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Suero OR, Valluri SK, Farias-Kovac MH, Simpson L, Loor G, Guerra DM, Diaz-Gomez JL, Chatterjee S. Recovery of Lung Function After 149 Days on Extracorporeal Membrane Oxygenation for COVID-19. Tex Heart Inst J 2023; 50:e238132. [PMID: 37876039 PMCID: PMC10658157 DOI: 10.14503/thij-23-8132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
This report highlights survival and the patient's perspective after prolonged venovenous extracorporeal membrane oxygenation (ECMO) for COVID-19-related respiratory failure. A 36-year-old man with COVID-19 presented with fever, anosmia, and hypoxia. After respiratory deterioration necessitating intubation and lung-protective ventilation, he was referred for ECMO. After 3 days of conventional venovenous ECMO, he required multiple creative cannulation configurations. Adequate sedation and recurrent bradycardia were persistent challenges. After 149 consecutive days of ECMO, he recovered native lung function and was weaned from mechanical ventilation. This represents the longest-duration ECMO support in a survivor of COVID-19 yet reported. Necessary strategies included unconventional cannulation and flexible anticoagulation.
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Affiliation(s)
- Orlando R. Suero
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Anesthesiology, The Texas Heart Institute, Houston, Texas
| | - Sri Kartik Valluri
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Division of Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Mario H. Farias-Kovac
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Anesthesiology, The Texas Heart Institute, Houston, Texas
| | - Leo Simpson
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Diana M. Guerra
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Anesthesiology, The Texas Heart Institute, Houston, Texas
| | - Jose L. Diaz-Gomez
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Anesthesiology, The Texas Heart Institute, Houston, Texas
| | - Subhasis Chatterjee
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
- Division of Trauma and Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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2
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Gurnani PK, Barlow B, Boling B, Busse LW, Diaz-Gomez JL, Ford J, Gibson GA, Khanna AK, Lee JS, Rivosecchi RM, Spezzano KM, Thornton N, Vallabhajosyula S, Witenko CJ, Wieruszewski PM. Major Publications in the Critical Care Pharmacotherapy Literature: 2022. Crit Care Explor 2023; 5:e0981. [PMID: 37753239 PMCID: PMC10519466 DOI: 10.1097/cce.0000000000000981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVES A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022. DATA SOURCES PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. STUDY SELECTION Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article. DATA EXTRACTION Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature. DATA SYNTHESIS The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia. CONCLUSIONS This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.
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Affiliation(s)
- Payal K Gurnani
- Department of Pharmacy, Memorial Hermann The Woodlands Medical Center, The Woodlands, TX
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann The Woodlands Medical Center, The Woodlands, TX
| | - Bryan Boling
- Department of Anesthesiology, Division of Critical Care Medicine, University of Kentucky, Lexington, KY
| | | | - Jose L Diaz-Gomez
- Department of Anesthesiology and Critical Care Medicine, Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Jenna Ford
- Department of Neurology, University of Florida, Gainesville, FL
| | | | - Ashish K Khanna
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | | | - Nathan Thornton
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Saraschandra Vallabhajosyula
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Corey J Witenko
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY
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3
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Akkanti B, Suarez EE, O'Neil ER, Rali AS, Hussain R, Dinh K, Tuazon DM, MacGillivray TE, Diaz-Gomez JL, Simpson L, George JK, Kar B, Herlihy JP, Shafii AE, Gregoric ID, Masud F, Chatterjee S. Extracorporeal Membrane Oxygenation for COVID-19: Collaborative Experience From the Texas Medical Center in Houston With 2 Years Follow-Up. ASAIO J 2022; 68:1443-1449. [PMID: 36150083 DOI: 10.1097/mat.0000000000001791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Patients with severe refractory hypoxemic respiratory failure may benefit from extracorporeal membrane oxygenation (ECMO) for salvage therapy. The Coronavirus disease 2019 (COVID-19) pandemic offered three high-volume independent ECMO programs at a large medical center the chance to collaborate to optimize ECMO care at the beginning of the pandemic in Spring 2020. Between March 15, 2020, and May 30, 2020, 3,615 inpatients with COVID-19 were treated at the Texas Medical Center. During this time, 35 COVID-19 patients were cannulated for ECMO, all but one in a veno-venous configuration. At hospital discharge, 23 (66%) of the 35 patients were alive. Twelve patients died of vasodilatory shock (n = 9), intracranial hemorrhage (n = 2), and cannulation-related bleeding and multiorgan dysfunction (n = 1). The average duration of ECMO was 13.6 days in survivors and 25.0 days in nonsurvivors ( p < 0.04). At 1 year follow-up, all 23 discharged patients were still alive, making the 1 year survival rate 66% (23/35). At 2 years follow-up, the overall rate of survival was 63% (22/35). Of those patients who survived 2 years, all were at home and alive and well at follow-up.
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Affiliation(s)
- Bindu Akkanti
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Erik E Suarez
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Erika R O'Neil
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Department of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Aniket S Rali
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Rahat Hussain
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Kha Dinh
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Divina M Tuazon
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas
| | | | - Jose L Diaz-Gomez
- Department of Anesthesia, Division of CV Anesthesia & Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Leo Simpson
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Joggy K George
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Biswajit Kar
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - J Patrick Herlihy
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Alexis E Shafii
- Department of Cardiovascular Surgery, Baylor St. Luke's Medical Center-Texas Medical Center, Houston, Texas
| | - Igor D Gregoric
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Faisal Masud
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Subhasis Chatterjee
- Department of Cardiovascular Surgery, Baylor St. Luke's Medical Center-Texas Medical Center, Houston, Texas
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
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Bughrara N, Pustavoitau A, Diaz-Gomez JL. In reply: The value of subcostal echocardiographic assessment and directions for future research. Can J Anaesth 2022; 69:678-679. [DOI: 10.1007/s12630-022-02226-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 10/19/2022] Open
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5
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Asch FM, Mor-Avi V, Rubenson D, Goldstein S, Saric M, Mikati I, Surette S, Chaudhry A, Poilvert N, Hong H, Horowitz R, Park D, Diaz-Gomez JL, Boesch B, Nikravan S, Liu RB, Philips C, Thomas JD, Martin RP, Lang RM. Deep Learning-Based Automated Echocardiographic Quantification of Left Ventricular Ejection Fraction: A Point-of-Care Solution. Circ Cardiovasc Imaging 2021; 14:e012293. [PMID: 34126754 DOI: 10.1161/circimaging.120.012293] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We have recently tested an automated machine-learning algorithm that quantifies left ventricular (LV) ejection fraction (EF) from guidelines-recommended apical views. However, in the point-of-care (POC) setting, apical 2-chamber views are often difficult to obtain, limiting the usefulness of this approach. Since most POC physicians often rely on visual assessment of apical 4-chamber and parasternal long-axis views, our algorithm was adapted to use either one of these 3 views or any combination. This study aimed to (1) test the accuracy of these automated estimates; (2) determine whether they could be used to accurately classify LV function. METHODS Reference EF was obtained using conventional biplane measurements by experienced echocardiographers. In protocol 1, we used echocardiographic images from 166 clinical examinations. Both automated and reference EF values were used to categorize LV function as hyperdynamic (EF>73%), normal (53%-73%), mildly-to-moderately (30%-52%), or severely reduced (<30%). Additionally, LV function was visually estimated for each view by 10 experienced physicians. Accuracy of the detection of reduced LV function (EF<53%) by the automated classification and physicians' interpretation was assessed against the reference classification. In protocol 2, we tested the new machine-learning algorithm in the POC setting on images acquired by nurses using a portable imaging system. RESULTS Protocol 1: the agreement with the reference EF values was good (intraclass correlation, 0.86-0.95), with biases <2%. Machine-learning classification of LV function showed similar accuracy to that by physicians in most views, with only 10% to 15% cases where it was less accurate. Protocol 2: the agreement with the reference values was excellent (intraclass correlation=0.84) with a minimal bias of 2.5±6.4%. CONCLUSIONS The new machine-learning algorithm allows accurate automated evaluation of LV function from echocardiographic views commonly used in the POC setting. This approach will enable more POC personnel to accurately assess LV function.
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Affiliation(s)
| | | | - David Rubenson
- Scripps Clinic and Prebys Cardiovascular Institute, La Jolla, CA (D.R.)
| | | | | | - Issam Mikati
- Feinberg School of Medicine, Northwestern University, Chicago, IL (I.M., R.H., J.D.T.)
| | - Samuel Surette
- Caption Health Inc, San Francisco, CA (S.S., A.C., N.P., H.H., R.P.M.)
| | - Ali Chaudhry
- Caption Health Inc, San Francisco, CA (S.S., A.C., N.P., H.H., R.P.M.)
| | - Nicolas Poilvert
- Caption Health Inc, San Francisco, CA (S.S., A.C., N.P., H.H., R.P.M.)
| | - Ha Hong
- Caption Health Inc, San Francisco, CA (S.S., A.C., N.P., H.H., R.P.M.)
| | - Russ Horowitz
- Feinberg School of Medicine, Northwestern University, Chicago, IL (I.M., R.H., J.D.T.)
| | - Daniel Park
- University of North Carolina Medical Center (D.P)
| | | | | | - Sara Nikravan
- University of Washington Medical Center, Seattle (S.N.)
| | | | | | - James D Thomas
- Feinberg School of Medicine, Northwestern University, Chicago, IL (I.M., R.H., J.D.T.)
| | - Randolph P Martin
- Caption Health Inc, San Francisco, CA (S.S., A.C., N.P., H.H., R.P.M.).,Emory University Medical Center, Atlanta, GA (R.P.M.)
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6
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Rali AS, Taylor Z, George J, Trevino S, Diaz-Gomez JL. Refractory Hypoxemia Despite Extracorporeal Membrane Oxygenation: Point-of-Care Ultrasound Is Needed for Patients With COVID-19. Chest 2021; 159:e289-e291. [PMID: 34022034 PMCID: PMC8021944 DOI: 10.1016/j.chest.2020.08.2138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Aniket S Rali
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Baylor College of Medicine, Houston, TX.
| | - Zachary Taylor
- Division of Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | | | - Sergio Trevino
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Baylor College of Medicine, Houston, TX
| | - Jose L Diaz-Gomez
- Division of Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX
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7
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Wiegers SE, Ryan T, Arrighi JA, Brown SM, Canaday B, Damp JB, Diaz-Gomez JL, Figueredo VM, Garcia MJ, Gillam LD, Griffin BP, Kirkpatrick JN, Klarich KW, Lui GK, Maffett S, Naqvi TZ, Patel AR, Poulin MF, Rose GA, Swaminathan M, Arrighi JA, Mendes LA, Adams JE, Brush JE, Dec GW, Denktas A, Fernandes S, Freeman R, Hahn RT, Halperin JL, Housholder-Hughes SD, Khan SS, Klarich KW, Lin CH, Marine JE, McPherson JA, Niazi K, Ryan T, Solomon MA, Spicer RL, Tam M, Wang A, Weissman G, Weitz HH, Williams ES. 2019 ACC/AHA/ASE Advanced Training Statement on Echocardiography (Revision of the 2003 ACC/AHA Clinical Competence Statement on Echocardiography): A Report of the ACC Competency Management Committee. J Am Soc Echocardiogr 2020; 32:919-943. [PMID: 31378259 DOI: 10.1016/j.echo.2019.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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8
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Bughrara N, Diaz-Gomez JL, Pustavoitau A. Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation. Anesthesiol Clin 2020; 38:123-134. [PMID: 32008647 DOI: 10.1016/j.anclin.2019.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.
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Affiliation(s)
- Nibras Bughrara
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA.
| | - Jose L Diaz-Gomez
- Cardiovascular Critical Care, Professional Development, Education, and Clinical Research, Critical Care Medicine, Division of Cardiovascular Anesthesia, Texas Heart Institute - Baylor St. Luke's Medical Center, 6720 Bertner Avenue, Suite 0-520, Houston, TX 77030, USA; Critical Care Echocardiography and Point of Care Ultrasound, Baylor College of Medicine, Houston, TX, USA
| | - Aliaksei Pustavoitau
- Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 297, Baltimore, MD 21287, USA
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Chaudhuri D, Herritt B, Lewis K, Diaz-Gomez JL, Fox-Robichaud A, Ball I, Granton J, Rochwerg B. Dosing Fluids in Early Septic Shock. Chest 2020; 159:1493-1502. [PMID: 33058814 DOI: 10.1016/j.chest.2020.09.269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/15/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022] Open
Abstract
Early IV fluid administration remains one of the modern pillars of sepsis treatment; however, questions regarding amount, type, rate, mechanism of action, and even the benefits of fluid remain unanswered. Administering the optimal fluid volume is important, because overzealous fluid resuscitation can precipitate multiorgan failure, prolong mechanical ventilation, and worsen patient outcomes. After the initial resuscitation, further fluid administration should be determined by individual patient factors and measures of fluid responsiveness. This review describes various static and dynamic measures that are used to assess fluid responsiveness and summarizes the evidence addressing these metrics. Subsequently, we outline a practical approach to the evaluation of fluid responsiveness in early septic shock and explore further areas crucial to ongoing research examining this topic.
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Affiliation(s)
- Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Brent Herritt
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jose L Diaz-Gomez
- Division of Cardiovascular Anesthesiology and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Alison Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Ottawa, ON, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John Granton
- Division of Respirology, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
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10
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Prada G, Vieillard-Baron A, Martin AK, Hernandez A, Mookadam F, Ramakrishna H, Diaz-Gomez JL. Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth 2019; 35:310-322. [PMID: 31883769 DOI: 10.1053/j.jvca.2019.11.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 11/11/2022]
Abstract
Today, proficiency in cardiopulmonary ultrasound is considered essential for anesthesiologists and critical care physicians. Conventional 2-dimensional images, however, do not permit optimal characterization of specific conditions (eg, diaphragmatic paralysis, major atelectasis, and pneumothorax) that may have relevant clinical implications in critical care and perioperative settings. By contrast, M-mode (motion-based) ultrasonographic imaging modality offers the highest temporal resolution in ultrasonography; this modality, therefore, can provide important information in ultrasound-driven approaches performed by anesthesiologists and intensivists for diagnosis, monitoring, and procedural guidance. Despite its practicability, M-mode has been progressively abandoned in echocardiography and is often underused in lung and diaphragmatic ultrasound. This review describes contemporary applications of M-mode ultrasonography in the practice of critical care and perioperative medicine. Information presented for each clinical application includes image acquisition and interpretation, evidence-based clinical implications in critically ill and surgical patients, and main limitations. The article focuses on tracheal, lung, and diaphragmatic ultrasound. It reviews tracheal ultrasound for procedural guidance during endotracheal intubation, confirmation of correct tube placement, and detection of esophageal intubation; lung ultrasound for the confirmation of endotracheal and endobronchial (selective) intubation and for the diagnosis of pneumothorax, alveolar-interstitial syndrome (cardiogenic v noncardiogenic pulmonary edema), pulmonary consolidation (pneumonia v major atelectasis) and pleural effusion; and diaphragmatic ultrasound for the diagnosis of diaphragmatic dysfunction and prediction of extubation success.
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Affiliation(s)
- Gabriel Prada
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne Billancourt, France; Faculty of Medicine Paris Ile de France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint Quentin En Yvelines, France; INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Phoenix, AZ.
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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11
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Kwon M, Debella YT, Moss JE, Paniagua O, Diaz-Gomez JL. A 59-Year-Old Man in Refractory Shock. Chest 2019; 154:e93-e96. [PMID: 30290954 DOI: 10.1016/j.chest.2018.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/29/2018] [Accepted: 04/14/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Minkyung Kwon
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Yalew T Debella
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - John E Moss
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Olga Paniagua
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
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12
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Wiegers SE, Ryan T, Arrighi JA, Brown SM, Canaday B, Damp JB, Diaz-Gomez JL, Figueredo VM, Garcia MJ, Gillam LD, Griffin BP, Kirkpatrick JN, Klarich KW, Lui GK, Maffett S, Naqvi TZ, Patel AR, Poulin MF, Rose GA, Swaminathan M. 2019 ACC/AHA/ASE Advanced Training Statement on Echocardiography (Revision of the 2003 ACC/AHA Clinical Competence Statement on Echocardiography): A Report of the ACC Competency Management Committee. Circ Cardiovasc Imaging 2019. [DOI: 10.1161/hci.0000000000000026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Builes-Aguilar A, Diaz-Gomez JL, Bilotta F. Education in neuroanesthesia and neurocritical care: trends, challenges and advancements. Curr Opin Anaesthesiol 2019; 31:520-525. [PMID: 29994944 DOI: 10.1097/aco.0000000000000628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees. RECENT FINDINGS Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises. SUMMARY High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies.
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Affiliation(s)
- Angela Builes-Aguilar
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine.,Department of Anesthesiology.,Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy
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Martin AK, Allen WL, Fritz AV, Diaz-Gomez JL. Successful Rescue Utilization of Intraoperative Tissue Plasminogen Activator in the Setting of Massive Thrombosis of Avalon Catheter and Patient in Extremis with Refractory Hypoxemia. J Cardiothorac Vasc Anesth 2018; 32:2278-2281. [DOI: 10.1053/j.jvca.2017.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Indexed: 11/11/2022]
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Prada G, Vieillard-Baron A, Martin AK, Hernandez A, Mookadam F, Ramakrishna H, Diaz-Gomez JL. Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth 2018; 33:1559-1583. [PMID: 30077562 DOI: 10.1053/j.jvca.2018.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Indexed: 02/03/2023]
Abstract
Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.
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Affiliation(s)
- Gabriel Prada
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne-Billancourt, France; Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint-Quentin En Yvelines, France; INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Phoenix, AZ.
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Diaz-Gomez JL, Grek AA, Venegas-Borsellino CP, Chirila AC, Builes AM, Ratzlaff RA. Focused transthoracic echocardiography curriculum for advanced practice providers assures good concordance with intensivists at echocardiography. Heart Lung 2018; 47:622-625. [PMID: 29903639 DOI: 10.1016/j.hrtlng.2018.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients. METHODS Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients. RESULTS After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohen's κ of 0.745 [95% CI, 0.385-1.0; P < .01]) in the diagnosis of shock when compared to experienced intensivists. CONCLUSIONS Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.
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Affiliation(s)
- Jose L Diaz-Gomez
- Department of Critical Care Medicine, Echocardiography Laboratory, Mayo Clinic, Jacksonville, Florida, USA.
| | - Ami A Grek
- Department of Critical Care Medicine, Echocardiography Laboratory, Mayo Clinic, Jacksonville, Florida, USA
| | - Carla P Venegas-Borsellino
- Department of Critical Care Medicine, Echocardiography Laboratory, Mayo Clinic, Jacksonville, Florida, USA
| | - Andreea C Chirila
- Department of Critical Care Medicine, Echocardiography Laboratory, Mayo Clinic, Jacksonville, Florida, USA
| | - Angela M Builes
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Robert A Ratzlaff
- Department of Critical Care Medicine, Echocardiography Laboratory, Mayo Clinic, Jacksonville, Florida, USA
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Werlang ME, Pimentel MR, Diaz-Gomez JL. Thoracentesis-reverting cardiac tamponade physiology in a patient with myxedema coma and large pleural effusion. Proc (Bayl Univ Med Cent) 2017; 30:295-297. [PMID: 28670061 DOI: 10.1080/08998280.2017.11929620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A large pleural effusion causing cardiac tamponade physiology and severe hemodynamic compromise is an uncommon event. We report a case of a 53-year-old woman with severe hypothyroidism presenting with myxedema coma and refractory shock. Her hemodynamic status failed to respond to fluid resuscitation and vasopressors. A transthoracic echocardiogram and chest radiograph demonstrated a pericardial fluid accumulation associated with a large left-sided pleural effusion. Thoracostomy tube insertion resulted in prompt improvement of the patient's hemodynamic status. Our finding demonstrates that a large pleural effusion may play an important role in cardiac tamponade physiology.
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Affiliation(s)
- Monia E Werlang
- Departments of Internal Medicine (Werlang) and Critical Care Medicine (Pimentel, Diaz-Gomez), Mayo Clinic, Jacksonville, Florida. Dr. Pimentel is currently at Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
| | - Mario R Pimentel
- Departments of Internal Medicine (Werlang) and Critical Care Medicine (Pimentel, Diaz-Gomez), Mayo Clinic, Jacksonville, Florida. Dr. Pimentel is currently at Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
| | - Jose L Diaz-Gomez
- Departments of Internal Medicine (Werlang) and Critical Care Medicine (Pimentel, Diaz-Gomez), Mayo Clinic, Jacksonville, Florida. Dr. Pimentel is currently at Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
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Abstract
A 54-year-old man presented to the emergency department with acute left-sided chest pain and left upper quadrant abdominal pain. He had a significant history of squamous cell carcinoma of the lung previously treated with right pneumonectomy who ; is currently receiving adjuvant chemotherapy with cisplatin. Physical examination was remarkable for tachycardia, hypertension and mild abdominal tenderness. CT angiography revealed an aortic mural thrombus in the ascending aorta and aortic arch without dissection, aneurysm or tortuosity of the aorta. In addition, an infarction of the inferior spleen was reported. Given the high risk of surgery for this patient, he was treated conservatively with esmolol and heparin infusion. His subsequent hospital course was uneventful, and he was successfully discharged on enoxaparin therapy that was successively bridged to rivaroxaban treatment. Follow-up transesophageal echocardiography and CT angiography at one month showed no thrombus in the aorta.
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Affiliation(s)
| | - Andree H Koop
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Ratzlaff RA, Ripoll JG, Kassab LL, Diaz-Gomez JL. Acute oxygenator failure: a new presentation of heparin-induced thrombocytopenia in a patient undergoing venovenous extracorporeal membrane oxygenation support. BMJ Case Rep 2016; 2016:bcr-2016-218179. [PMID: 27986695 DOI: 10.1136/bcr-2016-218179] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 58-year-old man with medical history of thrombocytopenia was admitted to an outside hospital for a 6-day history of worsening dyspnoea requiring mechanical ventilator support. He was transferred to our institution for extracorporeal membrane oxygenation (ECMO) given his refractory hypoxaemia. On arrival, H1N1 influenza virus was confirmed and all measures to improve oxygenation were ineffective. Thus, the decision was made to start venovenous (VV)-ECMO. Although a low baseline platelet count was recognised (60-70×109/L), a sudden further decrease occurred (30×109/L) and platelet transfusion was initiated. A substantial increase in the pressure across the ECMO oxygenator was identified, and the diagnosis of type II heparin-induced thrombocytopenia was suspected and confirmed. Heparin was discontinued, the oxygenator was exchanged and argatroban was used for anticoagulation. After 28 days on VV-ECMO support, the decision was made to withdraw organ support in conjunction with the patient and family wishes.
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Affiliation(s)
- Robert A Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Juan G Ripoll
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Lena L Kassab
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Anesthesiology and Neurosurgery, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
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Almeida-Chen G, Niezgoda J, Diaz-Gomez JL, Motta P. The role of echocardiography in the management of an embolized atrial septal Helex occluder. Anesth Analg 2010; 110:734-6; discussion 736. [PMID: 20042445 DOI: 10.1213/ane.0b013e3181cb3edc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gracie Almeida-Chen
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
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