Outcomes following additional drainage during veno-venous extracorporeal membrane oxygenation: A single-center retrospective study.

Refractory hypoxemia during veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may require an additional cannula (VV-V ECMO) to improve oxygenation. This intervention includes risk of recirculation and other various adverse events (AEs) such as injury to the lung, cannula malpositioning, bleeding, circuit or cannula thrombosis requiring intervention (i.e., clot), or cerebral injury. During the study period, 23 of 142 V-V ECMO patients were converted to VV-V utilizing two separate cannulas for bi-caval drainage with an additional upper extremity cannula placed for return. Of those, 21 had COVID-19. In the first 24 h after conversion, ECMO flow rates were higher (5.96 vs 5.24 L/min, p = .002) with no significant change in pump speed (3764 vs 3630 revolutions per minute [RPMs], p = .42). Arterial oxygenation (PaO2) increased (87 vs 64 mmHg, p < .0001) with comparable pre-oxygenator venous saturation (61 vs 53.3, p = .12). By day 5, flows were similar to pre-conversion values at lower pump speed but with improved PaO2. Unadjusted survival was similar in those converted to VV-V ECMO compared to V-V ECMO alone (70% [16/23] vs 66.4% [79/119], p = .77). In a mixed effect regression model, any incidence of AEs, demonstrated a negative impact on PaO2 in the first 48 h but not at day 5. VV-V ECMO improved oxygenation with increasing flows without a significant difference in AEs or pump speed. AEs transiently impacted oxygenation. VV-V ECMO is effective and feasible strategy for refractory hypoxemia on VV-ECMO allowing for higher flow rate and unchanged pump speed.

Outcomes associated with prolonged ECMO in COVID-19 associated ARDS: A single center experience.

PURPOSE OF STUDY: The COVID-19 pandemic has led to a significant increase in the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) as a bridge to transplantation versus recovery. Unlike other etiologies of acute respiratory distress syndrome (ARDS), utilization of V-V ECMO in COVID-19 has been associated with longer duration of ECMO support requirements. Our team sought to evaluate outcomes associated with prolonged duration of ECMO support in this patient population. METHODS: Single-center retrospective review of patients who were placed on ECMO due to COVID-19 associated ARDS. Specifically examining outcomes-transplant free survival, mortality and discharge rates-of patients requiring V-V ECMO support for greater than 50 days. RESULTS: The median age of the cohort was 48 years and 13 patients (72%) were males. The median duration of ECMO support was 84 days (IQR 55-106). 11 patients (61%) had right ventricular dysfunction and 13 patients (72%) had pneumothoraces. There was a 33% percent (n = 6) mortality rate within cohort. One patient continues to require ECMO support at time of abstract submission. 11 patients (61%) patients were discharged, of which 3 patients required a lung transplant. SUMMARY: Prolonged V-V ECMO can be associated with comparable outcomes to conventional V-V ECMO runs that are relatively shorter in duration. With availability of device and staffing, prolonged ECMO runs can potentially be justified in a highly selected patient population.

Early Tracheostomy May Be Performed Safely in Obese COVID-19 Patients Supported on VV-ECMO.

OBJECTIVE: Obese patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory failure (ARDS) often require prolonged intubation. However, data are sparse regarding optimal tracheostomy timing in obese adults with COVID-19 requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). This study retrospectively describes the course of obese patients with COVID-19 who underwent tracheostomy on VV-ECMO between March 2020 and December 2022. METHODS: There were 62 participants with a median age of 43 (interquartile range [IQR] 33 to 53) years and a median body mass index of 42 (IQR 34 to 50) kg/m2 who received VV-ECMO for COVID-19-associated ARDS. Of those, 42 underwent tracheostomy on VV-ECMO, and 50% (n = 21) of the 42 patients underwent early (within 14 days of initiated ventilatory support) tracheostomy. RESULTS: Among patients who received tracheostomies, the combined respiratory tract and lung parenchymal bleeding rate was 29% (n = 12), but only 7% required surgical intervention for bleeding from the tracheostomy site (n = 3). The hospital length of stay (LOS) was 42 (IQR 36 to 57) days, and mortality rate was 38% (n = 16). Tracheostomy timing was not associated with differences in respiratory tract bleeding, mechanical ventilatory support duration, VV-ECMO support duration, intensive care unit LOS, hospital LOS, mortality, or survival probability. CONCLUSIONS: Although an individualized and holistic approach to clinical decision making continues to be necessary, the findings of this study suggest that early tracheostomy may be performed safely in obese patients with COVID-19 on VV-ECMO.

Extracorporeal membrane oxygenation as acute rescue therapy for negative pressure pulmonary edema in the post anesthesia care unit: A case report.

Negative pressure pulmonary edema (NPPE) may result in respiratory failure refractory to conventional management strategies. Venovenous extracorporeal membrane oxygenation (VV ECMO) can serve as a rescue therapy in cases of severe respiratory failure. Rapid initiation of VV ECMO can decrease morbidity and mortality while facilitating early liberation from mechanical ventilation and promoting early rehabilitation. We describe the successful utilization of VV ECMO as rescue therapy for severe NPPE-induced hypoxic respiratory failure and peri-arrest state in the postanesthesia care unit (PACU) in a patient with postextubation airway obstruction after undergoing patellar tendon repair.

"Beyond waking and walking. Intensive rehabilitation in patients requiring extended durations of advanced mechanical circulatory support: A case series".

Physical therapy (PT) utilization in patients requiring mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) has been reported; however, little is known about intensive rehabilitation and associated outcomes in patients requiring extended complex MCS and/or ECMO support.Authors sought to explore safety, feasibility and outcomes associated with active rehabilitation in patients requiring prolonged advanced MCS/ECMO support.Single-center retrospective series evaluated functional, clinical, and longitudinal outcomes of sample of eight critically ill, adult (≥18 years of age) patients who underwent a intensive rehabilitation while receiving prolonged MCS/ECMO through advanced configurations including: venovenous (VV-ECMO), venoarterial (VA-ECMO), oxygenator with right ventricular assist device (Oxy-RVAD) and right ventricular assist device (RVAD).406 sessions were conducted; 246 during provision of advanced MCS/ECMO support.Incidence of major adverse events-accidental decannulation, migration of cannulas, circuit failure, hemorrhage, major flow limitations, and major hemodynamic instability-was 1.2 events per 100 sessions. None of reported major adverse events impeded longitudinal ability to participate in PT. Increased time to PT initiation was associated with a statistically significant increase in intensive care unit (ICU) length-of-stay (ß1 1.93, CI 0.55-3.30) and reduced ambulatory distance during last session on MCS/ECMO (ß1 -47.64, CI - 93.93, -1.66). All patients survived to hospital discharge and 12 months from sentinel hospitalization. Amongst those patients discharged to an inpatient rehabilitation center (n = 4), all were discharged home within 3 months.Findings support the safety and feasibility of active rehabilitational PT in patients requiring extended durations of advanced MCS/ECMO support. Moreover, it highlights potentially associated benefits of this degree of intensive rehabilitation for these unique patients. Further investigation is needed to identify associations with longitudinal clinical outcomes, as well as predictors of success in this population.

"Pushing Geographic Boundaries: Interfacility transport and remote extracorporeal membrane oxygenation cannulation of patients during COVID-19 pandemic".

Amidst the pandemic, geographical boundaries presented challenges to those in need of higher levels of care from referral centers. Authors sought to evaluate potential predictors of treatment success; assess our transport and remote cannulation process; and identify transport associated complications.Retrospective series of critically ill adults with COVID-19 transferred by our Extracorporeal Membrane Oxygenation (ECMO) team 24 March 2020 through 8 June 2021. Descriptive statistics and associated interquartile ranges (IQR) were used to summarize the data.Sixty-three patients with COVID associated acute respiratory distress syndrome (ARDS) requiring ECMO support were admitted to our ECMO center. Mean age was 44 years old (SD 12; IQR 36-56). 59% (n = 37) of patients were male. Average body mass index was 39.7 (SD 11.3; IQR 31-48.5). Majority of patients (77.8%; n = 35) had severe ARDS. Predictors of treatment success were not observed.Transport distances ranged from 2.2 to 236 miles (median 22.5 miles; IQR 8.3-79); round trip times from 18 to 476 min (median 83 min; IQR 44-194). No transport associated complications occurred. Median duration of ECMO support was 17 days (IQR 9.5-34.5). Length of stay in the Intensive Care Unit (median 36 days; IQR 17-49) and hospital (median 39 days; IQR 25-57) varied. Amongst those discharged, 60% survived.

Institutional Experience With Venoarterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism: A Retrospective Case Series.

OBJECTIVE: Despite advances in treatment, massive pulmonary embolism (PE) remains associated with significant morbidity and mortality. The role of venoarterial extracorporeal membrane oxygenation (VA ECMO) in the setting of massive PE is evolving and includes potential roles both in initial management and as a rescue strategy. DESIGN: Single-center case series that reported demographics and outcomes for patients with massive PE who underwent VA ECMO. SETTING: This investigation was performed at a quaternary referral center with several hospitals throughout the greater Atlanta, GA, area. PARTICIPANTS: The study comprised adult patients (age ≥18 y) admitted to the authors' hospital system. Patients were identified using an internal registry of ECMO patients that contains basic demographic information (age, weight, treatment dates and times, ECMO configuration) and primary diagnosis. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: Seventeen patients who met the inclusion criteria were identified, with 16 patients cannulated peripherally and one patient cannulated centrally for VA ECMO. Survival to hospital discharge was 80% for patients who underwent VA ECMO as an initial approach versus 42% for those in whom it was used as a rescue modality. CONCLUSIONS: The results suggested that patients placed on VA ECMO earlier during their course of massive PE may have improved mortality. Additional investigation is needed to clarify the optimal sequence and timing of therapies surrounding the initiation of VA ECMO in patients with massive PE.

Fibrinolysis Shutdown and Thrombosis in a COVID-19 ICU.

ABSTRACT: The coronavirus disease (COVID-19) pandemic has threatened millions of lives worldwide with severe systemic inflammation, organ dysfunction, and thromboembolic disease. Within our institution, many critically ill COVID-19-positive patients suffered major thrombotic events, prompting our clinicians to evaluate hypercoagulability outside of traditional coagulation testing.We determined the prevalence of fibrinolysis shutdown via rotational thromboelastometry (ROTEM, Instrumentation Laboratories, Bedford, Mass) in patients admitted to the intensive care unit over a period of 3 weeks. In 25 patients who had a ROTEM test, we found that 11 (44%) met criteria for fibrinolysis shutdown. Eight of 9 (73%) of the VTE patients met criteria for fibrinolysis shutdown.Given the high rate of fibrinolysis shutdown in these patients, our data support using viscoelastic testing to evaluate for the presence of impaired fibrinolysis. This may help identify patient subsets who might benefit from the administration of fibrinolytics.

Trends and diagnostic value of D-dimer levels in patients hospitalized with coronavirus disease 2019.

Coronavirus disease 2019 (COVID-19) has been associated with increased incidence of venous thromboembolic events (VTE) as well as mortality. D-dimer is a marker of fibrinolysis and has been used as a diagnostic and prognostic marker in VTE among other diseases. The purpose of our study is to describe outcomes from out center and to examine trends in D-dimer levels as it relates to VTE and mortality.Patients admitted with confirmed COVID-19 cases to Emory Healthcare from March 12, 2020 through April 6, 2020 with measured plasma D-dimer levels were included in our retrospective analysis. Relevant data about comorbidities, hospitalization course, laboratory results, and outcomes were analyzed.One hundred fifteen patients were included in our study. Mean age was 64 ±â€Š15 years, 47 (41%) females and 84 (73%) African-American. Hypertension was present in 83 (72%) and diabetes in 60 (52%). Mean duration of hospitalization was 19 ±â€Š11 days with 62 (54%) patients intubated (mean duration of 13 ±â€Š8 days). VTE was diagnosed in 27 (23%) patients (mean time to diagnosis 14 ±â€Š9 days). Median D-dimer within the first 7 days of hospitalization was higher (6450 vs. 1596 ng/mL, p < 0.001) in VTE cases compared to non-VTE cases, and was predictive of VTE (area under the curve [AUC] = 0.72, optimal threshold 2500 ng/mL) although not of mortality (AUC 0.55, P = .34). Change in D-dimer level (AUC = 0.72 P = .004) and rate of D-dimer rise (AUC = 0.75 P = .001) were also predictive of VTE, though neither predicted death (P > .05 for all). Within the first 7 days of hospitalization, peak D-dimer level of >2500 ng/mL and a rate of change exceeding 150 ng/mL/d were predictive of future diagnosis of VTE. Rise in D-dimer >2000 ng/mL within any 24 hour period through hospital day 10 had 75% sensitivity and 74% specificity for diagnosis of VTE.We found that both magnitude and rate of rise in d-dimer within the first 10 days of hospitalization are predictive of diagnosis of VTE but not mortality. These parameters may aid in identifying individuals with possible underlying VTE or at high risk for VTE, thereby guiding risk stratification and anticoagulation policies in COVID-19 patients.

C-Reactive protein as a prognostic indicator in hospitalized patients with COVID-19.

Recent studies have reported that CRP levels are elevated in patients with COVID-19 and may correlate with severity of disease and disease progression. We conducted a retrospective cohort analysis of the medical records of 268 adult patients, who were admitted to one of the six cohorted COVID ICUs across Emory Healthcare System and had at least two CRP values within the first seven days of admission to study the temporal progression of CRP and its association with all-cause in-hospital mortality. The median CRP during hospitalization for the entire cohort was 130 mg/L (IQR 82-191 mg/L), and the median CRP on ICU admission was 169 (IQR 111-234). The hospitalization-wide median CRP was significantly higher amongst the patients who died, compared to those who survived [206 mg/L (157-288 mg/L) vs 114 mg/L (72-160 mg/L), p<0.001]. CRP levels increased in a linear fashion during the first week of hospitalization and peaked on day 5. Compared to patients who died, those who survived had lower peak CRP levels and earlier declines. CRP levels were significantly higher in patients who died compared to those who survived (p<0.001). Our findings support the utility of daily CRP values in hospitalized COVID-19 patients and provide early thresholds during hospitalization that may facilitate risk stratification and prognostication.

Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report.

Amniotic fluid embolism is a rare obstetric emergency that can be accompanied by profound hypoxemia, coagulopathy, hemorrhage, and cardiogenic shock. Extracorporeal membrane oxygenation may provide a rescue strategy in amniotic fluid embolism with cardiopulmonary collapse. Approaches to anticoagulation must be balanced against the risk of hemorrhage with concomitant coagulopathy. Although extracorporeal membrane oxygenation has been described for cardiopulmonary collapse in the setting of amniotic fluid embolism, its initiation as a bridge to hemostasis and cardiopulmonary recovery in amniotic fluid embolism-induced hemorrhagic and cardiogenic shock remains a novel resuscitation strategy. DESIGN SUBJECT AND INTERVENTION: We present a case detailing the initiation of extracorporeal life support with veno-arterio-venous extracorporeal membrane oxygenation in a patient with hemorrhagic shock and cardiopulmonary failure due to amniotic fluid embolism. The patient was ultimately discharged home 19 days after presentation free from neurologic or other significant disability. MAIN RESULTS AND CONCLUSION: Through this case, we describe a tailored approach to extracorporeal life support initiation and advanced extracorporeal membrane oxygenation management as a bridge to recovery in patients with mixed shock. Additionally, we discuss how the culmination of prehospital, outpatient and inpatient provider teamwork, easily portable extracorporeal membrane oxygenation equipment, and multispecialty collaboration can afford promising therapeutic options for patients who were previously deemed ineligible for extracorporeal life support.

Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department.

BACKGROUND: To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED). METHODS: Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach's alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis. RESULTS: We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach's alpha = 0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r = 0.66) and patient recommendation of the ED to friends and family (r = 0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction. CONCLUSIONS: The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.

A Systematic Approach to Comfort Care Transitions in the Emergency Department.

BACKGROUND: Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress. OBJECTIVES: To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient. METHODS: Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients. DISCUSSION: Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy. CONCLUSION: Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.

Facilitators of research registry enrollment and potential variation by race and gender.

INTRODUCTION: Little is known about what motivates people to enroll in research registries. The purpose of this study is to identify facilitators of registry enrollment among diverse older adults. METHODS: Participants completed an 18-item Research Interest Assessment Tool. We used logistic regression analyses to examine responses across participants and by race and gender. RESULTS: Participants (N=374) were 58% black, 76% women, with a mean age of 68.2 years. All participants were motivated to maintain their memory while aging. Facilitators of registry enrolled varied by both race and gender. Notably, blacks (estimate=0.71, p<0.0001) and women (estimate=0.32, p=0.03) were more willing to enroll in the registry due to home visits compared with whites and men, respectively. CONCLUSIONS: Researchers must consider participant desire for maintaining memory while aging and home visits when designing culturally tailored registries.