Treatment and outcome of gram-positive bacteremia in patients receiving extracorporeal membrane oxygenation.

BACKGROUND: While guidance exists for management of blood stream infections with various invasive devices, there are currently limited data to guide antibiotic selection and duration for bacteremia in patients receiving extracorporeal membrane oxygenation (ECMO). OBJECTIVE: To evaluate the treatment and outcomes of thirty-six patients with Staphylococcus aureus and Enterococcus bacteremia on ECMO support. METHODS: Blood culture data was retrospectively analyzed from patients with Staphylococcus aureus bacteremia (SAB) or Enterococcus bacteremia who underwent ECMO support between March 2012 and September 2021 at Brooke Army Medical Center. RESULTS: Of the 282 patients who received ECMO during this study period, there 25 (9%) patients developed Enterococcus bacteremia and 16 (6%) developed SAB. SAB occurred earlier in ECMO as compared to Enterococcus (median day 2 IQR (1-5) vs. 22 (12-51), p = 0.01). The most common duration of antibiotics was 28 days after clearance for SAB and 14 days after clearance for Enterococcus. 2 (5%) patients underwent cannula exchange with primary bacteremia, and 7 (17%) underwent circuit exchange. 1/3 (33%) patients with SAB and 3/10 (30%) patients with Enterococcus bacteremia who remained cannulated after completion of antibiotics had a second episode of SAB or Enterococcus bacteremia. CONCLUSION: This single center case series is the first to describe the specific treatment and outcomes of patients receiving ECMO complicated by SAB and Enterococcus bacteremia. For patients who remain on ECMO after completion of antibiotics, there is a risk of a second episode of Enterococcus bacteremia or SAB.

Critical Care Education and Skills Validation Course for Internal Medicine Physicians in the Military.

INTRODUCTION: Military internist and internal medicine (IM) subspecialist physicians must be prepared to function in both traditional inpatient and outpatient settings, as well as manage critically ill patients within a deployed austere environment. As many critical care procedures are not performed on a routine basis in general IM practice, many active duty IM physicians experience skills degradation and lack confidence in performing these procedures. In order to address this perceived deficiency, the U.S. Army and Air Force Internal Medicine Education and Skills Validation Course was developed to provide essential training in critical care procedures for active duty military IM physicians and subspecialists. MATERIALS AND METHODS: Staff internist and subspecialist physicians at multiple military treatment facilities participated in a 2-day simulation-based training course in critical care procedures included in the Army Individual Critical Task Lists and the Air Force Comprehensive Medical Readiness Program. Educational content included high-yield didactic lectures, multi-disciplinary Advanced Cardiac Life Support/Advanced Trauma Life Support high-fidelity simulation scenarios, and competency training/validation in various bedside procedures, including central venous and arterial line placement, trauma-focused ultrasound exam, airway management and endotracheal intubation, chest tube thoracotomy, and mechanical ventilation, among others. RESULTS: A total of 87 staff IM physicians participated in the course with an average of 2-4 years of experience following completion of graduate medical education. Upon course completion, all participants successfully achieved rigorous, checklist-based, standardized validation in all the required procedures. Survey data indicated a significant improvement in overall skills confidence, with 100% of participants indicating improvement in their ability to function independently as deployed medical officers. CONCLUSIONS: Broad implementation of this program at military hospitals would improve pre-deployment critical care procedural readiness in military IM physicians.

Argatroban for Anticoagulation in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019.

A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population. DESIGN: Retrospective cohort. SETTING: Single-center tertiary-care facility in Fort Sam Houston, TX, from 2020 to 2021. PATIENTS: Twenty-four patients who were cannulated for venovenous extracorporeal membrane oxygenation due to respiratory failure secondary to coronavirus disease 2019. INTERVENTIONS: Argatroban, with or without aspirin, was substituted for heparin in coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Eighty percent of our coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation demonstrated heparin resistance, and patients who were initially started on heparin were significantly more likely to require a change to argatroban than vice versa due to difficulty achieving or maintaining therapeutic anticoagulation goals (93.4% vs 11.1%; p < 0.0001). The time to reach the therapeutic anticoagulation goal was significantly longer for patients who were initially started on heparin in comparison with argatroban (24 vs 6 hr; p = 0.0173). Bleeding and thrombotic complications were not significantly different between the two cohorts. CONCLUSIONS: Argatroban, with or without aspirin, is an effective anticoagulation strategy for patients who require venovenous extracorporeal membrane oxygenation support secondary to coronavirus disease 2019. In comparison with heparin, this anticoagulation strategy was not associated with a significant difference in bleeding or thrombotic complications, and was associated with a significantly decreased time to therapeutic anticoagulation goal, likely as a result of high rates of heparin resistance observed in this patient population.

Simulation-Based Medical Education Improves Procedural Confidence in Core Invasive Procedures for Military Internal Medicine Residents.

Introduction The American Board of Internal Medicine (ABIM) requires that trainees receive procedural training for certification; however, Internal Medicine (IM) residents perform a variable number of procedures throughout residency training. This results in differences in confidence levels as well as procedural competence. For active-duty military trainees, this is especially problematic, as these procedural skills are often required during deployment soon after residency graduation. This deficit can be improved through standardized simulation-based training. Methods All internal medicine residents at our institution were invited to participate in a standardized simulation-based training program for core internal medicine procedures (lumbar puncture, arterial line, central line, thoracentesis, paracentesis, and arthrocentesis). Residents were asked to qualitatively rate their perceived procedural confidence using a Likert scale ranging from 1 (not at all confident) to 5 (extremely confident) in their ability to independently perform core internal medicine procedures prior to the simulation exercise. Experienced senior residents and internal medicine faculty instructed and supervised each resident as they performed the procedures. Following the simulation exercise, the residents repeated the survey and were asked to report whether or not they found the exercise useful.  Results Of the 96 residents invited to participate, 49 completed the pre-simulation questionnaire and 36 completed the post-simulation questionnaire. The cumulative mean Likert scale confidence rating for all procedures showed a statistically significant improvement post-simulation as compared to pre-simulation, including lumbar puncture (2.45±1.1 vs. 3.42±0.87, p<0.05), arterial line (2.48±1.06 vs. 3.39±1.04, p < 0.05), central line (2.86±1.08 vs. 3.5±1.02, p < 0.05), thoracentesis (2.67±1.10 vs. 3.64±0.83, p < 0.05), paracentesis (3.1±1.08 vs. 3.82±0.74, p < 0.05), and arthrocentesis (2.56±1.07 vs. 3.67±0.80, p < 0.05). All (36/36) trainees reported that they perceived the simulation exercise as valuable. Conclusion Internal medicine residents across all post-graduate year (PGY) levels at our institution lacked confidence to independently perform core internal medicine procedures. Utilizing simulation-based medical education as an adjunct to clinical training is well accepted by internal medicine trainees, and resulted in significantly improved procedural confidence. This intervention was well received by trainees and could feasibly be replicated at other active-duty military internal medicine residency programs to assist with readiness. Research is currently in progress to correlate in-situ competency and evaluate clinical outcomes of this improved confidence.