Browsing by Subject "extracorporeal membrane oxygenation"

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    Antifungal Prophylaxis for Adult Recipients of Veno-Venous Extracorporeal Membrane Oxygenation: A Cautionary Stance During the COVID-19 Pandemic
    (Wolters Kluwer, 2021-03) Epelbaum, Oleg; Carmona, Eva M.; Evans, Scott E.; Hage, Chadi A.; Jarrett, Benjamin; Knox, Kenneth S.; Limper, Andrew H.; Pennington, Kelly M.; Medicine, School of Medicine
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    Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2—pediatric patients
    (Elsevier, 2019) Lorusso, Roberto; Raffa, Giuseppe Maria; Kowalewski, Mariusz; Alenizy, Khalid; Sluijpers, Niels; Makhoul, Maged; Brodie, Daniel; McMullan, Mike; Wang, I-Wen; Meani, Paolo; MacLaren, Graeme; Dalton, Heidi; Barbaro, Ryan; Hou, Xaotong; Cavarocchi, Nicholas; Chen, Yih-Sharng; Thiagarajan, Ravi; Alexander, Peta; Alsoufi, Bahaaldin; Bermudez, Christian A.; Shah, Ashish S.; Haft, Jonathan; Oreto, Lilia; D’Alessandro, David A.; Boeken, Udo; Whitman, Glenn; Surgery, School of Medicine
    Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.
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    The Heparin-Antithrombin Product: A Novel Value for Pediatric Extracorporeal Anticoagulation
    (EDP Sciences, 2022-06) Rogerson, Colin M.; Hobson, Michael J.; Pediatrics, School of Medicine
    Hematologic complications are a source of morbidity and mortality for patients receiving extracorporeal membrane oxygenation (ECMO) support. There is no consensus strategy for monitoring anticoagulation for children supported with ECMO. This study evaluated a novel measurement of anticoagulation for children on ECMO. This was a single-center observational study of children supported with ECMO from 2015 to 2020. Each patient’s current unfractionated heparin dose was multiplied by the current antithrombin III (AT) level to obtain a novel anticoagulation value, the heparin-antithrombin product (HAP). This value was compared with the heparin dose, AT, and activated clotting time (ACT) to predict anti-Xa value using linear correlation and decision tree methods. Data were obtained from 128 patients supported with ECMO. The HAP value was more highly correlated with anti-Xa level than heparin dose, AT level, and ACT. This correlation was highest in the neonatal population (r = .7). The variable importance metrics from the regression tree and random forest models both identified the HAP value as the most influential predictor variable for anti-Xa value. The HAP value is more highly correlated with the anti-Xa level than heparin dose, AT level, or ACT. Further research is needed to evaluate the effectiveness of the HAP value as a measurement of anticoagulation for children on ECMO.
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    Ventilation Strategies during Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches among Level IV Neonatal ICUs
    (Wolters Kluwer, 2022-11) Ibrahim, John; Mahmood, Burhan; DiGeronimo, Robert; Rintoul, Natalie E.; Hamrick, Shannon E.; Chapman, Rachel; Keene, Sarah; Seabrook, Ruth B.; Billimoria, Zeenia; Rao, Rakesh; Daniel, John; Cleary, John; Sullivan, Kevin; Gray, Brian; Weems, Mark; Dirnberger, Daniel R.; Surgery, School of Medicine
    OBJECTIVES: To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). DESIGN: Cross-sectional electronic survey. SETTING: Email-based Research Electronic Data Capture survey. PATIENTS: Neonates undergoing ECMO for respiratory failure at level IV NICUs. INTERVENTIONS: A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children’s Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. MEASUREMENTS AND MAIN RESULTS: Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16–20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9–10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10–15 (60%), and Fio2 22–30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6–7 (45%), PIP of 21–25 (55%), and tidal volume 5–5.9 mL/kg (50%). CONCLUSIONS: The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients.
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    What Should We Learn From Early Hemodialysis Allocation About How We Should Be Using ECMO?
    (AMA, 2019-05) Gutteridge, Daniel; bosslet, Gabriel T.; Medicine, School of Medicine
    Early hemodialysis allocation deliberations should inform our current considerations of what constitutes reasonable uses of extracorporeal membrane oxygenation. Deliberative democracy can be used as a strategy to gather a plurality of views, consider criteria, and guide policy making.