Unique vascular complication following extended VV-ECMO support

Objectives: To present an unusual complication related to prolonged ECMO support in a patient with COVID19 induced acute respiratory syndrome (ARDS). Method(s): Clinical chart review of the care process after obtaining the informed consent from the patient. Result(s): A 48-year-old female with COVID-19 infection during second wave of pandemic in August 2021 progressed to severe ARDS. She was put on VV-ECMO support after failing conventional therapy for refractory hypoxemia. Her cannulation configuration included a 25 F venous drainage cannula in the right femoral vein and a 21 F venous return cannula in the right Internal Jugular (IJ) vein. Cannulations were performed using the ;Seldinger technique;under USG guidance, and no difficulties or complications were reported. Her hospital course was notable for delirium, and intermittent bleeding from the cannula sites. After 80 days of support, she showed adequate respiratory improvement which allowed ECMO decannulation. She continued to show improvement, and was eventually discharged after 102 days of total hospital stay. During her 6 weeks follow-up clinic visit a palpable thrill was noted at the jugular ECMO cannula site. A CT angiogram of the neck demonstrated a large venous varix connecting the right IJ and the left common carotid artery with filling from the left common carotid artery. ECMO cannulation site complications such as aneurysm, clots, infections and stenosis are well known. What was unusual in this case is the nature of the aneurysm given that there were no arterial procedures performed on the left side of the neck. She was managed by an ;Amplatzer plug;to the carotid artery at the level of the connection to the varix without any complications. Conclusion(s): Longer duration of ECMO support needs careful follow-up for timely recognition and management of vascular complications. (Figure Presented).

Clinical characteristics, complications, and outcomes of severe COVID-19 ARDS patients supported by ECMO and triaged for lung transplantations

Objectives: More than 200 patients have benefited from lung transplantation who failed to recover from COVID-19-induced acute respiratory distress (ARDS) with conventional ventilatory support and/ or extracorporeal membrane oxygenation support (ECMO) in USA. We aim to share our experience and lessons learned at our institute through this case series. Method(s): After IRB approval, we performed a retrospective chart review and identified 37 patients who received ECMO for COVID-19 induced ARDS between May 2020 through January 2022. Out of these, 12 received a formal consultation from the transplant team. We studied patient characteristics, interventions during ECMO support, and evaluation outcomes. Result(s): Most of our patients had single organ failure i.e., lung, except for two who required dialysis after ECMO initiation. Six out of the 12 patients received bilateral lung transplant. One patient received the transplant before ECMO initiation. However, the patient required two runs of ECMO after the transplant due to postop complications from suspected COVID19 reinfection and deceased on postoperative day 101. All the patients after transplant had an expedited recovery except one who required prolonged hospitalization before starting physical therapy. The median length of hospital stay for the transplant group was 148 (89- 194) days and for the non-transplant group was 114 (58-178) days. The 30-day survival rate was 100% for the transplant group. At a median follow-up of 207 (0- 456) days after discharge, 5(83.3%) patients in the transplant group and 3(50%) patients in the nontransplant group were alive. In the non-transplant group, 4 patients received ECMO support for more than 75 days and at last follow-up 2 were alive and functioning well without needing new lungs. This asks for an objective prospective study to define the timeline of irreversibility of the lung injury. Conclusion(s): Lung transplantation is a viable salvage option in patients with COVI-19 induced irreversible lung injury. However, the irreversibility of the lung injury and the timing of lung transplant remains to be determined case-by-case. (Figure Presented).

Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

Real-time, leukocyte-related, four times validated, patient data partitioning

Introduction: Indicators that assess relationships among leukocytes may inform more and/or earlier than those measured in isolation. Method(s): Blood leukocyte differential counts collected from 101 Mayo Clinic COVID-19 patients were related to later outcomes following two approaches: (i) as unstructured data (e.g., lymphocyte percentages) and (ii) as data structures that assess intercellular interactions. Analyzing the same primary data, it was asked whether information contents differed among methods and/or when two sets of structured indicators are used. Result(s): While unstructured data did not distinguish survivors from non-survivors (Fig. 1, rectangle A), one data structure (here identified with letters expressed in italics) exhibited one perpendicular inflection that differentiated two patient groups (B). Two survivor-related observations were also distinguished from the remaining data points (B). A second data structure also revealed a single line of observations and a perpendicular data inflection (C), while more (four) patient groups were identified (D). Four validations were conducted: (i) increasing mortality levels among contiguous data subsets (0, 7.1, 16.2, or 44.4%) suggested construct validity (D);(ii) internal validity was indicated because 22 of the 45 survivors detected by the first data structure were also captured by the second one;(iii) the analysis of patients that differed in address, co-morbidities and other aspects supported external validity;and (iv) quasi non-overlapping data intervals predicted statistical validity (E, F). The structured approach also uncovered new and/ or dissimilar information: different leukocyte-related ratios explained the clusters identified in these analyses (E, F). Conclusion(s): Structured data may yield more information than methods that do not assess multicellular interactions. Possible applications include daily, longitudinal, and personalized analysis of hospital data.

Assessment of Readmission Risk Factors after Index Hospital Discharge for Covid-19 Patients

INTRODUCTION: During the COVID-19 pandemic, the burden on the healthcare system makes it critical to examine readmission patterns. In this study, we evaluated the readmission rates and risk factors associated with COVID-19 from the large SCCM Discovery VIRUS: COVID-19 Registry. METHOD(S): This was a retrospective, cohort study including hospitalized adult patients from 181 hospitals in 24 countries within the VIRUS: COVID-19 Registry. Demographic, clinical, and outcome data were extracted and divided into two groups: Patients with readmission with COVID-19 in 30 days from discharge and those who were not. A univariate analysis is done using chi-square and t-test as appropriate. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission. RESULT(S): Among 20,283 patients, 1,195 (5.9%) were readmitted within 30 days from discharge. The median (IQR) age of readmitted patients was 66 (55-78) years and 45.2% were female, 60.2% were white, and 78.9% non-Hispanic. Higher odds of readmission were observed in patients aged >60 vs 18-40 years (OR 2.76;95% CI, 2.23-3.41), moderate COVID-19 disease (WHO Ordinal scale 4-5) vs Severe COVID-19 (WHO Ordinal scale 6-9) (OR 1.23;95% CI, 1.10-1.39), no ICU admission at index hospitalization (OR 1.70;95% CI, 1.32-1.80), and Hospital length of stay <=14 vs >14 days (OR 1.53;95% CI, 1.32-1.80) vs those not readmitted (p= < 0.001). Comorbidities including coronary artery disease (OR 2.14;95% CI 1.84-2.48), hypertension (OR 1.58;95% CI 1.40-1.78), congestive Heart Failure (OR 2.54;95% CI 2.16-2.98), chronic pulmonary disease (OR 2.26;95% CI 1.94-2.63), diabetes (OR 1.32;95% CI 1.17-1.49) or chronic kidney disease (CKD) (OR 2.41;95% CI 1.2.09-2.78) were associated with higher odds of readmission. In multivariate logistic regression adjusted for age group, hospital length of stay <=14 days and, highest WHO COVID-19 ordinal scale and index ICU admission coronary artery disease, congestive heart failure, chronic pulmonary disease, chronic kidney disease, hospital length of stay <=14 days and age >60 years remained independent risk factors for readmission within 30 days. CONCLUSION(S): Among hospitalized patients with COVID-19, those readmitted had a higher burden of comorbidities compared to those non-readmitted.

Operability of a drape with port connection as a barrier for aerosolgenerating procedures

INTRODUCTION: Frontline healthcare workers who perform aerosol-generating procedures (AGP) are at increased risk of exposure to SARS-CoV-2 causing COVID-19. In order to continue to care for patients with COVID-19, minimizing exposure is paramount and barrier devices are potentially the answer. Using an intubation manikin with two different barrier devices (Plexiglas intubation box and a modified horizontal drape), we evaluated the operators' experience and satisfaction with these two devices and no device METHODS: This was a single-center study that prospectively intubated a manikin three different ways, no device, Plexiglas intubation box, and horizontal drape (Snaport). Each operator completed a survey about ease of use, likelihood to use each device in the future, and any comments following all three intubations. A separate survey was sent to all providers that perform intubations in the hospital about using barrier devices while intubating RESULTS: Fifty-six participants completed the pre-survey. The majority had not previously used a barrier during AGP (64.3%), during bronchoscopy (88.5%), or transporting a patient (87.5%). Most participants would use Snaport during an AGP (85.7%) Thirty participants completed barrier testing and post-survey. The average age was 39.7 years, average years in practice 11.5, and with an average of 22.6 intubations per month. There were no intubation failures. First pass intubation success was achieved for all except for one with Snaport and two with the Plexiglas intubation box. On average, participants found that it was ?easy? to intubate with Snaport (2.3, range 1-5), that it provided enough visibility during intubation (2.8, range 1-3), and did not hinder maneuverability (1.7, range 1-2). Eighteen participants preferred Snaport (60%), seven preferred the Plexiglas box (23%), three preferred to use nothing (10%), and one participant preferred to use Snaport only if the arm slits were redesigned to allow more maneuverability CONCLUSIONS: Snaport was the provider preferred method of barrier protection for intubation. Most participants felt it provided enough visibility without compromising maneuverability. The materials to assemble Snaport are inexpensive and the design is easy to assemble. Snaport is a good option in resource-limited healthcare settings.

COVID-19 infodemics: how social media shared information rapidly to global healthcare teams

INTRODUCTION: The global coronavirus disease 2019 (COVID-19) pandemic created a considerable need for rapid knowledge transmission, but most traditional peer-reviewed journals are struggling to keep up. Other modes of sharing information, such as social media and preprint publications have rapidly become a source of information. While some academicians might argue that these media lack the rigor of a peer-reviewed process, others argue that the current journal submission process is too slow and laborious and delays the free and open exchange of ideas and potentially useful information. METHODS: We measured the reach of social media posts related to the global coronavirus disease 2019 (COVID-19) pandemic, the number of times the posts were shared, the number of countries the posts reached, and the speed of dissemination. RESULTS: @CMichaelGibson tweeted regarding a comparison of different dyi materials from a University of Cambridge research article. This post with #macgyvercare was heavily retweeted and within 3 days the post had been shared by people in 53 countries, and within a week, 79 countries. During this time, the US and the CDC had not commented on the utility of masks for the public or on a universal need for health care workers to wear masks except during procedures with a high risk of aerosolization. Secondly a post on a social media platform tagged #aerosolbox described an improvised, low-cost, aerosol box to help give health care workers additional protection against the novel coronavirus when intubating was shared. In 12 days the idea that was initially posted on Facebook subsequently spread through news media and social media to 6 continents was modified and implemented in hospitals around the globe, and was ultimately described in a leading medical journal. Also, within the same 12-day span, information about #aerosolbox was shared publicly over 26,400 times on social media by people in 110 countries. CONCLUSIONS: Social media is a powerful tool for the dissemination of digital health information. As seen the information traveled far and fast during the COVID-19 pandemic and underwent considerable online feedback while spreading, often transforming into news articles and traditional academic peer-reviewed publication.

Tele-monitoring non-critically ill COVID-19 patients: An advanced practice provider-led initiative

INTRODUCTION: The COVID-19 pandemic has required adaptation and implementation of innovative healthcare practices, including patient triage and limiting staff exposure. Early recognition of deteriorating patients is an imperative step in preventing adverse events, improving outcomes, and limiting unnecessary exposures. Here we describe a critical care medicine (CCM) advanced practice provider (APP) led initiative to implement remote monitoring of non-critically ill COVID-19 patients for signs of deterioration, prompt intervention, and rapid transfer to the intensive care unit (ICU). METHODS: Every admitted COVID-19 patient received an initial remote telemedicine consult by a CCM APP. Patients were then monitored via EMR review once per 12-hour shift for the following indicators: oxygen modality and flow, increase in oxygen requirements, sustained tachypnea, and hemodynamic instability (mean arterial pressure less than 65mmHg or arrhythmias). If signs of deterioration were noted, the APP would remotely reassess the patient, provide recommendations to the primary team, and/or transfer the patient to the ICU. The primary endpoint was avoidance of acute cardiopulmonary deterioration requiring aerosolgenerating procedures (AGPs) outside of the ICU. RESULTS: Over 65 days, there were 2204 total hospital admissions, of which 113 (5.1%) (86 PUIs and 27 SARSCoV- 2-positive) patients were followed by the CCM APPs. Early ICU transfer was initiated on 13 occasions (12 patients, 1 of which had 2 transfer occurrences). Of those transfers, 4 (30.8%) required intubation, 2 (15.4%) required non-invasive ventilation, and 5 (38.5%) required high flow nasal cannula, all of which occurred in negative pressure rooms within the ICU. Vasoactive support was initiated for 5 (38.5%) patients after transfer. Of the 2091 admitted patients not followed by CCM APPs, 9 (0.4%) experienced cardiopulmonary arrest outside of the ICU and 96 (4.6%) required rapid responses. Of the 113 monitored patients, 0 (0%) required rapid responses or experienced cardiopulmonary arrest or required an AGP outside of the ICU. CONCLUSIONS: An APP-led tele-monitoring program may potentially avoid unnecessary viral exposures, decrease the risk of performing emergent AGPs, optimize ICU bed elasticity, and potentially minimize preventable in-hospital mortality.