ABSTRACT
Background: Guidelines for long-term ventilation agree that tracheotomy has several benefits for patien t treatment . During the coronavirus disease-19 (COVID-19) pandemic it is widely seen as an unsafe procedure with a high risk of infection. To assess the risk, we used a mathematical model and assessed our tracheotomies in COVID-19 patients. Material(s) and Method(s): First, theoretical risk of infectio n durin g tracheotomy was assessed using a Monte-Carlo (MC) simulation of airborne transmission based on the Wells-Riley equation. Second, we evaluated early tracheotomies performed in 16 COVID-19 patients. Tracheotomies were performed by experienced ICU physicians and trainees under supervision. Personal protective equipment (PPE) was used in all procedures. Patients or legal representatives gave informed consent to the procedure. Result(s): Our theoretical model revealed a risk of infection between 0.08 +/- 0.03% and 2.5 +/- 0.8%, depending on the assumptions made. MC simulations showed that the stochastic risk of infection is low to very low, if PPE is correctly used. Patients were a mean of 61 years old (median age 60 +/- 7 years;15/16 male), mean BMI was 31.3 kg/m2 (median 29.6 +/- 6.9 kg/m2). All procedures were percutaneous dilatation tracheotomies (PDT). There was no procedure-related complication or death due to tracheotomy. Overall mortality in COVID-19 patients undergoing tracheotomy was 6 out of 16 (37.5%). No SARS-CoV-2 infections were recorded in 59 tracheotomy-performing healthcare workers (HCW) or other team members. Conclusion(s): The theoretical risk of infections during tracheotomy is low. Technically, tracheotomy in COVID-19 patients is almost identical to patients without COVID-19, the only difference being PPE during the intervention Copyright ©.
ABSTRACT
To our knowledge, we would like to present you the first interhospital, international extracorporeal membrane oxygenation transport of a COVID-19 patient from Romania to Germany in November 2020. Cannulating patients at an outside facility and transporting them on ECMO is a challenge for the most experienced centers. Organizing personnel and equipment, establishing well-practiced procedures, and achieving appropriate response times to a patient in distress are complex tasks. We have retrieved 3 Covid-19 patients from Romanias different institutions. Covid-19 posed new issues to the ECMO team our Hospital. As an overregional ECMO-Center we are constantly retrieving Patients with need for extracorporeal circulation all over Germany, but because a pandemic situation is a global problem we decided to help countrys who don t have such therapy options. Exposure risk control is a very high priority. Due to patients condition and given distance (2600km) he was deemed to need airborne mobile ECMO. What was remarkable in these case is the fact that in about 4 hours after we were contacted and the ECMO indication was given, everything has been organized and with help of the Johanniter Luftrettungszentrum our team was ready for take-off. The airborne transfer lasted 3 h. During the flight, the patient remained on deep sedation (RASS-5) neuromuscular blockade and lung protective ventilation. Hemodynamics parameters remained stable with low-dose catecholamines. No complication occurred during the flight. All team members constantly used adequate PPE according to the risk of airborne infection. For the transportation of the COVID-19 patient, the crew (pilot and copilot) used droplet and contact sufficient PPE, embarked and disembarked at different times than the healthcare personnel and the patient. Because of the plane size the cabin could not be isolated from the rest of the plane.
ABSTRACT
RATIONALE There is ongoing dispute whether COVID-19 related Acute Respiratory Distress Syndrome (CARDS) has unique physiology, setting it apart from 'classic' ARDS. While ECMO has proven valuable in the treatment of acute lung failure, little is known about when and how it should be used to support critically ill COVID-19 patients. METHODS We performed an international email survey to assess how ECMO providers worldwide have previously used ECMO during the treatment of critically ill patients with COVID-19. Questions targeted indications to begin ECMO, technical specifications, anticoagulation strategy and reasons for treatment discontinuation. RESULTS 276 centers worldwide responded that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECMO was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECMO varied between less than two and more than four weeks. The main reason to discontinue ECMO treatment prior to patient's recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators were responsible for the discontinuation of ECMO support. Most ECMO physicians (66% ± 26%) agreed that patients with COVID-19 induced ARDS benefitted from ECMO. Overall mortality of COVID-19 patients on ECMO was estimated to be about 55%, scoring higher than what has previously been reported for Influenza patients on ECMO (29-36%). Most ECMO providers agreed that, while COVID-19 patients were longer on ECMO compared to patients with ARDS of different origin, supposed hypercoagulation was hardly an issue during ECMO therapy and oxygenator change was not required more frequently than they were used to. CONCLUSION ECMO has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure, despite initial recommendations from scientific societies were mostly reluctant. Age and multimorbidity limited the use of ECMO. Triage situations were rarely a concern. ECMO providers stated that patients with severe COVID-19 benefitted from ECMO. An increasing use in patients with respiratory failure in a future stage of the pandemic may be expected. Early apprehensions that COVID-19 related hypercoagulation would result in severe thromboembolic complications during extracorporeal circulation were mostly mitigated judging from survey experience.