Observational study of thrombosis and bleeding in COVID-19 VV ECMO patients.

INTRODUCTION: COVID-19 has been associated with increased risk of thrombosis, heparin resistance and coagulopathy in critically ill patients admitted to intensive care. We report the incidence of thrombotic and bleeding events in a single center cohort of 30 consecutive patients with COVID-19 supported by veno-venous extracorporeal oxygenation (ECMO) and who had a whole body Computed Tomography Scanner (CT) on admission. METHODOLOGY: All patients were initially admitted to other hospitals and later assessed and retrieved by our ECMO team. ECMO was initiated in the referral center and all patients admitted through our CT scan before settling in our intensive care unit. Clinical management was guided by our institutional ECMO guidelines, established since 2011 and applied to at least 40 patients every year. RESULTS: We diagnosed a thrombotic event in 13 patients on the initial CT scan. Two of these 13 patients subsequently developed further thrombotic complications. Five of those 13 patients had a subsequent clinically significant major bleeding. In addition, two patients presented with isolated intracranial bleeds. Of the 11 patients who did not have baseline thrombotic events, one had a subsequent oropharyngeal hemorrhage. When analyzed by ROC analysis, the area under the curve for % time in intended anticoagulation range did not predict thrombosis or bleeding during the ECMO run (0.36 (95% CI 0.10-0.62); and 0.51 (95% CI 0.25-0.78); respectively). CONCLUSION: We observed a high prevalence of VTE and a significant number of hemorrhages in these severely ill patients with COVID-19 requiring veno-venous ECMO support.

Subxiphoid, Nonintubated, Opioid-Free, Video-Assisted Pneumonectomy: A New Frontier in Thoracic Surgery.

Surgical approaches to major pulmonary resections have evolved from thoracotomy to multiportal video-assisted thoracoscopy (VATS) and subsequently uniportal VATS. The efficacy of this progress has been validated in a multitude of publications demonstrating reductions in complications, patient perception of pain, and postoperative length of stay. More recent advances include subxiphoid extrathoracic access and nonintubated, opioid-free anesthesia. Early publications have demonstrated promising results with respect to safety, technical feasibility, and enhanced recovery. However, there remains a paucity of literature relating to hybrid approaches comprising both subxiphoid and nonintubated, opioid-free anesthesia in the context of pneumonectomy. The current report is the case of a patient undergoing pneumonectomy. Both subxiphoid and nonintubated, opioid-free techniques were utilized. The authors describe preoperative workup, surgical and anesthesia-related caveats, and postoperative recovery. In conclusion, this approach is technically feasible, safe, and may be associated with enhanced recovery.

Continuous hemadsorption with cytokine adsorber for severe COVID-19: A case series of 15 patients.

BACKGROUND: Hyperinflammation and cytokine release has been associated with severe Covid-19. Hemadsorption cartridges may have a potential role in treatment of cytokine storm associated with the development of severe Covid-19. METHODS: We retrospectively examined the case records of patients with severe Covid-19 receiving adjunctive hemadsorption (HA) in our ICU. We analyzed inflammatory biomarkers pre- and post- HA. RESULTS: Fifteen patients received HA during the study period. All were intubated, ventilated and required renal replacement therapy. 11/15 were supported on ECMO. Mean ferritin 2652 (±3286) ng/ml, mean CRP 154 (±92) mg/ml, median D-dimer 3071 (±2689) ng/ml, mean troponin 236 (±461) ng/L. We found significant difference in pre-and post- treatment ferritin 3622 ng/ml versus 1682 ng/ml (p = 0.022), CRP 222 mg/ml versus 103 mg/ml (p = 0.008, 95% CI 22.4-126.5), lactate 2 mmol/L versus 1.3 mmol/L (p = 0.017), and procalcitonin 15.3 ng/ml versus 4.2 ng/ml (p = 0.023). No significant difference in pre- and post- treatment IL-6 14 pg/ml versus 43 pg/ml (p = 0.32), IL-10 3.4 pg/ml versus 2.6 pg/ml (p = 0.31), IL1 ß 0.37 pg/ml versus 0.77 pg/ml (p = 0.75), TNF α 12.77 pg/ml versus 12.49 pg/ml (p = 0.75), VIS 10.04 versus 6.01 (p = 0.31, 95% CI 5.98-17.16) was seen. CONCLUSIONS: The use of HA as adjunctive treatment in a critically unwell group of COVID-19 patients lead to a reduction in ferritin, CRP, procalcitonin and lactate with no significant change in other parameters. The use of HA in the treatment of severe COVID-19 requires further larger randomized studies.

Anesthesia for minimally invasive cardiac surgery.

Due to its potential benefits and increased patient satisfaction minimal invasive cardiac surgery (MICS) is rapidly gaining in popularity. These procedures are not without challenges and require careful planning, pre-operative patient assessment and excellent intraoperative communication. Assessment of patient suitability for MICS by a multi-disciplinary team during pre-operative workup is desirable. MICS requires additional skills that many might not consider to be part of the standard cardiac anesthetic toolkit. Anesthetists involved in MICS need not only be highly skilled in performing transesophageal echocardiography (TEE) but need to be proficient in multimodal analgesia, including locoregional or neuroaxial techniques. MICS procedures tend to cause more postoperative pain than standard median sternotomies do, and patients need analgesic management more in keeping with thoracic operations. Ultrasound guided peripheral regional anesthesia techniques like serratus anterior block can offer an advantage over neuroaxial techniques in patients on anti-platelet therapy or anticoagulation with low molecular weight or unfractionated heparin The article reviews the salient points pertaining to pre-operative assessment and suitability, intraoperative process and postoperative management of minimally invasive cardiac procedures in the operating theatre as well as the catheterization lab. Special emphasis is given to anesthetic management and analgesia techniques.

Functional respiratory imaging identifies redistribution of pulmonary blood flow in patients with COVID-19.

An increasing observation is that some patients with COVID-19 have normal lung compliance but significant hypoxaemia different from typical acute respiratory distress syndrome (ARDS). We hypothesised that changes in pulmonary blood distribution may be partially responsible and used functional respiratory imaging on CT scans to calculate pulmonary blood volume. We found that patients with COVID-19 had significantly reduced blood volume in the smaller calibre blood vessels (here defined as <5 mm2 cross-sectional area) compared with matched ARDS patients and healthy controls. This suggests that using high levels of PEEP may not alone be enough to oxygenate these patients and that additional management strategies may be needed.

Opioid-Free Anesthesia for Lung Cancer Resection: A Case-Control Study.

OBJECTIVE: To assess the feasibility and effectiveness of an opioid-free anesthesia (OFA) technique in lung cancer resection surgery versus standard opioid-based techniques. DESIGN: Retrospective, propensity-matched, case-control study. SETTING: A single, specialty cardiothoracic center between January 2018 and July 2019. PARTICIPANTS: Adult patients undergoing lung cancer resection surgery. INTERVENTIONS: A cohort of 83 patients undergoing an OFA technique (OFA group) for lung cancer resection surgery was matched with 83 patients who underwent similar surgery with a standard anesthesia technique (STD group). Outcome measures compared between the 2 groups included postoperative pain scores at 0, 1, and 24 hours; 24-hour postoperative morphine patient-controlled analgesia consumption; recovery room and hospital lengths of stay; and 30-day all-cause mortality. MEASUREMENT AND MAIN RESULTS: No difference was found in median pain scores (interquartile range [IQR]) at 0 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.48. Median pain scores (IQR) at 1 hour were statistically significantly greater in the STD group compared with the OFA group: STD 1 (0-1), OFA 0 (0-1); p = 0.03. There was no difference in median pain scores (IQR) at 24 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.49. Mean postoperative 24-hour patient-controlled analgesia morphine consumption (standard deviation) was similar between groups: STD 21.1 (±18.8) mg, OFA 16.2 (±18.1) mg; p = 0.16. There was no difference in mean time spent in the postoperative recovery (standard deviation) area between the 2 groups: STD 116 (±49) minutes, OFA 108 (±34) minutes; p = 0.27. Median hospital length of stay (IQR) was longer in the STD group compared with the OFA group: STD 4 (2-6) days, OFA 3 (2-4) days; p = 0.002. CONCLUSIONS: This case-control study demonstrated that an OFA technique in lung cancer resection surgery offers a feasible and safe approach, resulting in similar postoperative pain scores and morphine consumption compared with standard opioid-containing techniques.

Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes. DESIGN: A retrospective case series. SETTING: A tertiary referral cardiothoracic transplantation center. PARTICIPANTS AND INTERVENTIONS: Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central). MEASUREMENTS AND MAIN RESULTS: All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%. CONCLUSIONS: The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.

Three consecutive cases of fatal intraoperative intracardiac thrombosis associated with the initiation of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin.

Central venoarterial extracorporeal membrane oxygenation has been used since the 1970s to support patients with cardiogenic shock following cardiac surgery. Despite this, in-hospital mortality is still high, and although rare, thrombus within the cardiac chambers or within the extracorporeal membrane oxygenation circuit is often fatal. Aprotinin is an antifibrinolytic available in Europe and Canada, though not currently in the United States. Due to historical safety concerns, use of aprotinin is generally limited and is commonly reserved for patients with the highest bleeding risk. Given the limited availability of aprotinin over the last decade, it is not surprising to find a complete absence of literature describing the use of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin. We present three consecutive cases of rapid fatal intraoperative intracardiac thrombosis associated with post-cardiotomy central venoarterial extracorporeal membrane oxygenation in patients receiving aprotinin.

Oxygenator failure in acute myeloid leukaemia. A case report.

Extracorporeal membrane oxygenation (ECMO) therapy can be used to rescue patients who develop respiratory failure with acute myeloid leukaemia. We describe a unique case of rapid failure of an oxygenator on ECMO, secondary to high leukocyte count and cell lysis in an adult patient with acute myeloid leukaemia.

Anaesthetic considerations for pectus repair surgery.

Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.