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Rationale: Early mobilization of ECMO-supported patients is increasingly common, but it remains unknown whether there are factors predictive of achieving higher intensity mobilization among those a...

Rationale Two distinct subphenotypes have been identified in acute respiratory distress syndrome (ARDS), but the presence of subgroups in ARDS associated with COVID-19 is unknown. The objective of this study was to identify clinically relevant, novel subgroups in COVID-19-related ARDS, and compare them to previously described ARDS subphenotypes. Methods Eligible participants were adults with COVID-19 and ARDS at Columbia University Irving Medical Center. Latent class analysis (LCA) was used to identify subgroups with baseline clinical, respiratory, and laboratory data serving as partitioning variables. A previously-developed machine learning model was used to classify patients as the hypoinflammatory and hyperinflammatory subphenotypes. Baseline characteristics and clinical outcomes were compared between subgroups. Heterogeneity of treatment effect (HTE) for corticosteroid-use in subgroups was tested. Measurements and Main Results From 3/2-4/30/2020, 483 patients with COVID-19-related ARDS met study criteria. A two-class LCA model best fit the population (p=0.0075). Class 2 (23%) had higher pro-inflammatory markers, troponin, creatinine and lactate, lower bicarbonate and lower blood pressure than Class 1 (77%). 90-day mortality was higher in Class 2 versus Class 1 (75% vs 48%; p

Background Extracorporeal membrane oxygenation (ECMO) is increasingly utilized as a bridge to lung transplantation , but ECMO status is not explicitly accounted for in the Lung Allocation Score (LAS). We hypothesized that among waitlist patients on ECMO, patients with pulmonary arterial hypertension (PAH) would have lower transplantation rates. Methods Using United Network for Organ Sharing data, we conducted a retrospective cohort study of patients who were ≥12 years old, active on the lung transplant waitlist, and required ECMO support from June 1, 2015 through June 12, 2020. Multivariable competing risk analysis was used to examine waitlist outcomes. Results 1064 waitlist subjects required ECMO support; 40 (3.8%) had obstructive lung disease (OLD), 97 (9.1%) had PAH,138 (13.0%) had cystic fibrosis (CF), and 789 (74.1%) had interstitial lung disease (ILD). Ultimately, 671 (63.1%) underwent transplant, while 334 (31.4%) died or were delisted. The transplant rate per person-years on the waitlist on ECMO was 15.41 for OLD, 6.05 for PAH, 15.66 for CF, and 15.62 for ILD. Compared to PAH patients, OLD, CF, and ILD patients were 78%, 69%, and 62% more likely to undergo transplant throughout the study period, respectively (adjusted SHRs 1.78 p = 0.007, 1.69 p = 0.002, and 1.62 p = 0.001). The median LAS at waitlist removal for transplantation, death, or delisting were 75.1 for OLD, 79.6 for PAH, 91.0 for CF, and 88.3 for ILD (p Conclusions Among patients bridging to transplant on ECMO, patients with PAH had a lower transplantation rate than patients with OLD, CF, and ILD.

Disclaimer:This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.

There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.

Objectives Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus. Design Retrospective review. Setting Medical ICU. Patients Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal. Interventions None. Measurements and main results Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs. Conclusions In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.

Background Over the course of the COVID-19 pandemic, the care of patients with COVID-19 has changed and the use of extracorporeal membrane oxygenation (ECMO) has increased. We aimed to examine patient selection, treatments, outcomes, and ECMO centre characteristics over the course of the pandemic to date.Methods We retrospectively analysed the Extracorporeal Life Support Organization Registry and COVID-19 Addendum to compare three groups of ECMO-supported patients with COVID-19 (aged >= 16 years). At early-adopting centres-ie, those using ECMO support for COVID-19 throughout 2020-we compared patients who started ECMO on or before May 1, 2020 (group A1), and between May 2 and Dec 31, 2020 (group A2). Late-adopting centres were those that provided ECMO for COVID-19 only after May 1, 2020 (group B). The primary outcome was in-hospital mortality in a time-to-event analysis assessed 90 days after ECMO initiation. A Cox proportional hazards model was fit to compare the patient and centre-level adjusted relative risk of mortality among the groups.Findings In 2020, 4812 patients with COVID-19 received ECMO across 349 centres within 41 countries. For earlyadopting centres, the cumulative incidence of in-hospital mortality 90 days after ECMO initiation was 36.9% (95% CI 34.1-39.7) in patients who started ECMO on or before May 1 (group A1) versus 51.9% (50.0-53.8) after May 1 (group A2); at late-adopting centres (group B), it was 58.9% (55.4-62.3). Relative to patients in group A2, group A1 patients had a lower adjusted relative risk of in-hospital mortality 90 days after ECMO (hazard ratio 0.82 [0.70-0.96]), whereas group B patients had a higher adjusted relative risk (1.42 [1.17-1.73]).Interpretation Mortality after ECMO for patients with COVID-19 worsened during 2020. These findings inform the role of ECMO in COVID-19 for patients, clinicians, and policy makers. Copyright (C) 2021 Elsevier Ltd. All rights reserved.

Background Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has become a critical component of caring for patients with end-stage lung disease. This study examined outcomes of patients who received ECMO as a BTT. Methods Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients who received ECMO as BTT at Columbia University Medical Center from April 2009 through July 2018. Results A total of 121 adult patients were placed on ECMO as BTT, and 70 patients (59%) were successfully bridged to lung transplantation. Simplified Acute Physiology Score II, unplanned endotracheal intubation, renal replacement therapy, and cerebrovascular accident were identified as independent predictors of unsuccessful BTT. Ambulation was the only independent predictor of successful BTT (odds ratio, 7.579; 95% confidence interval, 2.158 to 26.615; p = 0.002). Among the 64 patients (91%) who survived to hospital discharge, survival was 88% at 1 year and 83% at 3 years. Propensity matching between BTT and non-BTT lung transplant recipients did not show a significant difference in survival (log-rank = 0.53) despite significant differences in the lung allocation score (median, 92.2 [interquartile range, 89.0 to 94.2] vs 49.6 [interquartile range, 40.6 to 72.3], p Conclusions ECMO can be used successfully to bridge patients with end-stage lung disease to lung transplantation. When implemented by an experienced team with adherence to stringent protocols and patient selection, outcomes in BTT patients were comparable to patients who did not receive pretransplant support.

Objective Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO. Methods Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017. Results Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge. Conclusions Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols.

Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support patients with acute respiratory failure, most commonly, and severe forms of acute respiratory distress syndrome (ARDS). The marked increase in the global use of ECMO followed the publication of a large randomized trial in 2009 and the experience garnered during the 2009 influenza A (H1N1) pandemic, and has been further supported by the release of a large, randomized clinical trial in 2018, confirming a benefit from using ECMO in patients with severe ARDS. Despite a rapid expansion of ECMO-related publications, optimal management of patients receiving ECMO, in terms of patient selection, ventilator management, anticoagulation, and transfusion strategies, is evolving. Most recently, ECMO is being utilized for an expanding variety of conditions, including for cases of severe pulmonary or cardiac failure from coronavirus disease 2019 (COVID-19). This review evaluates modern evidence for ECMO for respiratory failure and the current challenges in the field.

Objectives The Coronavirus disease 2019 (COVID-19) pandemic has rapidly spread since its emergence in December 2019, and has been associated with severe morbidity and mortality. This report includes an in-depth discussion on the unique challenges that the obstetrical population provides when considering optimal management strategy. Case presentation We describe our approach to a preterm patient with high clinical suspicion for COVID-19 whose condition turned critical in the postpartum state. Conclusions Differences in physiology during pregnancy, and goals for reducing both maternal and fetal risks, provide challenges when considering intensive care management, delivery timing, and method of delivery.

This chapter explains the utilization of venovenous extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). Venovenous ECMO provides respiratory support and is the most common ECMO configuration used during ARDS. Patient selection is of the utmost importance for successful use of ECMO. Patients being considered for venovenous ECMO for ARDS should meet criteria for severe ARDS. Best guidance can be taken from the Extracorporeal Life Support Organization recommendations and the multicenter Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome trial. The main contraindication to ECMO is any condition or organ dysfunction that would limit the overall benefit of ECMO, such as severe brain injury, metastatic cancer, or decompensated cirrhosis. Once the ECMO circuit is operational, ventilator settings must be optimized to protect the injured lungs by adhering to an ultra-lung-protective “lung rest” strategy.

Background Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments. Methods In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged >= 18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m(2) or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 mu g/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders. Findings At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1.5 L/min per m(2) vs 2.2 L/min per m(2), LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 mu g/kg per min vs 145 mu g/kg per min, lactataemia 8.9 mmol/L vs 6.5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p

Objectives:The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.Design:Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication.Setting:In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education.Patients:None.Interventions:None.Measurements and Main Results:The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development.Conclusions:Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.

Background Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation for end-stage interstitial lung disease (ILD) and pulmonary hypertension (PH) has varying results based on ECMO configuration. We compare our experience using venovenous (VV) and venoarterial (VA) ECMO bridge to transplantation for ILD with PH on survival to successful transplantation. Methods A single-center retrospective review was done of patients with ILD and secondary PH who were placed on either VV or VA ECMO as bridge to transplantation from 2010 to 2016. Comparisons for factors associated with survival to transplantation between VV and VA ECMO strategies were made using Cox proportional hazards model. Subgroup analysis included comparisons of VV ECMO patients who remained on VV or were converted to VA ECMO. Results A total of 50 patients with ILD and PH were treated initially with either VV (n = 19) or VA (n = 31) ECMO as bridge to lung transplantation. Initial VA ECMO had a significantly higher survival to transplantation compared with initial VV ECMO (p = 0.03). Cox proportional hazards modeling showed a 59% reduction in risk of death for VA compared with VV ECMO (hazard reduction 0.41, 95% confidence interval: 0.18 to 0.92, p = 0.03). Patients converted from VV to VA ECMO had significantly longer survival awaiting transplant than patients who remained on VV ECMO (p = 0.03). Ambulation on ECMO before transplantation was associated with an 80% reduction in the risk of death (hazard reduction 0.20, 95% confidence interval: 0.08 to 0.48, p Conclusions Venoarterial ECMO upper body configuration for patients with end stage ILD and PH significantly improves overall survival to transplantation.

Transporting patients receiving extracorporeal membrane oxygenation (ECMO) support is safe and reliable with a dedicated program and established management protocols. As our program has grown, our teams have had to adapt to manage surges in transport volume while maintaining patient safety. We assessed the outcomes at peak use of our ECMO transport services during surges.We conducted a single-center retrospective review of all patients transported to our institution while supported with ECMO from September 2008 to September 2016. Survival to discharge was the primary outcome. Surge patients were defined as those transported during months with at least 8 transports or patients transported within 24 hours of another patient in nonsurge months.From 2008 to 2016, 222 patients were transported to our institution while supported with ECMO. Baseline characteristics and indices of disease severity were comparable between surge and nonsurge patients. Of the 84 patients transported during surges, 59 surge patients (70%) survived to hospital discharge vs 86 (63%) of nonsurge patients (p = 0.31). Multivariable logistic regression showed that age and APACHE II (Acute Physiology and Chronic Health Evaluation) severity index score were predictors of in-hospital death (p0.05), but transportation during a surge was not (odds ratio, 0.91; 95% confidence interval, 0.46 to 1.80; p = 0.79).Patient safety and clinical outcomes can be maintained during surges in ECMO transport volume if the ECMO program has developed plans for handling transient increases in volume and considers staff fatigue and burnout. Standardizing interhospital communication, patient selection, and management protocols are critical to maintaining quality of care.

Background Extracorporeal membrane oxygenation (ECMO) is used as a bridge to lung transplantation, but characteristics that influence its success are poorly understood. This large, single-center experience evaluated the implementation and outcomes of ECMO in this setting. Methods Data were collected for patients at our institution (New York-Presbyterian Hospital/Columbia University Medical Center in New York) who received ECMO as a bridge to lung transplantation from January 1, 2007 through July 10, 2016. Data were analyzed for demographics, baseline characteristics, survival, and ECMO configuration. Results Seventy-two patients received ECMO as a bridge to lung transplantation. Of the 72 patients, 40 (55.6%) underwent the transplantation procedure, 37 (92.5%) survived to discharge, and 21 (84.0%) survived for 2 years. Inotropy or vasopressor support (70% vs 93.8%; p = 0.011), Simplified Acute Physiology Score (26.8 vs 30.5; p = 0.048), and ambulation (80% vs 56.2%; p = 0.030) were significantly different between the patients who underwent lung transplantation and those who did not. Patients with cystic fibrosis were more likely to have a bridge to transplantation than patients with other lung diseases (47.5% vs 25%; p = 0.050). Daily participation in physical therapy was achieved in 50 patients (69.4%). Conclusions This study demonstrated favorable survival in patients receiving ECMO as a bridge to lung transplantation and achieved high rates of physical therapy and avoidance of mechanical ventilation while ECMO was used in patients awaiting lung transplantation. With more than half of these patients successfully bridged to lung transplantation, we gained insight into the factors influencing patients' outcomes, including patient selection, timing of ECMO, and patient management.

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45–72) with a median ECLS duration of 2.2 days (IQR 0.6–5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8–1.7) vs. 1.7 (0.7–2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30–50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22–8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14–0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.

Patients receiving extracorporeal membrane oxygenation (ECMO) often require prolonged mechanical ventilation. Providers may be reluctant to perform tracheostomies on patients during ECMO due to their tenuous clinical status and systemic anticoagulation. We report our experience with performing open and percutaneous tracheostomies on patients supported on ECMO from August 2009 to December 2017. Of the 127 patients who underwent tracheostomy during ECMO support, the median age was 42 years (interquartile range [IQR], 29-54), 99 (78%) patients had venovenous (VV) cannulation, 22 (17%) patients had venoarterial (VA) cannulation, and six (5%) patients had hybrid configurations. Percutaneous tracheostomy was performed in 110 (87%) patients. Median-activated partial thromboplastin time (aPTT) at the time of tracheostomy was 47.5 seconds (IQR, 41-57.6 seconds). The median time from ECMO initiation to tracheostomy was 7 days (IQR, 4-11 days). A total of 55 patients (43%) received packed red blood cell (pRBC) transfusions within 48 hours after tracheostomy with a median transfusion of 2 units (IQR, 1-3). There was no procedural mortality. Overall, 88 (69%) patients survived to decannulation and 74 (58%) survived to hospital discharge. Our experience with the largest published series of tracheostomies during ECMO demonstrates that excellent outcomes can be achieved without significant morbidity.

Background Application of extracorporeal life support (ECLS) for advanced pulmonary hypertension (PH) is evolving and may be deployed as a bridge to transplantation (BTT) or in one of several non-BTT uses, such as bridge to recovery (BTR) to the chronic PH clinical state in the setting of an acute PH trigger, bridge through non-transplant surgery (BTNTS), or bridge post-transplantation (BPT). Methods We conducted a retrospective analysis of all adult patients with World Symposium on Pulmonary Hypertension Group 1, 3, 4, or 5 PH who received ECLS at Columbia University Medical Center/New York Presbyterian Hospital between January 1, 2010 and August 18, 2018. We describe patient characteristics, outcomes, and our approach to medical and surgical management of these patients. Results There were 98 patients with significant PH in the cohort (54 female; median age, 48 years [interquartile range, 32–58]). Of these, 44 (45%) patients with PH received ECLS as non-BTT with intent to recover back to their baseline functional state, optimize therapy, or support through a definitive surgery, including 19 BTR, 17 BTNTS, and 8 BPT, and 54 (55%) patients received ECLS as BTT. In the overall cohort, 67 (68.4%) patients received venoarterial ECLS and 31 (31.6%) received venovenous (VV) ECLS. Out of 83 patients, 52 (63%) were liberated from invasive mechanical ventilation, and 85.2% of BTT patients with PH ambulated while on ECLS. Management of PH medications was individualized, often requiring titration with use of inhaled pulmonary vasodilators increased after cannulation in non-BTT. Overall 30-day survival was 73.5%, survival to ECLS decannulation was 66.3%, and survival to hospital discharge was 54.1%. All 8 BPT patients (100%) survived to hospital discharge, 64.7% of BTNTS patients survived to hospital discharge, and 32 (59.3%) BTT patients survived to lung transplantation. Early-era use of VV-ECLS for BTT had worse survival to discharge than those initially configured with venoarterial ECLS, impacting the overall survival and leading to limited use of VV-ECLS in the current era for BPT, BTNTS, and select BTR cases. Conclusions ECLS instituted by a specialized, multidisciplinary team has a role in the management of advanced PH as BTT or as non-BTT (including BTR, BTNTS, and BPT). Careful selection of ECLS cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be effective strategies in managing these complex patients.

Purpose To characterize monitoring of pain, agitation, and delirium; investigate opioid and sedative choices; and describe prevention and treatment of delirium in adults receiving venovenous extracorporeal membrane oxygenation (vv-ECMO) for respiratory failure. Materials and methods International, cross-sectional survey distributed January 2018 to members of the Society of Critical Care Medicine. Results Respondents were predominately physicians (58%) from North America (89%). Fentanyl (77%) and hydromorphone (48%) were the most common intravenous opioids used to manage pain. A deep level of sedation was targeted in the first 24-h after initiation of vv-ECMO 64% of the time. When deep sedation was targeted, propofol (70%) and benzodiazepines (41%) were the most common sedatives. The most common sedatives for light sedation were dexmedetomidine (45%) and propofol (39%). Delirium prevention included avoidance of benzodiazepines (73%), whereas the most common treatment strategy was scheduled atypical antipsychotics (83%). Centers that extubated patients during vv-ECMO used dexmedetomidine as the second preferred sedative as compared to benzodiazepines at non-extubating centers (p = 0.04). Conclusions Most respondents use validated scales and protocols to assess and manage pain, agitation/sedation, and delirium. The majority of respondents reported targeting a deep level of sedation with propofol being used for both deep and light levels of sedation.

Background Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support pregnant and postpartum patients with severe cardiac or pulmonary failure, although patient management and clinical outcomes are underreported. This study represents patients who received ECMO during the peripartum period. Methods All pregnant or postpartum patients treated with ECMO in the medical intensive care unit between January 1, 2009, and June 30, 2015, were included in this study. Data were analyzed retrospectively. The primary objective was to characterize the circumstances and clinical characteristics of the patients who received ECMO, describe our management during pregnancy and at the time of delivery, evaluate maternal and fetal outcomes, and report bleeding and thrombotic complications. Results Eighteen peripartum patients were treated with ECMO during the study period; 4 were pregnant at the time of cannulation. Median age was 32.6 years, and median gestational age in pregnant patients was 32 weeks. Sixteen patients (88.9%) survived to hospital discharge. Fetal survival was 14 (77.8%) in the entire cohort and 100% in patients cannulated after fetal viability. Two patients successfully delivered on ECMO. Bleeding complications developed in 6 patients (33.3%) and were associated with disseminated intravascular coagulation. No fetal complications were attributed to ECMO. Conclusions ECMO can be used during pregnancy and postpartum with favorable maternal and fetal outcomes, and it outweighs the risk of bleeding or thrombotic complications when managed by an experienced, multidisciplinary team.

Patients with acute pulmonary embolism (PE) have variable risk for mortality depending on host and disease-related factors. An improved understanding of how frailty status relates to risk for outcomes after treatment for PE is needed. Modified body mass index (mBMI) is an easily measurable proxy for

Patients receiving extracorporeal membrane oxygenation (ECMO) face a unique set of hematologic challenges beyond those experienced by other critically ill patients in the intensive care unit. In addition to any hematologic dysregulation related to the patient’s underlying disease processes, the ECMO circuit exerts shear stress on blood components and alters the balance between pro- and anticoagulant pathways thereby increasing the risk of bleeding, thrombosis, and hemolysis, all of which may be severe. These factors, as well as evolving anticoagulation practices in ECMO-supported patients, have introduced additional challenges that complicate an already complex hematologic landscape. Despite the rapid growth of ECMO in recent years, limited high-quality evidence exists in how to best diagnose, mitigate, and manage the hematologic complications associated with it. Because of this, a thorough understanding of physiology and the interaction of blood elements with the ECMO circuit are paramount to the successful delivery of patient care in this setting.

Purpose Patients receiving extracorporeal membrane oxygenation (ECMO) are at risk for thrombocytopenia including heparin-induced thrombocytopenia (HIT). The purpose of this study was to determine the frequency of suspected HIT in patients receiving ECMO and unfractionated heparin (UFH). Materials and methods We conducted a retrospective review in adult patients on ECMO. Patients were included if they received ECMO for at least 5 days and concomitant UFH. Results There were 119 patients who met inclusion criteria. Twenty-three patients (19%) had a heparin–platelet factor 4 immunoassay performed. Patients with suspected HIT had a significantly lower platelet count within the first 3 days of ECMO, 69 × 10 9 /L (22-126 × 10 9 /L) vs 87.5 × 10 9 /L (63-149 × 10 9 /L); P = .04. The lowest platelet count on the day of HIT testing was 43 × 10 9 /L (26-73), representing a 71% reduction from baseline. Twenty patients (87%) had an optical density score less than 0.4, and all patients had a score less than 1.0. A functional assay was performed in 7 patients (30%), with only 1 patient having laboratory-confirmed HIT. Conclusions The evaluation of HIT occurred in a small percentage of patients, with HIT rarely being detected. Patients who had heparin–platelet factor 4 immunoassay testing exhibited lower platelet counts with a similar duration of ECMO and UFH exposure.

OBJECTIVES Extracorporeal membrane oxygenation (ECMO) transport has not been described in morbidly obese patients, a population that can pose significant challenges in obtaining vascular access, indexed flows and transport logistics. We sought to study the feasibility and safety of transporting obese and morbidly obese patients during extracorporeal support. METHODS We conducted a retrospective review of all patients transported to our institution while receiving ECMO from September 2008 to September 2016. Survival to decannulation and survival to discharge were the primary outcomes. Obesity and morbid obesity were defined as a body mass index of greater than 30 kg/m2 and greater than 40 kg/m2, respectively. RESULTS From 2008 to 2016, 222 patients were transported to our institution while receiving ECMO. Among these included patients, 131 were non-obese (interquartile range 22-27 kg/m2), 63 were obese (interquartile range 31-35 kg/m2) and 28 were morbidly obese (interquartile range 41-49 kg/m2), with 6 patients having a body mass index greater than 50 kg/m2 (range 52.3-79 kg/m2). Pre-ECMO arterial blood gases, disease severity indices, cannulation strategies and transport distances were similar between these 3 groups. There was no mortality of patients during transport, and survival to discharge was 66% (n = 87) in non-obese patients, 56% (n = 35) in obese patients and 82% (n = 23) in morbidly obese patients (P = 0.042). On multivariable logistic regression analysis, body mass index was not a predictor of in-hospital mortality (odds ratio 0.99, 95% confidence interval 0.95-1.03; P = 0.517). CONCLUSIONS Transport of morbidly obese patients receiving ECMO may be performed safely and with excellent results in the setting of a dedicated ECMO transport programme with well-established management protocols.

Use of extracorporeal membrane oxygenation (ECMO) in adults has surged in recent years. Typical configurations are venovenous (VV), which provides respiratory support, or venoarterial (VA), which provides both respiratory and circulatory support. In patients supported with VV ECMO who develop hemodynamic compromise, an arterial limb can be added (venovenous-arterial ECMO) to provide additional circulatory support. For patients on VA ECMO who develop concomitant respiratory failure in the setting of some residual cardiac function, an oxygenated reinfusion limb can be added to the internal jugular vein (venoarterial-venous ECMO) to improve oxygen delivery to the cerebral and coronary circulation. Such hybrid configurations can provide differential support for various forms of cardiopulmonary failure. We describe 21 patients who ultimately received a hybrid configuration at our institution between 2012 and 2013. Eight patients (38.1%) died during ECMO support, four patients (19.0%) died after decannulation but before hospital discharge, and nine patients (42.9%) survived to hospital discharge. Our modest survival rate is likely related to the complexity and severity of illness of these patients, and this relative success suggests that hybrid configurations can be effective. It serves patients well to maintain a flexible and adaptable approach to ECMO configurations for their variable cardiopulmonary needs.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used to support adults with severe forms of respiratory failure. Fueling the explosive growth is a combination of technological improvements and accumulating, although controversial, evidence. Current use of ECMO extends beyond its most familiar role in the support of patients with severe acute respiratory distress syndrome (ARDS) to treat patients with various forms of severe hypoxemic or hypercapnic respiratory failure, ranging from bridging patients to lung transplantation to managing pulmonary hypertensive crises. The role of ECMO used primarily for extracorporeal carbon dioxide removal (ECCO2R) in the support of patients with hypercapnic respiratory failure and less severe forms of ARDS is also evolving. Select patients with respiratory failure may be liberated from invasive mechanical ventilation altogether and some may undergo extensive physical therapy while receiving extracorporeal support. Current research may yield a true artificial lung with the potential to change the paradigm of treatment for adults with chronic respiratory failure.

Purpose Despite advanced targeted medical therapy, patients with pulmonary hypertension (PH) can experience gradual or sudden progression of their symptoms due to an acute insult. Application of extracorporeal life support (ECLS) for advanced PH is evolving. We examined our single-center experience using ECLS as bridge to recovery (BTR), non-transplant surgery (BTNTS), or lung transplantation (BTT) in patients with PH. Methods We conducted a retrospective analysis of all adult patients with non-WHO group 2 PH who received ECLS at New York Presbyterian - Columbia University Medical Center between 2010 and 2018. We describe clinical characteristics and our specialized approach to medical and surgical management in this cohort. Results There were 98 PH patients in the cohort (54 female; median age 48 years (IQR 32-58)). Thirty-six (36.7%) patients received ECLS with intent to BTR (including 10 BTNTS) and 62 (63.3%) to BTT, including 8 who received ECLS during or immediately after lung transplantation. In the overall cohort, 58 (59.1%) patients received VA-ECLS, including upper body Sport Model (n=13), and upper body Central Sport Model (n=7). Nine (9.2%) patents received VVA-ECLS. Thirty-two (32.7%) patients received VV-ECLS including 4 via a congenital pulmonary-systemic shunt for “VA” physiology. Serum lactate, creatinine, brain natriuretic peptide, and arterial blood gas measures improved after ECLS cannulation. Sixty-eight (70%) patients were liberated from invasive mechanical ventilation while receiving ECLS. Management of PH medications followed an intentional strategy of de-escalation for BTT and ramp down and then ramp up for non-surgical BTR. PH medications including intravenous and inhaled prostanoids, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors were used most often in BTR patients and in WHO group 1 PH BTT patients. Survival to decannulation in this cohort was 85.7%; 30-day survival was 71.4%. Conclusion ECLS instituted by a specialized, multidisciplinary PH/ECLS team has a growing role in the management of advanced non-WHO group 2 PH as BTR, BTNTS, or to BTT. Careful selection of cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be an effective strategy in managing these complex patients.

Severe (massive and sub-massive) pulmonary embolism (PE) is associated with significant rates of morbidity and mortality. We sought to assess severe PE before and after the inception of a multidisciplinary PE Response Team (PERT). Acute PE patients in the pre-PERT and early-PERT years (2013-2016)

Extracorporeal membrane oxygenation (ECMO) may be used to support patients with severe hypoxemic respiratory failure refractory to conventional mechanical ventilation. However, because systemic anticoagulation is generally required to maintain circuit patency, severe bleeding is often seen as a contraindication to ECMO. We describe our center's experience with four patients who received ECMO for refractory hypoxemic respiratory failure due to diffuse alveolar hemorrhage (DAH), a condition for which anticoagulation is typically contraindicated, and provide a review of the literature. The mean age was 35.8 ± 16.4 years. The mean pre-ECMO PaO2 to FIO2 ratio was 52.3 ± 9.4 mm Hg. All patients were treated with continuous infusions of heparin with a goal-activated partial thromboplastin time between 40 and 60 seconds (mean, 47.4 ± 11.6 seconds). All four subjects (100%) survived to decannulation, and three subjects (75%) survived to discharge. The results from this case series, along with previously published data, suggest that ECMO is a reasonable management option for patients with DAH-associated severe, refractory hypoxemic respiratory failure. This is especially true in the era of modern ECMO technology where lower levels of anticoagulation are able to maintain circuit patency while minimizing bleeding risk.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) requiring invasive mechanical ventilation (IMV) are associated with significant morbidity and mortality. Extracorporeal carbon dioxide removal (ECCO₂R) may facilitate extubation and ambulation in these patients and potentially improve outcomes.We assessed the feasibility of achieving early extubation and ambulation in subjects requiring IMV for exacerbations of COPD using single-site ECCO₂R.Five subjects with exacerbations of COPD with uncompensated hypercapnia requiring IMV were enrolled in this single-center, prospective, feasibility trial using a protocol of ECCO₂R, extubation, and physical rehabilitation. The primary endpoint was extubation within 72 hours of starting ECCO₂R.Mean preintubation pH and PaCO₂ were 7.23 ± 0.05 and 81.6 ± 15.9 mm Hg, respectively. All subjects met the primary endpoint (median duration, 4 h; range, 1.5-21.5 h). Mean duration of extracorporeal support was 193.0 ± 76.5 hours. Mean time to ambulation after extracorporeal initiation was 29.4 ± 12.6 hours. Mean maximal ambulation on extracorporeal support was 302 feet (range, 70-600). Four subjects were discharged home, and one underwent planned lung transplantation. Two minor bleeding complications occurred. There were no complications from mobilization on extracorporeal support.ECCO₂R facilitates early extubation and ambulation in exacerbations of COPD requiring IMV and has the potential to serve as a new paradigm for the management of a select group of patients. Rigorous clinical trials are needed to corroborate these results and to investigate the effect on long-term outcomes and cost effectiveness over conventional management.

Pulmonary arterial hypertension (PAH) is a disease with significant morbidity and mortality, particularly during an acute decompensation. We describe a single-center experience of three patients with severe Group 1 PAH, refractory to targeted medical therapy, in which an extubated, nonsedated, extracorporeal membrane oxygenation (ECMO) strategy with an upper-body configuration was used as a bridge to recovery or lung transplantation. All three patients were extubated within 24 hours of ECMO initiation. Two patients were successfully bridged to lung transplantation, and the other patient was optimized on targeted PAH therapy with subsequent recovery from an acute decompensation. The upper-body ECMO configuration allowed for daily physical therapy, including one patient, who would otherwise have been unsuitable for transplantation, ambulating over 850 meters daily. This series demonstrates the feasibility of using ECMO to bridge PAH patients to recovery or transplantation while avoiding the complications of immobility and invasive mechanical ventilation.

The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia. We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤50,000/μL) while on ECMO. Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β −0.85, 95 % CI −2.05 to 0.36), nor after considering and controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β −0.83, 95 % CI −1.9 to 0.25). Twenty-two subjects (22 %) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35 % for every 5-point increase in APACHE II score (OR 1.35, 95 % CI 0.94–1.94) and increased 35 % for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95 % CI 1.10–1.64). Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.

Expeditious recognition and effective intervention during crises is essential to the successful management of patients receiving extracorporeal life support (ECLS). Crises during ECLS can be partitioned into those originating in the circuit and those originating in the patient. Circuit crises, such as the presence of circuit air, thrombosis, oxygenator failure, pump failure, tubing rupture, heater malfunction, and inadvertent decannulation, and patient crises such as bleeding, hemolysis, refractory hypoxemia, and shock, may quickly become life-threatening emergencies. Providers must be trained to promptly identify and respond to both common and uncommon complications of ECLS in order to optimize patient safety and improve clinical outcomes.

Right ventricular function is a key determinant of exercise capacity and survival in pulmonary arterial hypertension (PAH). We aimed to study the predictors of right ventricular ejection fraction (RVEF) in patients with newly diagnosed PAH.We performed a cross-sectional analysis of a retrospective cohort of consecutive patients with idiopathic, familial, or anorexigen-associated PAH who underwent equilibrium radionuclide angiography for measurement of RVEF at baseline.Of the 84 patients in the cohort, 63 underwent equilibrium radionuclide angiography and right heart catheterization and were included. The mean age was 41 +/- 13 years, and 79% of the patients were female. The mean RVEF was 30 +/- 8%. RVEF was directly associated with right ventricular stroke volume index and cardiac index, and inversely associated with pulmonary vascular resistance index from right heart catheterization (all p0.001). Older age and male sex were associated with lower RVEF (p0.05) after adjustment for pulmonary vascular resistance index and left ventricular ejection fraction. Higher plasma von Willebrand factor levels were also independently associated with lower RVEF (p = 0.01) (n = 55). Body size and type of PAH were not associated with RVEF.Older patients and males with PAH had lower RVEF at baseline than younger patients and females, even after controlling for left ventricular function and hemodynamics. Higher plasma von Willebrand factor levels, a marker of endothelial dysfunction, were also associated with lower RVEF.

The role of endovascular therapy for thrombosed dialysis access has grown despite the paucity of data on its viability. The purpose of this study was to characterize the outcomes of a universal endovascular dialysis declot policy at a tertiary medical center. A database of patients undergoing endovascular treatment of thrombosed dialysis access between 1997 and 2003 was maintained. A two-puncture, combined percutaneous mechanical and pharmacologic thrombectomy technique was used. Data were collected on the success rate, complication rate, long-term patency, and presence and location of stenosis. Fistulograms were reviewed in all cases to assess lesion characteristics and pre- and postprocedure results. Results were standardized to current Society of International Radiology and Society for Vascular Surgery criteria. Failure was considered as either an anatomic defect requiring therapy or loss of functionality of the fistula. Life-table analyses were performed to assess time-dependent outcomes. Cox's proportional hazard analyses were performed to identify factors associated with outcomes. Values are the mean +/- standard error of the mean. There were 114 patients (50% male; average age 58 years, range 21-78) who presented with 174 thrombosed grafts. Therapy was performed for 237 thrombotic events (median 2, range 1-5 thrombotic events per hemodialysis access). After successful declot, anastomotic venous stenoses were encountered in 72% and central venous stenoses in 18% of cases; no cause was found in 10%. All stenoses were treated with balloon angioplasty. The technical failure rate was 4.6%. The 30-day all-cause mortality rate was 1.7%, and major morbidity rate was 2.4%. There were 413 interventions (236 percutaneous transluminal angioplasty and/or 183 declot) performed to maintain patency, which amounted to 2.3 interventions per patient. Average primary functional dialysis life span was 6.7 months up to the primary thrombotic event. Aggressive endoluminal therapy added a further average of 12 months of functionality (defined as continued dialysis access). A universal policy of endovascular therapy for occluded dialysis access results in reestablishment of function in the majority of patients and will triple functional longevity. Furthermore, while this approach remains procedure-intensive, it carries low morbidity and mortality and preserves future sites of access.

Le role du traitement endovasculaire des thromboses d'acces pour hemodialyse s'est accru malgre le peu de donnees concernant sa viabilite. Le but de cette etude etait de caracteriser les resultats d'une politique universelle de traitement endovasculaire des thromboses d'acces pour hemodialyse dans un centre medical tertiaire. Une banque de donnees concernant les malades ayant eu le traitement endovasculaire d'un acces pour hemodialyse thrombose entre 1997 et 2003 a ete mise sur pied. Une technique combinee percutanee mecanique et pharmacologique avec deux points de ponction a ete utilisee. Les donnees concernant le taux de succes, le taux de complications, la permeabilite a long terme et la presence et la topographie des stenoses ont ete colligees. Les fistulographies ont ete revues dans tous les cas pour etudier les caracteristiques des lesions et les resultats avant et apres la procedure. Les resultats ont ete standardises conformement aux criteres actuels de la Society of International Radiology et de la Society for Vascular Surgery. L'echec a ete defini comme soit une lesion anatomique necessitant un traitement soit la perte de la fonctionnalite de la fistule. Une analyse actuarielle a ete realisee pour mesurer les resultats dependant du temps. Des analyses des risques proportionnels de Cox ont ete realisees pour identifier les facteurs associes aux resultats. Les valeurs considerees sont la moyenne ± la deviation standard de la moyenne. Il y a eu 114 malades (50% d'hommes, âge moyen 58 ans, extremes 21 et 78 ans) qui se sont presentes avec 174 greffons thromboses. Le traitement a ete realise pour 237 evenements thrombotiques (mediane 2, extremes 1 et 5 evenements thrombotiques par acces pour hemodialyse). Apres thrombectomie avec succes, des stenoses anastomotiques veineuses ont ete observees dans 72% des cas et les stenoses veineuses centrales dans 18% des cas. Aucune cause n'a ete trouvee dans 10% des cas. Toutes les stenoses ont ete traitees par angioplastie par ballonnet. Le taux d'echec technique a ete de 4,6%. Le taux de mortalite de toutes causes a 30 jours a ete de 1,7% et le taux de morbidite majeure a ete 2,4%. Il y a eu 413 interventions (236 angioplasties transluminales percutanees et/ou 183 decaillotages) realisees pour maintenir la permeabilite, ce qui represente 2,3 interventions par malade. La duree moyenne de permeabilite primaire de l'acces pour hemodialyse a ete de 6,7 mois jusqu'au premier evenement thrombotique. Un traitement endoluminal agressif a ajoute une moyenne supplementaire de 12 mois de fonctionnalite (definie comme le maintien de l'acces pour hemodialyse). Une politique universelle de traitement endovasculaire des acces pour hemodialyse occlus a entraine le retablissement de la fonctionnalite chez la majorite des malades et triple la longevite fonctionnelle. De plus, meme si cette approche multiplie les procedures, elle a une faible morbidite et mortalite et preserve les futurs sites d'acces.

Extracorporeal carbon dioxide removal (ECCO2R) may be indicated for refractory status asthmaticus when severe dynamic hyperinflation or life-threatening respiratory acidosis persists despite optimal medical and ventilator management. Most prior reports describe the application of ECCO2R to rapid-onset asthma exacerbation, requiring a short duration of extracorporeal support. We report two patients with refractory status asthmaticus managed with ECCO2R, emphasizing the use of modern extracorporeal technology, cannulation technique and management protocols, which may improve the risk-to-benefit profile of this strategy. This report highlights the challenges in managing patients with distinct asthma exacerbation phenotypes. The potential need for prolonged device support may alter provider expectations and offers a new perspective of the role of ECCO2R for status asthmaticus.

Background Extracorporeal life support technology has gained acceptance as a salvage mode for patients in respiratory or cardiac failure. Patients who are sick enough to require extracorporeal membrane oxygenation (ECMO) support are often too unstable for transfer to a hospital with ECMO capabilities. We highlight the progressive development of an ECMO transport team and the manner in which it provides reliable transport with excellent outcomes. Methods All data were collected retrospectively from our hospital's electronic medical record. Patient outcomes are reported through April 2, 2014. Results Our institution began an ECMO transport program in 2008, with the initial phase involving transport of highly selected patients for short distances. With experience we refined our intake and evaluation process. We also consolidated care for ECMO patients into two intensive care units and developed a dedicated ECMO intensivist position. As the program has matured, patient selection has become more inclusive and we have extended our capabilities to include interstate and international transport. All 100 patients were successfully placed on ECMO and transported to our center. Seventy-nine patients were placed on venovenous ECMO, 19 on venoarterial ECMO, and 2 on venovenous arterial ECMO. The median transport distance was 16 miles and ranged from 2.5 to 7,084 miles. Conclusions Extracorporeal membrane oxygenation transport can be performed safely and reliably with excellent outcomes with a dedicated team that maintains stringent adherence to well-designed management protocols.

Venovenous extracorporeal membrane oxygenation (ECMO) is used for patients with severe, potentially reversible, respiratory failure unresponsive to conventional management. It is relatively contraindicated in patients with traumatic brain injury (TBI) due to bleeding complications and use of anticoagulation. We report two cases of TBI patients treated with ECMO.

Background Extracorporeal membrane oxygenation support (ECMO) typically requires multiple blood transfusions and is associated with frequent bleeding complications. Blood transfusions are known to increase morbidity and mortality in critically ill patients, which may extend to patients receiving ECMO. Aiming to reduce transfusion requirements, we implemented a blood conservation protocol in adults with severe acute respiratory distress syndrome (ARDS) receiving ECMO. Methods This was a retrospective study of adults receiving ECMO for ARDS after initiation of a blood conservation protocol that included a transfusion trigger of hemoglobin of less than 7.0 g/dL, use of low-dose anticoagulation targeting an activated partial thromboplastin time of 40 to 60 seconds, and autotransfusion of circuit blood during decannulation. The primary objective was to evaluate transfusion requirements during ECMO support. Clinical outcomes included survival, neurologic function, renal function, bleeding, and thrombotic complications. Results The analysis included 38 patients; of these, 24 (63.2%) received a transfusion while receiving ECMO. Median hemoglobin was 8.29 g/dL. A median of 1.0 units (range, 250 to 300 mL) was transfused during ECMO support over a median duration of 9.0 days, equivalent to 0.11 U/d (range, 27.5 to 33.3 mL/d). The median activated partial thromboplastin time was 46.5 seconds. Bleeding occurred in 10 patients (26.3%); severe bleeding occurred in 2 patients (5.3%). Twenty-eight patients (73.7%) survived to hospital discharge. Conclusions Implementation of a blood conservation protocol in adults receiving ECMO for ARDS resulted in lower transfusion requirements and bleeding complications than previously reported in the literature and was associated with comparable survival and organ recovery.

Introduction: Critical illness is a well-recognized cause of neuromuscular weakness and impaired physical functioning. Physical therapy (PT) has been demonstrated to be safe and effective for critically ill patients. The impact of such an intervention on patients receiving extracorporeal membrane oxygenation (ECMO) has not been well characterized. We describe the feasibility and impact of active PT on ECMO patients. Methods: We performed a retrospective cohort study of 100 consecutive patients receiving ECMO in the medical intensive care unit of a university hospital. Results: Of the 100 patients receiving ECMO, 35 (35%) participated in active PT; 19 as bridge to transplant and 16 as bridge to recovery. Duration of ECMO was 14.3 ± 10.9 days. Patients received 7.2 ± 6.5 PT sessions while on ECMO. During PT sessions, 18 patients (51%) ambulated (median distance 175 feet, range 4 to 2,800) and 9 patients were on vasopressors. Whilst receiving ECMO, 23 patients were liberated from invasive mechanical ventilation. Of the 16 bridge to recovery patients, 14 (88%) survived to discharge; 10 bridge to transplant patients (53%) survived to transplantation, with 9 (90%) surviving to discharge. Of the 23 survivors, 13 (57%) went directly home, 8 (35%) went to acute rehabilitation, and 2 (9%) went to subacute rehabilitation. There were no PT-related complications. Conclusions: Active PT, including ambulation, can be achieved safely and reliably in ECMO patients when an experienced, multidisciplinary team is utilized. More research is needed to define the barriers to PT and the impact on survival and long-term functional, neurocognitive outcomes in this population.