Recovery of aki on ecmo: A case series and approach to discontinuing crrt in patients on reno-pulmonary support

Introduction: A significant proportion of patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 developed combined renopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) and renal replacement therapy (RRT). While some survivors developed chronic renal failure dependent on dialysis, some recovered renal function following pulmonary recovery and a small proportion recovered renal function prior to pulmonary function. Methods: A retrospective review was performed at a single center with a high volume of ECMO support. Inclusion criteria were ARDS secondary to COVID-19 with concomitant acute kidney injury requiring ECMO and CRRT. Primary end point was discontinuation of renal replacement therapy while on ECMO support. Results: From March 1, 2020 to April 1, 2021a total of 70 patients with COVID-19 were supported with ECMO, 48 of which survived. Of the 70, 33 required renal replacement therapy and 14 recovered renal function and were ultimately separated from renal replacement therapy. In 5 of these 14 patients, RRT was discontinued while still on ECMO support. Discussion: Renal recovery can occur prior to pulmonary recovery in patients with renopulmonary failure secondary to COVID-19. Clinical parameters can be utilized to guide discontinuation of renal replacement therapy while still on ECMO support and should be considered.

Does telemedicine impact stroke clinic follow-up during the COVID-19 pandemic

Introduction: The COVID-19 pandemic has led to rapid implementation of telemedicine (TM) care in outpatient neurology clinics. Early follow-up after acute stroke hospitalization has been associated with decreased readmission and improved care transitions. Stroke survivors may face multiple barriers to in-person follow-up, including inability to drive, limited mobility, and reliance on working caregivers;therefore TM may be preferred. We sought to evaluate the impact of TM care provision during the COVID-19 pandemic on patient follow-up. Methods: Using our clinic EMR, we included patients scheduled for stroke hospitalization follow-up in the Stroke Transitions, Education, and Prevention (STEP) clinic from 10/1/2019 till 7/31/2019. We calculated arrival rates, no-show rates, and cancellation rates for the pre-COVID time period (10/1/19 - 3/13/20) and the period following the implementation of TM services (3/17/20 - 7/31/20). Results: We identified 593 eligible patients with 282 patients scheduled in the pre-COVID period and 311 patients in the COVID period. Arrival, cancellation, and same day no-show rates were 63.1%, 23.0%, and 12.4% in the pre-COVID period and 54.0%, 37.9%, and 7.07% in the COVID period, respectively. The arrival rate decreased significantly (p=0.03) and the cancellation rate increased significantly (p<0.001);the same day no-show rate also decreased significantly (p=0.04). Conclusion: Despite the availability of TM services, the arrival rate for stroke patients scheduled for follow-up during the pandemic decreased significantly, largely because of cancellations. Low noshow rates do not explain the full picture of follow-up. Increased cancellations might be explained by several factors including barriers to technology, apprehension regarding TM, reliance on caregivers to participate in TM visits while practicing social distancing. Identification of barriers to TM follow-up should be further investigated to prevent the deleterious impact of poor care transitions on strokepatients.

The impact of patient demographics on the utilization of video vs telephonic care in a telemedicine clinic during the COVID-19 pandemic

Background: In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic. Methods: We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher's exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses. Results: Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance. Conclusions: We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.(Figure Presented).

Clinical characteristics of COVID-19 patients on venovenous extracorporeal membrane oxygenation who develop severe thrombocytopenia

Background: Thrombocytopenia (<150 x109/L) is often encountered during mechanical circulatory support. Coagulopathy in SARS-COV-2 illness (COVID-19) is increasingly recognized as a risk factor for more severe illness and higher mortality. Thrombocytopenia in COVID-19 patients requiring venovenous (VV) extracorporeal membrane oxygenation (ECMO) is challenging, and therefore identification of contributing factors may aid in management of these complex patients. Methods: A retrospective review was performed for consecutive adult patients on VV ECMO for COVID-19 respiratory failure at a single institution from March to July 2020. Patient data was obtained from our internal registry with IRB approval. Group comparisons of means were made using unadjusted t-tests and proportions were evaluated with a simple chi-square test. Results: The majority (85%) of COVID-19 patients on VV ECMO developed thrombocytopenia. Twelve of 27 patients (44%) exhibited larger drops in platelet counts following ECMO initiation (73% vs 52% fall to nadir) raising concern for heparin-induced thrombocytopenia (HIT). Nine of the 12 (75%) patients tested positive for anti-PF4 antibodies;however, none tested positive via serotonin release assay. Characteristics that affected the degree of platelet decline included the need for simultaneous continuous renal replacement therapy (CRRT) and treatment with an immunomodulating agent, convalescent plasma, or azithromycin. Discussion: Thrombocytopenia in COVID-19 patients on VV ECMO is likely multifactorial, but a more severe thrombocytopenia exists in a subset of patients. CRRT therapy and certain COVID-directed pharmacotherapy agents appear to be influential factors. Anti-PF4 antibody testing may be falsely positive and should be interpreted cautiously.

Extracorporeal cardiopulmonary resuscitation for hypoxemic cardiac arrest secondary to COVID-19

Introduction: Due to the anticipated poor outcome, risk of health care worker exposure, and potential limited resource capacity during a pandemic, extracorporeal cardiopulmonary resuscitation (ECPR) in the COVID-19 population has been discouraged. Exception to this recommendation is when an arrest occurs in a patient already being evaluated or treated with extracorporeal membrane oxygenation (ECMO). To date, experience in this subset of patients has been limited. Methods: A retrospective review was performed for all patients supported with ECMO during the COVID-19 pandemic from March 2020 to August 2020 at a single institution including patient demographics, cannulation strategies, outcomes, and complications. Results: During the study period, 32 patients were supported with ECMO. Twenty-nine patients were supported with venovenous (VV) ECMO alone;3 patients suffered cardiac arrest secondary to an acute episode of hypoxemia requiring ECPR: 1 upon presentation and 2 while already supported on VV ECMO. All 3 patients were subsequently transitioned from venoarterial (VA) to veno-arterio-venous (VAV) ECMO to VV ECMO;1 has been weaned off ECMO and discharged alive, 1 has been weaned off ECMO and remains in the ICU on mechanical ventilation, and 1 remains on VV ECMO. None of the patients suffered any complications related to the cannulation procedure. None of the patients suffered any neurological complications and have a Cerebral Performance Category scale (CPC) of 1. Conclusions: ECPR is safe and feasible in COVID-19 patients being evaluated or treated with ECMO. Centers with significant ECPR experience should consider this option in COVID-19 patients.

Progressive mobility for COVID-19 patients on venovenous extracorporeal membrane oxygenation therapy

Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) has shown to be beneficial for the treatment of severe COVID-19. Barriers to mobilization include acuity, devices, personal protective equipment, negative pressure rooms, and healthcare worker safety. We report our experience with progressive mobility in this complex patient population. Methods: A retrospective review of adult patients requiring VV ECMO for COVID-19 was performed at a single institution from April to July 2020. A multidisciplinary team collaborated daily to determine readiness for progressive mobility. Therapy interventions followed a five-stage protocol and were evaluated using three standardized functional mobility tools (Table 1). Scores were recorded at baseline, highest during ECMO run, and at discharge. Results: Seventeen of 28 COVID-19 patients received protocolized progressive mobility during their extracorporeal support period. The mean scores of the three mobility tools demonstrated an improvement over the course of hospitalization (Table 1). At the time of data analysis, one patient had expired and four patients were still on ECMO support. Twelve (71%) were weaned from ECMO and all were alive at discharge. Of the 12 discharged patients, 6 (50%) were discharged home or inpatient rehab, 4 (33%) to long-term acute care facility and 2 (17%) to their referring hospitals. There were no adverse events or circuit complications. No health care worker infection occurred. Discussion: Early and progressive mobility with a multidisciplinary team is safe and feasible in patients with COVID-19 supported by VV ECMO and may contribute to a high rate of weaning from extracorporeal support and survival to discharge.

When Third Time's a Charm: Successful Outcome after Third Orthotopic Heart Transplantation

Introduction: Cardiac re-transplantation represents a small but growing proportion of total transplants being performed. Medical, ethical, moral and social dynamics continue to remain individualized and highly debated but more evolved with advancement in medicine for patients needing cardiac re-transplantation. We describe a case of a successful outcome in a patient requiring her third orthotopic heart transplant. Case: A 26 year old female with history of orthotopic heart transplant at age 11 for hypertrophic cardiomyopathy and subsequent re-transplantation for cardiac allograft vasculopathy (CAV) ten years later presented to our emergency room with cardiac arrest. Prior to the index hospitalization, the patient had an echocardiogram with a mildly reduced ejection fraction and an angiogram with chronic total occlusions of the right coronary artery and left circumflex artery with excellent collaterals and preserved cardiac output. Nuclear stress test showed no evidence of ischemia. Cardiac allograft vasculopathy prophylaxis with aspirin and pravastatin in addition to a triple regimen of immunosuppression of tacrolimus, sirolimus and mycophenolate mofetil were verified. The hospitalization was complicated by rapidly deteriorating biventricular function and three more episodes of cardiac arrest ultimately requiring extracorporeal membrane oxygenation (ECMO). Fortunately, the patient had negative HLAs with 0% CPRA and preserved end organ function. The selection committee thoughtfully considered her history of intermittent social marijuana use, active COVID 19 precautions in the hospital and a third sternotomy at such a young age, with likely need of possible 4th heart transplant in the future, but ultimately approved the patient for listing. Despite being Status 1, the patient had near daily loss of pulsatility for greater than 10-15 minutes which made us consider the possibility of total artificial heart. Fortunately, the patient received a local heart due to the COVID travel restrictions with total ischemic time of 98 minutes. She was induced with basiliximab and had negative retrospective and prospective crossmatches. There were no intra-op complications and post-op the patient had mild RV dysfunction requiring 4 days of inotropes. Patient was successfully discharged 9 days following her third OHT. Conclusion: Patients undergoing re-transplantation have overall poorer outcomes than those undergoing primary transplantation. Several factors influence these outcomes including timing from prior transplant, previous sternotomy, sensitization status, and renal dysfunction. With advances in medicine and pediatric patients living well into adulthood, there will be more patients requiring re-transplantation. As these trends emerge, individualized patient selection remains the key factor to improved outcomes. Our case presents an otherwise healthy young woman with graft failure without evidence of sensitization who underwent a successful third transplantation.