Patients requiring ECMO have acquired haemostatic disorders due to a vast interplay of factors including drugs, disease and device. In this heterogenous population it is impossible to define the isolated and combined effects of critical illness and ECMO on haemostasis.This study aimed to characterise changes in haemostasis attributable to ECMO in an in vivo ovine model using ROTEM ® and Multiplate ® analysis. In our validated model, 10 healthy sheep and 10 sheep with smoke-induced acute lung injury (S-ALI) were supported on venovenous ECMO. Heparin infusion commenced at 4 U/kg/h to achieve activated clotting time of 200-300 s. Samples were collected at baseline, pre-ECMO and 0.25, 1, 1.5 and 2 h post-ECMO initiation. Analysis included platelet counts, EXTEM and FIBTEM on ROTEM ® , and Multiplate ® analysis with ADP and collagen agonists.For both groups, platelet count remained within normal range. ECMO induced no significant changes to ADP or collagen-induced platelet aggregation or EXTEM clotting time. EXTEM clot formation time (CFT) was increased (p < 0.01) and EXTEM maximum clot firmness (MCF) (p < 0.001) was decreased compared to baseline for both groups throughout ECMO. A smaller decrease in FIBTEM-MCF was documented during ECMO in healthy sheep (p < 0.05) compared to sheep with S-ALI prior (p < 0.01).ECMO induces an increase in clot formation time and decrease in fibrinogen function and overall clot quality in healthy sheep. S-ALI prior to ECMO exacerbates these haemostatic alterations. Platelet number and function was maintained during ECMO, which, when assessed with the decrease in EXTEM-MCF and FIBTEM-MCF, suggests fibrinogen may be central to these haemostatic alterations.http://dx.

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The aim of this study is to evaluate the amalgamation and maturation of a Pediatric Intensive Care Outreach Service (PICOS) with a rapid response system (RRS) and associated outcomes over a 10-year period. It is a single-center retrospective study analyzing patient outcomes within the context of significant organizational changes introducing a track and trigger RRS called Between the Flags (BTF) and evolution of this system to electronic observation charting and alerts (eBTF) in a tertiary metropolitan children's hospital. Children on inpatient wards who required urgent activation of the RRS and admission to the pediatric intensive care unit (PICU) between 2009 and 2018 were included. Three cohorts were identified according to the system changes—pre-BTF (2009–2011), BTF (2012–2017), and eBTF (2017–2018). The PICOS dose (number of activations per 1000 hospital admissions) increased with the introduction of BTF and the RRS and this trend continued following eBTF. The number of PICU admissions via the PICOS did not vary across the decade. When comparing the pre-BTF to the BTF group, PICU mortality decreased (p < 0.05), Pediatric Index of Mortality 2 Risk of Death scores improved, and hospital length of stay decreased (p < 0.05) in the BTF group. Introduction of a track and trigger RRS and electronic charting augmenting an existing PICOS is associated with increasing dose and workload, with no significant impact on PICU admission rates or length of stay. PICOS patient mortality has notably decreased with the introduction of an RRS; however, this impact was not sustained with the addition of electronic charting and alerts in the patient medical record.