Extracorporeal Membrane Oxygenation in Patients with Covid-19: Duration and Outcomes

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has been utilized as a rescue therapy for patients with severe ARDS. Multiple case series have suggested that the duration of veno-venous ECMO support in patients with COVID-19 pneumonia may be longer than patients with ARDS secondary to alternative etiology. However, the impact of longer run of ECMO on patient outcomes are not clear. METHOD(S): This was a retrospective study performed at Mayo Clinic Florida and Mayo Clinic Rochester, tertiary ECMO centers in USA. Analysis includes all consecutive patients who were placed on VV ECMO for COVID-19- induced ARDS between January 2019 to March 2022. The study population was classified into two groups: short term ECMO duration (< 4 weeks) and prolonged ECMO support (>4 weeks). Demographic data, baseline clinical characteristics, treatments administered, mechanical ventilator data, lab data, ECMO data and outcome related data were collected and analyzed. RESULT(S): A total of 63 COVID-19 patients were included. For the entire cohort, the 30 day mortality was 6%, the 90 day mortality was 30% and the median duration of ECMO support was 35 days (IQR 38). A total of 6 (10%) patients went on to receive lung transplant. Among these, 25(40%) patients required ECMO for < 4 weeks and 38(60%) patients for >4 weeks. The median SOFA values (13 vs 11, 0.016) for the <=4 weeks cohort was higher. Both groups received similar COVID-19 therapies: glucocorticoids (96 vs 100%, p=0.397), tocilizumab (52 vs 50%, p=1.000), antivirals (88 vs 87%, p=1.000), and convalescent plasma (48 vs 45%, p=1.000). The cumulative mortality rates for the 2 groups were 8% vs 5% at 30 days (p=1.0), 12% vs 42% at 60 days (p=0.013), 12% vs 50% at 90 days (p=0.002) and 12% vs 50%(p=0.002) at 180 days. CONCLUSION(S): The study demonstrated that a substantial number of COVID19 patients require ECMO for > 4 weeks. In this cohort, the mortality rate in the first 4 weeks of ECMO support was low, at 6%. The patients who required ECMO for >4 weeks were more likely to have higher mortality compared to the patients treated with ECMO for shorter duration.

INCIDENTAL PULMONARY CAVITARY LESIONS AS AN UNCOMMON PRESENTATION OF LEMIERRE SYNDROME

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer

Social responsibility for health during COVID-19 pandemic

Health is a fundamental right for which concerned sides should bear the responsibility at the individual, societal, state, and international level. Not only curative but preventive, promotive, and rehabilitative services should also be availed in accessible, affordable, and acceptable form. The quest for health becomes more intense during adverse periods like a pandemic. The whole world has witnessed the COVID-19 pandemic, the unprecedented pandemic of this century. This quest is more dismal in developing nations like Nepal when even resource- rich countries are laid down by it. The quest of health demands, hence more during this pandemic, for the bearing of the responsibility by all. Here, we have made an attempt to draw together the general and some specific responsibilities of various direct stakeholders in this pandemic with multifaceted mayhem. We have incorporated here, the responsibilities of the public, COVID and non-COVID patients, media personnel, health science students, professionals, institutions, state, and media to ensure or safeguard the health of self and others in this pandemic.