Unique vascular complication following extended VV-ECMO support

Objectives: To present an unusual complication related to prolonged ECMO support in a patient with COVID19 induced acute respiratory syndrome (ARDS). Method(s): Clinical chart review of the care process after obtaining the informed consent from the patient. Result(s): A 48-year-old female with COVID-19 infection during second wave of pandemic in August 2021 progressed to severe ARDS. She was put on VV-ECMO support after failing conventional therapy for refractory hypoxemia. Her cannulation configuration included a 25 F venous drainage cannula in the right femoral vein and a 21 F venous return cannula in the right Internal Jugular (IJ) vein. Cannulations were performed using the ;Seldinger technique;under USG guidance, and no difficulties or complications were reported. Her hospital course was notable for delirium, and intermittent bleeding from the cannula sites. After 80 days of support, she showed adequate respiratory improvement which allowed ECMO decannulation. She continued to show improvement, and was eventually discharged after 102 days of total hospital stay. During her 6 weeks follow-up clinic visit a palpable thrill was noted at the jugular ECMO cannula site. A CT angiogram of the neck demonstrated a large venous varix connecting the right IJ and the left common carotid artery with filling from the left common carotid artery. ECMO cannulation site complications such as aneurysm, clots, infections and stenosis are well known. What was unusual in this case is the nature of the aneurysm given that there were no arterial procedures performed on the left side of the neck. She was managed by an ;Amplatzer plug;to the carotid artery at the level of the connection to the varix without any complications. Conclusion(s): Longer duration of ECMO support needs careful follow-up for timely recognition and management of vascular complications. (Figure Presented).

Clinical characteristics, complications, and outcomes of severe COVID-19 ARDS patients supported by ECMO and triaged for lung transplantations

Objectives: More than 200 patients have benefited from lung transplantation who failed to recover from COVID-19-induced acute respiratory distress (ARDS) with conventional ventilatory support and/ or extracorporeal membrane oxygenation support (ECMO) in USA. We aim to share our experience and lessons learned at our institute through this case series. Method(s): After IRB approval, we performed a retrospective chart review and identified 37 patients who received ECMO for COVID-19 induced ARDS between May 2020 through January 2022. Out of these, 12 received a formal consultation from the transplant team. We studied patient characteristics, interventions during ECMO support, and evaluation outcomes. Result(s): Most of our patients had single organ failure i.e., lung, except for two who required dialysis after ECMO initiation. Six out of the 12 patients received bilateral lung transplant. One patient received the transplant before ECMO initiation. However, the patient required two runs of ECMO after the transplant due to postop complications from suspected COVID19 reinfection and deceased on postoperative day 101. All the patients after transplant had an expedited recovery except one who required prolonged hospitalization before starting physical therapy. The median length of hospital stay for the transplant group was 148 (89- 194) days and for the non-transplant group was 114 (58-178) days. The 30-day survival rate was 100% for the transplant group. At a median follow-up of 207 (0- 456) days after discharge, 5(83.3%) patients in the transplant group and 3(50%) patients in the nontransplant group were alive. In the non-transplant group, 4 patients received ECMO support for more than 75 days and at last follow-up 2 were alive and functioning well without needing new lungs. This asks for an objective prospective study to define the timeline of irreversibility of the lung injury. Conclusion(s): Lung transplantation is a viable salvage option in patients with COVI-19 induced irreversible lung injury. However, the irreversibility of the lung injury and the timing of lung transplant remains to be determined case-by-case. (Figure Presented).

Real-time, leukocyte-related, four times validated, patient data partitioning

Introduction: Indicators that assess relationships among leukocytes may inform more and/or earlier than those measured in isolation. Method(s): Blood leukocyte differential counts collected from 101 Mayo Clinic COVID-19 patients were related to later outcomes following two approaches: (i) as unstructured data (e.g., lymphocyte percentages) and (ii) as data structures that assess intercellular interactions. Analyzing the same primary data, it was asked whether information contents differed among methods and/or when two sets of structured indicators are used. Result(s): While unstructured data did not distinguish survivors from non-survivors (Fig. 1, rectangle A), one data structure (here identified with letters expressed in italics) exhibited one perpendicular inflection that differentiated two patient groups (B). Two survivor-related observations were also distinguished from the remaining data points (B). A second data structure also revealed a single line of observations and a perpendicular data inflection (C), while more (four) patient groups were identified (D). Four validations were conducted: (i) increasing mortality levels among contiguous data subsets (0, 7.1, 16.2, or 44.4%) suggested construct validity (D);(ii) internal validity was indicated because 22 of the 45 survivors detected by the first data structure were also captured by the second one;(iii) the analysis of patients that differed in address, co-morbidities and other aspects supported external validity;and (iv) quasi non-overlapping data intervals predicted statistical validity (E, F). The structured approach also uncovered new and/ or dissimilar information: different leukocyte-related ratios explained the clusters identified in these analyses (E, F). Conclusion(s): Structured data may yield more information than methods that do not assess multicellular interactions. Possible applications include daily, longitudinal, and personalized analysis of hospital data.

Deterioration Scores in Covid-19 Delta Variant

Rationale: The early recognition of COVID-19 patients at high risk of clinical deterioration is important to help triage, allocate resources, and improve patient care. In this study, we aimed to compare the performance of the Charlson Comorbidity Index (CCI), mSOFA, MEWS, qCSI, and PRIEST COVID-19 Clinical Severity scores in predicting risk of admission to the intensive care unit (ICU) and in-hospital mortality. Methods: This was a multicenter retrospective cohort study which included a random sample of confirmed COVID-19 patients admitted to three academic medical centers. All patients were admitted in July 2021. Patients with a positive COVID-19 polymerase chain reaction at time of admission were included. All scores were calculated within the first 24 hours of admission to the hospital. A univariate and backward multivariate logistic regression analysis were used to evaluate correlation of CCI, mSOFA, MEWS, qCSI, and PRIEST COVID-19 Clinical Severity score to the primary outcome, ICU admission, and secondary outcome, death (in-hospital). Results: One-hundred and three patients were included in this study with a median age of 59 years old (IQR 51-70). The majority were male (64.1%, n = 66) and Caucasian (81.6%, n = 84). Twenty-six patients (25.2%) required ICU admission with an in-hospital death occurring in nine patients (8.7%). In the multivariate analysis, patients admitted to the ICU were more likely to be African-American (12.96 OR;95% CI 1.49, 155.91), and of the five scores assessed, mSOFA (1.61 OR;95% CI 1.13, 2.41), MEWS (1.74 OR;95% CI 1.06, 3.09), and qCSI (1.52 OR;95% CI 1.12, 2.16) scores were associated with ICU admission. However, only mSOFA score (1.93 OR;95% CI 1.34, 3.11) was associated with in-hospital mortality. Conclusions: There are multiple scores for COVID-19 clinical deterioration that are accurate in predicting the need for ICU admission. Despite the ability to predict clinical deterioration, other scores were not associated with an increased in-hospital mortality. Interestingly, the CCI was not associated with an increased in-hospital mortality. This study provides evidence to use the mSOFA, along with other scores to accurately triage patients to a higher level of care.