RESUMEN
There is minimal reported experience with long-range retrieval of pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support. We report the case of a 10-month old boy with necrotizing staphylococcal pneumonia complicated by a bronchopleural fistula, who was successfully retrieved and transported while receiving ECMO to our unit in Sydney, Australia, from a referring hospital 2,000 kilometers away in the Pacific Islands. He was successfully weaned from ECMO to receive single-lung ventilation after 13 days, and he underwent surgical repair of his bronchopleural fistula through a thoracotomy 3 days after decannulation. He has made a full recovery.
Asunto(s)
Fístula Bronquial/cirugía , Oxigenación por Membrana Extracorpórea/métodos , Internacionalidad , Insuficiencia Respiratoria/terapia , Transporte de Pacientes/métodos , Fístula Bronquial/complicaciones , Estudios de Seguimiento , Humanos , Lactante , Masculino , Nueva Gales del Sur , Islas del Pacífico , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/etiología , Índice de Severidad de la Enfermedad , Toracotomía/métodos , Resultado del TratamientoRESUMEN
The occurrence of gaseous microemboli (GME) within the extracorporeal membrane oxygenation circuit is largely overlooked, as are methods to ameliorate this occurrence. We aimed to determine if the air handling capability of the Quadrox D oxygenator was dependent upon whether it was used in conjunction with a centrifugal or roller pump; and if application of a Pall air eliminating filter (AEF) would prevent circuit air introduction from intravenous infusions. Using a blood primed circuit 1 mL of air was infused pre pump. GME were quantified post pump and post oxygenator using the EDAC Quantifier. Trials were conducted at 1 and 2 L/min flow. To prevent GME recirculation a Capiox SX18 was used in circuit with negative pressure applied to its oxygenator; an EDAC cuvette distal to this device quantified GME recirculation. Following air infusion, 3-5 minute data recordings were carried out for each trial. Separate trials were carried out for centrifugal and roller pumps, and for each flow rate. The process was then repeated following the application of the AEF to the air infusion line. More GME were detected post Quadrox D when the centrifugal pump was used in comparison to the roller pump at 1 L/min (p < .05), and 2 L/min (p = .05). A greater volume of air was detected post Quadrox D when used in conjunction with the centrifugal device at 1 L/min (p < or = .05), and 2 L/min (p < or = .05). Application of the AEF resulted in zero GME detected at any circuit location. The results of this study confirm that a greater total count and volume of GME are detected distal to the Quadrox D when used in conjunction with a Rotaflow centrifugal pump. Application of a Pall AEF to infusion and drug lines can prevent air introduction from this source.
Asunto(s)
Oxigenación por Membrana Extracorpórea/instrumentación , Embolia Aérea/prevención & control , Filtración , Técnicas In VitroRESUMEN
Typically, the standard practice for measuring the arterial blood carbon dioxide tension (PaCO2) during cardiopulmonary bypass (CPB) is to take intermittent blood samples for analysis by a bench blood gas analyzer. Continuous inline blood gas monitors are available but are expensive. A potential solution is the capnograph, which was evaluated by determining how accurately the carbon dioxide tension in the oxygenator exhaust gases (PECO2) predicts PaCO2. A standard capnograph monitoring line was attached to the exhaust port of the membrane oxygenator. During CPB, the capnograph reading and arterial blood temperature were recorded at the same time as routine arterial blood gases were taken. One hundred fifty-seven blood samples were collected from 78 patients. A good correlation was found between the PECO2 and the temperature corrected PaCO2 (r2 = 0.833, P < .001). There was also a reasonable degree of agreement between the PECO2 and the temperature corrected PaCO2 during all phases of CPB: accuracy (bias or mean difference between PaCO2 and PECO2) of -1.2 mmHg; precision (95% limits of agreement) of +/- 4.7 mmHg. These results suggest that oxygenator exhaust capnography may be a simple and inexpensive adjunct to the bench blood gas analyzer in continuously estimating PaCO2 of a clinically useful degree of accuracy during CPB.
Asunto(s)
Capnografía/métodos , Dióxido de Carbono/sangre , Puente Cardiopulmonar , Oxigenación por Membrana Extracorpórea/instrumentación , Oxigenadores de Membrana , Adulto , Australia , Análisis de los Gases de la Sangre/métodos , Humanos , Estudios Prospectivos , Método Simple CiegoRESUMEN
There has been a proliferation in the number of coronary artery bypass grafts (CABG) being performed without the use of cardiopulmonary bypass (CPB). However, the benefits of off-pump coronary artery grafting (OPCAB) are still being determined. The aim of this retrospective review was to compare the perioperative outcomes of CPB patients with OPCAB patients and to identify the patients most likely to benefit from the off-pump procedure. We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period of August 2000 to September 2001. The two groups (OPCAB vs. CPB) were further divided into subgroups identifying patients by their predicted mortality (higher-risk and lower-risk) and the number of distal graft anastomoses received (1, 2, 3, 4, or 5). A p value less than .05 was considered significant. Out of the total of 882 patients, 46.2% were OPCAB cases. Both CPB and OPCAB groups were similar in terms of demographics and predicted risk of mortality. Intraoperatively, OPCAB patients had fewer distal graft anastomoses (2.4 +/- 1.0 vs. 3.2 +/- 1.0, p < .001). Postoperatively, patients in the OPCAB group had less chest drainage (889 +/- 588 vs. 989 +/- 662 mls, p < .001), sustained fewer strokes (0.2 vs. 1.9%, p < .05), were transfused less (15.4 vs. 32.5%, p < .001) and were discharged earlier (7.3 +/- 5.6 vs. 8.5 +/- 9.1 days, p < .05). For higher-risk patients, OPCAB was associated with fewer reoperations for bleeding (1.3 vs. 6.4%, p < .05), a lower stroke rate (0 vs. 3.2%, p < .05), and a trend toward lower mortality (7.1 vs. 15.1%, p = .08). However, lower-risk OPCAB patients' stroke incidences (0.5% OPCAB group vs. 1.4% CPB group), and mortality rates (0.5 vs. 0.5%) were similar. Comparisons by number of grafts performed revealed that only the single-grafted OPCAB patients had statistically fewer postoperative complications, reduced chest drainage, and a shorter intensive care stay. Differences between either operation groups in transfusion rates were only statistically significant for the one to three grafted patients, while postoperative stays were similar for patients having four grafts. These results suggest that OPCAB is associated with a reduction in mortality and morbidity, particularly within the higher-risk patients. However, the benefits of OPCAB diminished with an increasing number of distal anastomoses performed.