Pump-controlled retrograde trial off for weaning from venoarterial extracorporeal membrane oxygenation in an adult patient with pulmonary embolism.

Background: Although pump-controlled retrograde trial off (PCRTO) is a practical method for weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO), its advantages and safety for patients with pulmonary embolism are not yet reported. Case Presentation: A 62-year-old man with coronavirus disease 2019 experienced sudden cardiac arrest, and VA-ECMO was introduced. After confirming a massive acute pulmonary embolism, unfractionated heparin treatment was initiated. On day 6, the patient was confirmed stable with a flow rate of 1.0 L/min. However, decannulation led to cardiac arrest and reintroduction of VA-ECMO. After further treatment, a residual thrombus was observed, and pulmonary arterial pressure remained high. On day 23, ECMO was decannulated successfully after a weaning test with PCRTO, which simulated ECMO withdrawal by generating a partial arteriovenous shunt. Conclusion: PCRTO is a feasible weaning strategy and can be considered for patients with uncertain cardiorespiratory recovery.

Delayed Acute Perimyocarditis and Bilateral Facial Nerve Palsy in a Patient with COVID-19.

A 41-year-old Japanese man was admitted to our hospital with acute perimyocarditis 4 weeks after coronavirus disease 2019 (COVID-19) infection. Ten days after admission, the patient showed bilateral facial nerve palsy in the course of improvement of perimyocarditis under treatment with aspirin and colchicine. After prednisolone therapy, perimyocarditis completely improved, and the facial nerve palsy gradually improved. Acute perimyocarditis and facial nerve palsy can occur even 4 weeks after contracting COVID-19.

Threshold of increase in oxygen demand to predict mechanical ventilation use in novel coronavirus disease 2019: A retrospective cohort study incorporating restricted cubic spline regression.

BACKGROUND: Rapid deterioration of oxygenation occurs in novel coronavirus disease 2019 (COVID-19), and prediction of mechanical ventilation (MV) is needed for allocation of patients to intensive care unit. Since intubation is usually decided based on varying clinical conditions, such as required oxygen changes, we aimed to elucidate thresholds of increase in oxygen demand to predict MV use within 12 h. METHODS: A single-center retrospective cohort study using data between January 2020 and January 2021was conducted. Data were retrieved from the hospital data warehouse. Adult patients diagnosed with COVID-19 with a positive polymerase chain reaction (PCR) who needed oxygen during admission were included. Hourly increments in oxygen demand were calculated using two consecutive oxygen values. Covariates were selected from measurements at the closest time points of oxygen data. Prediction of MV use within 12 h by required oxygen changes was evaluated with the area under the receiver operating curves (AUCs). A threshold for increased MV use risk was obtained from restricted cubic spline curves. RESULTS: Among 66 eligible patients, 1835 oxygen data were analyzed. The AUC was 0.756 for predicting MV by oxygen demand changes, 0.888 by both amounts and changes in oxygen, and 0.933 by the model adjusted with respiratory rate, PCR quantification cycle (Ct), and days from PCR. The threshold of increments of required oxygen was identified as 0.44 L/min/h and the probability of MV use linearly increased afterward. In subgroup analyses, the threshold was lower (0.25 L/min/h) when tachypnea or frequent respiratory distress existed, whereas it was higher (1.00 L/min/h) when viral load is low (Ct ≥20 or days from PCR >7 days). CONCLUSIONS: Hourly changes in oxygen demand predicted MV use within 12 h, with a threshold of 0.44 L/min/h. This threshold was lower with an unstable respiratory condition and higher with a low viral load.

Characteristics of burn injury during COVID-19 pandemic in Tokyo: A descriptive study.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has drastically changed everyday life worldwide. This study aimed to determine how COVID-19 affected the characteristics and outcomes of patients with severe burn injury by examining a city-wide burn database in Tokyo. PATIENTS AND METHODS: A descriptive study was conducted in 14 burn centers using the Tokyo Burn Unit Association registry from 1999-2020. The pandemic started in 2020, while the stay-at-home order lasted from April to May. The demographics, mechanisms, severity, and clinical outcomes were assessed before and during these two time periods. RESULTS: In total, 7061 patients with burn injury were enrolled. During the pandemic, there were less patients during the pandemic than previous years, except for April-May; this decreased toward the end of 2020. There were also more scald/contact burns in the upper extremity, less intended and assault injuries, shorter length of hospital stay, and lower in-hospital mortality. During the stay-at-home order, there was increased incidence of flame burns, inhalation injuries, and in-hospital mortality, as well as higher total body surface area of full-thickness burns. CONCLUSIONS: This study described the characteristics of burns during the COVID-19 pandemic. The association between the stay-at-home order and severity of burns should be further examined.

Hospital Preparedness for COVID-19: The Known and The Known Unknown.

In late March 2020, we faced a nosocomial outbreak of novel coronavirus disease 2019 (COVID-19) at Keio University Hospital, Tokyo, Japan. Presently, COVID-19 is an unprecedented worldwide biohazard, and a nosocomial outbreak can occur in any hospital at any time. Therefore, we reviewed the literature regarding hospital preparedness, the initial management of COVID-19, and the surveillance of healthcare workers (HCWs) to find information that would be generally useful for physicians when confronted with COVID-19. In terms of hospital preparedness, each hospital should develop an incident management system and establish a designated multidisciplinary medical team. To initiate case management, COVID-19 should be suspected based on patient symptoms and/or high-risk history and then should be confirmed by viral testing, such as reverse transcription polymerase chain reaction (RT-PCR) analysis. Although some patients will become critically ill, the guidelines for respiratory failure and septic shock for non-COVID-19 cases can be followed for supportive treatment. Antiviral medications should be carefully selected because the available information is confused by the large volume of preprint literature and unreliable data. HCWs who have come into contact with patients with COVID-19 can generate new in-hospital clusters of COVID-19 cases. Quarantine following contact tracking with risk stratification is effective in preventing transmission, and the essentials of medical surveillance include monitoring different types of symptoms, delegation of supervision, and continuation of surveillance regardless of the RT-PCR results. Preparation for COVID-19 is recommended before the first COVID-19 case is encountered.

Comparison of the Clinical Course of COVID-19 Pneumonia and Acute Respiratory Distress Syndrome in 2 Passengers from the Cruise Ship Diamond Princess in February 2020.

BACKGROUND Patients with coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 can rapidly progress to acute respiratory distress syndrome (ARDS). Because clinical diagnosis of ARDS includes several diseases, understanding the characteristics of COVID-19-related ARDS is necessary for precise treatment. We report 2 patients with ARDS due to COVID-19-associated pneumonia. CASE REPORT Case 1 involved a 72-year-old Japanese man who presented with respiratory distress and fever. Computed tomography (CT) revealed subpleural ground-glass opacities (GGOs) and consolidation. Six days after symptom onset, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis of COVID-19-associated pneumonia. He was intubated and received veno-venous extracorporeal membrane oxygenation (ECMO) 8 days after symptom onset. Follow-up CT revealed large diffuse areas with a crazy-paving pattern and consolidation, which indicated progression of COVID-19-associated pneumonia. Following treatment with antiviral medications and supportive measures, the patient was weaned off ECMO after 20 days. Case 2 involved a 70-year-old Asian man residing in Canada who presented with cough, malaise, nausea, vomiting, and fever. COVID-19-associated pneumonia was diagnosed based on a positive result from RT-PCR testing. The patient was then transferred to the intensive care unit and intubated 8 days after symptom onset. Follow-up CT showed that while the initial subpleural GGOs had improved, diffuse GGOs appeared, similar to those observed upon diffuse alveolar damage. He was administered systemic steroid therapy for ARDS and extubated after 6 days. CONCLUSIONS Because the pattern of symptom exacerbation in COVID-19-associated pneumonia cases seems inconsistent, individual treatment management, especially the CT-based treatment strategy, is crucial.