DOCSLIB.ORG

Extracorporeal Membrane Oxygenation (ECMO)

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Extracorporeal Membrane Oxygenation (ECMO) 20, 2012 Health Technology Assessment Extracorporeal Membrane Oxygenation (ECMO) Final Evidence Report February 12, 2016 Health Technology Assessment Program (HTA) Washington State Health Care Authority PO Box 42712 Olympia, WA 98504-2712 (360) 725-5126 www.hca.wa.gov/hta [email protected] FINAL APPRAISAL DOCUMENT Extracorporeal Membrane Oxygenation (ECMO) February 12, 2016 Karin U. Travers, DSc Research Director Elizabeth Russo, MD Research Scientist Patricia Synnott, MALD, MS Research Associate Rick Chapman, PhD, MS Director of Health Economics Steven D. Pearson, MD, MSc President Daniel A. Ollendorf, PhD Chief Scientific Officer WA – Health Technology Assessment February 12, 2016 Contents List of Acronyms........................................................................................................................................ ii About ICER ............................................................................................................................................... iii Acknowledgements ................................................................................................................................. iv Executive Summary ............................................................................................................................. ES-1 ICER Integrated Evidence Ratings ...................................................................................................... ES-38 1. Background ........................................................................................................................................... 1 2. Washington State Agency Utilization Data ........................................................................................... 3 3. Treatment Strategies: Interventional and Conventional ...................................................................... 4 4. Clinical Guidelines and Training Standards ........................................................................................... 8 5. Medicare and Representative Private Insurer Coverage Policies ....................................................... 12 6. Previous Health Technology Assessments and Systematic Reviews .................................................. 14 7. Ongoing Comparative Studies ............................................................................................................ 17 8. Methods .............................................................................................................................................. 20 9. Results ................................................................................................................................................. 25 ICER Integrated Evidence Ratings ........................................................................................................... 52 Appendix A: Milestones in the Development of ECMO .......................................................................... 63 Appendix B: Literature Search Strategy .................................................................................................. 64 Appendix C: Summary Evidence Tables .................................................................................................. 66 Appendix D: ICER Integrated Evidence Ratings ...................................................................................... 91 Extracorporeal Membrane Oxygenation: Final Evidence Report Page i WA – Health Technology Assessment February 12, 2016 List of Acronyms AED Automated external defibrillators ARDS Acute respiratory distress syndrome AV Arteriovenous avECCO2-R Arteriovenous extracorporeal carbon dioxide removal CADTH Canadian Agency for Drugs and Technology in Health CI Confidence interval CMS Centers for Medicare and Medicaid COPD Chronic obstructive pulmonary disease CPB Cardiopulmonary bypass CPR Cardiopulmonary resuscitation ECCO2-R Extracorporeal carbon dioxide removal ECMO Extracorporeal membrane oxygenation ECLS Extracorporeal life support ED Emergency department ELSO Extracorporeal Life Support Organization FiO2 Fraction of inspired oxygen HR Hazard ratio ICU Intensive care unit iLA Interventional lung assist IQR Interquartile range LOS Length of stay LV Left ventricle NICE National Institute for Health and Care Excellence NIV Noninvasive ventilation NS Not significant OR Odds ratio PaC O2 Partial pressure of arterial CO2 PaO2 Arterial oxygen pressure pECLA Pumpless extracorporeal lung assist PEEP Positive end-expiratory pressure PICO Population, Intervention, Comparators, Outcomes PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses RCT Randomized controlled trial RR Relative risk SD Standard deviation SLR Systematic literature review SPO2 Oxygen saturation USPSTF united States Preventive Services Task Force VA Veno-arterial VAD Ventricular assist device VA-ECMO Veno-arterial ECMO VV Veno-venous VV-ECMO Veno-venous ECMO Extracorporeal Membrane Oxygenation: Final Evidence Report Page ii WA – Health Technology Assessment February 12, 2016 About ICER The Institute for Clinical and Economic Review (ICER) is an independent non-profit health care research organization dedicated to improving the interpretation and application of evidence in the health care system. ICER directs three core programs: the California Technology Assessment Forum (CTAF), the Midwest Comparative Effectiveness Public Advisory Council (Midwest CEPAC) and the New England Comparative Effectiveness Public Advisory Council (New England CEPAC). For more information about ICER, please visit ICER’s website, www.icer-review.org. Extracorporeal Membrane Oxygenation: Final Evidence Report Page iii WA – Health Technology Assessment February 12, 2016 Acknowledgements ICER would like to thank the following individuals for their expert opinions as well as peer review of draft documents: Eileen Bulger, MD FACS Professor of Surgery Chief of Trauma University of Washington Harborview Medical Center Michael Mulligan, MD Professor of Cardiothoracic Surgery Director of Lung Transplant Program Director of Advanced Lung Disease Surgery Program University of Washington Medical Center We would also like to thank Shanshan Liu of ICER for her contributions to this report. Extracorporeal Membrane Oxygenation: Final Evidence Report Page iv WA – Health Technology Assessment February 12, 2016 Executive Summary Background Extracorporeal membrane oxygenation (ECMO) is a form of life support that provides cardiopulmonary assistance outside the body. ECMO may be used to support lung function for severe respiratory failure or heart function for severe cardiac failure. An ECMO circuit can be set up as veno-venous (VV) or veno- arterial (VA). VV-ECMO provides external gas exchange, bypassing the lungs and protecting them from high tidal volumes of ventilation that would otherwise be needed to oxygenate and ventilate the patient. VV-ECMO is indicated for patients with potentially reversible respiratory failure, including those with severe acute respiratory distress syndrome (ARDS), primary graft dysfunction following lung transplant, and trauma to the lungs. VA-ECMO provides the same external gas exchange as VV-ECMO, but also augments blood flow in settings of severe cardiac injury. VA-ECMO is indicated for patients with cardiac failure, including cardiogenic shock unresponsive to typical intensive care medicines and cardiac arrest that does not respond to cardiopulmonary resuscitation (CPR). VA-ECMO may also be used for patients following heart surgery or as a bridge to heart transplantation. Both VA- and VV-ECMO may be used intraoperatively as a planned alternative to traditional cardiopulmonary bypass in selected patient populations (e.g., lung or heart transplantation). Other external gas exchange systems provide similar functions without the pump component of VV- or VA-ECMO. These arteriovenous extracorporeal lung assist devices bypass the lungs, but not the heart, and use the patient’s blood pressure in order to sustain circulation of externally oxygenated blood.1-3 Because of the requirement for adequate cardiac function in candidate patients, these systems have more limited application. These devices are known by a variety of names, including pumpless extracorporeal lung assist (pECLA), arteriovenous extracorporeal membrane carbon dioxide removal (avECCO2-R), or interventional lung assist (iLA). In this report, we refer to these devices by the name used by their clinical investigators, although these devices are functionally equivalent. Over the past 30 years, ECMO has become a well-established treatment for infants with lung and heart failure and has become a standard of care in many pediatric care centers.4 A large multicenter randomized controlled trial published in 1996 demonstrated a clear survival benefit with ECMO as well as a reduction in risk of severe disability in neonatal patients with severe respiratory failure.5 In contrast, early studies of ECMO in adults showed poor survival rates, and its use was limited for many years to pediatric populations with life-limiting illness.6,7 The lack of demonstrated benefit from these studies, published in 1979 and 1994, halted enthusiasm for widespread ECMO use. However, several developments have prompted renewed interest and wider utilization of ECMO in recent years.8 First, technological advancements have improved the safety of the technique and broadened the application.9 These improvements include heparin-coated cannulae, new oxygenators, and more efficient pump technology.10
Load more

Recommended publications
  • Mechanical Circulatory Support As Bridge Therapy for Heart Transplant: Case Series Report Javier D
    Garzon‑Rodriguez et al. BMC Res Notes (2018) 11:430 https://doi.org/10.1186/s13104-018-3515-2 BMC Research Notes CASE REPORT Open Access Mechanical circulatory support as bridge therapy for heart transplant: case series report Javier D. Garzon‑Rodriguez1, Carlos Obando‑Lopez2, Manuel Giraldo‑Grueso3* , Nestor Sandoval‑Reyes2, Jaime Camacho2 and Juan P. Umaña2 Abstract Background: Mechanical circulatory support (MCS) represents an efective urgent therapy for patients with cardiac arrest or end-stage cardiac failure. However, its use in developing countries as a bridge therapy remains controversial due to costs and limited duration. This study presents fve patients who underwent MSC as bridge therapy for heart transplantation in a developing country. Case presentation: We present fve patients who underwent MCS as bridge therapy for heart transplant between 2010 and 2015 at Fundación Cardioinfantil-Instituto de Cardiología. Four were male, median age was 36 (23–50) years. One patient had an ischemic cardiomyopathy, one a lymphocytic myocarditis, two had electrical storms (recurrent ventricular tachycardia) and one an ischemic cardiomyopathy with an electrical storm. Extracorporeal life sup‑ port (ECLS) was used in three patients, left ventricular assistance in one, and double ventricular assistance in one ­(Levitronix® ­Centrimag®). Median assistance time was 8 (2.5–13) days. Due to the inability of cardiopulmonary bypass weaning, two patients required ECLS after transplant. One patient died in the intensive care unit due to type I graft rejection. Endpoints assessed were 30-day mortality, duration of bridge therapy and complications related to MCS. Patients that died on ECLS, or were successfully weaned of ECLS were not included in this study.
    [Show full text]
  • Periprocedural Management of Oral Anticoagulation
    Nicole Hlavacek, PharmD candidate; Drew McMillan, PharmD Periprocedural management candidate; Jeremy Vandiver, PharmD, BCPS University of Wyoming of oral anticoagulation: School of Pharmacy, Laramie (Ms. Hlavacek, Mr. McMillan, and Dr. Vandiver); When and how to hit “pause” Swedish Family Medicine Residency, Littleton, Colo (Dr. Vandiver) Here’s how best to assess patients’ bleeding and [email protected] thrombotic risks and 5 key questions to ask as you The authors reported no consider withholding oral anticoagulants. potential conflict of interest relevant to this article. CASE 1 u PRACTICE Debra P is a 62-year-old African American woman who calls RECOMMENDATIONS your office to report that she has an upcoming routine colo- ❯ Don’t stop oral antico- noscopy planned in 2 weeks. She has been taking warfarin agulation for procedures with for the past 2 years for ischemic stroke prevention secondary minimal bleeding risk, such as minor dermatologic, dental, to atrial fibrillation (AF), and her gastroenterologist recom- or ophthalmic procedures. C mended that she contact her family physician (FP) to discuss periprocedural anticoagulation plans. Ms. P is currently tak- ❯ Reserve periprocedural ing warfarin 5 mg on Mondays, Wednesdays, and Fridays, bridging with a parenteral an- ticoagulant for those patients and 2.5 mg all other days of the week. Her international nor- on warfarin who are at high- malized ratio (INR) was 2.3 when it was last checked 2 weeks est risk for thromboembolism ago, and it has been stable and within goal range for the past (those with severe thrombo- 6 months. Her medical history includes AF, well-controlled philia, active thrombosis, or hypertension, and type 2 diabetes mellitus, as well as gout and mechanical heart valves).
    [Show full text]
  • Assessment Report COVID-19 Vaccine Astrazeneca EMA/94907/2021
    29 January 2021 EMA/94907/2021 Committee for Medicinal Products for Human Use (CHMP) Assessment report COVID-19 Vaccine AstraZeneca Common name: COVID-19 Vaccine (ChAdOx1-S [recombinant]) Procedure No. EMEA/H/C/005675/0000 Note Assessment report as adopted by the CHMP with all information of a commercially confidential nature deleted. Official address Domenico Scarlattilaan 6 ● 1083 HS Amsterdam ● The Netherlands Address for visits and deliveries Refer to www.ema.europa.eu/how-to-find-us Send us a question Go to www.ema.europa.eu/contact Telephone +31 (0)88 781 6000 An agency of the European Union © European Medicines Agency, 2021. Reproduction is authorised provided the source is acknowledged. Table of contents 1. Background information on the procedure .............................................. 7 1.1. Submission of the dossier ..................................................................................... 7 1.2. Steps taken for the assessment of the product ........................................................ 9 2. Scientific discussion .............................................................................. 12 2.1. Problem statement ............................................................................................. 12 2.1.1. Disease or condition ........................................................................................ 12 2.1.2. Epidemiology and risk factors ........................................................................... 12 2.1.3. Aetiology and pathogenesis .............................................................................
    [Show full text]
  • Organ Transplant Discrimination Against People with Disabilities Part of the Bioethics and Disability Series
    Organ Transplant Discrimination Against People with Disabilities Part of the Bioethics and Disability Series National Council on Disability September 25, 2019 National Council on Disability (NCD) 1331 F Street NW, Suite 850 Washington, DC 20004 Organ Transplant Discrimination Against People with Disabilities: Part of the Bioethics and Disability Series National Council on Disability, September 25, 2019 This report is also available in alternative formats. Please visit the National Council on Disability (NCD) website (www.ncd.gov) or contact NCD to request an alternative format using the following information: [email protected] Email 202-272-2004 Voice 202-272-2022 Fax The views contained in this report do not necessarily represent those of the Administration, as this and all NCD documents are not subject to the A-19 Executive Branch review process. National Council on Disability An independent federal agency making recommendations to the President and Congress to enhance the quality of life for all Americans with disabilities and their families. Letter of Transmittal September 25, 2019 The President The White House Washington, DC 20500 Dear Mr. President, On behalf of the National Council on Disability (NCD), I am pleased to submit Organ Transplants and Discrimination Against People with Disabilities, part of a five-report series on the intersection of disability and bioethics. This report, and the others in the series, focuses on how the historical and continued devaluation of the lives of people with disabilities by the medical community, legislators, researchers, and even health economists, perpetuates unequal access to medical care, including life- saving care. Organ transplants save lives. But for far too long, people with disabilities have been denied organ transplants as a result of unfounded assumptions about their quality of life and misconceptions about their ability to comply with post-operative care.
    [Show full text]
  • Ventilation Recommendations Table
    SURVIVING SEPSIS CAMPAIGN INTERNATIONAL GUIDELINES FOR THE MANAGEMENT OF SEPTIC SHOCK AND SEPSIS-ASSOCIATED ORGAN DYSFUNCTION IN CHILDREN VENTILATION RECOMMENDATIONS TABLE RECOMMENDATION #34 STRENGTH & QUALITY OF EVIDENCE We were unable to issue a recommendation about whether to Insufficient intubate children with fluid-refractory, catecholamine-resistant septic shock. However, in our practice, we commonly intubate children with fluid-refractory, catecholamine-resistant septic shock without respiratory failure. RECOMMENDATION #35 STRENGTH & QUALITY OF EVIDENCE We suggest not to use etomidate when intubating children • Weak with septic shock or other sepsis-associated organ dysfunction. • Low-Quality of Evidence RECOMMENDATION #36 STRENGTH & QUALITY OF EVIDENCE We suggest a trial of noninvasive mechanical ventilation (over • Weak invasive mechanical ventilation) in children with sepsis-induced • Very Low-Quality of pediatric ARDS (PARDS) without a clear indication for intubation Evidence and who are responding to initial resuscitation. © 2020 Society of Critical Care Medicine and European Society of Intensive Care Medicine Care Medicine. RECOMMENDATION #37 STRENGTH & QUALITY OF EVIDENCE We suggest using high positive end-expiratory pressure (PEEP) • Weak in children with sepsis-induced PARDS. Remarks: The exact level • Very Low-Quality of of high PEEP has not been tested or determined in PARDS Evidence patients. Some RCTs and observational studies in PARDS have used and advocated for use of the ARDS-network PEEP to Fio2 grid though adverse hemodynamic effects of high PEEP may be more prominent in children with septic shock. RECOMMENDATION #38 STRENGTH & QUALITY OF EVIDENCE We cannot suggest for or against the use of recruitment Insufficient maneuvers in children with sepsis-induced PARDS and refractory hypoxemia.
    [Show full text]
  • Use of Left Ventricular Assist Devices As Destination Therapy in End-Stage Congestive Heart Failure: a Systematic Review
    Department of Veterans Affairs Health Services Research & Development Service Evidence-based Synthesis Program Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review May 2012 Prepared for: Investigators: Department of Veterans Affairs Principal Investigators: Veterans Health Administration Thomas S. Rector, Ph.D. Quality Enhancement Research Initiative Brent C. Taylor, Ph.D., M.P.H. Health Services Research & Development Service Washington, DC 20420 Research Associates: Nancy Greer, Ph.D. Prepared by: Indulis Rutks, B.S. Evidence-based Synthesis Program (ESP) Center Minneapolis VA Medical Center Minneapolis, MN Timothy J. Wilt, M.D., M.P.H., Director Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review Evidence-based Synthesis Program PREFACE Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to improve the health and healthcare of Veterans. The ESP disseminates these reports throughout VA. QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The ESP Centers generate evidence syntheses on important clinical practice topics, and these reports help: • develop clinical policies informed by evidence, • guide the implementation of effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures, and • set the direction for future research to address gaps in clinical knowledge. In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central Office and the four ESP sites by developing and maintaining program processes.
    [Show full text]
  • Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan Laila Morrison a Dissertation Submitte
    1 Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan Laila Morrison A dissertation Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Washington 2016 Reading Committee: Ardith Doorenbos, Chair Barbara McGrath J. Randall Curtis Program Authorized to Offer Degree: School of Nursing 2 © Copyright 2016 Megan L. Morrison 3 University of Washington Abstract Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan L. Morrison Chair of the Supervisory Committee: Professor Ardith Z. Doorenbos School of Nursing End-stage heart failure is a growing problem in the United States as well as world-wide. The definitive treatment in heart failure that is refractory to medical treatment is a heart transplant. But there are a limited numbers of hearts available for transplant and a growing number of patients in need. There has recently been tremendous development in the area of mechanical circulatory support. One of these developments is the left ventricular assist device (LVAD). The LVAD is a pump that assists the failing left ventricle of the heart. The LVAD has proven to increase survival and improve symptoms of end-stage heart failure. Initially the LVAD was used to support patients with heart failure to survive to either recovery or heart transplant, thus termed a bridge therapy. But eventually these devices would be implanted without the intent of heart transplant or recovery, becoming known as destination therapy. A third category of LVAD designation is called bridge to candidacy. In this category 4 patients undergo the implantation of the LVAD and then are later determined whether they are appropriate for heart transplant.
    [Show full text]
  • Use of Extracorporeal Membrane Oxygenation in Patients with Acute High-Risk Pulmonary Embolism: a Case Series with Literature Review
    Acute and Critical Care 2019 May 34(2):148-154 Acute and Critical Care https://doi.org/10.4266/acc.2019.00500 | pISSN 2586-6052 | eISSN 2586-6060 Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review You Na Oh1, Dong Kyu Oh1, Younsuck Koh1, Chae-Man Lim1, Jin-Won Huh1, Jae Seung Lee1, Sung-Ho Jung2, Pil-Je Kang2, Sang-Bum Hong1 Departments of 1Pulmonary and Critical Care Medicine and 2Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: Although extracorporeal membrane oxygenation (ECMO) has been used for the treatment of acute high-risk pulmonary embolism (PE), there are limited reports which focus Original Article on this approach. Herein, we described our experience with ECMO in patients with acute high-risk PE. Received: April 10, 2019 Revised: May 16, 2019 Methods: We retrospectively reviewed medical records of patients diagnosed with acute high- Accepted: May 18, 2019 risk PE and treated with ECMO between January 2014 and December 2018. Results: Among 16 patients included, median age was 51 years (interquartile range [IQR], 38 Corresponding author to 71 years) and six (37.5%) were male. Cardiac arrest was occurred in 12 (75.0%) including Sang-Bum Hong two cases of out-of-hospital arrest. All patients underwent veno-arterial ECMO and median Department of Pulmonary and Critical Care Medicine, Asan Medical ECMO duration was 1.5 days (IQR, 0.0 to 4.5 days). Systemic thrombolysis and surgical embo- Center, University of Ulsan College lectomy were performed in seven (43.8%) and nine (56.3%) patients, respectively including of Medicine, 88 Olympic-ro 43-gil, three patients (18.8%) received both treatments.
    [Show full text]
  • Mechanical Ventilation Bronchodilators
    A Neurosurgeon’s Guide to Pulmonary Critical Care for COVID-19 Alan Hoffer, M.D. Chair, Critical Care Committee AANS/CNS Joint Section on Neurotrauma and Critical Care Co-Director, Neurocritical Care Center Associate Professor of Neurosurgery and Neurology Rana Hejal, M.D. Medical Director, Medical Intensive Care Unit Associate Professor of Medicine University Hospitals of Cleveland Case Western Reserve University To learn more, visit our website at: www.neurotraumasection.org Introduction As the number of people infected with the novel coronavirus rapidly increases, some neurosurgeons are being asked to participate in the care of critically ill patients, even those without neurological involvement. This presentation is meant to be a basic guide to help neurosurgeons achieve this mission. Disclaimer • The protocols discussed in this presentation are from the Mission: Possible program at University Hospitals of Cleveland, based on guidelines and recommendations from several medical societies and the Centers for Disease Control (CDC). • Please check with your own hospital or institution to see if there is any variation from these protocols before implementing them in your own practice. Disclaimer The content provided on the AANS, CNS website, including any affiliated AANS/CNS section website (collectively, the “AANS/CNS Sites”), regarding or in any way related to COVID-19 is offered as an educational service. Any educational content published on the AANS/CNS Sites regarding COVID-19 does not constitute or imply its approval, endorsement, sponsorship or recommendation by the AANS/CNS. The content should not be considered inclusive of all proper treatments, methods of care, or as statements of the standard of care and is not continually updated and may not reflect the most current evidence.
    [Show full text]
  • Tracheotomy in Ventilated Patients with COVID19
    Tracheotomy in ventilated patients with COVID-19 Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety Committee of the University of Pennsylvania Health System Tiffany N. Chao, MD1; Benjamin M. Braslow, MD2; Niels D. Martin, MD2; Ara A. Chalian, MD1; Joshua H. Atkins, MD PhD3; Andrew R. Haas, MD PhD4; Christopher H. Rassekh, MD1 1. Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia 2. Department of Surgery, University of Pennsylvania, Philadelphia 3. Department of Anesthesiology, University of Pennsylvania, Philadelphia 4. Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia Background The novel coronavirus (COVID-19) global pandemic is characterized by rapid respiratory decompensation and subsequent need for endotracheal intubation and mechanical ventilation in severe cases1,2. Approximately 3-17% of hospitalized patients require invasive mechanical ventilation3-6. Current recommendations advocate for early intubation, with many also advocating the avoidance of non-invasive positive pressure ventilation such as high-flow nasal cannula, BiPAP, and bag-masking as they increase the risk of transmission through generation of aerosols7-9. Purpose Here we seek to determine whether there is a subset of ventilated COVID-19 patients for which tracheotomy may be indicated, while considering patient prognosis and the risks of transmission. Recommendations may not be appropriate for every institution and may change as the current situation evolves. The goal of these guidelines is to highlight specific considerations for patients with COVID-19 on an individual and population level. Any airway procedure increases the risk of exposure and transmission from patient to provider.
    [Show full text]
  • Anticoagulation Protocol
    ANTICOAGULATION PROTOCOL Federal Bureau of Prisons Clinical Guidance MARCH 2018 This Anticoagulation Protocol is made available to the public for informational purposes only. The Federal Bureau of Prisons (BOP) does not warrant this guidance for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and that treatment decisions are patient specific. Consult the BOP Clinical Guidance Web page to determine the date of the most recent update to this document: http://www.bop.gov/resources/health_care_mngmt.jsp Federal Bureau of Prisons Anticoagulation Protocol Clinical Guidance March 2018 WHAT’S NEW IN THIS DOCUMENT? The following changes have been made to the BOP Anticoagulation Protocol since it was last issued in April 2013: • A new table has been added to Section 4, Heparin Products. See Table 2. Dosing of LMWHs for Treatment and Prevention. • In Section 5, Warfarin, the discussion has been expanded to include lifestyle factors and health conditions affecting warfarin therapy. See Interactions with Food, Drugs, Lifestyle, and Health Conditions. • A new Section 6 on Novel Oral Anticoagulants (NOACs) has been added. • Information on Treatment of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) has been updated in Section 7. • The Inmate Fact Sheet on Warfarin is now available in Spanish. See Appendix 9B. • The CHA2DS2-VASc score has replaced the CHADS2 score for predicting thromboembolic stroke risk in non-valvular atrial fibrillation. See Appendix 10, Table B. i Federal Bureau of Prisons Anticoagulation Protocol Clinical Guidance March 2018 TABLE OF CONTENTS 1.
    [Show full text]
  • Mechanical Ventilation Page 1 of 5
    UTMB RESPIRATORY CARE SERVICES Policy 7.3.53 PROCEDURE - Mechanical Ventilation Page 1 of 5 Mechanical Ventilation Effective: 10/26/95 Formulated: 11/78 Revised: 04/11/18 Mechanical Ventilation Purpose Mechanical Artificial Ventilation refers to any methods to deliver volumes of gas into a patient's lungs over an extended period of time to remove metabolically produced carbon dioxide. It is used to provide the pulmonary system with the mechanical power to maintain physiologic ventilation, to manipulate the ventilatory pattern and airway pressures for purposes of improving the efficiency of ventilation and/or oxygenation, and to decrease myocardial work by decreasing the work of breathing. Scope Outlines the procedure of instituting mechanical ventilation and monitoring. Accountability • Mechanical Ventilation may be instituted by a qualified licensed Respirator Care Practitioner (RCP). • To be qualified the practitioner must complete a competency based check off on the ventilator to be used. • The RCP will have an understanding of the age specific requirements of the patient. Physician's Initial orders for therapy must include a mode (i.e. mandatory Order Ventilation/Assist/Control, pressure control etc., a Rate, a Tidal Volume, and an Oxygen concentration and should include a desired level of Positive End Expiratory Pressure, and Pressure Support if applicable. Pressure modes will include inspiratory time and level of pressure control. In the absence of a complete follow up order reflecting new ventilator changes, the original ventilator settings will be maintained in compliance with last order until physician is contacted and the order is clarified. Indications Mechanical Ventilation is generally indicated in cases of acute alveolar hypoventilation due to any cause, acute respiratory failure due to any cause, and as a prophylactic post-op in certain patients.
    [Show full text]