The Journal of extra-corporeal technology
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J Extra Corpor Technol · Mar 2011
Extracorporeal membrane oxygenation--understanding the evidence: CESAR and beyond.
Extracorporeal membrane oxygenation (ECMO) has been used for nearly 40 years for treating life threatening respiratory failure. Two historic randomized trials in adults, conducted using outdated techniques, did not show a survival advantage. However, recent case series and a large randomized controlled trial have demonstrated good outcomes from ECMO in adults. ⋯ Treatments such as ECMO are extremely difficult to assess by randomized controlled trials. Observational data demonstrate excellent results from ECMO for treating patients with life threatening respiratory failure caused by pandemic H1N1 influenza, and have greatly influenced practice in Australia and New Zealand. Used as part of a multi-modal approach to treating acute respiratory failure in adults, ECMO is an important, potentially life saving, technique.
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J Extra Corpor Technol · Mar 2011
Thrombography reveals thrombin generation potential continues to deteriorate following cardiopulmonary bypass surgery despite adequate hemostasis.
The intrinsic and extrinsic activation pathways of the hemostatic system converge when prothrombin is converted to thrombin. The ability to generate an adequate thrombin burst is the most central aspect of the coagulation cascade. The thrombin-generating potential in patients following cardiopulmonary bypass (CPB) may be indicative of their hemostatic status. ⋯ Transfusions received, conventional blood coagulation testing results, and blood loss volumes are also presented. Despite adequate hemostasis, thrombography reveals an underlying coagulopathic process that could put some cardiac surgical patients at risk for postoperative bleeding. Thrombography is a novel technique that could be developed into a useful tool for perfusionists and physicians to identify coagulopathies and optimize blood management following CPB.
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J Extra Corpor Technol · Mar 2011
Review Case ReportsHeparin-induced thrombocytopenia and extracorporeal membrane oxygenation: a case report and review of the literature.
Heparin-induced thrombocytopenia (HIT) is an immune-mediated coagulation side effect of heparin therapy characterized by thrombocytopenia and by a paradoxical prothrombotic state following heparin exposure when thrombotic or thromboembolic events accurse, the condition is classified as Heparin-induced thrombocytopenia with thrombosis (HITT). We report a case of HITT with evidence of small-vessel arterial thrombosis in a 5-day-old newborn receiving extracorporeal membrane oxygenation (ECMO) for congenital diaphragmatic hernia, and our attempt of bivalirudin alternative treatment. We also review previous reports regarding HIT and ECMO with the alternative management in this unique population.
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The current literature pertaining to associated morbidity and mortality with homologous blood transfusion in the surgical patient seems to be pointing only in one direction, which is we must start reducing our patients exposure to homologous blood and products. There appears to be ever mounting evidence of increases in infraction, stroke, transfusion related lung injury, infection, and death that authors are associating with transfusion. ⋯ At our institution we have taken note of these reports and have taken the first steps in the formation of a Cardiac Surgical Transfusion Management Group where all specialties involved in the decision making process of transfusion in the cardiac surgical patient can have representation and be directly involved in the establishment of protocols, transfusion algorithms, and a transfusion audit system. The main goal of this group is to implement a change in transfusion practice and to assess the impact the change has had on transfusion requirements and make appropriate recommendations to the treating specialists.
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J Extra Corpor Technol · Mar 2011
Human error in medicine: change in cardiac operating rooms through the FOCUS initiative.
Human error in medicine is a significant cause of patient mortality. While there has been increased attention to safety in medicine since the Institute of Medicine publication To Err is Human, the profession at large has not progressed to the same degree as other highly complex industries such as aviation and nuclear power. The Flawless Operative Cardiovascular Unified Systems initiative (FOCUS) is a multi-year study/intervention to learn about and to improve human error in cardiac surgery. ⋯ FOCUS is an initiative to change practice driven by science. Interventions based upon the observations already underway include efforts to decrease infection, adoption of the aviation concept of the "sterile cockpit", briefing and debriefing, reduction of drug error, and peer-to-peer assessment. The first FOCUS data is sobering and shows tremendous possibility for improvement.