Anticoagulation practices and complications associated with Impella® support at an advanced cardiac center in the Middle East gulf region.

Anticoagulation during Impella® support is a challenge due to its complications and inconsistent practice across the globe. This observational, retrospective chart review included all patients with Impella® support at our advanced cardiac center at a quaternary care hospital in the Middle East gulf region. The study was conducted over six years (2016-2022), a time period during which manufacturer recommendations for purge solution, anticoagulation protocols as well as Impella® place in therapy and utilization were all evolving. We aimed to evaluate the efficacy of different anticoagulation practices and association with complications and outcomes. Forty-one patients underwent Impella® during the study period, including 25 patients with support for more than 12 h, and are the focus of our analysis. Cardiogenic shock (n = 25, 60.9%) was the primary indication for Impella®, followed by facilitating high-risk PCI (n = 15, 36.7%) and left ventricular afterload reduction in patients undergoing veno-arterial extracorporeal membrane oxygenation (n = 1, 2.4%). Our overall Impella® usage evolved over the years from a primary use to facilitate a high-risk PCI to the recent more common use of LV unloading in cardiogenic shock. No patients experienced device malfunction and the incidence of other complications including ischemic stroke and bleeding were comparable to those reported in the literature (12.2% and 24% respectively). The 30-day all-cause mortality of 41 patients was 53.6%. In line with the evolving recommendations and evidence, we observed an underutilization of non-heparin-based purge solutions and inconsistent management of anticoagulation in the setting of both Impella® and VA ECMO which necessitates more education and protocols.

Peripartum veno-venous extracorporeal membrane oxygenation in patients with severe CoViD-19-related-ARDS.

We describe a case series of five pregnant or postpartum women with severe CoViD-19-related ARDS requiring VV ECMO at our centre between Jan 1 and Sep 30, 2021. All patients were cannulated at the referring hospitals by our team before transferring to our centre. None of the women were vaccinated against CoViD-19. All had severe ARDS with Murray's Lung Injury Score of 3-4 and met the severity threshold for ECMO initiation that was used in the EOLIA study. All patients were discharged alive to home, acute rehabilitation, or lung transplant centre. One patient suffered intrauterine death before ECMO initiation and another while on ECMO. VV ECMO for refractory CoViD-19 related ARDS in the peripartum period is safe, and in this small series, it was associated with good maternal survival rates.

Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6-7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.

Custodian of Oxygen Monitoring: Is There a Winner?

How to cite this article: Praveen Kumar G, Kakar V. Custodian of Oxygen Monitoring: Is There a Winner? Indian J Crit Care Med 2021;25(9):967-968.

Long Runs and Higher Incidence of Bleeding Complications in COVID-19 Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: A Case Series from the United Arab Emirates.

Although the pathophysiology of pulmonary disease caused by coronavirus disease-2019 (COVID-19) is not yet fully understood, successful extracorporeal membrane oxygenation (ECMO) use has been reported for COVID-19-related severe acute respiratory distress syndrome (ARDS). We report a case series of 12 patients who received long venovenous ECMO (VV ECMO) runs for refractory hypoxia (median PF ratio of 71.8, interquartile range (IQR) 53.5-78.5) from COVID-19-related ARDS. A majority (75%) of the patients were males with a median age of 44 (IQR 37-53.5). Overall, six (50%) patients survived to hospital discharge with five of them (83.3%) noted to be cerebral performance category 1 or 2 at the time of discharge. Survivors consistently showed an improvement in sequential organ failure assessment scores within 72 hours of ECMO initiation. The median ECMO duration was 28 days (IQR 13.5-50). Despite using standard anticoagulation strategy, six (50%) of our patients had one or more major bleeding episodes, which proved to be directly fatal in four (25%) patients. Although the overall outcomes of our cohort were acceptable, our patients had much longer ECMO runs (mean 38 days in survivors) and with much higher, often fatal bleeding complications. We compare our data with other published COVID-19 VV ECMO series. HOW TO CITE THIS ARTICLE: Kakar V, North A, Bajwa G, Raposo N, Kumar PG. Long Runs and Higher Incidence of Bleeding Complications in COVID-19 Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: A Case Series from the United Arab Emirates. Indian J Crit Care Med 2021;25(12):1452-1458.

Fenoldopam to prevent acute kidney injury after major surgery-a systematic review and meta-analysis.

BACKGROUND: Acute kidney injury (AKI) after surgery is associated with increased mortality and healthcare costs. Fenoldopam is a selective dopamine-1 receptor agonist with renoprotective properties. We conducted a systematic review and meta-analysis of randomised controlled trials comparing fenoldopam with placebo to prevent AKI after major surgery. METHODS: We searched EMBASE, PubMed, meta-Register of randomised controlled trials and Cochrane CENTRAL databases for trials comparing fenoldopam with placebo in patients undergoing major surgery. The primary outcome was incidence of new AKI. Secondary outcomes were requirement for renal replacement therapy and hospital mortality. RESULTS: Eighty-three publications were screened; 23 studies underwent full data extraction and scoring. Six trials were suitable for inclusion in the data synthesis (total of 507 subjects undergoing cardiovascular surgery, partial nephrectomy, liver transplant surgery). Five studies were rated at high risk of bias. Data on post-operative incidence of AKI were available in five of the six trials (total of 471 patients) but definitions of AKI varied between studies. Of the 238 patients receiving fenoldopam, 45 (18.9%) developed AKI compared to 62 (26.6%) of the 233 patients who received placebo (p = 0.004, I (2) = 0 %; random-effects model odds ratio 0.46, 95% confidence interval 0.27-0.79). In patients treated with fenoldopam, there was no difference in renal replacement therapy (n = 478; p = 0.11, I (2) = 47%; fixed-effect model odds ratio 0.27, 95% confidence interval 0.06-1.19) or hospital mortality (p = 0.60, I (2) = 0 %; fixed-effect model odds ratio 1.0, 95% confidence interval 0.14-7.37). CONCLUSIONS: In this analysis, peri-operative treatment with fenoldopam was associated with a significant reduction in post-operative AKI but it had no impact on renal replacement therapy or hospital mortality. Equipoise remains for further large trials in this area since the studies were conducted in three types of surgery, the majority of studies were rated at high risk of bias and the criteria for AKI varied between trials.

Management of acute aortic services during the COVID-19 pandemic: a retrospective cohort study from the Middle East.

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program. Methods: The authors included consecutive patients presenting with TAAD (n=36) in the years 2019 and 2020 [pre-pandemic period (2019; n=16) and the pandemic era (2020; n=20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years. Results: An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P=0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8-56) vs. 14.5 (8.5-53.3) days, P=0.5] and intensive care unit stay [5 (2.3-14.5) vs. 5 (3.3-9.3) days, P=0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P=0.93]. Conclusions: Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

Sustaining Life versus Altering Life-Saving Drugs: Insights to Explain the Paradoxical Effect of Extracorporeal Membrane Oxygenation on Drugs.

There has been a substantial increase in the use of extracorporeal membrane oxygenation (ECMO) support in critically ill adults. Understanding the complex changes that could affect drugs' pharmacokinetics (PK) and pharmacodynamics (PD) is of suitable need. Therefore, critically ill patients on ECMO represent a challenging clinical situation to manage pharmacotherapy. Thus, clinicians' ability to predict PK and PD alterations within this complex clinical context is fundamental to ensure further optimal and, sometimes, individualized therapeutic plans that balance clinical outcomes with the minimum drug adverse events. Although ECMO remains an irreplaceable extracorporeal technology, and despite the resurgence in its use for respiratory and cardiac failures, especially in the era of the COVID-19 pandemic, scarce data exist on both its effect on the most commonly used drugs and their relative management to achieve the best therapeutic outcomes. The goal of this review is to provide key information about some evidence-based PK alterations of the drugs used in an ECMO setting and their monitoring.

Thoracic surgery in United Arab Emirates.

The United Arab Emirates (UAE) has undergone a significant change in its population and economy in the last decades and in parallel its healthcare system has evolved rapidly to provide advanced, innovative and world-leading care. At the forefront of this revolution in healthcare is the development of a multidisciplinary multimodality thoracic service provision, offered at quaternary referral hospitals amalgamating academics, training, research and innovation. Previously, thoracic service care was limited to single providers at various public and private hospitals, usually performing lower complexity cases. Most complex thoracic cases were repatriated outside the UAE. This practice was replaced with the opening of Cleveland Clinic Abu Dhabi (CCAD), in 2015, which created a multidisciplinary thoracic program. This included the start of a mini-invasive surgical and lung transplantation program. Since that time other public and private hospitals have emerged providing care in a similar model. The impact of these programs has been a decreased transfer of patients abroad for treatment. Under the umbrella of the Emirates Thoracic Society (ETS) a platform for greater collaboration aimed at improving patient care, potential research and physician education has been created. Direct links have been established with world-leading Thoracic surgery and Respiratory Medicine Centers facilitating this development and offering support and guidance. This article charts these changes in thoracic care in the recent past, present, and delineates plans for the future in the UAE.