what is in your ecmo? 1245 Decontamination Prior to 2017. From the summer of 2015
to December 2017, the decontamination of the ECMO unit involved draining each HU35, refilling it with filtered tap water (0.2 µm filter, Pall, New York, NY; changed every month as per manufacturer’s instructions) and addition of a Disifin tablet (buffered sodium p-toluenesulfonchloramide, Disifin, Bedfordshire, UK) to the device. The HU35 was switched on, and the tablet was circulated in the unit for 30 minutes, after which the water was removed and tank was rinsed. Decontamination After 2017. A change in the manufacturer’s
guidance in September 2016 resulted in the use of a chlorine- releasing agent.10 At UHB, we have carried out the new guidance fromJanuary 2017 to the present.Ahigh-level disinfection atUHB was performed on the HU35 to reduce the bioburden. This procedure was performed once because atypical mycobacteria were present in the water system. Briefly, the HU35 was emptied while the device was off, then the entire water volume of theHU35 was refilled with a 5% chloramine-T (Chlorina, Germany) solution. According to the manufacturer’s instructions, each HU35 was disinfected for 110 minutes while the device was on. Afterward, the solution was left in the tank for 24 hours (with the unit was switched off). The HU35 was then switched on for 5minutes, the solution was removed, and the tankwas rinsed. The HU35 was running for 3 minutes during the rinse process.10 Following this high-level disinfection, a weekly disinfection protocol using 2% chloramine-T was carried out every 7 days and after each use of the device.10 Briefly, this procedure involved emptying the HU35 while it was switched off, disinfecting the device for 110 minutes with 2%chloramine-Twhileit was running, and finally rinsing the HU35 with filtered water while it was running for 3 minutes.10
results Water Results
Water counts from the HU35s using the pre-2017 disinfection method yielded TVCs >300 CFU per 100 mL, including a range of environmental Gram-negative isolate (e.g., Pseudomonas aeruginosa)and as non-Aspergillus molds (Table 1). Mycobacterium chimaera was cultured from water samples sent to the Myco- bacterium Reference Laboratory (Table 1).With TVCs>300 CFU
per 100 mL using the pre-2017 disinfection regimen, a high-level disinfection was undertaken, this time with a chlorine-releasing agent (5%chloramine-T) to reduce the bioburden in the HU35s. After the high-level disinfection procedure, water samples yielded 0CFU per100 mL.Eversince, weekly watersamples have been taken before and after the weekly disinfection and/or disinfection after use; thus far, these weekly water samples have yielded 0 CFU per 100 mL and no atypicalmycobacteria.
discussion
Invasive M. chimaera infections associated with HCUs have been reported throughout Europe.6 The risk for transmission of waterborne pathogens and subsequent infection risk posed by ECMOdevices at present
remainsunclear.Trudzinskietal8 (2016) detected M. chimaera in 9 of18water samplesfrom10different thermoregulatory ECMO devices; no mycobacteria were found in the 9 room air samples and other environmental samples. Among 118ECMOpatients, 76 had bronchial specimens analyzed for mycobacteria, and M. chimaera was found in 3 individuals without signs of mycobacterial infection at the time of sampling.8 Trudzinski et al8 (2016) concluded that M. chimaera can be detected in water samples from ECMO-associated thermo- regulatory devices and might potentially put patients at risk of infection. In patients presenting with severe acute respiratory distress
syndrome (ARDS) who become unresponsive to conventional treatment, the use of ECMO, which temporary replaces pulmon- ary function, can represent a life-saving alternative while the underlying cause is resolved.8 An ECMO can be used as a rescue therapy to avoid injurious effects of mechanical ventilation and to rescue patients from extreme gasometrical alterations.8 Data from our study show that the ECMO devices used at UHB were contaminated with environmental Gram-negative bacteria (eg, Pseudomonas species, atypical mycobacteria, and fungi),which may pose an infection risk in cardiac patients. Atypical myco- bacteria can be detected in household water and water-containing medical devices,4,8 andithasbeenshownthattheLivaNova 3T HCUs, which use water for thermoregulation during cardioplegia, are responsible for the recent M. chimaera outbreak worldwide.1,6 Chand et al6 (2017) postulated that a point source for the con- tamination of HCUs had occurred, that is, that the LivaNova
table 1. Decontamination Results of the Extracorporeal Membrane Oxygenator Heater Unit 35 (ECMO HU35) Devices Used at UHB
Decontamination Regimen Before 2017
After 2017 high-level disinfection intervention
Weekly countsa
Total Value Counts
>300 CFU 0 CFU
0 CFU
Environmental Gram Negative
+
Pseudomonas spp.
+
Fungi +
Mycobacterium chimaera
+
– −−− – −−−
NOTE: CFU, colony-forming units; +, organism(s) present; −, no organisms present. aWeekly water samples are taken before and after the weekly disinfection or disinfection after use. Thus far, weekly water samples have yielded 0 CFU per 100 mL and no atypical mycobacteria.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
