Outcomes of Patients Transported in the Prone Position to a Regional Extracorporeal Membrane Oxygenation Center: A Retrospective Cohort Study.

Prone positioning is associated with improved mortality in patients with moderate/severe acute respiratory distress syndrome (ARDS) and has been increasingly used throughout the COVID-19 pandemic. In patients with refractory hypoxemia, transfer to an extracorporeal membrane oxygenation (ECMO) center may improve outcome but may be challenging due to severely compromised gas exchange. Transport of these patients in prone position may be advantageous; however, there is a paucity of data on their outcomes. OBJECTIVES: The primary objective of this retrospective cohort study was to describe the early outcomes of ARDS patients transported in prone position for evaluation at a regional ECMO center. A secondary objective was to examine the safety of their transport in the prone position. DESIGN: Retrospective cohort study. SETTING: This study used patient charts from Ornge and Toronto General Hospital in Ontario, Canada, between February 1, 2020, and November 31, 2021. PARTICIPANTS: Patient with ARDS transported in the prone position for ECMO evaluation to Toronto General Hospital. MAIN OUTCOMES AND MEASURES: Descriptive analysis of patients transported in the prone position and their outcomes. RESULTS: One hundred fifteen patients were included. Seventy-two received ECMO (63%) and 51 died (44%) with ARDS and sepsis as the most common listed causes of death. Patients were transported primarily for COVID-related indications (93%). Few patients required additional analgesia (8%), vasopressors (4%), or experienced clinically relevant desaturation during transport (2%). CONCLUSIONS AND RELEVANCE: This cohort of patients with severe ARDS transported in prone position had outcomes ranging from similar to better compared with existing literature. Prone transport was performed safely with few complications or escalation in treatments. Prone transport to an ECMO center should be regarded as safe and potentially beneficial for patients with ARDS and refractory hypoxemia.

Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position.

OBJECTIVE: Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport. METHODS: This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events. RESULTS: From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47-144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14-176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport. CONCLUSION: Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

Can a screening tool safely identify low risk cardiac patients to be transported with primary care flight paramedics?

OBJECTIVES: We aimed to determine the rate of adverse events during interfacility transport of cardiac patients identified as low risk by a consensus-derived screening tool and transported by primary care flight paramedics (PCP(f)). METHODS: We conducted a health records review of adult patients diagnosed with a cardiac condition who were identified as low risk by the screening tool and transported by PCP(f). We excluded patients transported by an advanced care crew, those accompanied by a clinical escort from hospital, and those transported from a scene call, by rotary wing or ground vehicle. We recorded patient and transportation parameters using a piloted-standardized collection tool. We defined adverse events during transport a priori. We report descriptive statistics using mean (standard deviation), [range], (percentage). RESULTS: We included 400 patients: mean age 66.9 years old, 66.5% male. Mean transport duration was 136.2 (74.9) minutes. Most common comorbidities were hypertension (50.3%) and coronary artery disease (39.5%). Most transports originated out of Northern Ontario and were for cardiac catheterization (61.8%) or coronary artery bypass grafting (26.8%). Overall, the adverse event rate was low (0.3%), with no serious event such as cardiac arrest, death, or airway intervention. CONCLUSIONS: A screening tool can identify cardiac patients at low risk for clinical deterioration during air-medical transport. We believe patients screened with this tool can be transported safely by a PCP(f) crew, leading to potentially significant resource savings.

Air medical transport myths.

The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.

3D printing in critical care: a narrative review.

BACKGROUND: 3D printing (3DP) has gained interest in many fields of medicine including cardiology, plastic surgery, and urology due to its versatility, convenience, and low cost. However, critical care medicine, which is abundant with high acuity yet infrequent procedures, has not embraced 3DP as much as others. The discrepancy between the possible training or therapeutic uses of 3DP in critical care and what is currently utilized in other fields needs to be addressed. OBJECTIVE: This narrative literature review describes the uses of 3DP in critical care that have been documented. It also discusses possible future directions based on recent technological advances. METHODS: A literature search on PubMed was performed using keywords and Mesh terms for 3DP, critical care, and critical care skills. RESULTS: Our search found that 3DP use in critical care fell under the major categories of medical education (23 papers), patient care (4 papers) and clinical equipment modification (4 papers). Medical education showed the use of 3DP in bronchoscopy, congenital heart disease, cricothyroidotomy, and medical imaging. On the other hand, patient care papers discussed 3DP use in wound care, personalized splints, and patient monitoring. Clinical equipment modification papers reported the use of 3DP to modify stethoscopes and laryngoscopes to improve their performance. Notably, we found that only 13 of the 31 papers were directly produced or studied by critical care physicians. CONCLUSION: The papers discussed provide examples of the possible utilities of 3DP in critical care. The relative scarcity of papers produced by critical care physicians may indicate barriers to 3DP implementation. However, technological advances such as point-of-care 3DP tools and the increased demand for 3DP during the recent COVID-19 pandemic may change 3DP implementation across the critical care field.

Perceived versus actual cricothyroid membrane landmarking accuracy by emergency medicine residents and staff physicians.

OBJECTIVES: Cricothyrotomy is an intervention performed to salvage "can't intubate, can't ventilate" situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models. METHODS: Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated. RESULTS: Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30-65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12-51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = -0.081-0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1-0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33). CONCLUSION: We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

Prehospital use of furosemide for the treatment of heart failure.

INTRODUCTION: The diagnosis and management of acute decompensated heart failure (HF) in the prehospital setting can be challenging. The objectives of this study are to evaluate the appropriateness of furosemide use by Emergency Medical Services (EMS) and its association with adverse outcomes. METHODS: This study was a multi-centre health records review of EMS patients who received prehospital furosemide or had an emergency department (ED) diagnosis of HF. We included acutely ill patients ≥50 years of age with shortness of breath transported by land EMS. Univariate and logistic regression analyses were performed to determine associations between furosemide use and serious adverse outcomes (acute renal failure, intubation, vasopressors or death). RESULTS: The study population consisted of 330 patients (N=58, furosemide given by EMS but no HF diagnosed in ED; N=110, furosemide given, HF diagnosed; N=162, no furosemide given, HF diagnosed). The median dose of intravenous furosemide was 80 mg (range 20-80 mg). Serious adverse outcomes occurred in 61 patients (19.0%, 23.6% and 14.8% of the three groups, respectively; p=0.18). The adjusted ORs for adverse events with furosemide use was 0.62 (95% CI 0.33 to 1.43) in patients with a diagnosis of HF and 1.14 (95% CI 0.58 to 2.23) in those without. CONCLUSIONS: More than a third of patients who received prehospital furosemide did not have an HF diagnosis, suggesting that the prehospital diagnosis of HF can be challenging. Serious adverse outcomes were identified in all patient groups and we found no statistically significant associations between furosemide use and adverse events.