Antibiotic Prophylaxis in Patients On Extracorporeal Membrane Oxygenation: A Systematic Review.

Despite the frequent use of prophylactic antibiotics in hospitals for extracorporeal membrane oxygenation (ECMO) patients, the Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force does not recommend routine antibiotic prophylaxis due to a lack of compelling evidence. We assessed the effectiveness of prophylactic antibiotics in ECMO patients. We conducted a comprehensive search of multiple databases from their inception up to September 6, 2023, on various databases using keywords like "antibiotics," "prophylaxis," "extracorporeal membrane oxygenation," and "ECMO." Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included research. We collected data using Microsoft Excel version 2016, mean and standard deviations were calculated for continuous data, while frequencies and percentages were calculated for binomial data. A total of three studies was included in the review with a total of 8,954 participants, of which 4,483 (50.06%) received antibiotic prophylaxis, and 1,131 (25.22%) were female. The administration of antibiotics prophylactically was associated with reduction in rate of mortality, the risk of infections, and complications like acute kidney injury and diarrhea. Although there have been some benefits on antibiotic prophylaxis, prospective research, and possibly the creation of tailored, ECMO-specific bundles will be needed to identify efficient ways to prevent ECMO infection.

From numbers to medical knowledge: harnessing combinatorial data patterns to predict COVID-19 resource needs and distinguish patient subsets.

Background: The COVID-19 pandemic intensified the use of scarce resources, including extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV). The combinatorial features of the immune system may be considered to estimate such needs and facilitate continuous open-ended knowledge discovery. Materials and methods: Computer-generated distinct data patterns derived from 283 white blood cell counts collected within five days after hospitalization from 97 COVID-19 patients were used to predict patient's use of hospital resources. Results: Alone, data on separate cell types-such as neutrophils-did not identify patients that required MV/ECMO. However, when structured as multicellular indicators, distinct data patterns displayed by such markers separated patients later needing or not needing MV/ECMO. Patients that eventually required MV/ECMO also revealed increased percentages of neutrophils and decreased percentages of lymphocytes on admission. Discussion/conclusion: Future use of limited hospital resources may be predicted when combinations of available blood leukocyte-related data are analyzed. New methods could also identify, upon admission, a subset of COVID-19 patients that reveal inflammation. Presented by individuals not previously exposed to MV/ECMO, this inflammation differs from the well-described inflammation induced after exposure to such resources. If shown to be reproducible in other clinical syndromes and populations, it is suggested that the analysis of immunological combinations may inform more and/or uncover novel information even in the absence of pre-established questions.

Percutaneous Transseptal Extracorporeal Membrane Oxygenation to Rescue a Failing Right Ventricle in an Animal Model.

OBJECTIVE: We tested the feasibility and effectiveness of a percutaneous atrial transseptal extracorporeal membrane oxygenation (ECMO) cannulation strategy in a right ventricular failure (RVF) model. METHODS: We performed 4 nonsurvival porcine experiments. Percutaneous transseptal access was achieved using a steerable introducer. For guidance, we used fluoroscopy, transesophageal echocardiogram (TEE), and intracardiac echocardiography (ICE). A ProtekDuo rapid deployment cannula (LivaNova, London, UK) was advanced across the septum into the left atrium by 2 to 3 cm. Pulmonary hypertension (PH) was induced by partially clamping the pulmonary artery. ECMO flow was cycled from high (2 to 3 L/min) to low (0.2 to 0.3 L/min) over 2 to 3 hours. RESULTS: Transseptal access using TEE and fluoroscopy was successful in 1 animal and unsuccessful in 1 animal. ICE provided optimal visualization for the remaining 2 animals. Mean arterial pressure (MAP) was associated immediately and consistently with high versus low ECMO flow rate (mean difference: 29 ± 3.1 mm Hg, P = 0.004) but was not restored to baseline values. RV pressure values were dynamic. Given time to equilibrate, mean RV pressure was restored to a baseline level. CONCLUSIONS: Percutaneous right atrium to left atrium transseptal cannulation relieved PH-RVF. MAP was restored to a viable level, and mean RV pressure was restored to a baseline level. Transseptal ECMO shows promise as a cannulation strategy to bridge patients with PH-RVF to lung transplant.

Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions.

In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.

Association of plasma volume status with outcomes in hospitalized Covid-19 ARDS patients: A retrospective multicenter observational study.

PURPOSE: To evaluate the association of estimated plasma volume (ePV) and plasma volume status (PVS) on admission with the outcomes in COVID-19-related acute respiratory distress syndrome (ARDS) patients. MATERIALS AND METHODS: We performed a retrospective multi-center study on COVID-19-related ARDS patients who were admitted to the Mayo Clinic Enterprise health system. Plasma volume was calculated using the formulae for ePV and PVS, and these variables were analyzed for correlation with patient outcomes. RESULTS: Our analysis included 1298 patients with sequential organ failure assessment (SOFA) respiratory score ≥ 2 (PaO2/FIO2 ≤300 mmHg) and a mortality rate of 25.96%. A Cox proportional multivariate analysis showed PVS but not ePV as an independent correlation with 90-day mortality after adjusting for the covariates (HR: 1.015, 95% CI: 1.005-1.025, p = 0.002 and HR 1.054, 95% CI 0.958-1.159, p = 0.278 respectively). CONCLUSION: A lower PVS on admission correlated with a greater chance of survival in COVID-19-related ARDS patients. The role of PVS in guiding fluid management should be investigated in future prospective studies.

Liver Support Techniques in Acute and Hyperacute Liver Failure.

With the growing prevalence of acute liver failure or acute-on-chronic liver failure, on the one hand, and the limited supply of liver organs for transplantation, on the other hand, it is critical to the design, validate, and implement devices that can provide extracorporeal liver support (ECLS) as the bridge to transplantation or potentially destination therapies. The number of attempts to generate ECLS devices has resulted in several options with various levels of impact on clinical outcomes. The described ECLS tools could be as simple as devices used for kidney replacement therapies (e.g., continuous kidney replacement therapy) to tools that employ albumin (e.g., Prometheus, single-pass albumin dialysis, or molecular adsorbent recirculating system), fresh frozen plasma (e.g., high-volume plasmapheresis), or hepatocytes (e.g., extracorporeal liver assist device with hepatocytes) to support failing liver functions, that is, metabolic or synthetic functions. This chapter describes the current landscape of ECLS devices and their associated evidence-based data.

A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis.

Background: The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. Method: We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Results: Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. Conclusion: In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.

Sexual attitude and behavior among medical students: A single institution survey.

Background: Human behavior including sexual activity is mostly culturally bound; particularly individuals at a younger age do build their sexual knowledge through various sources like by forming intimacy with similar age group individuals and use of media or literature available for the information. Values and beliefs about sexuality are manifested in a person's individual sexual behaviors based on family, religion and socio-cultural influence on knowledge about sexuality and sexual experiences. However, modernization may have inadvertently changed people's attitudes and permissiveness among sexually active youths in our society. Methodology: This study adapted a cross-sectional descriptive-cum-exploratory research design conducted in an in-group of a single educational institute. A structured, pre-tested, self-administered questionnaire was used to collect the relevant information from the subjects. This study aims to receive information about the knowledge, practices and attitudes regarding sexual behavior among 340 undergraduate medical students in a medical college at Patna, Bihar. Results: This study showed significant findings regarding changing attitudes of the new generation toward sex and sexual practices as 78.5% of respondents were found between the age group of 20-25 years among which 58.5% were males and 41.5% were females. The average age of sexual debut was found to be 21 years among which 97.3% of the participants were heterosexual. Gender and religion were significantly associated with few components of sexual attitudes. Conclusion: Sex is one of the most sensitive aspects of a human life which is not usually talked about in open space and requires a lot of privacy in thoughts and practices. There is a strong need to introduce age-appropriate sexual knowledge at school and college level to establish healthy sexual attitudes among the young generation. As medical health practitioners, it is necessary to disseminate appropriate guidance and non-biased services to the welfare of the beneficiaries shaping their sexual attitudes for responsible and safe sexual practices.

Multidisciplinary Approach for Lung Transplantation due to COVID-19.

Coronavirus disease 2019 (COVID-19), a novel etiology of end-stage lung disease, has resulted in major disruptions to the process of health care delivery worldwide. These disruptions have led to team-based innovations globally, resulting in a broad range of new processes in cardiopulmonary perioperative management. A key intersection of multidisciplinary teamwork and COVID-19 is found in lung transplantation, in which diverse teams collaborate throughout the perioperative period to achieve optimal outcomes. In this article, we describe the multidisciplinary approach taken by Mayo clinic in Florida to manage patients with COVID-19 presenting for lung transplantation.

Veno-arteriovenous (V-AV) ECMO configuration: A single-center experience.

BACKGROUND: With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed "hybrid" configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno-arteriovenous (V-AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration. METHODS: We retrospectively reviewed all adult patients placed on V-AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO-specific information were analyzed systematically. RESULTS: 14 patients were placed on V-AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA-0 score of 15 and SAVE score of -12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 - 183.1) hours, consisting of 0.2 (IQR 0 - 17.7) hours of VA and 92.4 (IQR 53.7 - 115.1) hours of V-AV followed by 67.4 (IQR 20.3 - 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%). CONCLUSION: ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V-AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series.

Blue Sclera as a Complication of Micropulse Transscleral Laser Therapy.

We report 3 patients who underwent micropulse laser therapy for glaucoma and subsequently developed a bluish-black discoloration of the sclera in a semicircular pattern corresponding to the probe path. This complication has not yet been reported with the micropulse laser treatment.

Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience.

INTRODUCTION: To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation. METHODS: A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge. RESULTS: In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days. CONCLUSION: Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Meta-Analysis of Randomized Controlled Trials Involving Anterior Shoulder Instability.

BACKGROUND: Arthroscopic repair is gaining popularity over open repair for the treatment of bankart lesions. The study aims to evaluate the outcome of arthroscopic repair with open repair in randomised controlled trials conducted comparing the two techniques. METHODS: We searched the Cochrane library, PubMed and EMBASE up to December 2017 for clinical trials comparing the outcomes of arthroscopic bankart repair with open bankart repair. We used fixed or random effects model depending upon heterogenicity. Dichotomous variables were presented as Risk Ratios (RRs) with 95% Confidence Intervals (CIs), and continuous data were measured as measured differences with 95% CIs. RESULT: Five studies were included, with sample size ranging from 42 to 196. Fixed effect analysis showed that the shoulder was more stable in open repair (RR=0.897, 95% CI: 0.821 to 0.980, P= 0.94) but the loss of external rotation at shoulder joint was also higher in those had open repair (RR=0.325, SMD=-0.411, 95% CI: -1.229 to 0.407). The functional outcome assessed by Rowe score was better in open repair (P=0.325). The operative time was lesser in arthroscopic repair but was not statistically significant (P=0.085). CONCLUSION: Our meta-analysis showed that the use of arthroscopic repair though offers better shoulder movement but the open repair is superior in terms of shoulder stability.

Staphylococcal bullous impetigo in a neonate.

An otherwise healthy, full-term neonate presented at day 15 of life to the pediatric emergency with generalized papulo-pustular rash for 2 d. This was finally diagnosed as bullous impetigo caused by Staphylococcus aureus (S. aureus). The skin lesions decreased significantly after starting antibiotic therapy and drainage of blister fluid. There was no recurrence of the lesions on follow-up. This case of generalized pustular eruption due to S. aureus in a neonate is reported, as it poses a diagnostic dilemma and can have serious consequences if left untreated.

Incidence of Adverse Events during Continuous Renal Replacement Therapy.

BACKGROUND/AIMS: The incidence of adverse events (AEs) in adults who receive continuous renal replacement therapy (CRRT) is unknown. We report the incidence of mechanical, metabolic, and hemodynamic CRRT AEs. METHODS: This is a retrospective study of all consecutive adult patients (≥18 years) who underwent CRRT from January 1, 2007 to December 31, 2009. RESULTS: Out of 595 patients who underwent CRRT, 366 (62%) were male and 500 (84%) were Caucasian. Regional citrate anticoagulation was used in 98.6% of all patients. The most common clinically significant electrolyte derangements were ionized hypocalcemia (22%), ionized hypercalcemia (23%), and hyperphosphatemia (44%). Almost all (97%) patients had at least one additional AE including new onset hypotension (within the first hour after CRRT initiation) (43%), hypothermia (44%), new onset arrhythmias (29%), new onset anemia (31%) and thrombocytopenia (40%). CONCLUSIONS: ICU patients who require CRRT have a high incidence of AEs. Although the extent to which these complications are attributable to CRRT is not known, clinicians need to be cautious and aware of their high prevalence in this patient population.

Predictors of outpatient kidney function recovery among patients who initiate hemodialysis in the hospital.

BACKGROUND: Recent policy clarifications by the Centers for Medicare & Medicaid Services have changed access to outpatient dialysis care at end-stage renal disease (ESRD) facilities for individuals with acute kidney injury in the United States. Tools to predict "ESRD" and "acute" status in terms of kidney function recovery among patients who previously initiated dialysis therapy in the hospital could help inform patient management decisions. STUDY DESIGN: Historical cohort study. SETTING & PARTICIPANTS: Incident hemodialysis patients in the Mayo Clinic Health System who initiated in-hospital renal replacement therapy (RRT) and continued outpatient dialysis following hospital dismissal (2006 through 2009). PREDICTOR: Baseline estimated glomerular filtration rate (eGFR), acute tubular necrosis from sepsis or surgery, heart failure, intensive care unit, and dialysis access. OUTCOMES: Kidney function recovery defined as sufficient kidney function for outpatient hemodialysis therapy discontinuation. RESULTS: Cohort consisted of 281 patients with a mean age of 64 years, 63% men, 45% with heart failure, and baseline eGFR≥30mL/min/1.73m(2) in 46%. During a median of 8 months, 52 (19%) recovered, most (94%) within 6 months. Higher baseline eGFR (HR per 10-mL/min/1.73m(2) increase eGFR, 1.27; 95% CI, 1.16-1.39; P<0.001), acute tubular necrosis from sepsis or surgery (HR, 3.34; 95% CI, 1.83-6.24; P<0.001), and heart failure (HR, 0.40; 95% CI, 0.19-0.78, P=0.007) were independent predictors of recovery within 6 months, whereas first RRT in the intensive care unit and catheter dialysis access were not. There was a positive interaction between absence of heart failure and eGFR≥30mL/min/1.73m(2) for predicting kidney function recovery (P<0.001). LIMITATIONS: Sample size. CONCLUSIONS: Kidney function recovery in the outpatient hemodialysis unit following in-hospital RRT initiation is not rare. As expected, higher baseline eGFR is an important determinant of recovery. However, patients with heart failure are less likely to recover even with a higher baseline eGFR. Consideration of these factors at hospital discharge informs decisions on ESRD status designation and long-term hemodialysis care.

Intravenous immunoglobulin in pediatrics: A review.

There has been a rapid expansion of the use of intravenous immunoglobulin (IVIG) for an ever-growing number of conditions. IVIG is used at a 'replacement dose' (400-600 mg/kg/month) in antibody deficiencies and is used at a high dose (2 g/kg) as an 'immunomodulatory' agent in an increasing number of immune and inflammatory disorders.(1) The limitations for IVIG are the cost of the preparation and the need for intravenous infusions. Due to the cost, shortages and growing use of IVIG there have been attempts to develop evidence-based guidelines for the use of IVIG in a wide variety of immune disorders in children and neonates. This commentary provides the recommendations and recent publication regarding the use of IVIG in various conditions in children.

Intravenous immunoglobulin in children with acute myocarditis and/or early dilated cardiomyopathy.

We retrospectively studied medical records of all children with acute myocarditis and/or early DCM admitted to the Pediatric Critical Care Unit of our hospital between January 2010 and December 2012 were reviewed. 28 patients were included in the study, of which 12 were treated with IVIG (1 g/kg per day) for two days. The patients who received IVIG therapy had a higher left ventricular ejection fraction and a reduced left ventricular end diastolic diameter six months after treatment, as compared to children who had not received IVIG (P<0.001 and P=0.002, respectively).

Opioid tolerance--a predictor of increased length of stay and higher readmission rates.

The increasing use of opioids to manage pain in the United States over the last decade has resulted in a subset of our population developing opioid tolerance. While the management of opioid tolerant patients during acute episodes of care is well known to be a challenge amongst health care providers, there is little in the literature that has studied opioid tolerance as a predictor of outcomes. We conducted a review on all admissions to Massachusetts General Hospital over a period of 6 months, from January 2013 to June 2013, and identified opioid tolerant patients at admission using the FDA definition of opioid tolerance. To compare risk adjusted groups, we placed opioid tolerant patients and control patients into groups determined by expected length of stay of less than 2 days, 2 to 5 days, 5 to 10 days, and greater than 10 days. Opioid tolerant patients were then compared to the control for outcomes measures including observed length of stay and readmission rates. Our results show that all opioid tolerant patients have a significantly longer length of stay and a greater 30 day all cause readmission rate than the control group (P < 0.01). This trend was found in the first 3 risk adjusted groups, but not in the fourth group where expected length of stay was greater than 10 days. The opioid tolerant population is at risk given the poorer outcomes and higher health care costs associated with their care. It is imperative that we identify opportunities for improvement and delineate specific pathways for the care of these patients.