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1.
Perfusion ; : 2676591221105603, 2022 Jun 02.
Article in English | MEDLINE | ID: covidwho-1874962

ABSTRACT

INTRODUCTION: Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. METHODS: We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. RESULTS: Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/µL, p = .004). Overall in-hospital mortality was 33.7% (n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). CONCLUSION: COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.

2.
Perfusion ; : 2676591221097642, 2022 Apr 25.
Article in English | MEDLINE | ID: covidwho-1808004

ABSTRACT

INTRODUCTION: With the increased demand for veno-venous extracorporeal membrane oxygenation (VV ECMO) during the COVID-19 pandemic, guidelines for patient candidacy have often limited this modality for patients with a body mass index (BMI) less than 40 kg/m2. We hypothesize that COVID-19 VV ECMO patients with at least class III obesity (BMI ≥ 40) have decreased in-hospital mortality when compared to non-COVID-19 and non-class III obese COVID-19 VV ECMO populations. METHODS: This is a single-center retrospective study of COVID-19 VV ECMO patients from January 1, 2014, to November 30, 2021. Our institution used BMI ≥ 40 as part of a multi-disciplinary VV ECMO candidate screening process in COVID-19 patients. BMI criteria were not considered for exclusion criteria in non-COVID-19 patients. Univariate and multivariable analyses were performed to assess in-hospital mortality differences. RESULTS: A total of 380 patients were included in our analysis: The COVID-19 group had a lower survival rate that was not statistically significant (65.7% vs.74.9%, p = .07). The median BMI between BMI ≥ 40 COVID-19 and non-COVID-19 patients was not different (44.5 vs 45.5, p = .2). There was no difference in survival between the groups (73.3% vs. 78.5%, p = .58), nor was there a difference in survival between the COVID-19 BMI ≥ 40 and BMI < 40 patients (73.3, 62.7, p= .29). Multivariable logistic regression with the outcome of in-hospital mortality was performed and BMI was not found to be significant (OR 0.99, 95% CI 0.89, 1.01; p = .92). CONCLUSION: BMI ≥ 40 was not an independent risk factor for decreased in-hospital survival in this cohort of VV ECMO patients at a high-volume center. BMI should not be the sole factor when deciding VV ECMO candidacy in patients with COVID-19.

4.
Crit Care Explor ; 3(11): e0568, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1501167

ABSTRACT

OBJECTIVE: Public health emergencies, like the coronavirus disease 2019 pandemic, can cause unprecedented demand for critical care services. We describe statewide implementation of a critical care coordination center designed to optimize ICU utilization. To describe a centralized critical care coordination center designed to ensure appropriate intensive care resource allocation. DESIGN: A descriptive case series of consecutive critically ill adult patients. SETTING: ICUs, emergency departments, freestanding medical facilities in the state of Maryland and adjacent states, serving a population of over 6,045,000 across a land area of 9,776 sq mi (25,314 km2). PATIENTS: Adults requiring intensive care. INTERVENTIONS: Consultation with a critical care physician and emergency medical services clinician. MEASUREMENTS AND MAIN RESULTS: Number of consults, number of patient movements to higher levels of critical care, and number of extracorporeal membrane oxygenation referrals for both patients with and without coronavirus disease 2019. Over a 6-month period, critical care coordination center provided 1,006 critical care consultations and directed 578 patient transfers for 58 hospitals in the state of Maryland and adjoining region. Extracorporeal membrane oxygenation referrals were requested for 58 patients. Four-hundred twenty-eight patients (42.5%) were managed with consultation only and did not require transfer. CONCLUSIONS: Critical care coordination center, staffed 24/7 by a critical care physician and emergency medical service clinician, may improve critical care resource use and patient flow. This serves as a model for a tiered regionalized system to ensure that the demand for critical care services may be met during a pandemic and beyond.

5.
Anesth Analg ; 132(4): 930-941, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-1136265

ABSTRACT

BACKGROUND: Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality. METHODS: A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions. RESULTS: Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users. CONCLUSIONS: Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients.


Subject(s)
Aspirin/therapeutic use , COVID-19/therapy , Fibrinolytic Agents/therapeutic use , Intensive Care Units , Patient Admission , Platelet Aggregation Inhibitors/therapeutic use , Respiration, Artificial , Adult , Aged , COVID-19/diagnosis , COVID-19/mortality , Female , Hospital Mortality , Humans , Male , Middle Aged , Registries , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States
6.
Crit Care ; 25(1): 106, 2021 03 16.
Article in English | MEDLINE | ID: covidwho-1136238

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION: The study was registered with Clinical trials.gov Identifier: NCT04534569.


Subject(s)
COVID-19/complications , Consensus , Delphi Technique , Respiratory Insufficiency/therapy , Respiratory Insufficiency/virology , Humans
7.
Shock ; 55(6): 742-751, 2021 06 01.
Article in English | MEDLINE | ID: covidwho-1006210

ABSTRACT

ABSTRACT: Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.


Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Heart Arrest , Respiratory Distress Syndrome , SARS-CoV-2 , COVID-19/complications , COVID-19/physiopathology , COVID-19/therapy , Heart Arrest/etiology , Heart Arrest/physiopathology , Heart Arrest/therapy , Humans , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/physiopathology , Respiratory Distress Syndrome/therapy
8.
Anesth Analg ; 131(2): 365-377, 2020 08.
Article in English | MEDLINE | ID: covidwho-980520

ABSTRACT

In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic and the potential need for physicians to provide critical care services, the American Society of Anesthesiologists (ASA) has collaborated with the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF) to develop the COVID-Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) Intensive Care Unit (ICU) workgroup. CAESAR-ICU is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services.


Subject(s)
Anesthesia Department, Hospital/organization & administration , Betacoronavirus/pathogenicity , Coronavirus Infections/therapy , Delivery of Health Care, Integrated/organization & administration , Emergency Medical Services/organization & administration , Intensive Care Units/organization & administration , Pneumonia, Viral/therapy , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/virology , Humans , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/virology , Practice Guidelines as Topic , SARS-CoV-2
9.
Non-conventional in English | Homeland Security Digital Library, Grey literature | ID: grc-740542

ABSTRACT

From the Introduction: America's ability to survive the COVID-19 [coronavirus disease 2019] pandemic depends on our ability to protect the health of our citizens while we simultaneously sustain the critical infrastructure sectors that support our economy, and ultimately, the American way of life. The current debate between 'lives' and 'livelihood' is a false choice for the American public. If America, as a world leader, chooses to balance these challenges effectively, then through science and evidence best practices, both considerations can be served responsibly, consistently, and methodically across our sectors of critical infrastructure. In the process, the nation can emerge from the pandemic stronger and more resilient to threats from future natural or man-made infectious diseases. Until the risk of spreading infection can be mitigated, an unintended but very real side effect of our actions is the paralysis of our economy and the threat to our nation's ability to sensibly sustain and reopen critical infrastructure sectors. However, like all threats, COVID-19 presents a unique opportunity to manage the dilemma of the current pandemic, and actually build a stronger, more resilient nation going forward.COVID-19 (Disease);Disaster recovery;Critical infrastructure;Air defenses

10.
Anesth Analg ; 132(4): 930-941, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-890152

ABSTRACT

BACKGROUND: Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality. METHODS: A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions. RESULTS: Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users. CONCLUSIONS: Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients.


Subject(s)
Aspirin/therapeutic use , COVID-19/therapy , Fibrinolytic Agents/therapeutic use , Intensive Care Units , Patient Admission , Platelet Aggregation Inhibitors/therapeutic use , Respiration, Artificial , Adult , Aged , COVID-19/diagnosis , COVID-19/mortality , Female , Hospital Mortality , Humans , Male , Middle Aged , Registries , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States
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