Extracorporeal cardiopulmonary resuscitation in a patient with fulminant pulmonary embolism refractory to intraarrest thrombolysis.

INTRODUCTION: A fulminant pulmonary embolism is a potentially reversible cause of cardiac arrest with a reported mortality rate of up to 95%. Therapeutic strategies for fulminant pulmonary embolism continue to evolve. CASE REPORT: We present a case of a 38-year-old female who suffered an in-hospital cardiac arrest due to fulminant pulmonary embolism. Extracorporeal cardiopulmonary resuscitation (facilitated by the LUCAS™ mechanical chest compression device) was successfully performed in this patient following failure of intraarrest thrombolysis. DISCUSSION: For the management of fulminant pulmonary embolism, utilization of clot-directed therapies, especially intraarrest thrombolysis, has garnered increasing traction and interest. However, this therapeutic approach has its limitations. Fortuitously, the emergence of extracorporeal cardiopulmonary resuscitation has added a new dimension to the treatment of fulminant pulmonary embolism. A protocolized approach to treatment can improve outcomes in these patients. CONCLUSION: Extracorporeal cardiopulmonary resuscitation can be used as a salvage therapy in patients with fulminant pulmonary embolism in whom intraarrest thrombolysis has failed.

Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory.

The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.

COVID-19: A management update.

The management of COVID-19 has evolved through the course of the pandemic to now include options for outpatients, inpatients with life-threatening critical illness, and everyone in between. The goals of therapy include preventing disease progression and preventing worsening disease in those admitted to the hospital, with the hopes of preserving resources and improving patient outcomes. The Infectious Diseases Society of America and the National Institutes of Health have issued guidelines on treating COVID-19, which the authors review here.

Using a Low-Flow Extracorporeal Carbon Dioxide Removal (ECCO2R) System in the Management of Refractory Status Asthmaticus: A Case Series.

Rescue treatments for status asthmaticus remain limited. Current literature has mainly focused on using extracorporeal membrane oxygenation (ECMO) as a primary modality of care for these patients. Low-flow extracorporeal CO2 removal (ECCO2R) systems are an attractive option to improve refractory hypercapnic respiratory acidosis because of status asthmaticus. This is a retrospective case series that describes the feasibility and efficacy of the use of a low-flow ECCO2R device, the Hemolung Respiratory Assist System, in patients with refractory hypercapnic respiratory failure because of status asthmaticus. Eight patients were treated with the Hemolung Respiratory Assist System in eight separate locations globally. Seven (88%) of the patients survived to discharge in this case series. Both CO2 and pH resolution were seen in 6 hours. None of the ECCO2R runs were stopped because of mechanical- or device-related complications. One patient necessitated transition to ECMO. Low-flow ECCO2R systems is an effective option for resolution of refractory hypercapnia in status asthmaticus. Use of these systems are also associated with a survival rate of close to 90% in patients with status asthmaticus.

Outpatient management of asthma in adults: A snapshot of the 2020 GINA report.

The Global Strategy for Asthma Management and Prevention publishes an annual report on asthma management and prevention. The report reflects the most recent evidence on asthma and its treatment and provides recommendations for clinical practice. This article reviews the guidelines with a focus on what's new and clinically important for practitioners treating this patient population.

Pulmonary Critical Care Fellows' Use of and Self-reported Barriers to Learning Bedside Ultrasound During Training: Results of a National Survey.

BACKGROUND: Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. RESEARCH QUESTION: How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? STUDY DESIGN AND METHODS: A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors' discretion. RESULTS: Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. INTERPRETATION: Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

Management of patients with COVID-19 in the MICU.

COVID-19 management practices devised for the medical intensive care unit are centered on 2 main goals: ensuring caregiver safety and providing the highest quality patient care through adherence to evidence-based best practices. Rapid, sweeping changes for successful management are based on creating an educational platform to introduce and then further cement these concepts through a unified approach to clinical care. Creating a culture change in a short period of time requires overcoming a host of challenges; however, the result is a more unified and focused approach.