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IntroductionCardiac surgery-associated acute kidney injury (CSA-AKI) remains a serious complication. The ratio of the venous-arterial carbon dioxide partial pressure difference (Pv-aCO₂) to the arterial-venous oxygen content difference (Ca-vO₂) is an indicator of tissue perfusion and anaerobic metabolism. We aimed to assess whether peak Pv-aCO₂/Ca-vO₂ during cardiopulmonary bypass (CPB) predicts CSA-AKI in pediatric patients with cyanotic congenital heart disease (CHD).MethodsWe retrospectively reviewed patients aged < 10 years with cyanotic CHD who underwent cardiac surgery with CPB between January 2019 and August 2024. Peak Pv-aCO₂/Ca-vO₂ during CPB was analyzed for its association with CSA-AKI using multivariate logistic regression adjusted for age, weight, CPB duration, aortic cross-clamp (ACC) time, and red blood cell transfusion. Classification and regression tree (CART) analysis was conducted to develop a predictive model.ResultsThis study included 191 patients (96 (50.3 %) males; median age: 196 days [interquartile range (IQR), 55-474]). CSA-AKI occurred in 65 patients (34.0 %). Peak Pv-aCO₂/Ca-vO₂ was higher in the AKI group than in the non-AKI group (IQR, 4.8 [3.9-7.5] vs 3.9 [2.8-5.4] mmHg·dL/mL; p = 0.001) and was significantly associated with CSA-AKI (adjusted odds ratio: 1.14; 95% confidence interval: 1.04-1.27). A CART-derived predictive model included ACC time, peak Pv-aCO₂/Ca-vO₂, and weight. A Pv-aCO₂/Ca-vO₂ cut-off of 4.0 mmHg·dL/mL yielded 36.9 % sensitivity, 96.0 % specificity, 82.8 % positive predictive value, and 75.9 % negative predictive value.ConclusionsIn pediatric cardiac surgery for cyanotic CHD, high Pv-aCO₂/Ca-vO₂ predicts CSA-AKI. These findings highlight the potential role of Pv-aCO₂/Ca-vO₂ monitoring during CPB in developing novel pediatric goal-directed perfusion strategies.

IntroductionExtracorporeal membrane oxygenation (ECMO) is a high-risk, low-frequency intervention requiring specialized training and effective teamwork, for which simulation-based training is a valuable tool. Across medical disciplines escape room-style simulations have been developed to enhance teamwork and engagement among learners.MethodsWe conducted a prospective observational study at a large academic medical center to evaluate the feasibility and educational impact of an escape room-style ECMO simulation. Thirty-seven nurses completed the escape room simulation. Teamwork was assessed with the Clinical Teamwork Scale (CTS), and effectiveness with the Simulation Effectiveness Tool (SET-M).ResultsObserver-rated CTS scores for overall teamwork (r = -0.76), communication (r = -0.52), and decision-making (r = -0.55) correlated negatively with completion time, suggesting that stronger teamwork was associated with greater efficiency. Participant self-ratings were significantly higher than observer ratings across most domains (p < 0.01), and showed positive correlations with completion times. SET-M results indicated high satisfaction, with all participants reporting improved ECMO knowledge and skills, though prebriefing and debriefing received lower ratings.ConclusionsThese findings support escape room-style simulations as a feasible and engaging approach to ECMO education, with external observation playing a key role in assessing teamwork. Future studies should focus on structured briefing, randomized team assignments, and multidisciplinary cohorts to enhance generalizability and learning outcomes.

BackgroundEffective myocardial protection is essential for successful outcomes in open-heart surgery. Although both del Nido and St. Thomas cardioplegia solutions are widely used, comparative evidence in adult rheumatic mitral valve replacement remains limited. This study aimed to compare their myocardial protective efficacy and clinical outcomes.MethodsA prospective comparative study was conducted between May 2022 and October 2024. Total 50 adult patients undergoing mitral valve replacement-20 with severe mitral regurgitation (MR) and 30 with severe mitral stenosis (MS) were included. Patients were divided into two groups based on cardioplegia type (del Nido or St. Thomas). Intraoperative parameters, postoperative left ventricular ejection fraction (LVEF), troponin I levels, inotropic and ventilatory support, and ICU/hospital stay were analysed.ResultsBaseline characteristics were comparable across groups. The mean number of cardioplegia doses was significantly lower in the del Nido group (1.6 ± 0.5 vs 3.2 ± 0.8; p < 0.001). Postoperative LVEF was better preserved with del Nido cardioplegia (MS: 53.3 ± 7.2% vs 45.3 ± 10.6%; p = 0.023). Troponin I levels at 6, 24, and 48 h were lower in the del Nido group, though not statistically significant. Patients receiving del Nido required less inotropic and ventilatory support, with shorter ICU and hospital stays. One in-hospital death occurred in the del Nido group due to sepsis.ConclusionDel Nido cardioplegia offers comparable or superior myocardial protection to St. Thomas solution in adult mitral valve replacement, with fewer interruptions, reduced dosing, and faster postoperative recovery.

ObjectiveCardiopulmonary bypass (CPB), which induces pulmonary injury, significantly impacts the quality of life in patients undergoing cardiac surgery. Preventing and treating pulmonary complications has become a critical clinical issue. Optimizing ventilation strategies during the preoperative, intraoperative, and postoperative stages is essential for adequate lung protection and preventing CPB-related pulmonary injury.MethodsA comprehensive search of multiple databases including PubMed, Embase, and the Cochrane Library was conducted. After removing the duplicate studies, full-text review was performed, and all studies that reported mechanical ventilation strategies and lung protection during CPB were included.ResultsThis review systematically examines ventilation strategies during CPB, outlining optimized parameters and pharmacologic approaches across pre-, intra-, and post-CPB phases to reduce lung injury. Various modes - including volume control ventilation (VCV), pressure control ventilation (PCV), and pressure-controlled ventilation-volume guaranteed (PCV-VG) - demonstrate unique benefits and limitations. When combined with protective measures (low tidal volume [LTV], moderate positive end-expiratory pressure [PEEP], and recruitment maneuvers), they show clinical efficacy in lung protection. Pharmacologic agents like ambroxol, neutrophil elastase inhibitors, and sivelestat further enhance protection, underscoring the promise of combined mechanical-pharmacological strategies against CPB-induced lung injury.ConclusionsA comprehensive approach integrating individualized ventilation management and pharmacological intervention is key to reducing CPB-induced lung injury, enhancing postoperative respiratory function, and improving patient outcomes.

IntroductionExtracorporeal membrane oxygenation (ECMO) involves the use of a synthetic circuit, which initiates a complex interplay of inflammatory and pro-coagulant responses. This intricate, self-reinforcing process results in a prothrombotic state, predisposing patients to arterial, venous, or oxygenator thrombosis. Unfractionated heparin is the standard anticoagulant chosen in ECMO patients to prevent such complications.Case ReportIn this case report our patient presented heparin-induced thrombocytopenia (HIT), a possible complication.DiscussionAlternative strategies such as bivalirudin and argatroban are possible options but due the unavailability of those medications at our institution, nitric oxide (NO) via sweep-gas flow was deemed a reasonable alternative considering it's anti-aggregant effect.ConclusionThis case report details the use of NO as a possible alternative anticoagulant strategy in a patient with ECMO complicated by HIT.

PurposeExtracorporeal membrane oxygenation (ECMO) patients have increased risk for limb acute compartment syndrome (ACS), but diagnosis remains difficult given the lack of subjective and pulsatility assessments in this patient population. This exploratory study characterized ECMO patients who developed ACS and investigated laboratory measures that can aid diagnosis.MethodsWe reviewed records of adult patients placed on ECMO between 2016 and 2022 at our single center, collecting clinical, laboratory, and survival data upon cannulation. We performed comparisons of baseline and laboratory data between ACS and No ACS patients. Threshold regression was then used to develop laboratory cutoffs for ACS diagnosis and logistic regression to characterize predictors of ACS. Survival analysis relied on Cox proportional hazards modeling.Results278 ECMO patients were included, of which 14 (5%) developed ACS. ACS patients had a higher amputation rate (21.4% vs 1.9%, p < 0.001) and mortality risk (HR 2.35, p = 0.03); only 1 (7%) ACS patient had amputation-free survival. The most sensitive threshold cutoffs included maximum INR >1.95 (sensitivity 0.91), baseline lactate >7.85 (0.88), and 24-h lactate >3.75 (0.88). The most specific were baseline CpK >3765.5 (specificity 0.91), maximum K >5.95 (0.88), and maximum CpK >6362.0 (0.85). Laboratory values, namely CpK and lactate, predicted ACS with promising diagnostic sensitivity and specificity.ConclusionsACS remains associated with increased mortality and morbidity, most often occurring within 24 h after cannulation. Laboratory values, namely CpK and lactate values, independently predicted ACS development with promising sensitivity and specificity. These exploratory findings may help guide decision-making surrounding ACS in the ECMO setting.

BackgroundUtilization of extracorporeal membrane oxygenation (ECMO) has expanded substantially, yet structured training for surgical residents remain limited. We established a dedicated ECMO/mechanical circulatory support (MCS) fellowship for general surgery residents on dedicated academic time and evaluated its feasibility, educational impact, and association with institutional outcomes.MethodsA single-center retrospective review was performed comparing ECMO activity and outcomes before and after fellowship implementation. . Institutional outcomes were compared across pre-fellowship and fellowship eras. Fellows' clinical involvement was quantified through procedural logs and self-reported comfort levels. A multidisciplinary survey assessed perceptions of workflow, communication, and education using 5-point Likert scales and free-text feedback.ResultsTwo fellows completed the program during the study period. Since initiation, annual ECMO runs increased from 59 to 119 (+101%), with total ECMO hours rising 59%. The proportion of patients successfully weaned from ECMO improved significantly in 2025 compared with 2024 (59% vs 41%, χ² = 6.12, p = 0.013), with a corresponding decline in on-support mortality (22% vs 37%). Two fellows matriculated, each participating in approximately 75 cannulations annually and reporting independent cannulation competency by year-end. Of approximately 70 eligible stakeholders, 30 responded (42%), with most agreeing the fellowship improved ECMO care (90%) and ICU-surgical communication (90%), though fewer endorsed reduced workload (43%). Open-ended feedback emphasized enhanced teamwork and continuity of care.ConclusionsEarly implementation of a dedicated ECMO/MCS fellowship for surgical residents was feasible and associated with increased program volume, improved interdisciplinary communication, and robust trainee experience. Early results suggest potential educational and institutional benefits, warranting longer-term evaluation.

IntroductionIn children undergoing Extracorporeal Membrane Oxygenation (ECMO), anticoagulation is given to counterbalance the risk of thrombosis. Several laboratory tests are available to monitor heparin, but the ideal method still needs to be determined.MethodsThis retrospective cohort study included all patients under 18 years on ECMO support between 2010 and 2021. At our institution, the test used to monitor unfractionated heparin changed over time, dividing patients into three periods, using either activated clotting time (ACT) (2010-2014), activated partial thromboplastin time (aPTT) (2014-2018) or anti-Xa (2018-2021). The primary objective was to compare the occurrence of hemorrhagic complications. Secondary objectives included thrombotic complications, neurological complications, and survival.ResultsWe included 118 ECMO runs of which 30 ACT-guided, 40 aPTT-guided, and 48 anti-Xa-guided. No statistically significant differences were found in hemorrhagic complications [respectively 46.7% vs. 52.5% vs. 60.4%; p = 0.48], thrombotic complications (p = 0.15), neurological complications (p = 0.13), or 30-days survival (p = 0.84). Duration of ECMO and length of hospital stay were both the shortest in the anti-Xa-guided group (respectively p = 0.02; p = 0.02). During ECMO, the anti-Xa-guided group received a higher unfractionated heparin dose compared to the aPTT- and ACT-guided group [respectively 839 [651-981] vs. 543 [407-692] vs. 330 [223-489] IU/kg d^-1, p < 0.001].ConclusionIn our study, the test or titration method used to guide heparin-dosing in children on ECMO, was not associated with hemorrhagic complications and death. Of note, the dose of unfractionated heparin was significantly higher in the anti-Xa-guided group. Combined testing may be more effective than a single method, more studies are needed to establish the optimal strategy.

IntroductionOptimal sedation strategies for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV ECMO) are not well defined.MethodsPhysicians caring for patients on ECMO in an intensive care unit were invited to complete an international survey about sedation and analgesia practices for adult patients undergoing VV ECMO for severe Acute Respiratory Distress Syndrome (ARDS).ResultsThe survey was completed by 234 physicians, most commonly identifying as critical care (29.9%) and practicing in North America (38.9%). The Richmond Agitation Sedation Scale (88.5%) and Clinical Pain Observation Tool (40.2%) were commonly used for monitoring. Agents of choice were propofol (73.9% prior to ECMO and 56% within 48 h after initiation) and fentanyl (57.3% and 40.2%), with increasing preference for dexmedetomidine after ECMO initiation (14.5% prior to and 25.6% after initiation). Routine neuromuscular blockade use beyond 48 h after cannulation was rare (1.3%). Common strategies to reduce sedatives included sweep gas titration (74.4%) and minimizing nocturnal interventions (63.7%). Most respondents believe antipsychotics also work to this effect (57.3%).ConclusionsSedation strategies for adult ARDS patients receiving VV ECMO seem to be influenced by time from cannulation and patient factors. Future research should focus on identifying optimal sedation strategies and developing a consensus for best practice.