The protekduo cannula for acute right ventricular support in thyrotoxicosis.

A 25-year-old female was presented with acute right heart failure (aRHF) and cardiogenic shock secondary to thyrotoxicosis with concomitant acute respiratory failure. A ProtekDuo cannula was placed to provide temporary percutaneous right ventricular assistance and extracorporeal membrane oxygenation (ECMO) in venopulmonary (V-P) configuration, which provided both decompression of the right ventricle (RV) and oxygenation. With treatment of the underlying thyrotoxicosis, the RV function improved and respiratory failure resolved. She was discharged home in good condition. This case details alternative ECMO management with ProtekDuo compared to the gold standard of venoarterial (V-A) ECMO.

Bridging the gap: safety and outcomes of intensivist-led ECMO retrievals.

Purpose: Most extracorporeal membrane oxygenation (ECMO) cannulations are performed by cardiothoracic surgeons (CTS). Due to an increase in utilization of ECMO and limited availability of CTS, there is a mismatch between ECMO demand and CTS accessibility for remote cannulations. We report our intensivist-led program's experience in remote ECMO cannulations, retrievals, complications, and outcomes. Materials and methods: A prospective, single-center, observational study was performed on patients that required ECMO cannulation at the referring facilities and were transported to our institution between program initiation, on October 1, 2014 to September 30, 2022. Results were presented as mean ± SD, median (min - max) or number (%). Results: Since program commencement, 305 patients were accepted for ECMO retrieval. Three hundred and three patients were placed on ECMO at the 47 referring hospitals among 5 states. In our study, 185 (61%) patients required veno-arterial ECMO and 115 (38%) were placed on veno-venous ECMO. Three patients (1%) were cannulated for veno-arteriovenous ECMO. Twenty patients were cannulated under cardio-pulmonary resuscitation. Most of the patients were transported by ambulance (79%), 14% by helicopter, and 7% by airplane. Six out of the 303 patients did not leave the referring facility. All patients that left the referring hospitals arrived safely to our institution. No major complications occurred in route. Conclusion: Our study's findings indicate that non-CTS physicians can successfully cannulate and retrieve patients with a low complication profile.

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials.

Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN: A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING: Seven emergency departments and 17 ICUs across the United States. PATIENTS: One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66). CONCLUSIONS: The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

The ProtekDuo in percutaneous peripheral venopulmonary-arterial ECMO and PROpella configuration for cardiogenic shock with biventricular failure.

This article describes a case study where a patient with ProtekDuo + oxygenator and Impella CP (PROpella) in biventricular failure and cardiogenic shock was reconfigured to venopulmonary-arterial (VP-A) extracorporeal membrane oxygenation (ECMO), secondary to leg ischemia. The ProtekDuo was subsequently used as double-lumen drainage cannula, returning blood into a newly percutaneously placed femoral arterial cannula, mimicking venoarterial (V-A) ECMO in VP-A configuration. The following day, an Impella 5.5 could be placed and the ProtekDuo was reconfigured back to its default venopulmonary (V-P) ECMO configuration, now again as PROpella with minimally invasive biventricular groin-free full mechanical circulatory support. However, while in VP-A, good drainage blood flows of up to 4.5 LPM could be achieved similar to the ProtekDuo forward flow. None of the lumens collapsed secondary to negative pressure in the system. Drainage through the ProtekDuo for VP-A ECMO is feasible and without complications for a 24-hour period. This new method extends the ProtekDuo's spectrum of use.

Extracorporeal Life Support in Adult Burn Care: A Systematic Review.

We sought to review the role of extracorporeal membrane oxygenation (ECMO) for the management of burn and smoke inhalation injury in the adult patient population. Therefore, we conducted a systematic search of the literature according to specific combination of key words to ascertain the effectiveness of this support strategy. A total of 26 articles were filtered out of 269 and considered suitable for this study. The PICOS approach and PRISMA flow chart were followed for the purposes of our review. Although there is growing evidence supporting the role of ECMO as an option for burn injury in the adult patient population, this strategy should be considered if a likely successful outcome is expected.

Extracorporeal life support in pregnant and postpartum women with COVID-19-related acute respiratory distress syndrome.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is an intervention used for patients with acute respiratory distress syndrome (ARDS) from COVID-19 who have failed conventional ventilatory strategies. Very few studies have given insight into the outcomes of pregnant and postpartum patients requiring ECMO support. METHODS: Single center, retrospective, observational study of female pregnant and postpartum patients suffering COVID-19 ARDS and requiring ECMO. RESULTS: Eight SARS-CoV-2 positive patients were identified. The average age was 31 ± 4 years, with Body Mass Indices (BMI) and SOFA scores ranging between 32-49 and 8-11, respectively. Two patients were pregnant at the time of ECMO initiation, two were peripartum, and four were postpartum. Five patients (63%) had bleeding, and one patient had a hysterectomy. Seven patients (88%) were supported by V-V ECMO and one with V-A ECMO. Patients had between one and three circuit exchanges due to oxygenator failure or clots in the circuit. All patients were in ICU between 7 and 74 days, with hospital length of stay between 8 and 81 days. All patients were weaned off ECMO and were successfully discharged from the hospital. All newborns were born via cesarean section, and all survived to discharge. CONCLUSION: Our study shows a 100% neonatal and maternal survival rate demonstrating that ECMO in this patient population is safe. These patients should be transferred to experienced high-volume ECMO centers with the ability to perform emergent cesarean sections. ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19 with an overall excellent maternal and neonatal survival rate.

Laryngoscopy and Tracheal Intubation: Does Use of a Video Laryngoscope Facilitate Both Steps of the Procedure?

STUDY OBJECTIVE: To compare the effect of the use of a video laryngoscope versus a direct laryngoscope on each step of emergency intubation: laryngoscopy (step 1) and intubation of the trachea (step 2). METHODS: In a secondary observational analysis of data from 2 multicenter, randomized trials that enrolled critically ill adults undergoing tracheal intubation but did not control for laryngoscope type (video laryngoscope vs direct laryngoscope), we fit mixed-effects logistic regression models examining the 1) the association between laryngoscope type (video laryngoscope vs direct laryngoscope) and the Cormack-Lehane grade of view and 2) the interaction between grade of view, laryngoscope type (video laryngoscope vs direct laryngoscope), and the incidence of successful intubation on the first attempt. RESULTS: We analyzed 1,786 patients: 467 (26.2%) in the direct laryngoscope group and 1,319 (73.9%) in the video laryngoscope group. The use of a video laryngoscope was associated with an improved grade of view as compared with a direct laryngoscope (adjusted odds ratio for increasingly favorable grade of view 3.14, 95% confidence interval [CI] 2.47 to 3.99). Successful intubation on the first attempt occurred in 83.2% of patients in the video laryngoscope group and 72.2% of patients in the direct laryngoscope group (absolute difference 11.1%, 95% CI 6.5% to 15.6%). Video laryngoscope use modified the association between grade of view and successful intubation on the first attempt such that intubation on the first attempt was similar between video laryngoscope and direct laryngoscope at a grade 1 view and higher for video laryngoscope than direct laryngoscope at grade 2 to 4 views (P<.001 for interaction term). CONCLUSIONS: Among critically ill adults undergoing tracheal intubation, the use of a video laryngoscope was associated both with a better view of the vocal cords and with a higher probability of successfully intubating the trachea when the view of the vocal cords was incomplete in this observational analysis. However, a multicenter, randomized trial directly comparing the effect of a video laryngoscope with a direct laryngoscope on the grade of view, success, and complications is needed.

Defining Successful Intubation on the First Attempt Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data.

STUDY OBJECTIVES: Successful intubation on the first attempt has historically been defined as successful placement of an endotracheal tube (ETT) using a single laryngoscope insertion. More recent studies have defined successful placement of an ETT using a single laryngoscope insertion followed by a single ETT insertion. We sought to estimate the prevalence of first-attempt success using these 2 definitions and estimate their associations with the duration of intubation and serious complications. METHODS: We performed a secondary analysis of data from 2 multicenter randomized trials of critically ill adults being intubated in the emergency department or ICU. We calculated the percent difference in successful intubations on the first attempt, median difference in the duration of intubation, and percent difference in the development of serious complications by definition. RESULTS: The study population included 1,863 patients. Successful intubation on the first attempt decreased by 4.9% (95% confidence interval 2.5% to 7.3%) when defined as 1 laryngoscope insertion followed by 1 ETT insertion (81.2%) compared with when defined as only 1 laryngoscope insertion (86.0%). When successful intubation with 1 laryngoscope and 1 ETT insertion was compared with 1 laryngoscope and multiple ETT insertions, the median duration of intubation decreased by 35.0 seconds (95% confidence interval 8.9 to 61.1 seconds). CONCLUSION: Defining successful intubation on the first attempt as placement of an ETT in the trachea using 1 laryngoscope and 1 ETT insertion identifies attempts with the shortest apneic time.

Venoarterial extracorporeal membrane oxygenation for "protected" catheter-based embolectomy in high-risk/massive pulmonary embolism.

High-risk/massive pulmonary embolism (PE) has a high mortality rate, especially when cardiac arrest occurs. Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) can rapidly restore and maintain circulation while a decision regarding further care or performance of other interventions takes place. Catheter-based embolectomy (CBE) is a technology that allows for percutaneous access, clot removal, and potential resolution of shock while avoiding sternotomy required for traditional pulmonary embolectomy. Rapid placement of V-A ECMO in patients with high-risk/massive PE prior to CBE may confer circulatory protection before, during, and after the procedure.

Ventilatory Failure And Pulmonary Embolism In Covid-19 Requiring Enhanced Venous Drainage For Extracorporeal Membrane Oxygenation.

COVID-19 infection manifests as a spectrum of respiratory and vascular complications, including acute respiratory distress syndrome (ARDS) and pulmonary embolism. Herein, we describe a case of a healthy young male who presented with ARDS refractory to mechanical ventilation and concomitant bilateral pulmonary emboli managed with extracorporeal membrane oxygenation (ECMO) and embolectomy. The embolectomy and initial veno-venous ECMO configuration failed to correct the patient's hypoxemia despite maximal flows. This was thought to be due to a high-output state secondary to vasodilatory shock preventing adequate drainage from the existing single drainage ECMO cannulation, following which a second venous cannula was placed to form a unique veno-veno-venous ECMO circuit that resolved the persistent hypoxemia. The case underscores the importance of identifying embolic events and vasodilatory shock in COVID-19 patients, both of which need to be addressed simultaneously to avoid worsening right ventricular failure (via both mechanical and hypoxia-driven pathways) and the resulting veno-arterial ECMO along with its associated complications.

The ProtekDuo dual-lumen cannula for temporary acute mechanical circulatory support in right heart failure: A systematic review.

INTRODUCTION: Acute right ventricular failure (aRVF) is associated with high mortality and morbidity. Mechanical circulatory support (MCS) may be considered as an advanced treatment option. The ProtekDuo is a cannula that can be used to provide acute right ventricular support as part of a temporary percutaneous (tp) right ventricular assist device (RVAD) system. The primary objective of this systematic review is to describe patient survival and complications when the ProtekDuo cannula was used as part of an tpRVAD system. METHODS: MEDLINE, Embase, and Scopus were searched from database inception to August 26, 2022. Reference sections of studies were reviewed to screen for database omissions. RESULTS: Seven studies with 127 patients were eligible for inclusion. The studies included patients with aRVF from a variety of causes. Mean duration of support was between 10 and 58 days in five studies. Patient survival to discharge was between 60% and 85.2% in two studies. Four authors reported 30-day survival between 60% and 85.2%. Devicerelated and non-device related complications were low. CONCLUSIONS: Patients treated with RVAD using the ProtekDuo cannula have comparable survival rates and complications to other tpRVAD systems. Several advantages exist compared to other RVAD systems.

The ProtekDuo in ECMO configuration for ARDS secondary to COVID-19: A systematic review.

OBJECTIVE: Assessment of the results of the ProtekDuo cannula applied for dedicated right ventricular support with oxygenator in ARDS secondary to COVID-19. METHODS: Systematic literature search in NHS library, Medline (Pubmed) and EMBASE using appropriate keywords as well as PICOS and PRISMA approach. RESULTS: Out of 285 publications found, 5 publications met the search criteria and were included in this review. A total of 194 patients with ARDS secondary to COVID-19 underwent ProtekDuo placement to establish a combination of respiratory [veno-venous extracorporeal membrane oxygenation (V-V ECMO)] and right ventricular support. Patients treated using the ProtekDuo cannula had survival rates between 59% and 89% throughout the five studies, and a significant survival benefit when compared to an invasive ventilation group or compared to dual site V-V ECMO or other double lumen ECMO cannulas. One study focused on extubation and discontinuation of ventilator support, which could be achieved in 100% of ProtekDuo patients. An association for reduced incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) could be shown when the ProtekDuo was used. CONCLUSION: Only limited literature is available for the ProtekDuo in V-P ECMO configuration in the setting of COVID-19 ARDS and should be interpreted with caution. Data on the ProtekDuo is suggestive for lower rates of mortality, AKI and CRRT as compared to other respiratory support modalities.

Feasibility of using the ProtekDuo cannula in V-P ECMO and PROpella configurations during ground and air transport.

INTRODUCTION: Use of the ProtekDuo cannula has been described for right ventricular assist devices (RVADs) and extracorporeal membrane oxygenation (ECMO) systems. CASE REPORT: We describe remote cannulation and transport of two patients with ProtekDuo cannula. One patient had isolated acute right ventricular failure (aRVF), was cannulated with ProtekDuo cannula in venopulmonary (V-P) configuration and transported by ambulance. Another patient had biventricular failure after myocardial infarction, was supported with ProtekDuo and Impella CP in PROpella configuration, and transported by helicopter. DISCUSSION: We appear to be the first group to report remote cannulation using the ProtekDuo cannula followed by ambulance and helicopter transport, which were performed without complication. We describe the pros and cons of these configurations in comparison to the gold standard of shock management with venoarterial ECMO, as well as important considerations for transport. CONCLUSION: Use of the ProtekDuo cannula for remote cannulations and transport is feasible and appears safe.

The ProtekDuo for percutaneous V-P and V-VP ECMO in patients with COVID-19 ARDS.

OBJECTIVE: The ProtekDuo with oxygenator mimics veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) in veno-pulmonary (V-P) configuration. We have recently developed a new configuration by utilizing a 25 Fr multistage femoral venous drainage cannula and by returning oxygenated blood through both lumina of the double lumen ProtekDuo cannula (V-VP configuration), thereby creating partial right ventricular bypass and oxygenated blood flow of up to seven LPM. We investigated our experience with V-P and V-VP ECMO in patients suffering from COVID-19 acute respiratory distress syndrome (ARDS). METHODS: Single center, retrospective observational study. RESULTS: Of nine patients, one was initiated on V-A, two on V-P, and six on V-V ECMO. All patients were reconfigured to V-P and five patients in addition had V-VP ECMO configuration. All patients had at least one and up to three circuit exchanges. Patients were on ECMO support between 20 and 122 (55 ± 29) days, were in ICU between 46 and 161 (78 ± 40) days with a total hospital length of stay between 35 and 171 (82 ± 42) days. Six of nine (67%) patients could successfully be weaned off ECMO, survived, and were discharged. CONCLUSION: The ProtekDuo cannula in V-P configuration provides ECMO blood flow while reducing RV flow, wall-stress and dilatation, as well as oxygen consumption. The V-VP configuration is useful to provide high blood flows of up to seven LPM of oxygenated blood, and partial RV support without over-circulating the pulmonary vascular bed. Our results show that V-P and V-VP ECMO configurations are feasible, have good outcome and are without complications.

Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial.

Importance: Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain. Objective: To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death. Design, Setting, and Participants: This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021. Interventions: Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527). Main Outcomes and Measures: The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge. Results: Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55). Conclusions and Relevance: Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse. Trial Registration: ClinicalTrials.gov Identifier: NCT03787732.

Protocol and statistical analysis plan for the PREventing cardiovascular collaPse with Administration of fluid REsuscitation during Induction and Intubation (PREPARE II) randomised clinical trial.

INTRODUCTION: Cardiovascular collapse is a common complication during tracheal intubation of critically ill adults. Whether administration of an intravenous fluid bolus prevents cardiovascular collapse during tracheal intubation remains uncertain. A prior randomised trial found fluid bolus administration to be ineffective overall but suggested potential benefit for patients receiving positive pressure ventilation during tracheal intubation. METHODS AND ANALYSIS: The PREventing cardiovascular collaPse with Administration of fluid REsuscitation during Induction and Intubation (PREPARE II) trial is a prospective, multi-centre, non-blinded randomised trial being conducted in 13 academic intensive care units in the USA. The trial will randomise 1065 critically ill adults undergoing tracheal intubation with planned use of positive pressure ventilation (non-invasive ventilation or bag-mask ventilation) between induction and laryngoscopy to receive 500 mL of intravenous crystalloid or no intravenous fluid bolus. The primary outcome is cardiovascular collapse, defined as any of: systolic blood pressure <65 mm Hg, new or increased vasopressor administration between induction and 2 min after intubation, or cardiac arrest or death between induction and 1 hour after intubation. The primary analysis will be an unadjusted, intention-to-treat comparison of the primary outcome between patients randomised to fluid bolus administration and patients randomised to no fluid bolus administration using a χ2 test. The sole secondary outcome is 28-day in-hospital mortality. Enrolment began on 1 February 2019 and is expected to conclude in June 2020. ETHICS AND DISSEMINATION: The trial was approved by either the central institutional review board at Vanderbilt University Medical Center or the local institutional review board at each trial site. Results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER: NCT03787732.

Risk factors, complication and measures to prevent or reverse catastrophic sodium overcorrection in chronic hyponatremia.

Hyponatremia is the most common electrolyte disorder encountered in clinical practice. Patients who develop this condition for more than 48 hours are at risk for severe neurological sequelae if correction of the serum sodium occurs too rapidly. Certain medical disorders are known to place patients at an increased risk for rapid correction of serum sodium concentration. Large-volume polyuria in this setting is an ominous sign. For these patients, early identification of risk factors, close monitoring of serum sodium correction and the use of 5% dextrose with or without desmopressin to prevent or reverse overcorrection are important components of treatment.