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• W2944692123 abstract "Extracorporeal membrane oxygenation (ECMO) is a potentially lifesaving therapy for patients with pulmonary or cardiopulmonary failure. Although its use has increased tremendously in recent years,1Raiten J.M. Ko H. Gutsche J.T. Eliminating neurologic complications of extracorporeal membrane oxygenation—A multifaceted challenge.J Cardiothorac Vasc Anesth. 2017; 31: 1847-1848Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar its rapid expansion into the mainstream has generated as many questions about best practices and management strategies as it has answers. Extracorporeal membrane oxygenation has shown itself to be a tour de force in the clinical realm, not only saving lives, but also affecting virtually every medical service in the hospital in the process. In their article “Perioperative Anesthetic and Transfusion Management of Veno-Venous Extracorporeal Membrane Oxygenation Patients Undergoing Noncardiac Surgery: A Case Series of 21 Procedures,”2Fierro M.A. Dunne B. Manning M.W. et al.Perioperative anesthetic and transfusion management of veno-venous extracorporeal membrane oxygenation patients undergoing noncardiac surgery: A case series of 21 procedures.J Cardiothorac Vasc Anesth. 2019; (in press)Abstract Full Text Full Text PDF Scopus (3) Google Scholar Fierro and colleagues not only shed light on intraoperative management strategies for ECMO patients undergoing noncardiac surgery, but also in the process expose the vast impact ECMO patients have on the hospital system in general. Extracorporeal membrane oxygenation is an invasive procedure, and by definition patients receiving it are in critical condition and often suffer from multiorgan system failure. Its indications have expanded beyond traditional cardiac and cardiopulmonary failure to include burn victims,3Burke C.R. Chan T. McMullan D.M. Extracorporeal life support use in adult burn patients.J Burn Care Res. 2017; 38: 174-178Crossref PubMed Scopus (15) Google Scholar trauma patients,4Bosarge P.L. Raff L.A. McGwin Jr G. et al.Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome.J Trauma Acute Care Surg. 2016; 81: 236-243Crossref PubMed Scopus (51) Google Scholar and use as a bridge to lung transplantation.5Hayanga A.J. Aboagye J. Esper S. et al.Extracorporeal membrane oxygenation as a bridge to lung transplantation in the United States: An evolving strategy in the management of rapidly advancing pulmonary disease.J Thorac Cardiovasc Surg. 2015; 149: 291-296Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar Given the high acuity of the patients, it comes as no surprise that many patients require a noncardiac surgical procedure while on ECMO. In their review, Fierro and colleagues note that 14 patients underwent a total of 21 noncardiac procedures while on venovenous ECMO.2Fierro M.A. Dunne B. Manning M.W. et al.Perioperative anesthetic and transfusion management of veno-venous extracorporeal membrane oxygenation patients undergoing noncardiac surgery: A case series of 21 procedures.J Cardiothorac Vasc Anesth. 2019; (in press)Abstract Full Text Full Text PDF Scopus (3) Google Scholar A review of the authors’ own data of patients on venovenous ECMO at the University of Pennsylvania demonstrates a range of surgical procedures have been performed in this patient population, ranging from tracheostomy to intra-abdominal procedures to cannula site exploration for bleeding. Although the rate of ECMO utilization has increased rapidly, establishment of best practices for managing these patients lags behind, both in routine management of anticoagulation and transfusion,6Raiten J.M. Wong Z.Z. Spelde A. et al.Anticoagulation and transfusion therapy in patients requiring extracorporeal membrane oxygenation.J Cardiothorac Vasc Anesth. 2017; 31: 1051-1059Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar as well as in more unique situations such as intraoperative management. Fierro's paper nicely illustrates this lack of consensus, with a fairly large discrepancy in the fundamental anesthetic type that was used (71% of patients received an inhalational anesthetic).2Fierro M.A. Dunne B. Manning M.W. et al.Perioperative anesthetic and transfusion management of veno-venous extracorporeal membrane oxygenation patients undergoing noncardiac surgery: A case series of 21 procedures.J Cardiothorac Vasc Anesth. 2019; (in press)Abstract Full Text Full Text PDF Scopus (3) Google Scholar At the University of Pennsylvania, the use of intravenous anesthesia is more common than volatile anesthetics in this situation. There are gaps in understanding of drug pharmacokinetics in the presence of an ECMO circuit,7Shah A.G. Peahota M. Thoma B.N. et al.medication complications in extracorporeal membrane oxygenation.Crit Care Clin. 2017; 33: 897-920Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar making the ideal anesthetic while on ECMO uncertain. Likewise, Fierro and colleagues’ paper demonstrated considerable variation in management of the ventilator during surgery, potentially contributing to more than half of patients experiencing an undesirable increase in peak airway pressures intraoperatively. An expanding body of literature on all aspects of ECMO management eventually will dictate a more evidence-based approach to management, both in the intensive care unit and during inevitable surgical interventions. And although there are clearly defined areas where further research and knowledge is needed, such as transfusion and anticoagulation strategies, the old adage that it “takes a village” holds especially true for the ECMO patient population, whose care touches virtually every department in the hospital, and requires not only a high level of clinical competency, but also a large amount of staff, resources, and money.8Mishra V. Svennevig J.L. Bugge J.F. et al.Cost of extracorporeal membrane oxygenation: Evidence from the Rikshospitalet University Hospital, Oslo, Norway.Eur J Cardiothorac Surg. 2010; 37: 339-342Crossref PubMed Scopus (3) Google Scholar The financial costs of ECMO can be considerable, with an ECMO procedure costing more than $70,000 and a total hospital course for a patient requiring ECMO exceeding $200,000.9Ratnani I. Tuazon D. Zainab A. et al.The role and impact of extracorporeal membrane oxygenation in critical care.Methodist Debakey Cardiovasc J. 2018; 14: 110-119Crossref PubMed Scopus (30) Google Scholar Fierro observed that 14 patients on venovenous ECMO underwent 21 noncardiac surgical procedures, and other studies have corroborated the frequent surgical intervention requirements in the ECMO population.10Taghavi S. Jayarajan S.N. Mangi A.A. et al.Examining noncardiac surgical procedures in patients on extracorporeal membrane oxygenation.ASAIO J. 2015; 61: 520-525Crossref PubMed Scopus (20) Google Scholar Virtually every surgery for a patient on ECMO requires a perfusionist, an anesthesiologist with expertise in ECMO (usually trained in critical care or cardiac anesthesia), and the immediate availability of blood products. The need for a surgical intervention often is recognized first by the results of a computed tomography scan or other imaging modality, which usually requires perfusion, a robust team of nurses and respiratory therapists to facilitate transport of the patient to the scanner, or a portable computed tomography machine if the patient is too unstable for transport. Such demands may be difficult for a hospital's resources to absorb and, as they did at Emory University, may lead to surgical case cancellation and dissatisfaction among providers, patients, and hospital administrators.11Moll V. Teo E.Y. Grenda D.S. et al.Rapid development and implementation of an ECMO program.ASAIO J. 2016; 62: 354-358Crossref PubMed Scopus (22) Google Scholar At Penn Presbyterian Medical Center in Philadelphia, the initiation of a venovenous ECMO program has increased the demands significantly not only on perfusion, but also on other services that are integral to the care of critically ill patients, such as the nephrology service to manage renal replacement therapy. Extracorporeal membrane oxygenation is truly a lifesaving therapy that is being embraced by an increasing number of hospitals, and arguably becoming a standard of care for some patients.12Butt W. MacLaren G. Extracorporeal membrane oxygenation 2016: An update.F1000Res. 2016; 26: 5Google Scholar As physicians and ECMO teams increase their experience and comfort with managing these challenging patients, we should expect the number of patients being placed on ECMO to rise. The consideration of an increasingly acute patient population as eligible for ECMO will lead to a greater number of patients and opportunities to learn, improve, and standardize management of this patient population. Bleeding is one of the most common complications on both venovenous and venoarterial ECMO.13Aubron C. Cheng A.C. Pilcher D. et al.Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: A 5-year cohort study.Crit Care. 2013; 17: R73Crossref PubMed Scopus (227) Google Scholar This is an area of intense research, and one where improved technology and strategy may positively affect patient outcome and also reduce the need for surgical intervention, blood bank, and hospital personnel resources. Fierro and colleagues’ study clearly shows the need for further research and establishment of best practices for intraoperative management of patients on ECMO. Similarly, increasing patient numbers and the wide breath of specialists caring for ECMO patients will allow establishment of best practices in other aspects of care, from when to initiate renal replacement therapy to improved equipment, sedation strategies, and risk and prognostication tools to better assess who will benefit most from this lifesaving therapy. Perioperative Anesthetic and Transfusion Management of Veno-Venous Extracorporeal Membrane Oxygenation Patients Undergoing Noncardiac Surgery: A Case Series of 21 ProceduresJournal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 7PreviewTo analyze the perioperative management of veno-venous extracorporeal membrane oxygenation (VV ECMO) in patients undergoing major noncardiac surgical procedures, which is poorly described in the literature. In doing so, perioperative challenges related to hemodynamic instability, impaired gas exchange, bleeding, and coagulopathy will be quantified. Full-Text PDF" @default.
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• W2944692123 title "Establishing Best Practices for Patients on ECMO—A Multidisciplinary Challenge" @default.
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