The Research Imagination During COVID-19: Rethinking Norms of Group Size and Authorship in Anthropological and Anthropology-Adjacent Collaborations

This article explores some of the ways in which the COVID-19 pandemic has served as a collective critical event for anthropologists and other social scientists, examining how it has promoted new configurations of the research imagination. We draw on our own experiences of participating in a team of 17 researchers, hailing from anthropology and anthropology-adjacent disciplines, to research social life in Aotearoa/New Zealand during the pandemic, examining how our own research imaginations were transformed during, and via, the process of our collaboration. When our project first began, many of us had doubts reflective of norms, prejudices and anxieties that are common in our disciplines: that the group would be too large to function effectively, or that it would be impossible to develop an approach to authorship that would allow everyone to feel their contributions had been adequately recognised. In practice, the large group size was a key strength in allowing our group to work effectively. Difficulties with authorship did not arise from within the group but from disconnects between our preferred ways of working and the ways authorship was imagined within various professional and publishing bodies. We conclude that large-scale collaborations have many points in their favour, and that the research imaginations of funders, journals, universities and professional associations should be broadened to ensure that they are encouraged, supported and adequately rewarded. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Evaluation of Bivalirudin Anticoagulation in Patients on Ecmo Due to Covid-19 Respiratory Failure

INTRODUCTION: Patients supported on extracorporeal membrane oxygenation (ECMO) due to COVID-19 are at an increased risk of both thromboembolic complications and thrombocytopenia. Bivalirudin, a direct thrombin inhibitor, is increasingly being utilized for anticoagulation in the ECMO patient though there is largely a lack of literature within the COVID-19 population. The objective of our study was to evaluate the safety and efficacy of alternative anticoagulation with bivalirudin in patients on ECMO with COVID-19 respiratory failure. METHOD(S): This was a non-interventional retrospective chart review conducted at a single center large community hospital between January 2020 - November 2021. We included both venovenous (VV) and venoarterial (VA) adult ECMO patients anticoagulated with bivalirudin that tested positive for COVID-19. Patients were excluded if their duration of ECMO cannulation was less than 48 hours. Descriptive statistical analyses were performed utilizing median with interquartile range and frequency with percent as appropriate. RESULT(S): Overall, 180 ECMO patients were included in the study. The duration of ECMO cannulation was 29 (9-54) days and our cohort experienced a 42% mortality rate. The rate of thrombotic events including in-circuit thrombosis, arterial and venous thrombotic events was 22%. The median initial platelet count on ECMO was 206 (157-274) and the median nadir was 85 (48-121). ELSO defined major bleeding occurred at a rate of 53% within this cohort. CONCLUSION(S): To our knowledge, this study describes the largest number of patients anticoagulated with bivalirudin for ECMO secondary to COVID-19. Our results suggest similar rates of thrombotic events compared to ELSO registry data. While the half-life of bivalirudin is short, clinicians should still be cautious of bleeding due to lack of a specific reversal agent. Retrospective studies with a comparator cohort, as well as randomized trials are warranted to further evaluate the selection of intravenous anticoagulants in the ECMO population with and without COVID-19.

Ecmo for Acute Respiratory Failure Due to Covid-19: A Multicenter Retrospective Study

INTRODUCTION: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used successfully to treat COVID-19 patients in severe respiratory failure. The objective of our multi-center study is to evaluate mortality, time of ECMO initiation, and demographics in COVID-19 patients treated with VV-ECMO. METHOD(S): Electronic medical records from March 2020 to October 2021 were studied in 49 sites across the United States. Patients treated with ECMO who tested positive for COVID-19 were included in this retrospective data analysis (N=363, age interquartile range: 37-55 years). Odds of inhospital mortality were compared using logistic regression models. At thresholds 1-7 days, patients classified as 'early ECMO' were matched to 'delayed ECMO' patients using coarsened exact matching, resulting in 7 independent analyses for early/delayed ECMO cannulation relative to the number of days of pre-ECMO mechanical ventilation (MV). RESULT(S): There were no significant differences in mortality in patients who received early or delayed ECMO. There were also no significant differences in mortality between races, body mass index (BMI), smoking status, hypertension, chronic kidney disease, coronary artery disease, steroid use, or diabetes pre-cannulation. Lastly, pre-cannulation factors associated with mortality in COVID-19 patients treated with ECMO include the use of vasopressors, which was associated with an 87% increase in mortality (p=0.017, confidence interval [CI] 1.12, 3.15);proning, which was associated with a 85% increase in mortality (p=0.015, CI 1.13, 3.06);and the use of baricitinib, which was associated with a four-fold increase in mortality (p=0.041, CI 1.11, 17.6). CONCLUSION(S): We found no evidence that particular demographic characteristics (including race, BMI, or smoking status) contribute to mortality, nor did we find evidence that the length of time on MV prior to ECMO influences mortality. The analysis of large datasets in the ECMO population may better inform clinical decision making.

The Feasibility of Ecmo before Mechanical Ventilation for Severe Respiratory Failure Due to Covid-19

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is typically used to support severe ARDS after the failure of invasive mechanical ventilation (IMV). IMV may cause harm in patients with preexisting barotrauma, shock, or immune compromise. METHOD(S): Single center case-control study of VV-ECMO before IMV (awake ECMO;n=24) compared to conventional ECMO (n=76) after IMV in COVID-19 patients. Groups were compared at baseline before cannulation (awake ECMO) or intubation (conventional ECMO). Propensity matching was performed based on body mass index and injury severity (Simplified Acute Physiology Score II [SAPS II], PaO2:FiO2 ratio). The primary outcome was survival to discharge. Secondary measures of duration of IMV and adverse events were examined. Multivariable adjustments were performed. RESULT(S): Awake ECMO compared to conventional ECMO patients at baseline were more tachypneic (mean +/- standard deviation: 36.3 +/- 9.6 vs 27.4 +/- 7.3;p< 0.0001) with lower SpO2 (median [interquartile range]: 87% [81-92.5] vs 93% [87-96];p=0.01) but similar SAPS II. Fifteen (68%) of awake ECMO patients eventually required IMV. Survival to discharge in awake ECMO trended towards improvement compared to conventional ECMO (70.8% vs. 52.6%;p=0.12). After propensity matching, awake ECMO was associated with increased survival (adjusted odds ratio 6.84 [95% confidence interval 1.08 - 43.38]). Awake ECMO was associated with less duration of IMV before and after propensity matching. Adverse events were similar between groups. CONCLUSION(S): Awake ECMO before IMV is associated with acceptable survival, similar adverse events, and shorter duration of IMV compared to conventional ECMO. This strategy may be preferable in carefully selected patients.

A Single Center Experience with Early Initiation of ECMO Prior to Mechanical Ventilation in COVID-19 Patients with Severe ARDS

Background: Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that results in a viral pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Prognosis is poor among those that develop acute respiratory distress syndrome and progress to mechanical ventilation. Due to the high mortality associated with mechanical ventilation and the unique physiology associated with COVID-19, we compared outcomes in COVID-19 patients placed on ECMO prior to initiation of mechanical ventilation (early group) to patients treated with ECMO after mechanical ventilation (conventional group). Methods: This is a single center retrospective analysis of COVID-19 patients placed on veno-venous (VV) ECMO between 04/06/2020 and 01/15/2021 in a tertiary high-volume ECMO center. Patients between 18 - 70 years of age with a diagnosis of SARS-CoV-2 and diagnosed with ARDS. Patients were considered for ECMO if they had a P/F ratio of less than 50 mmHg for at least three hours, a P/F ratio of less than 80 mmHg for at least 6 hours or an arterial blood pH of less than 7.25 with a pCO2 greater than or equal to 60 mmHg for at least six hours despite optimized ventilator settings (RR> 35 breaths/minute, plateau pressure ≤ 32, tidal volume of 6ml/kg of predicted body weight, FiO2 ≥ 80% and PEEP ≥ 10 cm water). A subset of patients with a rapid deterioration (rapid escalation of O2 requirements, tachypnea RR > 30, tachycardia HR >100) or with clinical signs consistent with poor tolerance to positive pressure ventilation such as a pneumothorax or pneumomediastinum were considered for ECMO prior to mechanical ventilation if they had a P/F <80 despite selfproning with either HFNC 40L/100% in addition to a nonrebreather mask with 15L/100% or non-invasive positive pressure ventilation (NIPPV) with an FiO2 100%. The primary outcome was survival to discharge assessed as a binary outcome of survived or non-survived. Secondary outcomes evaluated included discharge location, length of stay, and incidence of adverse events such as bleeding events, infection, CVA, and pneumothorax requiring chest tube placement. Results: A total of 100 patients were reviewed, including 24 early ECMO patients and 76 conventional ECMO patients. The mean age of the cohort was 48.9 + 11.5 years, 28% were female, and 74% were Hispanic. At baseline, the mean BMI was 31.6 + 5.8, 55% had a history of hypertension, 36% were diabetic and 9% had a history of asthma. Overall, 57% of patients survived to discharge with a median of 23.3 (7.8-40.6) days on ECMO. There were no significant differences in age, gender, BMI, comorbidities, or APACHE scores between the two groups. Prior to ECMO, the early group had lower P/F ratios (52.7 + 11.5 vs. 71.1 + 20.7, p <0.0001), higher pH (7.4 + 0.0 vs. 7.3 + 0.1, p <0.0001), and lower CO2 (36.1 + 6.8 vs 50.9 + 19.1, p <0.0001) than the conventional cohort. Though not significant, there was a trend towards survival in the early ECMO group compared to the conventional group (71% survival vs. 53%, p= .12). Of the early cohort, 15 patients required intubation at some point after cannulation for a median time of 2.5 days (0- 27.0 days). Of the nine patients never intubated, two patients expired, two received a lung transplant, three were discharged home, one discharged to rehab and one to an LTAC facility. There was no difference in adverse events between the two groups. Conclusions: Certain patients with severe ARDS due to COVID-19 may benefit from VV-ECMO cannulation prior to mechanical ventilation with similar outcomes and a trend towards improved mortality.

Subclavian Cannulation Strategy

Background: For patients with acute respiratory distress requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO), there are several cannulation strategies that may be used. The typical cannulation strategy for VV ECMO is either femoral-femoral or a femoral-internal jugular due to the advantage of using larger vessels to access and can typically be done at the bedside under ultrasound and x-ray guidance. However, there is concern for limited mobility and an increased risk of infection due to the location of the cannulas. VV ECMO with a dual-lumen cannula placed via the subclavian approach is an effective cannulation strategy. Case Review: 38-year-old male with a past medical history of childhood asthma and depression. He was hospitalized for respiratory failure due to COVID-19 and intubated on hospital day 2. Despite heavy sedation, paralytics, and prone positioning, his P/F ratio remained less than 50 with peak pressures in the 40s. The multidisciplinary team decided to proceed with cannulation for VV ECMO on day four of intubation. He was cannulated using a 25 French multistage cannula via the left common femoral vein and a 21 French single-stage return cannula via the right common femoral vein. He underwent a tracheostomy on ECMO day four and was able to tolerate weaning of the ventilator over the next few days. Despite only requiring a sweep gas flow of 0.5L/min on ECMO day six, the patient had worsening oxygenation and was unable to achieve a blood flow of more than 3L/min due to chatter. The chest x-ray (CXR) revealed the drainage cannula was now too high and his PaO2 decreased from 101 to 50 despite the same ventilator settings. The drainage cannula was pulled back 6cm at the bedside and flows were increased from 3L/min to 4 L/min with an increase in the PaO2 to 83. On ECMO day seven, oxygenation remained suboptimal and the CXR demonstrated a worsening pneumomediastinum, so the decision was made to transition the patient to a dual-lumen cannula in order to optimize ECMO flow and allow for more aggressive weaning of the ventilator. By ECMO day 12, he was weaned off sedation, out of bed with physical therapy, tolerating CPAP and able to Facetime with his family. ECMO support was utilized to allow for more aggressive ventilator weaning given the pneumomediastinum and increase rehab and nutrition. On ECMO day 16, he was weaned off sweep while on a T-piece with 20L 60%. He remained off sweep for 24 hours and tolerated physical therapy without requiring additional support. By day 17, he was decannulated at bedside. Discussion: By transitioning the ECMO cannulation strategy to optimize oxygenation, facilitate weaning of mechanical ventilation and allow for increased mobility, patients may be decannulated at a higher functional status than if they continued with the original cannulation strategy. Since 2020, our institution has performed 137 dual-lumen subclavian cannulations for patients on VV ECMO with a survival rate of 63%.

ECMO Specialist to Primer: Redefining the role of the RN and RT

Background: Since 2018, Methodist Hospital's ECMO program has rapidly expanded and now cares for almost 200 ECMO patients per year. In order to support this growth, an ECMO specialist pathway was created for RNs and RTs. At the inception of the ECMO specialist program, the training took an average of 6 months to complete. As the program expanded, and the COVID-19 pandemic ensued, we redefined the training and increased the frequency of courses offered to facilitate a large volume of specialists. The ECMO training has been effectively condensed and is now often completed in less than a month. In anticipation of further growth and the need for cost-efficient ECMO management, an ECMO primer role was created to operate in tandem with the ECMO team. This position redefines the role of the RN and RT, allowing them to offload perfusion services by assisting in initial cannulations, responding to ECMO related emergencies, overseeing the specialists, and building and priming circuits for future use. Methods: ECMO specialist: The specialists' role encompasses the 24-hour management of the circuit. This includes hourly circuit maintenance checks, accessing the circuit, moving an ECMO patient, and responding to circuit complications. The specialist is charged with knowing when to clamp, when to initiate the emergency back-up drive, when to emergently change the circuit, and how to respond to an acute decannulation. The training encompasses a 10-hour didactic training course and 2-day wet lab training. Didactic curriculum includes physiology, ECMO fundamentals, ECMO physiology, and ECMO management. 2-day wet lab training integrates live instruction with hands on training integrating the themes and concepts from the 10-hour course. The specialist candidates are asked to showcase their new skills on the second day in fully immersive, high-fidelity, case-based simulations. Upon completion, the specialist candidates are required to complete four shadow shifts with an ECMO specialist/primer. On the final shift, the specialist candidate will complete a skills validation before earning their ECMO specialist badge. ECMO primers: The primer role encompasses the oversight and management of all the ECMO patients and specialist, up to 24 patients. This includes collaborating in patient care and multidisciplinary rounds, management of equipment and rolling stock, educating and mentoring specialist, responding to emergencies, and advanced troubleshooting. The training encompasses baseline mastery of specialist skills, a 3-day wet lab, plus a minimum of 4 weeks of shadow shifts. The 3-day wet lab includes circuit building and priming, bedside initiation, cath lab conversions, advanced configurations, advanced troubleshooting, and circuit changes. Primers will utilize the highfidelity case-based simulations as well as cannulation simulations. Most of the primer training occurs at the bedside. Shadow shifts are scheduled with a chief primer and candidates are evaluated on bedside management, building and priming circuits, intra-hospital transport, ECMO initiation, circuit change, sterile back table set up, maximum barrier prep and drape, bedside cannulation, decannulation, and cannula reconfigurations. Candidates are formally evaluated biweekly and action plans are written to facilitate candidate success. Results: Since the launch of the program in July 2021, 280 specialists and 8 primers have completed training. By January 1st of 2022, the primer will fully offload the perfusionists in 24-hour coverage for non-CVOR ECMO management for up to 24 pumps at a time. Conclusion: By implementing both the ECMO specialist and ECMO primer roles, our ECMO program has continued to grow without compromising patient outcomes despite the pandemic. In addition to being more cost-efficient, creating an alternative growth pathway for RNs and RTs at the bedside has led to improved morale and increased staff retention.

Case Report of a COVID-19 patient treated with Seraph® 100 on Extracorporeal Life Support

Background: The Seraph® 100 Microbind ® Affinity Blood Filter (Seraph ®100) is an extracorporeal broad-spectrum sorbent hemoperfusion filter that removes pathogens and cytokines from the blood and has Emergency Use Authorization (EUA) for the treatment of severe COVID-19. Seraph® 100 can be adapted and primed to a NxStage continuous renal replacement therapy (CRRT) machine and connected to the patient's ECMO circuit. This form of hemofiltration provided a safe and effective approach to decreasing pathogen response within the blood and was tested in our center. Case Review: A 42-year-old male with a past medical history of obesity, hypertension and hypothyroidism was admitted for acute hypoxemic respiratory failure secondary to COVID-19. His 65 day ECMO course was complicated by encephalopathy, right heart dysfunction, severe epistaxis, esophageal ulcers and enterococcus faecalis bacteremia. On ECMO day 16, the patient became febrile, C-reactive protein increased to 215 mg/L and he became hypotensive. In addition to appropriate antibiotics, the multidisciplinary team decided to initiate Seraph® 100 for the E.faecalis bacteremia. The filter was adapted and primed into the NxStage machine by the nurse caring for the patient. The NxStage lines were then connected to the ECMO circuit via pigtail connections. The blood was cycled from the post-oxygenator pigtail to the NxStage and returned to the pre-oxygenator pigtail on the ECMO circuit. The target time for continuous Seraph® 100 therapy is between 24-48 hours. Cultures were collected from the NxStage line pre-filter and again, six hours later, from a port post-filter. The pre-filter cultures came back positive for E.faecalis and the post-filter cultures were negative. Additional blood cultures collected the following day remained negative. The patient's condition improved rapidly and allowed him to begin physical therapy and reduce ventilator support over the next 48 days on ECMO. He was discharged from the hospital to rehab for two weeks before going home. Discussion: Introduction of hemofiltration by Exthera provided an additional therapy that has proven to be effective in the reduction of sepsis causing pathogens when used in conjunction with conventional care for patients with COVID-19 suffering from bacteremia. In this case, incorporating hemofiltration via the ECMO circuit showed no increase in undue risk to the patient with an efficacy in decreasing bacteremia, contributing to the survival of the patient.

'Safer communities horizontal ellipsis together'? Plural policing and COVID-19 public health interventions in Aotearoa New Zealand

International media have praised Aotearoa New Zealand for its response to the coronavirus pandemic. While New Zealand Police played a fundamental role in enforcing pandemic control measures, the policing landscape remained plural. This article employs Loader [2000. Plural policing and democratic governance. Social and legal studies, 9 (3), 323-345] model of plural policing to understand responses to public health emergencies. It identifies two forms of policing which were evident in Aotearoa during the COVID-19 lockdown that should be added to Loader's model. First, we argue that contexts with colonial history require that the model not only includes by-government and below-government policing but also next-to-government policing by Indigenous peoples - such as the 'community checkpoints' run by Maori. Second, and further developing Loader's model, we argue that the category of below-government policing be expanded to include 'peer-to-peer policing' in which government responsibilizes members of the public to subject each other to large-scale surveillance and social control. Since plural forms of policing affect each other's functionality and legitimacy, we argue that what happens at the synapses between policing nodes has profound implications for the process of community building. Because community building is essential to fighting pandemics, we conclude that the policing of pandemic intervention measures may require an expanded understanding and practice of plural policing to support an optimal public health strategy.