Lakshmi Raman

By Abdelaziz Farhat, Cindy Darnell Bowens, Ravi Thiagarajan and Lakshmi Raman

ECMO, or extracorporeal membrane oxygenation, is an advanced life support technique that provides cardiac and pulmonary support similar to cardiopulmonary bypass. ECPR (extracorporeal cardiopulmonary resuscitation) is the rapid deployment of VA-ECMO when conventional cardiopulmonary resuscitation fails to provide return of spontaneous circulation. Evidence in the literature is sparse, but with expanding reported applications, ECPR has shown promise to improve outcomes of cardiac arrest. ECPR is superior to conventional CPR for both survival and neurologic outcomes. ECPR has been successfully used to manage arrests secondary to cardiac and non-cardiac causes. Arrests secondary to primary cardiac causes have the best overall outcome. Other determinants of outcomes of ECPR include duration of low flow state and on-ECMO complications. A narrow list of ECPR contraindications exists, and includes severe neurologic injury and irreversible primary disease process. Various complications can occur with ECPR, and include mechanical, cardiovascular, pulmonary, hematologic, renal, and neurologic complications. Neurologic complications are the most serious, and significantly affect mortality or quality of life. ECPR is a nascent field, and substantial work remains to be done to optimize its application. Given the small number of patients at each institutional level, this is a field ripe for collaborative work and rewarding results.

Part of the book: Advances in Extracorporeal Membrane Oxygenation

By Jamie Weller, Lakshmi Raman, Ayesha Zia and Ali McMichael

Anticoagulation during extracorporeal membrane oxygenation (ECMO) is necessary to prevent catastrophic circuit clotting, but significant morbidity and mortality continue to be attributed to hemorrhagic and thrombotic complications. Due to the inflammatory response from the extracorporeal circuit and developmental hemostasis, anticoagulation can be challenging particularly for pediatric patients. Unfractionated heparin (UFH) is the gold standard anticoagulant used in ECMO, but there is an expanding area of research evaluating other anticoagulants, such as direct thrombin inhibitors. This chapter provides an overview of anticoagulant options for pediatric patients on ECMO as well as describes the various tests used to monitor and titrate anticoagulation.

Part of the book: Advances in Extracorporeal Membrane Oxygenation

By Priscilla Yu, Ivie D. Esangbedo, Lakshmi Raman and Cindy Darnell Bowens

This chapter will focus on four important topics in pediatric cardiac arrest. We will highlight recent developments in pediatric CPR quality, medications used in cardiac arrest, ECPR, and post-cardiac arrest care (PCAC) and discuss the existing literature behind AHA guidelines and gaps in knowledge. Optimization of CPR quality is critical during cardiac arrest. We will summarize literature regarding current guidelines which target provider-centered goals and discuss evidence behind patient-centered goals. We will also discuss the evidence behind drugs used in the PALS guidelines. In cases of refractory cardiac arrest, ECMO can be lifesaving; however, there are still many gaps in our knowledge of this field. We will summarize the literature regarding determination of candidacy, cannulation strategies, resuscitation practices during ECPR, and outcomes. After a cardiac arrest, PCAC is crucial to minimize further injury from post-cardiac arrest syndrome (PCAS). The main goals of PCAC are to prevent further brain injury, treat myocardial dysfunction, and systemic ischemia/reperfusion injury. We will discuss AHA guidelines on oxygenation and ventilation goals, targeted temperature management, hemodynamic monitoring, and neuromonitoring.

Part of the book: Sudden Cardiac Death