Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: COVID-19 can cause ARDS that is rapidly progressive, severe, and refractory to conventional therapies. ECMO can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined. SUMMARY BACKGROUND DATA: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best postcannulation management strategy, however, has not yet been defined. METHODS: We conducted a retrospective review from April 1 to July 31, 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality. RESULTS: Forty-four patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs 53.1 years; P < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:-FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs 19.9 days, P = 0.028) and shorter duration of intensive care unit (ICU) length of stay before cannulation (5.6 days vs 11.7 days, P = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%. CONCLUSIONS: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

Identification of Risk Factors for the Development of Pressure Ulcers Despite Standard Screening Methodology and Prophylaxis in Trauma Patients.

PURPOSE: To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients. OBJECTIVE: Pressure ulceration prevention has been emphasized over the past several years in inpatient hospital settings with subsequent decreases in the development of pressure ulcers (PrUs). However, there remains a subset of trauma and burn patients that develop PrUs despite standard screening methodology and prophylaxis. This study determines the conditions that predict development of pressure ulcers (PrUs) despite conventional prophylaxis and screening. METHODS: Demographic and PrU data were collected over a 5-year period from June 2008 to May 2013. Patients diagnosed with PrUs upon arrival in the trauma bay were excluded from analysis. An ordinal logistic regression of PrU stage was used to estimate odds ratios (ORs) and associated 95% confidence intervals (CIs) for the association between characteristics of interest and odds of a PrU. A backward selection process was used to select the most parsimonious model. RESULTS: During the study period, 14,616 trauma patients were admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63-9.01), mechanical ventilation (OR, 1.95; CI, 1.23-3.10) and age 40 to 64 (OR, 2.09; CI, 1.24-3.52) and age ≥ 65 (OR, 4.48; CI, 2.52-7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32-0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than -6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development. CONCLUSIONS: Spinal injuries, older than age 40, and mechanical ventilation predict the development of PrUs for a subset of patients, despite conventional prophylaxis and screening. Advanced prevention methods, such as low-air-loss mattresses for these patient subgroups should be considered immediately upon identification of these risk factors during the hospital course.

Treatment of Acute Severe Asthma Exacerbation with Extracorporeal Membrane Oxygenation and Inhaled Volatile Anesthetic.

Severe asthma affects approximately 1-2% of all asthmatic patients. Acute exacerbations are associated with high mortality in this population. There are many treatment options for asthma exacerbation; however, if these treatments fail, patients can develop progressive hypoxia, hypercarbia, respiratory acidosis, and hemodynamic instability. Extracorporeal membrane oxygenation (ECMO) and inhaled anesthetic both have a role in the management of acute severe refractory asthma exacerbation, though there is limited information about the use of both together. We present the case of a patient with severe asthma who suffered a refractory asthma exacerbation and was successfully managed with veno-venous ECMO and inhaled anesthetic. ECMO and inhaled volatile anesthetic both have a role in the management of severe refractory asthma exacerbations. It is safe and beneficial to use these therapies together and more benefit is noted if initiated early in the course of the patient's illness.

Posthospitalization outcomes after extracorporeal membrane oxygenation (ECMO) for COVID-19.

BACKGROUND: Critical illness from COVID-19 is associated with prolonged hospitalization and high mortality rates. Extracorporeal membrane oxygenation is used for refractory severe acute respiratory distress syndrome in COVID-19 with outcomes comparable to other indications for extracorporeal membrane oxygenation. However, long-term functional outcomes have yet to be fully elucidated. METHODS: We performed a retrospective chart review of 24 consecutive patients who required extracorporeal membrane oxygenation due to COVID-19 associated severe acute respiratory distress syndrome and survived to hospital discharge. After hospitalization, we contacted patients and administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 tool to assess longer-term outcomes. We abstracted demographics, clinical course, outcomes, and disposition variables from the electronic medical record. Descriptive statistical analysis was used on the retrospective data collection. RESULTS: Inpatient data were analyzed for 24 patients, and 21 of 24 (88%) patients completed the Patient-Reported Outcomes Measurement Information System tool at an average of 8.8 months posthospitalization. At hospital discharge, 62.5% of patients had ongoing oxygen requirements (nasal cannula, trach collar, or mechanical ventilation); 70.8% were discharged to a location other than home. However, at the time of follow-up, only 9.5% of patients required supplemental oxygen, all tracheostomies had been removed, and all patients resided at home. Patients reported relatively high levels of global physical function, and though there was a high reported incidence of fatigue, overall pain scores were low. CONCLUSION: Long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from coronavirus disease 2019 are promising. Extracorporeal membrane oxygenation therapy may confer morbidity benefits in patients with coronavirus disease and remains a valuable modality with excellent functional outcomes and preserved quality of life for survivors.

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS.

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome During Hemorrhagic Shock.

Despite overall improvements in critical care, mortality from acute respiratory distress syndrome (ARDS) remains high. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is used to rescue patients with severe ARDS. Although V-V ECMO can be life-saving, there are significant risks associated with this therapy. Hemorrhage is one of the most common complications. Therefore, some providers are reluctant to use V-V ECMO in patients with severe ARDS who concurrently have a high risk of bleeding or recent active hemorrhage. Several studies have been published detailing the safety of heparin-sparing or completely heparin-free anticoagulation strategies in patients on V-V ECMO. We present the cases of two patients with hemorrhagic shock and ongoing transfusion requirements who developed severe and refractory ARDS while in the operating room for hemorrhage control. After the massive bleeding was stopped, both patients were placed on V-V ECMO and were managed with minimal or no therapeutic anticoagulation for the duration of their course on V-V ECMO. Both patients required multiple operations and procedures while on V-V ECMO and there were no significant hemorrhagic complications. In conclusion, V-V ECMO can be considered for use in select patients with severe ARDS and high risk of hemorrhage, active hemorrhage, or ongoing transfusion requirements.

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting. METHODS: This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications. RESULTS: Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management. CONCLUSION: Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed. LEVEL OF EVIDENCE: Therapeutic, level IV.

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology. RESULTS: A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline. CONCLUSION: This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.