Regional extracorporeal membrane oxygenation retrieval service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: an interdisciplinary team approach to maintain service provision despite increased demand.

OBJECTIVES: Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing. METHODS: The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO. RESULTS: We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport. CONCLUSIONS: Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.

Evolutionary games and population dynamics: maintenance of cooperation in public goods games.

The emergence and abundance of cooperation in nature poses a tenacious and challenging puzzle to evolutionary biology. Cooperative behaviour seems to contradict Darwinian evolution because altruistic individuals increase the fitness of other members of the population at a cost to themselves. Thus, in the absence of supporting mechanisms, cooperation should decrease and vanish, as predicted by classical models for cooperation in evolutionary game theory, such as the Prisoner's Dilemma and public goods games. Traditional approaches to studying the problem of cooperation assume constant population sizes and thus neglect the ecology of the interacting individuals. Here, we incorporate ecological dynamics into evolutionary games and reveal a new mechanism for maintaining cooperation. In public goods games, cooperation can gain a foothold if the population density depends on the average population payoff. Decreasing population densities, due to defection leading to small payoffs, results in smaller interaction group sizes in which cooperation can be favoured. This feedback between ecological dynamics and game dynamics can generate stable coexistence of cooperators and defectors in public goods games. However, this mechanism fails for pairwise Prisoner's Dilemma interactions and the population is driven to extinction. Our model represents natural extension of replicator dynamics to populations of varying densities.

Venous thromboembolism prevention in patients undergoing colorectal surgery for cancer.

INTRODUCTION: Patients undergoing surgery for colorectal cancer are at high risk of post-operative venous thromboembolism (VTE). Thromboprophylaxis has been shown to have significant risk reduction, although there remains some controversy surrounding the optimal duration of pharmacological prophylaxis. Our institution does not routinely practise extended prophylaxis. The aim of this study was to retrospectively review the rate of post-operative thromboprophylaxis in colorectal cancer patients, and incidence of symptomatic VTE. METHODS: We conducted a retrospective audit of 200 consecutive patients who underwent colorectal surgery for cancer. Data to 90 days post-operatively were collected from medical records and imaging and phone calls to patients and family practitioners. RESULTS: Of the patients, 98% received pharmacological prophylaxis, with a median duration of eight days. Eight (4%) symptomatic VTEs were diagnosed within the 90-day follow-up period: two deep vein thrombosis (DVTs), five pulmonary emboli (PE) and one patient with both PE and DVT. A higher proportion of patients developed DVT/PE if they received prophylaxis other than low molecular weight heparin and similarly there was a trend in increased risk of DVT in the presence of metastatic disease. However, using univariate analysis, these results were not statistically significant (P = 0.18 and 0.11, respectively). DISCUSSION: The use of thromboprophylaxis was high in our centre, and the incidence of VTE was low when patients received a median of 8 days pharmacological prophylaxis combined with mechanical prophylaxis. The VTE incidence of 4% is similar to previous studies using extended prophylaxis. Our study findings do not support changing local protocol to extended prophylaxis.