How I manage differential gas exchange in peripheral venoarterial extracorporeal membrane oxygenation.

Dual circulation is a common but underrecognized physiological occurrence associated with peripheral venoarterial extracorporeal membrane oxygenation (ECMO). Competitive flow will develop between blood ejected from the heart and blood travelling retrograde within the aorta from the ECMO reinfusion cannula. The intersection of these two competitive flows is referred to as the "mixing point". The location of this mixing point, which depends upon the relative strengths of the native and extracorporeal pumps, will determine which regions of the body are perfused with blood ejected from the left ventricle and which regions are perfused by reinfused blood from the ECMO circuit, effectively establishing dual circulations. Because gas exchange within these circulations is dictated by the native lungs and membrane lung, respectively, oxygenation and carbon dioxide removal may differ between regions-depending on how well gas exchange is preserved within each circulation-potentially leading to differential oxygenation or differential carbon dioxide, each of which may have important clinical implications. In this perspective, we address the identification and management of dual circulation and differential gas exchange through various clinical scenarios of venoarterial ECMO. Recognition of dual circulation, proper monitoring for differential gas exchange, and understanding the various strategies to resolve differential oxygenation and carbon dioxide may allow for more optimal patient management and improved clinical outcomes.

One Year Outcomes Following Transplantation with COVID-19-Positive Donor Hearts: A National Database Cohort Study.

The current understanding of the safety of heart transplantation from COVID-19+ donors is uncertain. Preliminary studies suggest that heart transplants from these donors may be feasible. We analyzed 1-year outcomes in COVID-19+ donor heart recipients using 1:3 propensity matching. The OPTN database was queried for adult heart transplant recipients between 1 January 2020 and 30 September 2022. COVID-19+ donors were defined as those who tested positive on NATs or antigen tests within 21 days prior to procurement. Multiorgan transplants, retransplants, donors without COVID-19 testing, and recipients allocated under the old heart allocation system were excluded. A total of 7211 heart transplant recipients met the inclusion criteria, including 316 COVID-19+ donor heart recipients. Further, 290 COVID-19+ donor heart recipients were matched to 870 COVID-19- donor heart recipients. Survival was similar between the groups at 30 days (p = 0.46), 6 months (p = 0.17), and 1 year (p = 0.07). Recipients from COVID-19+ donors in the matched cohort were less likely to experience postoperative acute rejection prior to discharge (p = 0.01). National COVID-19+ donor heart usage varied by region: region 11 transplanted the most COVID-19+ hearts (15.8%), and region 6 transplanted the fewest (3.2%). Our findings indicate that COVID-19+ heart transplantation can be performed with safe early outcomes. Further analyses are needed to determine if long-term outcomes are equivalent between groups.

Feel the Burn: Case Report of Internal Thermal Injury from Liposculpture.

BACKGROUND Liposuction is a commonly performed aesthetic procedure. New technology is being integrated to target fine lines or creases in the skin, known as rhytides, and skin laxity that cannot be corrected with liposuction. "Liposculpture" is a new term to describe a variation of liposuction that integrates this new technology for both fat reduction and skin tightening. A new form of liposculpture known as Renuvion, which utilizes a helium-based plasma technology, is being added to improve cosmetic outcomes. In this case report, we describe a case of internal thermal injury masquerading as cellulitis from the use of this new technology. CASE REPORT A 37-year-old African-American woman with a history of anemia, hypertension, hyperlipidemia, and depression, with prior breast reduction and liposuction, presented to the emergency room with a 5-day history of waxing/waning fevers that began shortly after undergoing a liposculpture procedure. Imaging demonstrated subcutaneous emphysema and edema in the abdominal wall. Empiric antimicrobials were started given concern for surgical wound infection, but erythema and pain worsened despite treatment. Other infectious markers were negative including negative procalcitonin, normal white blood cell count, and no growth from wound and blood cultures, leading to consideration of a new diagnosis of thermal injury. Antibiotics were subsequently de-escalated to a combination of levofloxacin and doxycycline. She was also treated with topical silver sulfadiazine for her thermal injury. She required multiple rounds of infrared light therapy and lymphatic massage techniques with overall improvement but lasting hyperpigmentation by her 6-month follow-up. CONCLUSIONS Thermal injuries have been an extremely rare finding in patients undergoing cosmetic procedures. Treatments targeting skin laxity and rhytides may confer higher risk. It is important to note that presentations can mimic cellulitis or surgical site infection. In this case vignette, we describe a rare complication of thermal injury following a liposculpture procedure using a cold atmospheric plasma device in a previously healthy 37-year-old African-American woman.

Is Transplantation With Coronavirus Disease 2019-Positive Donor Lungs Safe? A US Nationwide Analysis.

BACKGROUND: Since the beginning of the pandemic, coronavirus disease 2019 (COVID-19) has caused debilitating lung failure in many patients. Practitioners have understandably been hesitant to use lungs from donors with COVID-19 for transplantation. This study aimed to analyze the characteristics and short-term outcomes of lung transplantation from donors with recent positive COVID-19 testing results. METHODS: Lung transplantations performed between January 2020 and June 2022 were queried from the United Network for Organ Sharing database. Pediatric, multiorgan, and repeat lung transplantations were excluded. Propensity scoring matched recipients of lungs from donors with recent positive COVID-19 testing results to recipients of lungs from donors with negative COVID-19 testing results, and comparisons of 30-day mortality, 3-month mortality, and perioperative outcomes were performed. RESULTS: A total of 5270 patients underwent lung transplantation during the study dates, including 51 patients who received lungs from donors with recent positive COVID-19 testing results. Forty-five recipients of lungs from donors with recent positive COVID-19 testing results were matched with 135 recipients of lungs from donors with negative COVID-19 testing results. After matching, there was no difference in 30-day (log-rank P = .42) and 3-month (log-rank P = .42) mortality. The incidence of other perioperative complications was similar between the groups. CONCLUSIONS: The 30-day and 3-month survival outcomes were similar between recipients of lungs from donors with recent positive COVID-19 testing results and recipients of lungs from donors with negative COVID-19 testing results. This finding suggests that highly selected COVID-19-positive donors without evidence of active infection may be safely considered for lung transplantation. Further studies should explore long-term outcomes to provide reassurance about the safety of this practice.

How Much Do Nurses Know About Residents?

Nurses work closely with residents on a daily basis but may not understand the details about residency training and experience. We investigated our institution to understand misconceptions nurses may have about residents and provide education. Nurses (n = 26) participated in a lecture about residents and were given identical surveys before and after the lecture. Twenty-two nurses (85%) were medical/surgical, 1 (4%) was obstetrical, and 3 (11%) were critical care. In the pre-education survey, nurses were able to correctly identify the main purpose of residency as educational. Most nurses knew that residents arrived at the hospital between 5:00 and 7:00 am and that residents could perform bedside procedures. A marked increase was found between correct pre- and post-survey answers in 4 questions: interns are doctors (15% vs. 77%), residents' work hours (23% vs. 65%), correct average salary (39% vs. 92%), and correct paid time off (PTO) days per year (8% vs. 85%). Salaries were overestimated, and work hours and PTO were underestimated. Most nurses did not know interns are in fact doctors. Our post-educational survey demonstrated improved knowledge of resident credentials, challenges, and work environment. The mean result for the post-educational survey was significantly higher than the pre-educational survey results, indicating that the educational intervention was effective in improving nurses' knowledge regarding residents.

What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous tapping?

OBJECT: Most CSF-diverting shunt systems have an access port that can be percutaneously tapped. Tapping the shunt can yield valuable information as to its function and whether an infection is present. The fear of causing a shunt infection by tapping may limit the physician's willingness to do so. The authors of this study investigate the risk of infecting a shunt secondary to percutaneous tapping. METHODS: Following institutional review board approval, CSF specimens obtained from tapping an indwelling CSF-diverting shunt during the 2011 and 2012 calendar years were identified and matched with clinical information. A culture-positive CSF sample was defined as an infection. If results were equivocal, such as a broth-only-positive culture, a repeat CSF specimen was examined. The CSF was obtained by tapping the shunt access port with a 25-gauge butterfly needle after prepping the unshaven skin with chlorhexidine. RESULTS: During the study period, 266 children underwent 542 shunt taps. With 541 taps, no clinical evidence of a subsequent shunt infection was found. One child's CSF went from sterile to infected 11 days later; however, this patient had redness along the shunt tract at the time of the initial sterile tap. CONCLUSIONS: The risk of infection from tapping a shunt is remote if the procedure is done correctly.