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.

Evaluation of Increase in Intraoperative Lactate Level as a Predictor of Outcome in Adults After Cardiac Surgery.

OBJECTIVES: Early onset hyperlactatemia develops intraoperatively or within the first 6 hours of admission to the intensive care unit (ICU) and is associated with a poor prognosis. The aim of the present study was to determine the utility of an increase in the intraoperative lactate level, independent of the absolute lactate value at baseline after induction, as a dynamic parameter for morbidity (ICU length of stay, postoperative renal failure, and inotrope use) and mortality in adults post-cardiac surgery. DESIGN: Retrospective observational study. SETTING: Single-center study in an academic hospital. PARTICIPANTS: The study comprised 779 patients who underwent elective cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified into the following 5 groups based on the increase in the intraoperative lactate level: (1) group 1-negative, (2) group 2-1- to 1.59-fold increase, (3) group 3-1.6- to 1.99-fold increase, (4) group 4-2- to 3-fold increase, and (5) group 5->3-fold increase. Logistic regression analyses were performed. Group 5 had a 4 times greater mortality (7.7%), the longest ICU length of stay (89.02 ± 78.73 h), and the greatest incidence of postoperative renal failure (n = 5 [19.2%]) compared with group 1. The increase in the intraoperative lactate level was a statistically significant predictor of mortality (p = 0.001) and ICU length of hospital stay (p = 0.0006) and was highly predictive for postoperative renal failure requiring renal replacement therapy (p = 0.001). CONCLUSIONS: An increase in intraoperative lactate, independent of the level on induction, is a useful dynamic parameter to identify patients at risk of postoperative morbidity and mortality and might provide an early trigger for introducing measures to avoid poor outcomes.

The role of cardiac rehabilitation using exercise to decrease natriuretic peptide levels in non-surgical patients: a systematic review.

Exercise is recommended in patients with cardiac failure. In the perioperative patient, exercise is also gaining popularity as a form of prehabilitation. In this meta-analysis, we examine if exercise is able to reduce natriuretic peptide levels. Natriuretic peptide (NP) has strong prognostic ability in identifying patients who will develop adverse postoperative cardiovascular outcomes. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcomes were to determine whether exercise therapy was effective in reducing NP levels as compared to control group, the shortest time period required to reduce NP levels after exercise therapy, and whether reducing NP levels decreased morbidity and mortality. Full texts of 16 trials were retrieved for this review. Exercise therapy showed a significant reduction in natriuretic peptide levels between the intervention and control groups (SMD - 0.45, 95% CI - 0.88 to - 0.03) with significant heterogeneity between the included trials. This was also shown in the within a 12-week period.