Faculty Bibliography

Extracorporeal membrane oxygenation (ECMO) is known to alter drug pharmacokinetics (PK). The PK changes can result from drug binding to the oxygenator, alterations in clearance, and drug adsorption or sequestration, but the published literature is with old equipment and oxygenators. There is limited data regarding the impact of the oxygenator on drug changes in ECMO circuits in comparison to the other components of the ECMO circuit. The purpose of this study was to determine the impact of the Quadrox-i adult oxygenators on the PK of voriconazole (VOR) in contemporary ECMO circuits. A 3/8-in. closed loop ECMO circuit was prepared with Quadrox-i adult oxygenator (Getinge) and one circuit without an oxygenator in series. The circuits were primed with (whole blood), tromethamine, heparin, calcium gluconate and pH was balanced to 7.35-7.45. VOR was added to the continuously flowing circuits and levels were obtained pre-and post-oxygenator or 2 samples from circuit without oxygenator at the following time intervals; 5 mins, 1, 2, 3, 4, 5, 6 and 24 hrs. VOR control was maintained in a glass vial and samples obtained at the same time periods. There was significant VOR loss in the 3/8-inch circuit with an oxygenator and no apparent VOR loss in the 3/8-inch circuit without an oxygenator. The drug loss started by 2 hours (~20%) and continued over 24-hours (~40%). VOR control showed no loss suggesting the VOR loss was not due to self-degradation. Additional studies are needed to determine dosing regimen alterations for VOR with an ECMO circuit

The majority of neonatal and pediatric patients require emergent cannulations at the bedside in the intensive care unit (ICU). To accomplish a bedside cannulation, multidisciplinary teams need to work together and perform tasks that may be different from the usual practices in the ICU. The complexity of the many tasks that need to be completed can lead to significant delay if not well choreographed. Our project goal was to streamline the pre-cannulation process to decrease the time from ECMO mobilization to procedure start. The initiative was implemented in September 2016. Interventions included formalization of ECMO Program policies & procedures and multidisciplinary education, as well as implementation of formal patient case reviews & quality assurance meetings. Our team collaborated with ancillary departments to ensure timeliness and efficiency with orders & processes related to ECMO initiation. We also created a detailed precannulation checklist which defines each team members' role and their responsibilities in the pre-cannulation process. The checklist is reviewed prior to the procedure time out as a final check to ensure all required tasks are completed. Upon retrospective chart review, the pre- & post-initiative data revealed a 54% decrease in time from ECMO mobilization to cannulation procedure start. The post-initiative average time of 65 minutes showed successful improvement from the pre-initiative average time of 136 minutes. We concluded that a structured process for pre-cannulation preparedness, role definition, multidisciplinary education, and team debriefs maximize efficiency in team readiness for a bedside ECMO cannulation procedure

Since March 2015, our Pediatric ECMO team has cared for 31 patients. Of these, 16 patients are still living today (53%). Patient & family support are necessary during ECMO, as well as post-ECMO and hospital discharge. Recent studies show that not only patients who required ECMO fulfill post-traumatic stress disorder diagnostic criteria, but also their close relatives are at risk to develop PTSD. Minimal peer to peer resources exist in the community for these patients and families. We found this to be a gap in ECMO care and an area of opportunity for us to provide additional support to this patient population. Our team explored options for engaging and decided to host our first Pediatric ECMO Reunion. The reunion included both patients & families and multidisciplinary staff members who cared for our prior ECMO patients. This venue provided an opportunity for sharing patient stories, for ECMO providers to reconnect with survivors and staff to experience the positive outcomes from their work. This allowed for a first step for families to understand their experience and help decrease burnout in providers and staff. We provided families the option to stay in touch with the ECMO Program through different family work groups. We also interviewed families and distributed surveys for direct feedback on their experience working with our team while their child was on ECMO. Next steps include creating an ECMO Family Work Group by partnering with families to develop new ways to support future ECMO families and improve the ECMO family experience

Objectives/UNASSIGNED:Our aim was to describe the pharmacokinetics of cefazolin in paediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) who received cefazolin for peri-operative surgical prophylaxis in addition to having cefazolin added to the CPB circuit priming solution. Secondary aims were to determine the pharmacodynamic exposure associated with the addition of cefazolin to the CPB priming solution and to assess whether a target cefazolin concentration range for the CPB priming solution could be identified. Methods/UNASSIGNED:A multicentre, prospective, open-label pharmacokinetic study was carried out in children from birth to 16 years of age undergoing cardiac surgery. Results/UNASSIGNED:Forty-one patients met the inclusion criteria and accounted for 492 samples for analysis. Cefazolin concentrations were best described by a one-compartment model with weight as a covariate on the volume of distribution (Vd) with allometric scaling. The mean ± standard deviation (SD) total body CL for the birth-6 month cohort was 0.009 ± 0.006 mL/min/kg with a mean ± SD Vd of 0.59 ± 0.26 L/kg, the mean ± SD total body CL for the 7 month-3 year cohort was 0.01 ± 0.005 mL/min/kg with a mean ± SD Vd of 0.79 ± 0.15 L/kg, and the mean ± SD total body CL for the 4-16 year cohort was 0.007 ± 0.004 mL/min/kg with a mean ± SD Vd of 3.4 ± 0.94 L/kg. The median cefazolin loss in the CPB circuit ranged from 78% to 95% and the median patient cefazolin concentration after CPB circuit detachment ranged from 92 to 197 mg/L. Conclusions/UNASSIGNED:These data demonstrate that mixing cefazolin in the CPB circuit priming solution was effective in maintaining cefazolin serum concentrations during surgery. If this practice is utilized, re-dosing of cefazolin during the CPB run and upon CPB circuit detachment is most probably not needed. Larger pharmacokinetic studies are warranted.