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Adequate and durable recovery in patients supported with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) can be challenging to predict. Extracorporeal membrane oxygenation weaning is the process by which the ECMO flows are decreased to assess if a patient is ready for decannulation. The optimal strategies for deciding who to wean and how to wean VA ECMO remain undefined. A retrospective literature review was performed to understand the evidence supporting current practices in ECMO weaning and in particular patient selection and methods. Most published work and expert opinions agree that once the underlying process has resolved, the minimum required physiologic parameters for weaning from ECMO include: hemodynamic stability and cardiac pulsatility, adequate lung function to support oxygenation and ventilation, and evidence of recovered end organ function. Echocardiography is universally used to assess cardiac function during the weaning process. Currently, there is no consensus regarding who is eligible to wean or how to wean ECMO in adults. We have reviewed the literature to summarize the evidence and expert opinions behind VA ECMO weaning, and give an example of the protocol used at our center. We believe this protocol optimizes patient selection for weaning and helps to predict successful decannulation.

A 25-year-old woman with severe tricuspid valve endocarditis and septic pulmonary emboli required VA-ECMO for recurrent hypoxemia-induced cardiac arrest. We present the clinical challenges requiring ECMO circuit reconfiguration and a percutaneous approach for vegetation debulking. (Level of Difficulty: Intermediate.), Central Illustration

Perioperative physicians should be well versed in atrial fibrillation (AF) management because it is the most common sustained arrythmia in the United States. In this narrative review of the 2019 American Heart Association/American College of Cardiologists/Heart Rhythm Society Focused Update on Atrial Fibrillation, the authors detail the emergence of new evidence from completed studies that may affect the management of patients with AF presenting for surgery. Updates regarding non-vitamin K oral anticoagulants (NOACs) comprise the bulk of the update with newer evidence emerging regarding their equivalence and/or superiority compared to Coumadin. Apixaban is now the preferred drug of choice for first line stroke prevention in nonvalvular AF over Coumadin. Renal dysfunction and the management of patients with AF on hemodialysis is examined; in patients on hemodialysis with AF, the focused update recommends administration of either warfarin or dose-reduced apixaban. Evidence from new trials addressing the appropriate bridging of NOACs before surgery is discussed. Patients with nonvalvular AF may not exhibit an added benefit from bridging of anticoagulation, and perioperative physicians should balance the risks of stroke and major bleeding before surgery. Advances in nonpharmacologic treatment and management of AF are outlined, including left atrial appendage occlusion devices, catheter ablations, and electrical cardioversion. Anesthesiologists' understanding of these 2019 updated guidelines will allow for more adept optimization of patients with AF presenting for surgery.

Summary and Background Data: VV ECMO can be utilized as an advanced therapy in select patients with COVID-19 respiratory failure refractory to traditional critical care management and optimal mechanical ventilation. Anticipating a need for such therapies during the pandemic, our center created a targeted protocol for ECMO therapy in COVID-19 patients that allows us to provide this life-saving therapy to our sickest patients without overburdening already stretched resources or excessively exposing healthcare staff to infection risk. Methods: As a major regional referral program, we used the framework of our well-established ECMO service-line to outline specific team structures, modified patient eligibility criteria, cannulation strategies, and management protocols for the COVID-19 ECMO program. Results: During the first month of the COVID-19 outbreak in Massachusetts, 6 patients were placed on VV ECMO for refractory hypoxemic respiratory failure. The median (interquartile range) age was 47 years (43–53) with most patients being male (83%) and obese (67%). All cannulations were performed at the bedside in the intensive care unit in patients who had undergone a trial of rescue therapies for acute respiratory distress syndrome including lung protective ventilation, paralysis, prone positioning, and inhaled nitric oxide. At the time of this report, 83% (5/6) of the patients are still alive with 1 death on ECMO, attributed to hemorrhagic stroke. 67% of patients (4/6) have been successfully decannulated, including 2 that have been successfully extubated and one who was discharged from the hospital. The median duration of VV ECMO therapy for patients who have been decannulated is 12 days (4–18 days). Conclusions: This is 1 the first case series describing VV ECMO outcomes in COVID-19 patients. Our initial data suggest that VV ECMO can be successfully utilized in appropriately selected COVID-19 patients with advanced respiratory failure.

A Woman with Hypotension and Trauma after a Motorcycle Accident A 57-year-old woman presented to the ED after a traumatic motorcycle accident. Bleeding from the pelvis and thigh resulted in hemorrh...

Adequate and durable recovery in patients supported with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) can be challenging to predict. Extracorporeal membrane oxygenation weaning is the process by which the ECMO flows are decreased to assess if a patient is ready for decannulation. The optimal strategies for deciding who to wean and how to wean VA ECMO remain undefined. A retrospective literature review was performed to understand the evidence supporting current practices in ECMO weaning and in particular patient selection and methods. Most published work and expert opinions agree that once the underlying process has resolved, the minimum required physiologic parameters for weaning from ECMO include: hemodynamic stability and cardiac pulsatility, adequate lung function to support oxygenation and ventilation, and evidence of recovered end organ function. Echocardiography is universally used to assess cardiac function during the weaning process. Currently, there is no consensus regarding who is eligible to wean or how to wean ECMO in adults. We have reviewed the literature to summarize the evidence and expert opinions behind VA ECMO weaning, and give an example of the protocol used at our center. We believe this protocol optimizes patient selection for weaning and helps to predict successful decannulation.

COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (p = 0.04), and procalcitonin levels (p = 0.02), and IL-6 levels (p = 0.05), lower blood pH before and after ECMO (p 

(244 words) In 2014, the International Society for Heart and Lung Transplantation (ISHLT) released guidelines from a consensus conference that clearly defined primary graft dysfunction (PGD) according to onset after surgery (

Effective management of cardiogenic shock (CS) is hampered by a lack of evidence-based information. This is a high-mortality condition, without clear, evidence-based guidelines for perioperative management, specifically-a lack of target endpoints for treatment (e.g.: mean arterial pressure or oxygenation), utility of regional care systems or the benefits of palliative care. The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) recently published a position statement that aimed to offer contemporary guidance on the diagnosis and treatment of acute myocardial infarction (AMI) complicated by CS. Herein, we review this complex clinical topic and review the ACCA statement on AMI associated with CS, with a focus on relevance to perioperative management.

A Woman with Chest Pain, Dyspnea, and Shock A 44-year-old woman presented with cough, dyspnea, and chest pain. On examination, she had tachycardia and hypotension. Evaluation revealed SARS-CoV-2 RN...

Objective The value of a simplified, focused intraoperative transesophageal echocardiography (TEE) protocol in patients undergoing liver transplantation (LT) is unknown. We sought to create and assess a 5-view LT TEE examination focused on 5 prespecified common causes of hypotension during LT. Design Retrospective cohort study. Setting Single-center tertiary academic hospital. Participants All patients undergoing LT with TEE from January 2010 through May 2019. Interventions None. Measurements and Main Results A 5-view LT TEE protocol adapted from a published rescue TEE protocol was assessed retrospectively in a cohort of 106 patients. The primary outcome was the frequency with which the protocol would have detected a composite of 5 prespecified causes of hypotension if the TEE exam had been limited to those views. To assess potential influence on intraoperative care, management changes associated with TEE images were extracted from the medical record. The prespecified diagnoses occurred 24 times; the LT TEE protocol would have detected 22 of 24 of these (92%, 95% confidence interval [CI]: 74%-98%). Intraoperative management changes occurred in 15 of 16 patients (94%) with 1 of the prespecified TEE findings, compared with 1 of 27 patients (3.7%) with TEE findings outside those diagnoses (p Conclusions In a retrospective cohort study, a simplified LT TEE protocol would have detected 92% of prespecified TEE findings. Management changes occurred in 94% of those patients, while changes rarely occurred in patients with other TEE findings. A focused LT TEE protocol may diagnose critical pathology adequately and guide management during LT when standard monitors are insufficient.

Liver transplantation for both acute and chronic liver failure results in excellent outcomes. Perhaps more than with any other surgical program, graft and patient outcomes for liver transplantation reflect the combined efforts of several specialties. The success stems from a multidisciplinary approach with close involvement of gastroenterologists, anesthesiologists, surgeons, and intensivists. This chapter will review topics related to the immediate care of the liver transplant patient in the intensive care unit (ICU). Existing evidence on hemodynamic monitoring, respiratory failure, neurologic management, electrolyte and glucose correction, coagulation management, systemic immunosuppression, graft function and rejection, and technical problems will be reviewed. The chapter will conclude with brief mention of long-term complications related to recurrence of disease that may lead to future ICU admissions.