Prehospital Ground and Helicopter-Based Extracorporeal Cardiopulmonary Resuscitation (ECPR) Reduce Barriers to ECPR: A GIS Model.

INTRODUCTION: Evidence suggests that Extracorporeal Cardiopulmonary Resuscitation (ECPR) can improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). However, when ECPR is indicated over 50% of potential candidates are unable to qualify in the current hospital-based system due to geographic limitations. This study employs a Geographic Information System (GIS) model to estimate the number of ECPR eligible patients within the United States in the current hospital-based system, a prehospital ECPR ground-based system, and a prehospital ECPR Helicopter Emergency Medical Services (HEMS)-based system. METHODS: We constructed a GIS model to estimate ground and helicopter transport times. Time-dependent rates of ECPR eligibility were derived from the Resuscitation Outcome Consortium (ROC) database, while the Cardiac Arrest Registry to Enhance Survival (CARES) registry determined the number of OHCA patients meeting ECPR criteria within designated transportation times. Emergency Medical Services (EMS) response time, ECPR candidacy determination time, and on-scene time were modeled based on data from the EROCA trial. The combined model was used to estimate the total ECPR eligibility in each system. RESULTS: The CARES registry recorded 736,066 OHCA patients from 2013 to 2021. After applying clinical criteria, 24,661 (3.4%) ECPR-indicated OHCA were identified. When considering overall ECPR eligibility within 45 min from OHCA to initiation, only 11.76% of OHCA where ECPR was indicated were eligible in the current hospital-based system. The prehospital ECPR HEMS-based system exhibited a four-fold increase in ECPR eligibility (49.3%), while the prehospital ground-based system showed a more than two-fold increase (28.4%). CONCLUSIONS: The study demonstrates a two-fold increase in ECPR eligibility for a prehospital ECPR ground-based system and a four-fold increase for a prehospital ECPR HEMS-based system compared to the current hospital-based ECPR system. This novel GIS model can inform future ECPR implementation strategies, optimizing systems of care.

The state of emergency department extracorporeal cardiopulmonary resuscitation: Where are we now, and where are we going?

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged in the context of the emergency department as a life-saving therapy for patients with refractory cardiac arrest. This review examines the utility of ECPR based on current evidence gleaned from three pivotal trials: the ARREST trial, the Prague study, and the INCEPTION trial. We also discuss several considerations in the care of these complex patients, including prehospital strategy, patient selection, and postcardiac arrest management. Collectively, the evidence from these trials emphasizes the growing significance of ECPR as a viable intervention, highlighting its potential for improved outcomes and survival rates in patients with refractory cardiac arrest when employed judiciously. As such, these findings advocate the need for further research and protocol development to optimize its use in diverse clinical scenarios.

Direct Connection to the ECMO Circuit versus a Hemodialysis Catheter Is Associated with Improved Urea Nitrogen Ultrafiltration during Continuous Renal Replacement Therapy for Patients on Extracorporeal Membrane Oxygenation.

For patients on extracorporeal membrane oxygenation (ECMO) who require renal replacement therapy (RRT), dialysis can be achieved through a dedicated hemodialysis (HD) catheter or direct connection to the ECMO circuit. The relative effect of each on filtration efficacy is not known. We conducted a retrospective single-center analysis of patients on ECMO who required CRRT. We examined the outcomes of blood biomarkers and transmembrane filter pressures, comparing sessions by attachment approach. All analyses were clustered by patient. Of the 33 patients (7 ECMO access and 23 HD catheter access) that met the inclusion criteria, there were a total of 493 CRRT sessions (93 ECMO access and 400 HD catheter access). At the end of the first 12 h of CRRT therapy, the ECMO group had a greater rate of decline in serum BUN than the HD catheter access group (2.5 mg/dl (SD 11) vs. 2 mg/dl (SD 6), p = 0.035). Additionally, the platelet level was significantly higher in the ECMO group compared to the HD catheter access group after 72 h (94.5 k/uL (SD 41) vs. 71 k/uL (SD 29), p = 0.008). Utilizing the ECMO circuit as direct venous access for CRRT was associated with some improved filtration proximal outcomes.

Effect of Portable, In-Hospital Extracorporeal Membrane Oxygenation on Clinical Outcomes.

The time between onset of cardiogenic shock and initiation of mechanical circulatory support is inversely related to patient survival as delays in transporting patients to the operating room (OR) for venoarterial extracorporeal membrane oxygenation (VA ECMO) could prove fatal. A primed and portable VA ECMO system may allow faster initiation of ECMO in various hospital locations and subsequently improve outcomes for patients in cardiogenic shock. We reviewed our institutional experience with VA ECMO based on two time periods: beginning of our VA ECMO program and from initiation of our primed and portable in-hospital ECMO system. The primary endpoint was patient survival to discharge. A total of 137 patients were placed on VA ECMO during the study period; n = 66 (48%) before and n = 71 (52%) after program initiation. In the second era, the proportion of OR ECMO initiation decreased significantly (from 92% to 49%, p < 0.01) as more patients received ECMO in other hospital units, including the emergency department (p < 0.01) and during cardiac arrest (12% vs. 38%, p < 0.01). Survival to hospital discharge was equivalent between the two groups (30% vs. 42%, p = 0.1) despite more patients being placed on ECMO during ongoing cardiac arrest. Finally, we observed increased clinical volume since initiation of the in-hospital, portable ECMO system. Developing an in-hospital, primed and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.

Impact of renin-angiotensin-aldosterone system inhibition on mortality in critically ill COVID-19 patients with pre-existing hypertension: a prospective cohort study.

BACKGROUND: The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients. METHODS: Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission. RESULTS: A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge. CONCLUSIONS: In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 .

A Rapid Antigen Detection Test to Diagnose SARS-CoV-2 Infection Using Exhaled Breath Condensate by A Modified Inflammacheck® Device.

BACKGROUND: The standard test that identifies the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is based on reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal (NP) swab specimens. We compared the accuracy of a rapid antigen detection test using exhaled breath condensate by a modified Inflammacheck® device with the standard RT-PCR to diagnose SARS-CoV-2 infection. METHODS: We performed a manufacturer-independent, cross-sectional, diagnostic accuracy study involving two Italian hospitals. Sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), positive (PPV) and negative predictive value (NPV) and diagnostic accuracy with 95% confidence intervals (95% CI) of Inflammacheck® were calculated using the RT-PCR results as the standard. Further RT-PCR tests were conducted on NP specimens from test positive subjects to obtain the Ct (cycle threshold) values as indicative evidence of the viral load. RESULTS: A total of 105 individuals (41 females, 39.0%; 64 males, 61.0%; mean age: 58.4 years) were included in the final analysis, with the RT-PCR being positive in 13 (12.4%) and negative in 92 (87.6%). The agreement between the two methods was 98.1%, with a Cohen's κ score of 0.91 (95% CI: 0.79-1.00). The overall sensitivity and specificity of the Inflammacheck® were 92.3% (95% CI: 64.0%-99.8%) and 98.9% (95% CI: 94.1%-100%), respectively, with a PLR of 84.9 (95% CI: 12.0-600.3) and a NLR of 0.08 (95% CI: 0.01-0.51). Considering a 12.4% disease prevalence in the study cohort, the PPV was 92.3% (95% CI: 62.9%-98.8%) and the NPV was 98.9% (95% CI: 93.3%-99.8%), with an overall accuracy of 98.1% (95% CI: 93.3%-99.8%). The Fagan's nomogram substantially confirmed the clinical applicability of the test in a realistic scenario with a pre-test probability set at 4%. Ct values obtained for the positive test subjects by means of the RT-PCR were normally distributed between 26 and 38 cycles, corresponding to viral loads from light (38 cycles) to high (26 cycles). The single false negative record had a Ct value of 33, which was close to the mean of the cohort (32.5 cycles). CONCLUSIONS: The modified Inflammacheck® device may be a rapid, non-demanding and cost-effective method for SARS-CoV-2 detection. This device may be used for routine practice in different healthcare settings (community, hospital, rehabilitation).

Characteristics of Patients Managed without Positive Pressure Ventilation While on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has expanding indications for cardiopulmonary resuscitation including severe acute respiratory distress syndrome (ARDS). Despite the adjunct of ECMO for patients with severe ARDS, they often have prolonged mechanical ventilation and are subject to many of its inherent complications. Here, we describe patients who were cannulated for venovenous (VV) ECMO and were taken off positive pressure ventilation. METHODS: This is a primary analysis of patients admitted at a tertiary medical center between the dates of August 2014 to January 2020 who were cannulated to ECMO for refractory respiratory failure. We included all patients ≥18 years old. Patients who were extubated or had a tracheostomy and taken off positive pressure while on ECMO were classified as "off positive pressure ventilation (PPV)" and were compared to patients who remained "on PPV" while on ECMO. Primary outcome was survival to hospital discharge. Secondary outcomes were ventilator free days at 30 days and 60 days after ECMO cannulation, time from cannulation to date of first out-of-bed (OOB), and hospital length of stay (LOS). Patient characteristics were derived from routine clinical information in the electronic health record (EHR). Categorical characteristics were compared using chi-square test or Fisher exact test. Continuous characteristics were compared using independent samples t-test or Wilcoxon-Mann-Whitney test. p-values were reported from all analysis. RESULTS: Sixty-five patients were included in this retrospective analysis. Forty-eight were managed on ECMO with PPV and 17 patients were removed from PPV. Patients removed from PPV had significantly higher lung injury scores prior to cannulation (2.5 ± 0.6 vs. 1.04 ± 0.3; p = 0.031) and non-significantly longer duration of ventilation prior to ECMO (6.1 days ± 2.1 vs. 5.0 days ± 01.1; p = 0.634). One hundred percent (100%) of patients removed from PPV survived to hospital discharge compared to 45% who received PPV throughout their duration of ECMO management (p < 0.001). The mean ventilator free days at day 60 was 15 with PPV and 36 without PPV (p = 0.003). The average duration from cannulation to mobilization (i.e., out-of-bed) was 18 days with PPV and 7 days without PPV (p = 0.015). CONCLUSIONS: Patients taken off PPV while on ECMO had a very high likelihood of survival to discharge and were mobilized in half as many days. While this likely reflects patient selection, the benefit of early mobilization is well documented and the approach of extubating while on ECMO warrants further investigation.

Telepresent mechanical ventilation training versus traditional instruction: a simulation-based pilot study.

Background: Mechanical ventilation is a complex topic that requires an in-depth understanding of the cardiopulmonary system, its associated pathophysiology and comprehensive knowledge of equipment capabilities. Introduction: The use of telepresent faculty to train providers in the use of mechanical ventilation using medical simulation as a teaching methodology is not well established. The aim of this study was to compare the efficacy of telepresent faculty versus traditional in-person instruction to teach mechanical ventilation to medical students. Materials and methods: Medical students for this small cohort pilot study were instructed using either in-person instruction or telementoring. Initiation and management of mechanical ventilation were reviewed. Effectiveness was evaluated by pre- and post-multiple choice tests, confidence surveys and summative simulation scenarios. Students evaluated faculty debriefing using the Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV). Results: A 3-day pilot curriculum demonstrated significant improvement in the confidence (in person P<0.001; telementoring P=0.001), knowledge (in person P<0.001; telementoring P=0.022) and performance (in person P<0.001; telementoring P<0.002) of medical students in their ability to manage a critically ill patient on mechanical ventilation. Participants favoured the in-person curriculum over telepresent education, however, resultant mean DASH-SV scores rated both approaches as consistently to extremely effective. Discussion: While in-person learners demonstrated larger confidence and knowledge gains than telementored learners, improvement was seen in both cases. Learners rated both methods to be effective. Technological issues may have contributed to students providing a more favourable rating of the in-person curriculum. Conclusions: Telementoring is a viable option to provide medical education to medical students on the fundamentals of ventilator management at institutions that may not have content experts readily available.

Trauma Resuscitation in a Left Ventricular Assist Device Patient: An Emergency Medicine Simulation Scenario.

Heart failure is a leading cause of death worldwide. While heart transplantation is the most successful treatment for end-stage heart failure, the scarcity in donor hearts has ushered in the use of alternative therapies, such as the left ventricular assist device (LVAD). This patient population may present with low frequency, but they require disease-specific management. Learners may fine-tune these principles in a safe learning environment, such as a medical simulation lab. Here, we present a case in which a patient with a LVAD sustained serious traumatic injuries.