ABSTRACT:Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients. Mechanical circulatory support (MCS) has evolved from a rarely used therapy reserved for the most critically ill hospitalized patients to an accepted longterm outpatient therapy for treating patients with advanced heart failure. This growth is attributable to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. With the number of patients supported by durable MCS systems increasing in the community, so too is the need for emergency care providers to receive specific guidance on how to assess and treat a patient with MCS who is unresponsive or hypotensive.No evidence-based or consensus recommendations currently exist for the evaluation and treatment of cardiovascular emergencies in patients with MCS. Because of the unique characteristics of mechanical support, these patients have physical findings that cannot be interpreted the same as for patients without MCS. For example, stable patients supported by a durable, continuous-flow ventricular assist device (VAD) often do not have a palpable pulse. Unfortunately, different and sometimes conflicting instructions are given by hospital providers and emergency medical services (EMS) directors to EMS and other healthcare personnel on core resuscitative practices such as the role of external chest compressions in such a patient who suddenly becomes or is found unresponsive. PURPOSEThe purpose of this scientific statement is to describe the common types of MCS devices that emergency healthcare providers may encounter and to present expert, consensus-based recommendations for the evaluation and resuscitation of adult and pediatric patients with MCS with suspected cardiovascular collapse or cardiac arrest. These recommendations focus initially on emergency first-response providers, whether outside or inside the hospital, with additional sections on advanced care that may be provided in the emergency department or in-hospital settings. CONSENSUS PROCESSThe need for standardized recommendations for the emergency treatment of acutely unstable patients with MCS was identified during the 2014 meeting of the American Heart Association (AHA) Science Subcommittee. A writing group was commissioned to review the current literature and to develop consensus-derived recommendations for the initial treatment of these patients. Members of the writing group were chosen for their combined expertise in MCS, cardiopulmonary resuscitation (CPR), emergenc...
Disclaimer: This guideline for the preparation for and undertaking of transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgement, knowledge and expertise. These guidelines do not take the place of physicians’ and other health professionals’ judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
In a multicenter, retrospective analysis of 435 patients with refractory COVID‐19 placed on V‐V ECMO, cannulation by a single, dual‐lumen catheter with directed outflow to the pulmonary artery was associated with lower inpatient mortality.
BACKGROUND Historically, there is perceived pressure to achieve therapeutic levels of tacrolimus quickly after heart transplant (HT). We evaluated the association between time within therapeutic tacrolimus range and time to therapeutic trough and rejection in the 30 days following HT. METHODS This is a single-center retrospective cohort study of consecutive adult HT patients receiving immunosuppression. Goal trough tacrolimus levels were 10-15 ng/ml. Surveillance endomyocardial biopsies were performed weekly for 4 weeks. Outcomes included the effect of time to and timein-therapeutic tacrolimus range (Rosendaal method) on 30-day clinical rejection, 1R/1B, and 2R or higher histologic occurrences. RESULTS We reviewed 67 HT patients (median age 58.8 yrs). For clinical rejection versus no-rejection groups, the median (25th, 75th percentile) time to therapeutic tacrolimus levels was 9.5 (8, 12.3) days versus 9.0 (7, 13) days (p=0.623). The median time-in-therapeutic tacrolimus range was 34.1% (23.2, 42.2) versus 36.2% (19.9, 51.2), respectively (p=0.512). Similarly, we observed no significant differences in time to and time-in-therapeutic tacrolimus range in patients who developed grade 1R/1B (p=0.650 and p=0.725) or grade 2R or higher histology (p=0.632 and p=0.933). CONCLUSIONS Our small single-center analysis suggests that neither time to nor time in therapeutic tacrolimus range predicted acute rejection within 30 days of HT.
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