Postcardiotomy extracorporeal membrane oxygenation: narrative review navigating the ethical issues

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Akram M Zaaqoq

MedStar Washington Hospital Center, USA

: J Nurs Patient Care

Abstract

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Post-cardiotomy shock (PCS) is an uncommon and lifethreatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a “therapeutic ceiling” or a “bridge to nowhere” is a common clinical scenario where medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, we conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations come from practice parameters or expert opinions to support specific interventions. We proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Our proposed algorithm is based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. We suggest focused discussions around the commencement of ECMO or other life-sustaining therapies – ideally preoperatively at the time of consent – through shared decision-making. Subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.

Biography

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Akram M Zaaqoq is a critical care physician and educator with primary research interest. He defines his purpose is to "advance patient care while building knowledge and helping a new generation of clinicians to pursue their career dreams". He is board certified in both internal medicine and critical care medicine by the American Board of Internal Medicine (ABIM). He finished his critical care medicine and research fellowship at University of Pittsburgh Medical Center (UPMC), where he still holds an adjunct research position in the department of surgery. The primary clinical focus is on managing critically ill patients and complex medical cases that require life-saving supportive measures, mainly acute mechanical support devices (ECMO). Also, interested in clinical research related to ECMO management, short-term and long-term outcomes. He is focusing on bridging the gap between basic science and clinical research in the field of inflammation. He worked on multiple research projects related to sepsis, trauma, and hemorrhagic shock. Mainly focusing on understanding the complex inflammatory process, utilizing mathematical modeling techniques for prediction and possible interventions.