiopulmonary resuscitation (ECPR) in patients who have experienced cardiac arrest. The study examines the association between patient age and outcomes following cardiac arrest. The authors found that older patients had lower odds of survival compared to younger patients. However, the study has limitations, including selection bias and the lack of long-term outcome measures. The authors suggest that further research is needed to understand how age and other factors impact the effectiveness of ECPR. [Extracted from the article]

The article discusses the process of weaning patients from venovenous extracorporeal membrane oxygenation (ECMO), a treatment used for severe acute respiratory distress syndrome (ARDS). The authors highlight the lack of standardized guidelines for weaning and the variation in practices among different ECMO centers. They present findings from a study conducted at a German ECMO center, which identified risk factors for failed weaning trials. The article also compares different weaning methods and discusses the importance of considering factors such as respiratory drive and fluid management during the weaning process. The authors emphasize the need for further research to develop optimal weaning approaches. [Extracted from the article]

OBJECTIVES: Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable. DESIGN: A retrospective cohort study based on the Extracorporeal Life Support Organization registry. SETTING: ECMO centers worldwide included in the Extracorporeal Life Support Organization registry. PATIENTS: All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020. INTERVENTIONS: Unilateral or bilateral femoral cannulation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral (n = 11,965) or bilateral (n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82–1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66–0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76–0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38–0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81–0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching. CONCLUSIONS: This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality. [ABSTRACT FROM AUTHOR]

This article discusses the use of extracorporeal membrane oxygenation (ECMO) as a treatment for respiratory failure in young patients. The study examines whether there are differences in outcomes between teenagers and young adults who receive ECMO. The researchers analyzed data from the International Registry of the Extracorporeal Life Support Organization and found that young adults had a higher survival rate compared to teenagers. The study also identified differences in pre-ECMO factors and management during ECMO between the two groups. The authors highlight the need for further research to determine optimal management strategies for these patients. [Extracted from the article]

OBJECTIVES: A recent study from Germany found that survival after respiratory extracorporeal life support (ECLS) was lower among patients 10–20 years old than 20–30 years old. The objective of this study was to compare survival between teenage and young adult patients who receive respiratory ECLS. DESIGN: Retrospective cohort study. SETTING: Extracorporeal Life Support Organization registry, an international prospective quality improvement database. PATIENTS: All patients ages 16–30 years cannulated for respiratory indications from 1990 to 2020 were included. Patients were divided into two groups, teens (16–19 yr old) and young adults (20–30 yr old). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was survival to discharge. Variables were considered for the multivariate logistic regression model if there was both a statistically significant difference (p ≤ 0.05) and a clinically meaningful absolute difference between the groups. A total of 5,751 patients were included, of whom 1,653 (29%) were teens and 4,098 (71%) were young adults. Survival to discharge was higher in young adults than teens, 69% versus 63% (p < 0.001). Severity of illness was higher among teens; however, survival within each stratum defined by Pa o 2/F io 2 ratio was higher in young adults than in teens. Use of venoarterial ECLS was higher in teens than in young adults, 15% versus 7%, respectively. Teens were more likely to receive high-frequency oscillatory ventilation and this therapy was associated with a longer time from admission to ECLS initiation. After adjusting for variables that differ significantly between the groups, the odds ratio for survival in young adults compared with teens was 1.14 (95% CI, 1.004–1.3). CONCLUSIONS: In this large multicenter retrospective study, mortality was higher in teens than in young adults who received respiratory ECLS. This difference persisted after adjusting for multiple variables and the mechanism underlying these findings remains unclear. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency. DESIGN: Single-center retrospective observational study. SETTING: Sixteen beds medical ICU at the University Hospital Regensburg. PATIENTS: Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients meeting our ECMO weaning criteria (Sp o 2 ≥ 90% with F io 2 ≤ 0.4 or Pa o 2/F io 2 > 150 mm Hg, pH = 7.35–7.45, positive end-expiratory pressure ≤ 10 cm H2O, driving pressure < 15 cm H2O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90–160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co 2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co 2: odds ratio [OR] 1.05; 95% CI, 1.001–1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04–1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o 2 and Pa o 2/F io 2 during EWTs was higher in failed than successful trials. CONCLUSIONS: Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS: Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS: The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18–49, 50–64, 65–74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46–66 yr). There was a significantly lower aOR of survival for those 65–74 (0.68l 95% CI, 0.57–0.81) or those greater than 75 (0.54; 95% CI, 0.41–0.69), compared with 18–49. Patients 50–64 had a significantly higher aOR of survival compared with those 65–74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79–1.05). A sensitivity analysis using alternative age categories (18–64, 65–69, 70–74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65–69: odds ratio [OR], 0.71; 95% CI, 0.59–0.86; for age 70–74: OR, 0.84; 95% CI, 0.67–1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50–0.81). CONCLUSIONS: This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Critically ill women may receive less vital organ support than men but the mortality impact of this differential treatment remains unclear. We aimed to quantify sex differences in vital organ support provided to adult ICU patients and describe the relationship between sex, vital organ support, and mortality. DESIGN: In this retrospective observational study, we examined the provision of invasive ventilation (primary outcome), noninvasive ventilation, vasoactive medication, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), or any one of these five vital organ supports in women compared with men. We performed logistic regression investigating the association of sex with each vital organ support, adjusted for illness severity, diagnosis, preexisting treatment limitation, year, and hospital. We performed logistic regression for hospital mortality adjusted for the same variables, stratified by vital organ support (secondary outcome). SETTING AND PATIENTS: ICU admissions in the Australia and New Zealand Intensive Care Society Adult Patient Database 2018–2021. This registry records admissions from 90% of ICUs in the two nations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined 699,535 ICU admissions (43.7% women) to 199 ICUs. After adjustment, women were less likely than men to receive invasive ventilation (odds ratio [OR], 0.64; 99% CI, 0.63–0.65) and each other organ support except ECMO. Women had lower adjusted hospital mortality overall (OR, 0.94; 99% CI, 0.91–0.97). Among patients who did not receive any organ support, women had significantly lower adjusted hospital mortality (OR, 0.82; 99% CI, 0.76–0.88); among patients who received any organ support women and men were equally likely to die (OR, 1.01; 99% CI, 0.97–1.04). CONCLUSIONS: Women received significantly less vital organ support than men in ICUs in Australia and New Zealand. However, our findings suggest that women may not be harmed by this conservative approach to treatment. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a rare, sudden, and catastrophic complication of pregnancy that can result in cardiopulmonary arrest, potentially leading to death. The pathophysiology of an AFE includes an inflammatory and coagulopathic response due to fetal materials entering maternal circulation with the hallmark triad of symptoms: acute respiratory distress, cardiovascular collapse, and coagulopathy. Management of AFE should include high-quality cardiopulmonary resuscitation, immediate delivery of the fetus if applicable, early intubation to provide adequate oxygenation and ventilation, fluid volume resuscitation, and ongoing evaluation of coagulopathy. Priorities include thromoboelastography interpretation if available, control of hemorrhage and coagulopathy with blood component therapy, and cardiovascular support through inotropes and vasopressor administration. More recent approaches include implementing the A-OK (atropine, ondansetron, and ketorolac) protocol for suspected AFE protocol, extracorporeal cardiopulmonary resuscitation (ECPR), and extracorporeal membrane oxygenation (ECMO) therapies to increase survival and decrease complications. Venoarterial ECMO is the highest form of life support that provides support in patients with pulmonary and cardiac failure. ECPR is the application of Venoarterial ECMO during cardiopulmonary resuscitation in cases where the cause of arrest is believed to be reversible. Early implementation of ECPR during the acute phase of AFE can provide support for end-organ perfusion in place of the weakened and recovering heart while optimizing oxygenation, making venoarterial ECMO an ideal adjunctive therapy. Because of the rarity of AFE, many obstetrical teams may have limited prior experience in managing these catastrophic cases; however, with ongoing education and simulation, teams can be better prepared in the recognition and management of these life-threatening events. During a cesarean birth, a woman experienced an amniotic fluid embolism. Through the work of a multidisciplinary team, and after numerous medications, blood products, and other treatments including extracorporeal cardiopulmonary resuscitation, she survived. A few weeks prior to this event, the multidisciplinary team in this maternity unit simulated an extracorporeal cardiopulmonary resuscitation maternal code scenario in the operating room. Several needs were identified and addressed prior to this case which contributed to the positive outcome. Multidisciplinary simulation on amniotic fluid embolism can help identify potential barriers and improve team knowledge and response. Details of the event and recommendations for other perinatal health care teams are provided. [ABSTRACT FROM AUTHOR]

Right ventricular failure (RVF) is a critical condition that significantly impacts morbidity and mortality in affected patients. This review article aims to provide a comprehensive understanding of RVF by discussing its background, etiology, pathophysiology, clinical presentation, diagnostic studies, medical treatment, and mechanical assistive devices. [ABSTRACT FROM AUTHOR]

The onset of the COVID-19 pandemic has led to an increased use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS); however, there are ongoing concerns about its associated risks and benefits, making a comprehensive understanding vital for clinical decision-making. This review aims to evaluate the efficacy, risks, and practical implications of ECMO as a therapeutic intervention in severe ARDS secondary to COVID-19. The results indicate that ECMO is a key therapeutic intervention for managing severe COVID-19, but due to its associated risks and resource constraints, its application needs careful consideration. Nurse practitioners need to acquire specialized skills to manage ECMO and stay updated with ongoing research and revised protocols. Given the potential for future virus mutations or pandemics, and finite resources, a multidisciplinary approach to ECMO therapy is necessary. Careful patient selection, strategic resource allocation, and continuous education are pivotal elements for improved patient outcomes. [ABSTRACT FROM AUTHOR]

The article discusses the potential benefits of Extracorporeal Cardiopulmonary Resuscitation (E-CPR) in pediatric cardiac critical care. It highlights the high rates of in-hospital cardiac arrest in children recovering from cardiac surgery and the significant long-term neurodevelopmental disabilities and resource utilization associated with it. The study compares survival rates between pediatric cardiac surgery patients who received E-CPR and those who received conventional CPR (C-CPR) using multicenter data from the American Heart Association. The study found that E-CPR was associated with higher survival rates and favorable neurologic outcomes compared to C-CPR. However, the study's retrospective and observational nature limits the establishment of causality, and further research is needed to validate and explore the benefits and risks of E-CPR. The article emphasizes the need for broader implementation of E-CPR in pediatric cardiac critical care and the importance of ongoing research in refining resuscitation strategies. [Extracted from the article]

The article explores the use of extracorporeal cardiopulmonary resuscitation (ECPR) in children with primary noncardiac diagnoses. A study comparing outcomes of pediatric patients who received ECPR versus conventional CPR found no significant difference in survival to discharge. However, more research is needed to fully understand the potential benefits of ECPR in this population. The document also references other studies and articles that discuss the effects of intra-arrest transport, immediate invasive assessment and treatment, and early ECPR on functional neurologic outcome in refractory cases of out-of-hospital cardiac arrest. These sources emphasize the need for further evidence and research in the field of ECPR for out-of-hospital cardiac arrest. [Extracted from the article]

Background: In response to the needs of patients infected with COVID-19, an interdisciplinary team was assembled to implement an adult extracorporeal membrane oxygenation (ECMO) program in the surgical ICU of a West Texas tertiary care hospital. Use of Extracorporeal Life Support Organization (ELSO) guidelines was essential to the development of this effort. Aim: The aim of this project was to develop, implement, and evaluate an adult ECMO program. Methods: A logic model was used in designing and evaluating the adult ECMO program. A 35-hour ECMO specialist training course was developed, and training began in August 2020, a month before implementation of the project began. Patient outcomes were measured between September 2020 and December 2021. Descriptive statistics were used to measure the clinical outcomes of interest. Results: Seventeen newly trained ECMO specialists included experienced critical care nurses and respiratory therapists. Protocols were developed for the initiation of ECMO, and tracked patient outcomes included survival off ECMO, survival to discharge, major and minor complications, and length of stay. Nine patients had COVID-19 and demonstrated an 11.11% mortality rate after adult ECMO program implementation. Conclusions: Use of the ELSO professional guidelines to design and develop this project led to the achievement of a sustainable ECMO program. Hospital leaders can now implement adult ECMO programs amid other demands for resources that may be created by future pandemics. A project to develop, implement, and evaluate an adult ECMO program in the surgical ICU of a tertiary care hospital. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Trimethoprim-sulfamethoxazole (TMP-SMX)-associated severe acute respiratory distress syndrome (ARDS) has gone underrecognized. We propose the first disease definition and clinical evaluation for a novel adverse drug reaction (ADR) based on a series of recently identified rare cases of life-threatening ADRs. DESIGN: A retrospective study was conducted. All medical records were evaluated. Available pathology samples were sent to Massachusetts General for clinical consultation. Blood samples from surviving patients were obtained and human leukocyte antigen (HLA) analysis was performed by the Children’s Mercy Hospital Genomic Center and Vanderbilt University Medical Center. SETTING: U.S. ICUs, 1996–2021. PATIENTS: Nineteen young patients (10–37) were identified. Patients were previously healthy, with no preexisting pulmonary disease, no other cause for respiratory failure, and no chronic history of smoking/vaping. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Through our retrospective analysis, we analyzed clinical characteristics associated with TMP-SMX. Pathology samples were reviewed, and HLA analysis was performed on available samples by the study team or as standard of care at treatment hospitals in some cases. In 19 critically ill patients, we identified a pattern of severe respiratory failure requiring ICU admission, mechanical ventilation, and frequent extracorporeal membrane oxygenation use. We describe the first three-part clinical diagnosis and evaluation strategy: 1) Clinical definition: Unexplained severe respiratory failure in a patient receiving greater than or equal to 6 days of TMP-SMX at treatment dose (not prophylaxis). TMP-SMX ARDS is a diagnosis of exclusion. 2) Genetic association: One hundred percent of currently available TMP-SMX respiratory failure patient genomic data, (n = 11) have been carriers of both HLA-B*07:02 and HLA-C*07:02 alleles. HLA allele evaluation could be considered in patients with suspected TMP-SMX respiratory failure. 3) Lung pathology: A unique pulmonary pathologic pattern of lung injury termed diffuse alveolar injury with delayed epithelialization has been observed in these cases. In suspected cases, surgical lung biopsy early in the clinical course could be considered. CONCLUSIONS: TMP-SMX is a commonly prescribed antibiotic. However, we find it imperative to share this relatively rare but life-threatening condition with clinicians as the mortality rate approaches 40%. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is an advanced treatment for acute severe respiratory failure. Patients on ECMO are frequently maintained sedated and immobilized until weaning from ECMO, first, and then from mechanical ventilation. Avoidance of sedation and invasive ventilation during ECMO may have potential advantages. We performed a systematic literature review to assess efficacy and safety of awake ECMO without invasive ventilation in patients with respiratory failure. DATA SOURCES: PubMed, Web of Science, and Scopus were searched for studies reporting outcome of awake ECMO for adult patients with respiratory failure. STUDY SELECTION: We included all studies reporting outcome of awake ECMO in patients with respiratory failure. Studies on ECMO for cardiovascular failure, cardiac arrest, or perioperative support and studies on pediatric patients were excluded. Two investigators independently screened and selected studies for inclusion. DATA EXTRACTION: Two investigators abstracted data on study characteristics, rate of awake ECMO failure, and mortality. Primary outcome was rate of awake ECMO failure (need for intubation). Pooled estimates with corresponding 95% CIs were calculated. Subgroup analyses by setting were performed. DATA SYNTHESIS: A total of 57 studies (28 case reports) included data from 467 awake ECMO patients. The subgroup of patients with acute respiratory distress syndrome showed a pooled estimate for awake ECMO failure of 39.3% (95% CI, 24.0–54.7%), while in patients bridged to lung transplantation, pooled estimate was 23.4% (95% CI, 13.3–33.5%). Longest follow-up mortality was 121 of 439 (pooled estimate, 28%; 95% CI, 22.3–33.6%). Mortality in patients who failed awake ECMO strategy was 43 of 74 (pooled estimate, 57.2%; 95% CI, 40.2–74.3%). Two cases of cannula self-removal were reported. CONCLUSIONS: Awake ECMO is feasible in selected patients, although the effect on outcome remains to be demonstrated. Mortality is almost 60% in patients who failed awake ECMO strategy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether multisite versus single-site dual-lumen (SSDL) cannulation is associated with outcomes for COVID-19 patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization Registry. Propensity score matching (2:1 multisite vs SSDL) was used to control for confounders. PATIENTS: The matched cohort included 2,628 patients (1,752 multisite, 876 SSDL) from 170 centers. The mean (sd) age in the entire cohort was 48 (11) years, and 3,909 (71%) were male. Patients were supported with mechanical ventilation for a median (interquartile range) of 79 (113) hours before VV-ECMO support. INTERVENTIONS: None. MEASUREMENTS: The primary outcome was 90-day survival. Secondary outcomes included survival to hospital discharge, duration of ECMO support, days free of ECMO support at 90 days, and complication rates. MAIN RESULTS: There was no difference in 90-day survival (49.4 vs 48.9%, p = 0.66), survival to hospital discharge (49.8 vs 48.2%, p = 0.44), duration of ECMO support (17.9 vs 17.1 d, p = 0.82), or hospital length of stay after cannulation (28 vs 27.4 d, p = 0.37) between multisite and SSDL groups. More SSDL patients were extubated within 24 hours (4% vs 1.9%, p = 0.001). Multisite patients had higher ECMO flows at 24 hours (4.5 vs 4.1L/min, p < 0.001) and more ECMOfree days at 90 days (3.1 vs 2.0 d, p = 0.02). SSDL patients had higher rates of pneumothorax (13.9% vs 11%, p = 0.03). Cannula site bleeding (6.4% vs 4.7%, p = 0.03), oxygenator failure (16.7 vs 13.4%, p = 0.03), and circuit clots (5.5% vs 3.4%, p = 0.02) were more frequent in multisite patients. CONCLUSIONS: In this retrospective study of COVID-19 patients requiring VV-ECMO, 90-day survival did not differ between patients treated with a multisite versus SSDL cannulation strategy and there were only modest differences in major complication rates. These findings do not support the superiority of either cannulation strategy in this setting. [ABSTRACT FROM AUTHOR]

OBJECTIVES: ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the “Activity index,” an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain. DESIGN: Retrospective national registry-based cohort study. SETTING: One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022). SUBJECTS: Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of “patients with 1:1 nursing” + “invasive ventilation” + “renal replacement” + “extracorporeal membrane oxygenation” + “active COVID19,” divided by total staffed ICU beds) during the patient’s stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40–1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38–1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21–1.34), readmission (OR, 1.18; 99% CI, 1.09–1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72–2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55–0.62): findings consistent with ICU strain. CONCLUSIONS: The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) is beneficial for the treatment of profound cardiogenic shock, peripheral VA-ECMO cannulation can increase left ventricular afterload, thus compromising myocardial recovery. We investigated whether early routine left ventricular unloading can reduce 30-day mortality compared with the conventional approach in patients with cardiogenic shock undergoing VA-ECMO. METHODS: This randomized clinical trial involved 116 patients with cardiogenic shock undergoing VA-ECMO from March 2021 to September 2022 at Chonnam National University Hospital, Gwangju, South Korea. The patients were randomly assigned to undergo either early routine left ventricular unloading with transseptal left atrial cannulation within 12 hours after randomization (n=58) or the conventional approach, which permitted rescue transseptal left atrial cannulation in case of an increased left ventricular afterload (n=58). The primary outcome was all-cause mortality within 30 days. RESULTS: All 116 randomized patients (mean age, 67.6±13.5 years; 34 [29.3%] women) completed the trial. At 30 days, all-cause death had occurred in 27 (46.6%) patients in the early group and 26 (44.8%) patients in the conventional group (hazard ratio, 1.02 [95% CI, 0.59-1.74]; P=0.942). Crossover to rescue transseptal left atrial cannulation occurred in 29 patients (50%) in the conventional group according to a clear indication. Time to rescue transseptal cannulation in the conventional group was a median of 21.8 (interquartile range, 12.4-52.2) hours after randomization. There were no significant differences in other secondary outcomes between the 2 groups except for a shorter time to disappearance of pulmonary congestion in the early group (median, 3 [interquartile range, 2-6] versus 5 [interquartile range, 3-7] days; P=0.027). CONCLUSIONS: Among patients with cardiogenic shock undergoing VA-ECMO, early routine left ventricular unloading with transseptal left atrial cannulation did not reduce 30-day mortality compared with the conventional strategy, which permitted rescue transseptal left atrial cannulation. These findings should be cautiously interpreted until the results of multicenter trials using other unloading modalities become available. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04775472. [ABSTRACT FROM AUTHOR]

Objective: Extracorporeal membrane oxygenation (ECMO) is a lifesaving modality that was in great demand for persons with severe COVID-19 infection. Although mobility of these patients has previously been safely reported anecdotally, there were no established guidelines to implement in a greatly expanded patient population, as occurred in the pandemic period. We describe the development and implementation of a program (Cannulate, Extubate, Ambulate) for team-based safe mobilization. Methods: The 3-phase protocol advances based on patient alertness/ability to actively participate. A physical therapist determined initial stage and progression and recommended mobility activities for carryover by nurses and/or ECMO specialists between skilled sessions. Results: The mobility program has been successfully implemented for 104 patients with severe COVID-19 without significant adverse events. Most patients (51%) ambulated while cannulated, and 60% were able to discharge directly home after hospitalization. Conclusions: This safe, effective program allowed extension of physical therapy goals in a highly complex patient population during a time of very high demand. Making early mobility a team goal enhanced buy-in, instead of relying exclusively on rehabilitation providers for mobilization. Utilization of the Cannulate, Extubate, Ambulate program may assist other programs to minimize complications of immobility in the ECMO population. [ABSTRACT FROM AUTHOR]

The article discusses the use of single-site versus multisite cannulation for venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19. The authors acknowledge the limitations of the existing evidence and emphasize the need for high-quality randomized controlled trials (RCTs) to assess patient-centered outcomes and mortality associated with blood purification techniques. They also highlight the lack of available information in the dataset used for their study, which limits the analysis of certain variables. The authors agree with the commenters that additional variables should be studied in future iterations of the dataset or other large, multicenter datasets. [Extracted from the article]

The article discusses the use of femoral vessel cannulation for extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO) in adults. While this method offers advantages such as avoiding neurologic injury associated with carotid artery cannulation, it is also associated with complications that can lead to amputation or death. The article reviews data from the Extracorporeal Life Support Organization (ELSO) and concludes that bilateral femoral vessel cannulation is associated with fewer complications and lower mortality compared to unilateral cannulation. However, the article acknowledges limitations in the data and calls for further research on factors such as cannula size and monitoring methods to prevent complications. [Extracted from the article]