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476 PART 4: Pulmonary Disorders

for initiation of hemodialysis were not controlled in this study mak-
ing comparison difficult. A post hoc subgroup analysis of 244 surgical
patients enrolled in the FACTT trial documented that a conservative
fluid strategy resulted in more ventilator-free and ICU-free days, and no
difference in mortality or renal failure. 44
A small (n = 40) RCT randomized patients with ALI/ARDS and
hypoproteinemia (serum total protein concentrations <6 g/dL) to receive
furosemide with albumin or furosemide with placebo for 72 hours,
titrated to fluid loss and normalization of serum total protein concentra-
tion. Albumin-treated patients had greater increase in oxygenation (mean
: +43 vs −24 mm Hg at 24 hours and +49 vs −13 mm Hg
change in Pa O 2 /Fi O 2
at day 3) with greater net negative fluid balance (−5480 vs −1490 mL at
day 3) and better maintenance of hemodynamic stability. Additional
45
trials are underway (comparative evaluation of albumin and starch effects
in acute lung injury, CEASE, NCT00796419) and larger definitive clinical
trials are warranted to confirm these preliminary findings.
■ WEANING OFF ECMO

Once the patient’s native lung function has improved, with documenta- FIGURE 53-7. Use of prone positioning in ECMO for lung recruitment.
tion of improved pulmonary compliance and oxygenation, the patient
is ready to wean off ECMO. This requires a slow reduction of ECMO cannula in place, as IVC thrombus is common, and the patient is at risk
sweep, and increase in mechanical ventilation to achieve adequate ven- for pulmonary embolus.
pressure and recruitment maneuvers to improve oxygenation. The opti- ■ COMPLICATIONS RELATED TO ECMO
tilation. We initiate recruitment with increased PEEP and mean airway
mal method for “re-recruitment” of the lung after ECMO lung rest is The most frequent complication during ECMO is hemorrhage, and the
not known. We also commonly use prone positioning for recruitment of most common sites are the cannula insertion sites, airway, intracranial
the posterior-dependent areas of the lungs in ARDS patients, since com- (Fig. 53-8), and intrathoracic (Fig. 53-9) hemorrhage. Whenever pos-
pressive atelectasis and edema in these areas are common (Fig. 53-7). sible, invasive procedures are avoided while on ECMO, including line
We have described a simple method of prone positioning that can be placement and tube thoracostomy as they can be associated with signifi-
used for the ECMO patient to minimize complications. If the patient cant bleeding risk. Intracranial hemorrhage is often a fatal hemorrhagic
46
tolerates ECMO weaning, we initiate a “trial off ECMO.” The trial off complication, and occurs in 10% to 15% of patients with ARDS on
60% with pla- ECMO. The vast majority of the deaths in the Australia/New Zealand
ECMO must demonstrate adequate gas exchange on Fi O 2
teau pressures <30 cm H O before we consider ECMO decannulation. H1N1 ECMO series were related to intracranial hemorrhage. Surgical
2
If the trial off of ECMO is successful, the ECMO cannulae are removed procedures, including tracheostomy, can be performed on ECMO, but
and the recovery continues. An inferior vena cava filter is placed prior they require cessation of anticoagulation and strict hemostatic tech-
to ECMO decannulation in patients who have had a femoral venous niques using electrocautery.

FIGURE 53-8. ECMO Complications—spontaneous intracranial hemorrhage in two adult patients resulting in death.

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