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membrane oxygenation (ECMO)?High‐frequency oscillatory ventilationAirway pressure release ventilationProne positioningRib fracture stabilizationDecompressive laparotomyThis patient is potentially a good candidate for venovenous extracorporeal membrane oxygenation (ECMO) for hypoxemic respiratory failure. The basic principles for determining a patient’s candidacy for ECMO include lack of response to conventional ventilator management and rescue interventions for severe hypoxemic or hypercarbic respiratory failure, an underlying process that is potentially reversible, and no contraindications to ECMO. The ventilator should be optimized for acute respiratory distress syndrome (ARDS) management, and proning can be employed as a rescue intervention to optimize gas exchange. Chemical paralysis can also be used along with deep sedation, particularly in the setting of ventilator dyssynchrony. If the patient’s oxygenation does not improve, ECMO is reasonable so long as his traumatic brain injury is not severe, his intracranial bleeding has stabilized, and there is no ongoing torso hemorrhage. The RESP score calculator can be used to quantify the patient’s projected outcome on ECMO (https://www.elso.org/Resources/ECMOOutcomePredictionScores.aspx).High‐frequency oscillatory ventilation requires special expertise and does not offer any clear survival benefit for this patient. Airway pressure release ventilation (APRV) is better suited to awake patients with moderate respiratory failure and ventilator synchrony problems. Rib fracture stabilization should be performed earlier in the hospital course. The patient would not likely benefit from this procedure and also would be unlikely to significantly improve with this intervention. In the absence of abdominal compartment syndrome or refractory intracranial pressure elevation, decompressive laparotomy has no role in the management of this patient.Answer: CBrodie D, Bacchetta M . Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med. 2011; 365(20):1905–14. doi: https://doi.org/10.1056/NEJMct1103720. PMID: 22087681.Brodie D, Slutsky AS, Combes A . Extracorporeal life support for adults with respiratory failure and related indications: a review. JAMA. 2019; 322(6):557–568. doi: https://doi.org/10.1001/jama.2019.9302. PMID: 31408142.Bullen EC, Teijeiro‐Paradis R, Fan E . How i select which patients with ARDS should be treated with venovenous extracorporeal membrane oxygenation. Chest. 2020; 158(3):1036–1045. doi: https://doi.org/10.1016/j.chest.2020.04.016. Epub 2020 Apr 21. PMID: 32330459.Cannon JW, Gutsche JT, Brodie D . Optimal strategies for severe acute respiratory distress syndrome. Crit Care Clin. 2017; 33(2):259–275. doi: https://doi.org/10.1016/j.ccc.2016.12.010. PMID: 28284294.ELSO Guidelines for Adult Respiratory Failure (2017). Extracorporeal Life Support Organization, Version 1. https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf (accessed 4 August 2017).Schmidt M, Bailey M, Sheldrake J, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014; 189(11):1374–82. doi: https://doi.org/10.1164/rccm.201311‐2023OC. PMID: 24693864.

      2 A 62‐year‐old man with a history of alcoholic cirrhosis (MELD 18), active alcohol abuse, mild aortic valve insufficiency, type II diabetes, and obesity (BMI = 35) presents to the emergency department with an ST‐elevation MI. He is immediately taken to the cardiac catheterization lab for percutaneous coronary intervention; a left anterior descending artery culprit lesion is successfully stented. However, postprocedure, he remains in profound shock on very high doses of intravenous epinephrine, norepinephrine, and vasopressin. Arterial blood pressure is 85/40 mm Hg. A bedside echocardiogram indicates significant left ventricular dysfunction with an ejection fraction of 25%. The cardiologist is requesting veno‐arterial (VA) ECMO given the patient’s shock state. Which of the following patient characteristics is the strongest contraindication for providing ECMO support?Age of 62Morbid obesity (BMI 35)Mild aortic valve insufficiencyAlcoholic cirrhosisImmediately post‐MI with LV dysfunctionThis patient is a poor candidate for several reasons; however, cirrhosis is the strongest contraindication to this therapy as it portends a poor overall outcome. Chronic end‐organ dysfunction with no exit strategy (such as transplant for which this patient is not a candidate given his active alcohol abuse) is an absolute contraindication to ECMO.Advanced age is a relative contraindication to ECMO, with age of 65 often used as a cutoff in older literature. However, VA ECMO in patients up to 75 years of age has proven safe and effective. Obesity is no longer a contraindication to ECMO, and in select patients it may even be protective. Severe aortic valve insufficiency is a relative contraindication to VA ECMO. Mild aortic valve insufficiency may require venting of the left ventricle with a microaxial pump, atrial septostomy, or LV drainage cannula, but it is not in itself a contraindication to VA ECMO. Cardiogenic shock after myocardial infarction is a reasonable indication for VA ECMO. It may also be considered in other forms of cardiogenic shock, including myocarditis, pulmonary embolism, and postcardiotomy. It may also be used to manage heart failure with a plan to bridge to permanent ventricular assist device placement or transplant.Answer: DYannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out‐of‐hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open‐label, randomised controlled trial. Lancet. 2020 Nov 12:S0140–6736(20)32338‐2. doi: https://doi.org/10.1016/S0140‐6736(20)32338‐2. Epub ahead of print. PMID: 33197396.Lee SN, Jo MS, Yoo KD . Impact of age on extracorporeal membrane oxygenation survival of patients with cardiac failure. Clin Interv Aging. 2017 Aug 24; 12:1347–1353. doi: https://doi.org/10.2147/CIA.S142994. PMID: 28883715; PMCID: PMC5576703.Salna M, Chicotka S, Biscotti M III, et al. Morbid obesity is not a contraindication to transport on extracorporeal support. Eur J Cardiothorac Surg. 2018; 53(4):793–798. doi: https://doi.org/10.1093/ejcts/ezx452. PMID: 29253111.Makdisi G, Wang IW . Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015; 7(7):E166–76. doi: https://doi.org/10.3978/j.issn.2072‐1439.2015.07.17. PMID: 26380745; PMCID: PMC4522501.

      3 A 45‐year‐old previously healthy man was a pedestrian struck by a motor vehicle resulting in multiple injuries including traumatic brain injury with a subarachnoid hemorrhage (SAH), multiple rib fractures, pulmonary contusion, hemothorax, splenic laceration, and a pelvic fracture. On postinjury day 5, he developed severe hypoxemic respiratory failure (PaO2:FiO2 ratio of 70 on FiO2 of 100%) and was diagnosed with an MRSA pneumonia. Workup for other causes of respiratory failure or sepsis was negative, and there was no evidence of SAH progression or torso hemorrhage on his most recent imaging. His hypoxemic respiratory failure did not improve with proning and neuromuscular blockade. What is the optimal ECMO cannulationstrategy for this patient?Femoral venous drainage, carotid arterial reinfusionFemoral venous drainage, femoral arterial reinfusionFemoral venous drainage, jugular venous reinfusionFemoral venous drainage, femoral venous reinfusionJugular venous drainage, right atrial reinfusion (dual lumen cannula)This patient has no evidence of cardiac failure, so veno‐arterial cannulation is unnecessary. This approach increases the potential for an arterial injury or thromboembolic event, will significantly increase the patient’s cardiac afterload, and may not provide adequate oxygenation.The most common cannulation strategy for venovenous ECMO is femoral drainage and jugular reinfusion. A multistage, large‐bore venous drainage cannula will adequately support the gas exchange needs for most adult patients (4–6 L/min flow) without risking flow limitations or recirculation that can be a problem with the bilateral femoral‐femoral venovenous approach. Single site cannulation with a dual lumen cannula facilitates early ambulation for ECMO patients; it is commonly used for those awaiting a lung transplant.Answer: CCannon JW, Gutsche JT, Brodie D . Optimal strategies for severe acute respiratory distress syndrome. Crit Care Clin. 2017; 33(2):259–275. doi: https://doi.org/10.1016/j.ccc.2016.12.010.

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