Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support.

BACKGROUND: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

Percutaneous Thrombus Removal in COVID-19-Infected Patient with Pulmonary Embolism.

We present a case describing the use of the AngioVac system (AngioDynamics, Inc.) and SENTINEL™ cerebral protection system (SCPS; Boston Scientific) in a patient with COVID-19 who initially presented with a large deep-vein thrombosis of the left lower extremity, complicated by a pulmonary embolism. Although he initially improved with systemic alteplase, he later developed a second large clot diagnosed in transit in the right atrium. Within 12 hours from initial thrombolysis, this large clot wedged across an incidental patent foramen ovale (PFO), the atrial septum, and the cavotricuspid annulus. We emergently performed a percutaneous clot extraction with preemptive placement of the SCPS in anticipation of cardioembolic phenomenon. A large (> 10 cm) clot was extracted without complication, and the patient was discharged home. The combined use of SCPS and AngioVac in this case suggests a potential role for percutaneous treatment of severe and consequential thromboembolic disease, especially in patients with a PFO, and may be considered as an alternative and less-invasive option in patients with COVID-19. While cerebral embolic protection devices are approved for and widely used in transcatheter aortic valve replacement procedures, there is a theoretical benefit for use in percutaneous thrombolectomies as well.

Off-Pump Continuous-Flow Left Ventricular Assist Device Implantation.

Continuous-flow left ventricular assist device implantation is the typical treatment for end-stage heart failure. Improvements in device engineering and technology, surgical experience and technique, and perioperative management have advanced the field, and short-term results approach those of heart transplantation. Further improvements may be achieved by minimizing adverse physiologic effects associated with cardiopulmonary bypass. Therefore, we have developed an off-pump implantation approach for continuous-flow left ventricular assist devices. We detail our surgical technique for off-pump implantation of the HeartWare device.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients.

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Deadly combination of Vaping-lnduced lung injury and Influenza: case report.

BACKGROUND: E-cigarette and vaping use-associated acute lung injury (EVALI) has been recently recognized as a complication in individuals who use vaping devices. Another consideration is that EVALI may have an adverse influence on the outcome of intercurrent respiratory infections. We document this deadly combination in the case of a young man who had EVALI and simultaneous 41 Influenza-A infection leading to severe Acute Respiratory Distress Syndrome (ARDS). CASE PRESENTATION: A 27-year-old male with a history of tobacco and vaping use was admitted to hospital after two weeks of flu-like symptoms, diarrhea and vomiting. A chest x-ray was consistent with multifocal pneumonia, and microbiological tests were positive for Influenza-A and methicillin-sensitive Staphalacoccus aureus (MSSA). Bronchoscopy provided evidence of acute inhalational injury. After admission, he acutely decompensated with severe hypoxia and hypotension; he required intubation, sedation and vasopressors. He developed sepsis with acute kidney failure, liver failure, biventricular systolic dysfunction and severe rhabdomyolysis. He was placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) initially and later changed to Veno-Arterial (VA) ECMO. Nevertheless, the patient continued to deteriorate, and he expired two weeks after admission. CONCLUSION: This case documents that EVALI can act as a major factor leading a respiratory infection to progress into severe ARDS with a fatal outcome.

CT Imaging of Complications Associated with Continuous-Flow Left Ventricular Assist Devices (LVADs).

Heart failure is becoming increasingly prevalent, and more patients are being treated with left ventricular assist devices (LVADs), either as a bridge to transplant or as destination therapy. The use of continuous-flow LVADs is on the rise. LVAD therapy is associated with several classes of complications, including bleeding, thrombosis, and infection. CT imaging can be used effectively to diagnose LVAD complications, including mediastinal hematomas and pericardial, abdominal wall, and retroperitoneal hemorrhage, inflow and outflow graft and aortic thrombi, and driveline and pump pocket infections. CT can also be helpful in cases of device malfunction and can detect outflow graft kinking and inflow cannula misalignment. When interpreting CT scans in patients with LVADs, accessory materials implanted with the device should not be mistaken for hemorrhage or calcification. With training in recognizing LVAD complications, radiologists can play an important role in the evaluation of patients with heart failure.

Short-Term Experience with Off-Pump Versus On-Pump Implantation of the HeartWare Left Ventricular Assist Device.

Implantation of left ventricular assist devices while avoiding cardiopulmonary bypass (CPB) may decrease bleeding and improve postoperative recovery. To understand the effectiveness of this approach, we reviewed the charts of 26 patients who underwent HeartWare left ventricular assist device (HVAD) implantation without use of CPB (off-CPB group) and 22 patients who had HVAD implanted with CPB (CPB group) with an emphasis on the 30 day postoperative period. Preoperatively, both groups had similar demographic, functional, and hemodynamic characteristics. Off-CPB patients had significantly shorter surgery times than CPB patients, 188.5 (161.5-213.3) min versus 265.0 (247.5-299.5) min, respectively; p < 0.001. Blood transfusion requirements during surgery and within the postoperative 48 hour period were significantly lower in the off-CPB group than in the CPB group (odds ratio: 5.9; 95% confidence interval: 1.1-31.1, p = 0.042). Compared with the CPB group, the off-CPB group patients had a shorter intubation time, 21 (17.4-48.5) hours versus 41 (20.6-258.4) hours; p = 0.042. Intensive care unit stay was 7.0 (4.75-13.5) days for off-CPB versus 10.0 (6.0-19.0) days for CPB (p = 0.256). The off-CPB approach allows HVAD to be implanted quickly with significantly less perioperative bleeding and transfusion requirements and facilitates postoperative rehabilitation.

Prolonged Venovenous Extracorporeal Membrane Oxygenation in a Patient With Acute Respiratory Distress Syndrome.

A 30 year-old Hispanic man with no significant previous medical history presented with refractory hypoxemia after flu-like symptoms. Because of progressive hypoxemia despite appropriate ventilator strategies, venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated for severe acute respiratory distress syndrome (ARDS). His course was complicated at our hospital by subarachnoid hemorrhage, right ventricular failure, multiple pneumothoraces, and significant deconditioning. He was able to be weaned off VV-ECMO after 193 days and was ambulatory at discharge from the hospital.