Dysphagia in COVID-19 Patients on Extracorporeal Membrane Oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) are infrequently nourished via oral feeding due to aspiration risks. Patients with COVID-19 and on ECMO represent a subpopulation that has additional factors that may affect their swallow function. This study aimed to describe the swallow function and ability to maintain oral feeding in patients with COVID-19 while on ECMO. A retrospective study of patients with COVID-19 who started veno-venous ECMO at the beginning of the COVID-19 pandemic (March 2020 and August 2020) was conducted at a tertiary care hospital. Clinical swallow evaluations and videofluoroscopic swallow studies (VFSS) were analyzed using standardized measurement scales. Pearson's correlation coefficient (r) identified relationships between ECMO and swallowing function at different time points. 19 patients were included; all underwent clinical swallow evaluation and 4 underwent VFSS while on ECMO. Mean age was 43.2 years (standard deviation: 9.2), mean duration of ECMO was 65.7 days (58.7), and mean duration of intubation was 14.4 days (8.6). All patients were able to undergo swallow function evaluation, regain swallow function, and resume oral feeding while cannulated. Duration of ECMO and time to feeding tube removal was positively correlated (r = 0.747, p < 0.001) with patients demonstrating less functional swallowing independence and requiring a more modified diet upon oral diet initiation. Clinical swallow evaluation and videofluoroscopic swallowing evaluation are possible for COVID-19 patients actively on ECMO. Patient swallow function can improve, and oral diet can be achieved while on ECMO, demonstrating benefit of SLP surveillance and swallowing assessment prior to ECMO decannulation.

Extracorporeal hemoadsorption in critically ill COVID-19 patients on VV ECMO: the CytoSorb therapy in COVID-19 (CTC) registry.

OBJECTIVES: The CytoSorb therapy in COVID-19 (CTC) registry evaluated the clinical performance and treatment parameters of extracorporeal hemoadsorption integrated with veno-venous extracorporeal membrane oxygenation (VV ECMO) in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) and respiratory failure under US FDA Emergency Use Authorization. DESIGN: Multicenter, observational, registry (NCT04391920). SETTING: Intensive care units (ICUs) in five major US academic centers between April 2020 and January 2022. PATIENTS: A total of 100 critically ill adults with COVID-19-related ARDS requiring VV ECMO support, who were treated with extracorporeal hemoadsorption. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographics, clinical characteristics, laboratory values and outcomes were recorded following individual ethics committee approval at each center. Detailed data on organ support utilization parameters and hemoadsorption treatments were also collected. Biomarker data were collected according to the standard practice at each participating site, and available values were compared before and after hemoadsorption. The primary outcome of mortality was evaluated using a time-to-event analysis. A total of 100 patients (63% male; age 44 ± 11 years) were included. Survival rates were 86% at 30 days and 74% at 90 days. Median time from ICU admission to the initiation of hemoadsorption was 87 h and was used to define two post hoc groups: ≤ 87 h (group-early start, GE) and > 87 h (group-late start, GL). After the start of hemoadsorption, patients in the GE versus GL had significantly shorter median duration of mechanical ventilation (7 [2-26] vs. 17 [7-37] days, p = 0.02), ECMO support (13 [8-24] vs. 29 [14-38] days, p = 0.021) and ICU stay (17 [10-40] vs 36 [19-55] days, p = 0.002). Survival at 90 days in GE was 82% compared to 66% in GL (p = 0.14). No device-related adverse events were reported. CONCLUSIONS: In critically ill patients with severe COVID-19-related ARDS treated with the combination of VV-ECMO and hemoadsorption, 90-day survival was 74% and earlier intervention was associated with shorter need for organ support and ICU stay. These results lend support to the concept of "enhanced lung rest" with the combined use of VV-ECMO plus hemoadsorption in patients with ARDS.

Central ECMO cannulation for severe dihydropyridine calcium channel blocker overdose.

Calcium channel blocker (CCB) toxicity carries a high mortality and is the sixth most fatal drug class reported to US poison centers. Amlodipine overdose is characterized by a life-threatening arterial vasodilation that compromises organ perfusion. The management of CCB intoxication is focused on maintaining adequate organ perfusion. In cases refractory to medical therapies, hemodynamic support with extracorporeal membrane oxygenation (ECMO) is warranted necessitating higher flows than usual to compensate for the vasodilation and requiring central cannulation. We present a case of a 12-year-old with severe dihydropyridine CCB ingestion, refractory to medical management and successfully treated with central ECMO cannulation. The patient was discharged home with no significant disability. Central ECMO cannulation may be helpful to facilitate adequate flows in vasodilatory shock such as CCB overdose.

Asymmetric septal edema masking as hypertrophy in an infant with COVID-19 myocarditis.

Cardiac disease in pediatric patients due to coronavirus SARS-CoV-2 disease (COVID-19) includes myocarditis and multisystem inflammatory syndrome, both of which can present with a broad range in severity. Here we describe an infant with COVID-19 causing fulminant myocarditis with inotrope-resistant acute heart failure requiring extracorporeal membrane oxygenation. The patient demonstrated an atypical finding of localized septal thickening suggestive of hypertrophic cardiomyopathy, but the diagnosis of myocarditis was confirmed by cardiac MRI. Serial echocardiography illustrated complete resolution of septal hypertrophy and normalized cardiac function. The current report highlights the potential severity of COVID-19 associated myocarditis, the potential for recovery, and the utility of cardiac MRI in confirming the mechanism.

A High-Fidelity Percutaneous Model Used to Demonstrate ECMO Cannulation.

Medical simulation provides a realistic environment for practitioners to experience a planned clinical event in a controlled educational setting. We established a simulation model composed of synthetic ballistic gelatin that provided an inexpensive high-fidelity model for our extracorporeal membrane oxygenation (ECMO) team members to develop, master, and maintain clinical skills necessary for percutaneous cervical or femoral cannulation. The simulation component includes a cervical torso or femoral percutaneous synthetic gelatin model that is attached to either a static fluid model or to the high-fidelity perfusion simulator. Either model can be accessed with ultrasound guidance, cannulated with appropriately sized cannula, and connected to an in situ ECMO circuit. This article explains how the model is made and connected to the simulator with the purpose of re-creating this high-fidelity experience at any institution.

COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) guidelines; revisiting the Western New York approach as the pandemic evolves.

Multisystem inflammatory syndrome of children (MIS-C) continues to be a highly concerning diagnosis in those recently infected with SARS-CoV-2. The diagnosis of MIS-C cases will likely become even more challenging as vaccine uptake and natural immunity in previously infected persons leads to lower circulating rates of SARS-CoV-2 infection and will make cases sporadic. Febrile children presenting with cardiac dysfunction, symptoms overlapping Kawasaki disease or significant gastrointestinal complaints warrant a thorough screen in emergency departments, urgent care centers, and outpatient pediatric or family medicine practices. An increased index of suspicion and discussion regarding higher level of care (transferring to pediatric tertiary care centers or to intensive care) continues to be recommended. Herein we outline a broad approach with a multidisciplinary team for those meeting the case definition and believe such an approach is crucial for successful outcomes.

Extracorporeal Cardiopulmonary Resuscitation in Indian Scenario: A Web-based Survey.

BACKGROUND: Practice and knowledge of extracorporeal cardiopulmonary resuscitation (ECPR) in an Indian setting is not known. The etiology could be multifactorial, such as lack of awareness, lack of facilities, and lack of finances. Unless we identify and rectify the underlying problems, utilization of this aspect of extracorporeal membrane oxygenation (ECMO) support would be difficult. MATERIALS AND METHODS: This cross-sectional observational study was done over 6 months in three phases: (A) Formation of questionnaire/tool kit by Delphi method for 1 month (July 2019), (B) circulation of questionnaire to participants in the form of Google Forms and data collection for 2 months (August and October 2019), and (C) analysis, compilation of data, and writing the final report over 1 month (November 2019). RESULTS: Sixty-four participants responded. The majority of the respondents were intensivists (50%). Only six respondents (9.5%) had done ECPR at their center with median ECPRs per year of 2 (1-10). All ECPRs were being done in private sector hospitals. The most common indication for initiation was conventional cardiopulmonary resuscitation (CPR) for more than 10 minutes without return of spontaneous circulation (ROSC)(n = 4, 66%). In all cases, the intensivists took decision for the initiation of ECPR. The rest 57 did not have the experience of ECPR at their center due to lack of equipment and experience (50%) and financial issues (50%). CONCLUSION AND CLINICAL SIGNIFICANCE: There is a huge need to increase the awareness of the ECPR program and teams to be trained in India. We also suggest that the tertiary care medical institutions in public sector as well as the private sector that is offering critical care courses should train fellows on ECPR to employ it at times when needed to improve the outcomes of critically ill patients. HOW TO CITE THIS ARTICLE: Gulla K M, Sahoo T, Pooboni S K, et al. Extracorporeal Cardiopulmonary Resuscitation in Indian Scenario: A Web-based Survey. Indian J Crit Care Med 2021;25(6):675-679.

ECMO as a Platform for Rapid Ammonia Removal in a Neonate with Multienzyme Urea Cycle Disorder.

Since the initial deployment of neonatal extracorporeal membrane oxygenation (ECMO) for respiratory failure, the use of ECMO in this population has diversified. We present a term female infant with carbamoyl phosphate synthetase 1 and partial N-acetylglutamate synthase deficiencies who developed severe hyperammonemia refractory to medical management requiring venoarterial ECMO-driven continuous veno-venous hemodiafiltration for ammonia detoxification. This case report illustrates a subpopulation where neonatal ECMO may improve survival and neurodevelopmental outcomes. To our knowledge, this is the first reported case of a urea cycle defect arising from two proximal enzyme deficiencies. Also, this is one of the few reported patients with UCD associated with peak ammonia levels >2,000 µmol/L who survived to hospital discharge after the successful use of ECMO for ammonia reduction. This case will add to the existing scant literature supporting the use of ECMO as a platform for rapid removal of serum ammonia.

Management Strategies during a VA ECMO Run in a Neonate with E. Coli Septic Shock Masquerading as Hypoxic Ischemic Encephalopathy.

Advances in neonatal care for hypoxic respiratory failure, with high-frequency ventilation and inhaled nitric oxide, have led to a decreased need for extracorporeal membrane oxygenation (ECMO). However, neonates resistant to such therapies are more complex and at higher risk of mortality. One such population includes those with hypoxic ischemic encephalopathy (HIE) undergoing controlled hypothermia (CH). We present a challenging case of a full-term neonate with inotrope-resistant Escherichia coli septic shock, profound coagulopathy, hypoxic respiratory failure, and HIE requiring CH and venoarterial (VA) ECMO. We illustrate that family-centered decision-making, ECMO, primary team, and subspecialist support is critical to success. In addition, we share the strategic medical interventions concomitantly used with VA ECMO to aid in the survival of this high-risk infant such as continuous veno-venous hemofiltration with AN69 membrane for cytokine and fluid removal, prostaglandin use to relieve right ventricular strain in malignant pulmonary hypertension, and cautious use of bronchoscopy to assist in lung recruitment.

A High-Fidelity Surgical Model and Perfusion Simulator Used to Demonstrate ECMO Cannulation, Initiation, and Stabilization.

Our high-fidelity simulation model provides a realistic example for health-care professionals to experience cannulation, initiation, and hemodynamic stabilization during extracorporeal membrane oxygenation (ECMO) therapy. This educational experience brings a variety of critical care specialties together, in a controlled simulation setting, to develop, master, and maintain clinical skills. This may include perfusionists, ECMO specialists, surgical technicians, registered nurses, physicians, and students. The simulation component includes a unique vascular access pad that is attached to either a static fluid model or to the Califia perfusion simulator system (Biomed Simulation, Inc., San Diego, CA). This collective high-fidelity simulation model can be surgically cannulated via a cutdown technique using an appropriately sized cannula and connected to an in situ ECMO circuit. This article explains the educational strategy, how the surgical pad is made, and the simulator connections so that any hospital can re-create this experience.

Long venous cannula on the arterial position for VA-ECMO.

Differential hypoxia and the arterial mixing zone are two important factors in managing peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). With the aim of improving perfusion to the aortic arch branches and coronaries, we describe our approach for VA-ECMO cannulation: bicaval drainage through the femoral vein and proximal retrograde ECMO flow using a multi-stage venous cannula inserted in the femoral artery and the tip placed at the proximal descending thoracic aorta. We report the use of this VA-ECMO approach on a 15-year-old female with combined cardiorespiratory failure and on a 12-year-old male with acute cardiac failure.

Safety and Efficacy of Extracorporeal Membrane Oxygenation Heating Units.

BACKGROUND: Patient temperature during extracorporeal membrane oxygenation (ECMO) is commonly managed by dedicated heating units (HUs) that are integrated into ECMO circuitry. Currently, no HU has received approval for ECMO by the FDA in the United States. Older FDA-approved HUs have been implicated in life-threatening patient infections and are no longer manufactured or available for use in the United States. METHODS: We performed laboratory tests to evaluate the safety and efficacy of the Micro-Temp and the HTP-1500 HU systems that are potentially suitable for use in ECMO and describe our initial experience with the HTP-1500 HU after being placed in clinical service. RESULTS: Both units demonstrated similar heating efficacy, with the HTP-1500 achieving steady-state temperature approximately 5 h earlier than the Micro-Temp. Microorganisms were detected in the water compartment of all HUs prior to and after performing the manufacturer's recommended cleaning procedure, and after implementation of the HTP-1500 into clinical use we observed a decrease in the rate of bloodstream infection/ECMO days which did not reach statistical significance. CONCLUSION: Based on the results of this analysis and our institutional experience, we believe that integration of the HTP-1500 HU, an easily replaceable HU, into ECMO systems may reduce the risk of bacterial contamination and thus nosocomial infection when the devices are cleaned and maintained according to manufacturer's guidelines.

1,1-Difluoroethane Hydrocarbon Cardiomyopathy.

1,1-Difluoroethane (DFE) cardiomyopathy results from the direct inhalation of toxic halogenated hydrocarbons. We present a case series of acute DFE cardiomyopathy illustrating the typical presentation of severe DFE cardiomyopathy along with a detailed description of its mechanism of injury. (Level of Difficulty: Advanced.).

A Multimodal Approach to Training Coronavirus Disease (COVID-19) Processes Across Four Intensive Care Units.

Background: Coronavirus disease (COVID-19) required innovative training strategies for emergent aerosol generating procedures in intensive care units. This manuscript summarizes institutional operationalization of COVID-specific training, standardized across four intensive care units. Methods & Results: An interdisciplinary team collaborated with the Simulator Program and OpenPediatrics refining logistics using process maps, walkthroughs and simulation. A multimodal approach to information dissemination, high-volume team training in modified resuscitation practices and technical skill acquisition included instructional videos, training superusers, small-group simulation using a flipped classroom approach with rapid cycle deliberate practice, interactive webinars, and cognitive aids. Institutional data on application of this model are presented. Conclusion: Success was founded in interdisciplinary collaboration, resource availability and institutional buy in.

High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways.

While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.

Prognosis in Patients With Cardiogenic Shock Who Received Temporary Mechanical Circulatory Support.

Background: Temporary mechanical circulatory support (MCS) is often used in patients with cardiogenic shock (CS), and the type of MCS may vary by cause of CS. Objectives: This study sought to describe the causes of CS in patients receiving temporary MCS, the types of MCS used, and associated mortality. Methods: This study used a nationwide Japanese database to identify patients receiving temporary MCS for CS between April 1, 2012, and March 31, 2020. Results: Of 65,837 patients, the cause of CS was acute myocardial infarction (AMI) in 77.4%, heart failure (HF) in 10.9%, valvular disease in 2.7%, fulminant myocarditis (FM) in 2.5%, arrhythmia in 4.5%, and pulmonary embolism (PE) in 2.0% of cases. The most commonly used MCS was an intra-aortic balloon pump alone in AMI (79.2%) and in HF (79.0%) and in valvular disease (66.0%), extracorporeal membrane oxygenation with intra-aortic balloon pump in FM (56.2%) and arrhythmia (43.3%), and extracorporeal membrane oxygenation alone in PE (71.5%). Overall in-hospital mortality was 32.4%; 30.0% in AMI, 32.6% in HF, 33.1% in valvular disease, 34.2% in FM, 60.9% in arrhythmia, and 59.2% in PE. Overall in-hospital mortality increased from 30.4% in 2012 to 34.1% in 2019. After adjustment, valvular disease, FM, and PE had lower in-hospital mortality than AMI: valvular disease, OR: 0.56 (95% CI: 0.50-0.64); FM: OR: 0.58 (95% CI: 0.52-0.66); PE: OR: 0.49 (95% CI: 0.43-0.56); whereas HF had similar in-hospital mortality (OR: 0.99; 95% CI: 0.92-1.05) and arrhythmia had higher in-hospital mortality (OR: 1.14; 95% CI: 1.04-1.26). Conclusions: In a Japanese national registry of patients with CS, different causes of CS were associated with different types of MCS and differences in survival.

2 Cases of Spontaneous Coronary Artery Dissection in Neonates.

Spontaneous coronary artery dissection in infants is a rare phenomenon. We present 2 neonates with severe ventricular dysfunction due to coronary artery dissection. Neither patient had evidence of extracardiac fibromuscular dysplasia or other comorbidities that would explain the presentation. (Level of Difficulty: Advanced.).

Extracorporeal Membrane Oxygenation-Supported Transcatheter Mitral Valve-in-Valve Replacement and Paravalvular Plugging for Critical Prosthetic Mitral Stenosis.

We present the case of a patient with rapidly progressive bioprosthetic mitral valve stenosis in the setting of end-stage renal failure. Critical valve stenosis led to cardiogenic shock requiring full hemodynamic support. Emergent extracorporeal membrane oxygenation-supported transcatheter mitral valve-in-valve implantation was successfully undertaken as a life-saving measure with an excellent final result. (Level of Difficulty: Advanced.).