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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
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SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Heparin is the preferred anticoagulant for use in pregnancy while on extracorporeal membrane oxygenation (ECMO) (1). Alternatives to heparin in this patient population are not well studied as heparin-induced thrombocytopenia is rare in pregnancy. Parenteral non-heparin anticoagulants available in the United States include the direct thrombin inhibitors argatroban and bivalirudin, both of which are utilized in ECMO. Guidelines recommend avoidance of these agents in pregnancy if at all possible (2). Whereas case reports support the safe use of argatroban in pregnancy, to our knowledge, there are no known documented reports of bivalirudin use in this patient population (3). Here we describe the successful use of bivalirudin during pregnancy. CASE PRESENTATION: A 25 year old G2P1 was transferred to our institution at 28 weeks gestation for further management of acute hypoxic respiratory failure secondary to COVID-19. On hospital day 2 the patient was urgently placed on venovenous (VV) ECMO for refractory hypoxemia, high dead space with acidosis, and the inability to provide adequate gas exchange and lung protection with mechanical ventilation alone. Following ECMO cannulation with a 25f cannula in the right femoral vein and a 21f cannula in the right internal jugular vein, she was anticoagulated with heparin at a rate of 12 units/kg/hr. This was titrated to target a PTT goal of 60-80 seconds. On ECMO day 2, the TEG demonstrated a markedly hypocoagulable state, and the heparin nomogram called for increasing heparin dosing based on PTT. Given the already high dose of heparin that the patient was on (32.9 units/kg/hr), the decision was made to switch from heparin to bivalirudin to prevent over anticoagulation and reduce bleeding risk. Bivalirudin was titrated to a goal PTT of 50-60 seconds, with an initial rate of 0.15 mg/kg/hr (dose range 0.15-0.22 mg/kg/hr). Therapy was continued and on ECMO day 11, at 29w6d the patient delivered via cesarean section. Bivalirudin was discontinued 2.5 hours prior to the surgical procedure which resulted with no fetal bleeding complications. The patient was decannulated from ECMO on day 20 and was later discharged from the hospital. The newborn is developing well and meeting age adjusted milestones. DISCUSSION: Bivalirudin was selected based on institutional experience and the pharmacokinetic properties of the drug (half-life of 25 minutes) as we considered a situation where an emergent delivery may be indicated. Bivalirudin successfully prevented clotting of the circuit with no maternal or fetal bleeding complications during its use. CONCLUSIONS: Our case report describes a multidisciplinary approach to managing a pregnant patient on ECMO requiring anticoagulation using an alternative medication to heparin. This is the first documented use of bivalirudin in pregnancy. Reference #1: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.4 August 2017. Ann Arbor, MI, USA www.elso.org. Reference #2: Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl): e691S–736S Reference #3: Young SK, Al-Mondhiry HA, Vaida SJ, et al. Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature. Pharmacotherapy 2008;28: 1531–6. DISCLOSURES: No relevant relationships by Jacqueline Finger No relevant relationships by Caitlin Gluck No relevant relationships by Cameron Hypes No relevant relationships by John Rathbun
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Introduction: Venovenous extracorpo-real membrane oxygenation (VV ECMO) is an established support option for patients with severe respiratory failure that has been used with increasing frequency throughout the world in recent years. During the coro-navirus disease 2019 (COVID-19) pandemic, ECMO was used for patients with severe COVID-19-associated respiratory failure. We analyzed 90-day survival of all COVID-19 patients supported with VV ECMO for 30 days or longer in our center. Material and methods: Retrospective single-center registry study including all patients with severe respiratory failure associated with SARS-CoV-2 infection, supported with VV ECMO for 30 days or longer. Results: At our center, between March 2020 and January 2022, 29 patients with severe respiratory failure and COVID-19 were supported with VV ECMO for 30 days or longer. 90 days after initia-tion of ECMO, 20/29 patients had survived (69%). Survival to day 90 of patients younger than 50 years (8/8, 100%) was significantly higher than of those older than 50 years (12/21, 57%, p = 0.037). Discussion: Even after prolonged ECMO support for more than 30 days in patients with severe COVID-19-associated respiratory failure, successful weaning from ECMO support is possible in many cases. The duration of previous ECMO support should not be the sole parameter for prognosis in individual patients with severe COVID-19-associated respiratory failure.
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Background: The impact of COVID-19 disease on previously healthy children has been minimal, yet there is limited data on the impact of COVID-19 on children and adolescents with kidney transplants. Methods: We used the existing infrastructure of the Improving Renal Outcomes Collaborative (IROC) learning health system to develop and rapidly implement a webbased registry for collecting clinical and outcomes data about COVID-19 disease in pediatric transplant recipients. We distributed the registry to 32 U.S. pediatric kidney transplant centers and requested clinical and outcomes data from all recipients suspected of having COVID-19 disease. Here, we present an interim analysis of the first 6 weeks of registry data. Results: Between April 6 and May 27, 2020, 18 IROC centers entered data on 99 pediatric kidney transplant recipients who had PCR based testing for COVID-19. 54 patients were tested due to symptoms of COVID-19 (most commonly fever and cough), 7 asymptomatic patients had a known COVID exposure. 34 patients were tested per hospital policy (e.g. pre-anesthesia), and 4 did not have a reported testing indication. Overall, 10/99 (10%) tested positive for COVID-19, 6 of whom had any symptoms, 3 had a known exposure with a COVID+ individual, and 1 was diagosed by a pre-anesthesia screen. Thus far, the clinical course and outcomes are known in 8/10 COVID-19+ patients: 5 received outpatient supportive care alone, 2 were admitted to intensive care and 1 was admitted to a non-intensive care inpatient unit. Transplant outcomes were excellent in all COVID-19+ patients. There were no cases with respiratory failure, acute kidney injury, or allograft rejection/failure. There were no deaths due to COVID-19 disease. Conclusions: In this interim analysis of the IROC learning health system, pediatric kidney transplant recipients had a relatively low incidence of COVID-19 disease and excellent short-term outcomes.