Improving ECMO therapy: Monitoring oxygenator functionality and identifying key indicators, factors, and considerations for changeout.

INTRODUCTION: The optimal timing for extracorporeal membrane oxygenation (ECMO) circuit change-out is crucial for the successful management of patients with severe cardiopulmonary failure. This comprehensive review examines the various factors that influence the timing of oxygenator replacement in the ECMO circuit. By considering these factors, clinicians can make informed decisions to ensure timely and effective change-out, enhancing patient outcomes and optimizing the delivery of ECMO therapy. METHODOLOGY: A thorough search of relevant studies on ECMO circuits and oxygenator change-out was conducted using multiple scholarly databases and relevant keywords. Studies published between 2017 and 2023 were included, resulting in 40 studies that met the inclusion criteria. DISCUSSION: Thrombosis within the membrane oxygenator and its impact on dysfunction were identified as significant contributors, highlighting the importance of monitoring coagulation parameters and gas exchange. Several factors, including fibrinogen levels, pre and post-membrane blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows and pressures, and anticoagulation strategy, were found to be important considerations when determining the need for an oxygenator or circuit change-out. The involvement of a multidisciplinary team and thorough preparation were also highlighted as crucial aspects of this process. CONCLUSION: In conclusion, managing circuit change-outs in ECMO therapy requires considering factors such as fibrinogen levels, blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows, pressures, and anticoagulation strategy. Monitoring these parameters allows for early detection of issues, timely interventions, and optimized ECMO therapy. Standardized protocols, personalized anticoagulation approaches, and non-invasive monitoring techniques can improve the safety and effectiveness of circuit change-outs. Further research and collaboration are needed to advance ECMO management and enhance patient outcomes.

Physical Activity, Mental Health, and Quality of Life among School Students in the Jazan Region of Saudi Arabia: A Cross-Sectional Survey When Returning to School after the COVID-19 Pandemic.

Increasing evidence suggests that physical activity (PA) can reduce depression and anxiety in adolescents. At the same time, quality of life (QoL) is sensitive to both mental health and PA, but little is known about the mechanism between these three variables among adolescents. This study aimed to assess the physical activity, mental health, and quality of life of school students when they returned to school after two years of distance learning in the Jazan region. This current investigation represented an observational cross-sectional survey conducted in January 2022 among a random sample of 601 students from intermediate and high schools in the Jazan region, Saudi Arabia. Three standardized questionnaires were used for data collection; the Arabic version of the Pediatric Quality of Life Inventory (PedsQL), Depression Anxiety Stress Scales (DASS21), and the Fels PAQ for children. The analysis revealed a moderate level of physical activity, decreased HRQoL, and symptoms of mental health problems (anxiety, depression, and stress) among the schools' students when they returned to school following COVID-19 lockdown. The overall Pediatric Quality of Life mean score was (81.4 ± 16.4), which differed significantly according to gender, age groups, and grade levels (p < 0.05 for all). There was a negative correlation between the overall quality of life and mental health domains. Sport was negatively correlated with mental illness symptoms and positively correlated (p < 0.05) with Pediatric Quality of Life. The regression models revealed that stress was a significant predictor for the quality of life of male and female adolescents ([ß = -0.30, (95% CI (-0.59) to (-0.02), p < 0.05)] and [ß = -0.40, (95% CI (-0.70) to (-0.01), p < 0.05)], respectively). The analysis revealed a moderate level of physical activity among the schools' students when they returned to school following COVID-19 lockdown. Children's involvement in physical activity was associated with improved quality of life and mental health. The results call for the need to develop appropriate intervention programs to increase school students' physical activity levels.

Therapeutic plasma exchange in patients with life-threatening COVID-19: a randomised controlled clinical trial.

Assessment of efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. This was an open-label, randomised clinical trial of ICU patients with life-threatening COVID-19 (positive RT-qPCR plus ARDS, sepsis, organ failure, hyperinflammation). Study was terminated after 87/120 patients enrolled. Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by PaO2/FiO2 ratio (>150 vs. ≤150), were compared. Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in SOFA score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length of stay (LOS). Eighty-seven patients [median age 49 (IQR 34-63) years; 82.8% male] were randomised (44 standard care; 43 standard care plus TPE). Days on MV (P = 0.007) and ICU LOS (P = 0.02) were lower in the TPE group. 35-Day mortality was non-significantly lower in the TPE group (20.9% vs. 34.1%; Kaplan-Meier, P = 0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity and decreased serum lactate, lactate dehydrogenase, ferritin, d-dimers and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO2/FiO2 ratio (HR, 0.98, 95% CI 0.96-1.00; P = 0.02]; ADAMTS-13 activity (HR, 0.89, 95% CI 0.82-0.98; P = 0.01); pulmonary embolism (HR, 3.57, 95% CI 1.43-8.92; P = 0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (P < 0.05). In critically-ill COVID-19 patients, addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.

Renal Tubular Acidosis in Critically Ill Patients with Coronavirus Disease 2019 Acute Respiratory Distress Syndrome.

The coronavirus disease 2019 (COVID-19) infection associated with multisystemic involvement including renal manifestations has been described in the literature. The recent data show a high mortality rate of 60%-90% once renal function begins to deteriorate. We report on three patients who were admitted to intensive care unit due to severe COVID-19 acute respiratory distress syndrome and developed distal renal tubular acidosis. The three COVID-19 patients had hyperchloremic acidosis which was investigated thoroughly through a biochemical analysis of arterial blood gases and urine test as well as serological tests for autoimmune diseases and chronic infections, in addition to renal ultrasound. Metabolic acidosis was managed through repeated doses of intravenous sodium bicarbonate therapy; however, continuous renal replacement therapy was initiated for two refractory cases. We found that severe COVID-19 infection may be accompanied by hyperchloremic acidosis due to the cytopathic damage of the distal renal tubules, making the buffering system nonefficient and if not managed adequately, it may lead to poor prognosis.

A 21-year-old woman with mediastinal mass and cardiac arrest.

Mediastinal mass syndrome (MMS) is a devastating respiratory and haemodynamic condition that might be encountered postintubation if special precautions are not carefully undertaken. We describe a case of MMS in a 21-year-old woman with a fatal outcome following emergency intubation for acute respiratory failure.

Pleomorphic rhabdomyosarcoma with pulmonary tumour embolism.

Pulmonary tumour embolism is a known complication of cancer disease. To date, pleomorphic rhabdomyosarcoma has been described once with this entity. We report a case of pulmonary tumour embolism diagnosed in the operation room after cardiac arrest of a 30-year-old male patient who had surgical amputation of his right upper limb due to recurrent sarcoma, mandating urgent and successful embolectomy.

Status epilepticus and cardiopulmonary arrest in a patient with carbon monoxide poisoning with full recovery after using a neuroprotective strategy: a case report.

INTRODUCTION: Carbon monoxide poisoning can be associated with life-threatening complications, including significant and disabling cardiovascular and neurological sequelae. CASE PRESENTATION: We report a case of carbon monoxide poisoning in a 25-year-old Saudi woman who presented to our facility with status epilepticus and cardiopulmonary arrest. Her carboxyhemoglobin level was 21.4 percent. She made a full recovery after we utilized a neuroprotective strategy and normobaric oxygen therapy, with no delayed neurological sequelae. CONCLUSIONS: Brain protective modalities are very important for the treatment of complicated cases of carbon monoxide poisoning when they present with neurological toxicities or cardiac arrest. They can be adjunctive to normobaric oxygen therapy when the use of hyperbaric oxygen is not feasible.

Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention.

We report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent life-threatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute's diabetic ketoacidosis clinical pathway.

A young patient with massive haematemesis.

Aortoesophageal fistula (AEF) is a rare and life-threatening cause of gastrointestinal haemorrhage which requires emergency surgical intervention. We report a case of aortoesophageal fistula due to previous endovascular stent grafting to the ascending thoracic aorta after previous traumatic injury. The patient presented with catastrophic haematemesis which was managed by repeated deployment of endovascular stent graft and aortic bypass surgery; however, the patient ultimately died due to massive haemoptysis.