ABSTRACT
Objectives: Preliminary results of the CTC Registry on the first 52 patients showed survival of 69% at 90 days [1]. The current exploratory analysis aimed to examine whether the time of initiation of hemoadsorption (i.e.: early vs late) had any effect organ support requirements and survival. Method(s): We included all 100 patients recruited in the CTC Registry in 5 U.S. intensive care units (ICU). The median time from ICU admission to the start of hemoadsorption was 86.7 h. We created two post hoc groups: <=86.7 h (group-early, GE) and >86.7 h (group-late, GL) and compared outcomes with special focus on the need of mechanical ventilation (MV), vasopressor, renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO). Result(s): There was no difference between groups in baseline characteristics. 90-day survival was 78% in GE and 62% in GL (p=0.08). Patients in the GL vs GE spent longer time on ECMO (p=0.021), mechanical ventilation (p=0.02) and needed significantly longer ICU-stay (p=0.002), (Fig. 1). There was also a trend for longer vasopressor support (8 [4-21] vs 4 [1-17] days, p=0.13). There was no significant difference between the groups regarding the need of CRRT. Conclusion(s): The current analysis shows that early initiation of hemoadsorption with ECMO in critically ill COVID-19 patients is associated with shorter duration of organ support measures and shorter ICU stays.
ABSTRACT
Purpose: Percutaneous cannulation for Veno-Venous (V-V) and Veno-Pulmonary Arterial (V-PA) ECMO has transformed our approach to extracorporeal support, particularly in the Covid-19 era. Along with the increase in percutaneous cannulation comes an increase in complications, some necessitating replacement of the cannula. We present a novel technique to exchange cannulas using the same site with minimal blood loss and time off support. Method: All procedures were performed in the hybrid OR with fluoroscopy and transesophageal echocardiography (TEE). A 4 Fr. dilator was placed posteromedial to the existing cannula with pressure directed toward the cannula to enter the vein. A wire was placed through the dilator to facilitate directing the wire into the PA or IVC, ultimately advancing the wire into the RPA (V-PA) or IVC (V-V). The ECMO circuit was clamped and both limbs transected. The existing cannula was removed simultaneously with the new cannula being placed over the wire into either PA or IVC (V-PA or V-V respectively). The cannula was deaired, reconnected to the ECMO circuit, and flow reestablished. Results: 8.1% (19/234) of our V-V or V-PA patients required replacement of the percutaneous cannula. 63% were due to RV failure diagnosed by echocardiography and 32% were for cannula migration below the pulmonary valve into the RV. Our technique was universally successful with a mean blood loss of 20cc, <1.5 minutes off ECMO, and no complications. Summary: The described technique is effective in replacing percutaneous V-V and V-PA ECMO cannulas using the original site with minimal time off support and blood loss. (Figure Presented).
ABSTRACT
Background: SARS-CoV-2 (i.e., COVID-19) has brought extracorporeal membrane oxygenation (ECMO) into the forefront of critical care. Its unique pathophysiology has added a level of complexity to ECMO therapy, particularly, the hematologic manifestations. Here we detail the spectrum and outcomes of bleeding complications in ECMO for COVID-19 and identify potential contributing factors. Methods: All patients who received ECMO for SARS-CoV-2 pneumonia severe acute respiratory distress syndrome at our institution between March 1, 2020 and April 12, 2021 were reviewed. Patient characteristics, laboratory results, and overall outcomes were recorded. Bleeding events were reviewed with regard to the type/location and intervention required. Severity was graded according to the degree of intervention for treatment (1 [conservative or minor] - 3 [major, life-threatening, or operative]). Laboratory results and patient characteristics were compared between patients with bleeding events and those without to identify factors associated with bleeding risk. Results: Fifty-four patients (mean age 53.2 years, 61.1% female, 51.9% Caucasian) underwent ECMO cannulation for SARSCoV-2 pneumonia at our institution. Thirty-eight (70.4%) received veno-pulmonary artery ECMO. The mean duration of support was 33.2 days with an in-hospital mortality of 42.6%. 68.5% of patients experienced at least one bleeding event during their ECMO course with 92 bleeding events (n=23 [grade 1], n=31 [grade 2], n=38 [grade 3]) over 1804 cannulation days. The most common types of bleeding types were nasal/oropharyngeal (n=30, 32.6%), pulmonary (n=18, 19.6%), and gastrointestinal (n=11, 12.0%). Eight (16.0%) patients required operative intervention and 11 (20.3%) died as a result of a bleeding event, mainly due to intracranial hemorrhages (n=5, 9.3%). There was no difference in the mean cumulative function for bleeding events between different ECMO support modalities (p=0.85) which demonstrated a linear pattern over time. Factors that increased the risk of bleeding included patient cumulative volume balance (OR 1.22 per 1000 mL increase from admission, p<0.001) while higher platelet count (OR 0.83 per 50x103/uL increase, p=0.03) was protective. Conclusion: ECMO for SARS-CoV-2 pneumonia is associated with a diverse and unique profile of bleeding complications. The incidence of bleeding complications is linearly related to cannulation duration. Certain patient factors may affect the risk of bleeding while on ECMO.
ABSTRACT
Background: The impact of clinician burnout on patient care is pervasive across medical delivery systems. The effects are also felt in preventive care where cancer screening efforts rely on clinician referrals through the electronic medical records (EMRs). Though designed to support healthcare, EMRs are a significant source of clinician burnout given the number of clicks or navigation time needed to refer a patient. This is a barrier to Patient Navigation (PN) when ordered tests do not materialize into screenings or when clinicians order labs/imaging and the pending orders are not created. This causes frustration for all clinical staff involved, delays the workflow processes, and leads to missed opportunities for PN. We implemented an 'order set' intervention to reduce the click burden linked to colorectal cancer (CRC) screening referral among clinicians in South Georgia. Methods: The 'order set' intervention was developed to facilitate PN for a Colorectal Cancer Control Program (CRCCP) aimed at implementing Evidence- Based Interventions to increase CRC screening rates in Georgia. The 'order set' was designed to address workflow issues by consolidating steps associated with CRC screening. This reduced typing input and the need to click between multiple windows within the EMR while making a referral to PN. The intervention was piloted in the Albany Area Primary Health Care (AAPHC) system after modifications were made to the EMR and clinician workflows. The monthly CRC screening rates continue to be generated and tracked post-implementation. Results: The use of the 'order set' reduced the click burden from 78 to 7 inputs and clinician EMR interaction time from 110 seconds to 29 seconds. Providers from 4/7 clinics have adopted the 'order sets' when making referrals for CRC screening. Two clinics provided post-implementation screening data. The pre-implementation screening rates for one clinic were comparable (August = 59.3%, September = 57.6%) to post-implementation (October = 56.3%, November = 56.6%, December = 57.2%), while the second clinic showed some increase (August = 58.6%, September = 60%) vs. (October = 61%, November = 62.1%, December = 62.8%). Conclusions: The 'order sets' intervention reduced the time clinicians spent creating referrals for CRC screening, including fecal immunochemical tests (FIT) and colonoscopies. Additional follow-up and rollout to clinics participating in the program is underway to evaluate further the impact of the order sets on CRC screening outcome and process measures, including qualitative interviews with clinicians. There is significant potential in the application of order sets to various workflow processes to aid in preventative health efforts. Challenges linked to the COVID-19 pandemic and staff turnover affected acquisition of patient referral data.
ABSTRACT
Introduction: The multicenter CTC Registry study collected patientlevel data in COVID-19 patients receiving CytoSorb therapy under FDA Emergency Use Authorization. An earlier report on the first 52 CTC patients on ECMO treated with CytoSorb showed 69% overall survival [1]. The current analysis focuses on changes in pulmonary function relative to the time of CytoSorb therapy. Methods: A total of 56 patients from 5 U.S. centers were included. Data on demographics, mechanical ventilation (MV), ECMO, and arterial blood gases during CytoSorb therapy were analyzed. Linear regression was used to evaluate the relationship between the timing of initiation of CytoSorb therapy to lung oxygenation according to changes in PaO2/FiO2 ratio. Results: In the current analysis, 71% (40/56) overall survival was observed. For these survivors, time to CytoSorb start after ICU admission, MV start, and ECMO start was 138 ± 171.3 h, 83 ± 111.0 h, and 55 ± 156.5 h, respectively, with mean duration of CytoSorb therapy of 83 ± 29.1 h. At the first 24 h following CytoSorb therapy, oxygenation was improved evidenced by decreased MV FiO2 and ECMO FdO2 requirements and an increased PaO2/FiO2 ratio (90.2 ± 58.13 mmHg to 166.3 ± 98.67 mmHg, p < 0.001, N = 21). Linear regression analysis suggested that earlier initiation of CytoSorb therapy following ICU admission may be correlated to greater improvements in PaO2/FiO2 ratio (r = -0.37, p = 0.103), however, this trend did not achieve statistical significance. Conclusions: High survival rates have been observed with adjunct CytoSorb therapy in critically ill COVID-19 patients on ECMO. The current analysis suggests that early initiation of hemoadsorption following ICU admission may contribute to earlier improvements in native lung oxygenation.
ABSTRACT
Background: The Georgia Breast Cancer Genomics Program was created with 2011-2014 funding from the Centers for Disease Control and Prevention and the Georgia Department of Public Health (GDPH). In collaboration with GDPH and the Georgia Center for Oncology Research and Education (Georgia CORE), the goal of the program has been to reduce disparities among high-risk minority and underserved women. The objective of this study is to report the 8-year surveillance data for women at increased risk for HBOC in statewide public health centers. The effect of the COVID pandemic on the program and sustainability is also reported. Methods: From 11/1/2012- 12/31/2020, the program provided education, outreach and collected surveillance data using an online genetics referral screening tool as recommended by USPSTF. Providers in 159 counties and health centers across Georgia were educated in cancer family history collection and appropriate referral to genetics. When an individual was found to be at high risk, she was referred to the Georgia CORE Genetics Advanced Practice Nurse for additional education, genetic testing and follow-up. Results: Online screenings attributable to GDPH totaled 29,087 with 1,656 positive screens. 28 % of clients were less than 25 years of age and 56 % ranged from 25-54. Race: 33 % white, 41 % black, 15 % Hispanic and 11 % other or N/A. 92 % of referrals were uninsured. Genetic testing was started or completed on 430 clients. 36 individuals declined testing after counseling (reconsideration, insurance, unknown reasons) and were provided with contact information. 47 (11%) pathogenic, clinically significant mutations were identified including 37 (79 %) HBOC related mutations and 10 (21 %) Lynch related mutations. Variants of uncertain significance were identified in 90 (21 %) clients, with multiple variants in 40 of those. 27 clients have been served through GDPH for physician consultation and surveillance. 13 were referred to area resources: one diagnosed with cancer, and 7 chose referral to other health care providers. Because of the pandemic, the program transitioned to telecommunications and remote access to testing in 5/2020. From 5/2020-12/2020, 34 clients completed testing (41% minority, all uninsured). 10 (29%) clinically significant mutations were identified and heightened surveillance initiated. Conclusions: The GDPH and Georgia CORE collaborative genomics program has served clients over the past 8 years, adjusting to changing resources while reaching a significant number of minority and underserved women. The program successfully converted to remote services during the COVID pandemic. Lessons learned from this transition have been incorporated into planning for future program sustainability.