Extracorporeal Membrane Oxygenation (ECMO) Cannula Stimulation of the Carotid Sinus Causing Bradycardic Pauses in a Patient With COVID-19.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation is a potential cause of episodic bradycardia during an intensive care course because of the proximal cannula insertion site being in the vicinity of the carotid sinus. Herein, we report the case of episodic bradycardia throughout a multi-week intensive care stay of a VV-ECMO recipient due to a severe coronavirus disease 2019 (COVID-19) infection that did not emerge for the rest of the patient's hospitalization after decannulation.

Management of two circulations in a COVID-19 patient with secondary superinfection.

Optimal oxygenation in the intensive care unit requires adequate pulmonary gas exchange, oxygen-carrying capacity in the form of hemoglobin, sufficient delivery of oxygenated hemoglobin to the tissue, and an appropriate tissue oxygen demand. In this Case Study in Physiology, we describe a patient with COVID-19 whose pulmonary gas exchange and oxygen delivery were severely compromised by COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. His clinical course was complicated by a secondary superinfection with staphylococcus aureus and sepsis. This case study is provided with two goals in mind (1) We outline how basic physiology was used to address life-threatening consequences of a novel infection-COVID-19. (2) We describe a strategy of whole-body cooling to lower the cardiac output and oxygen consumption, use of the shunt equation to optimize flow to the ECMO circuit, and transfusion to improve oxygen-carrying capacity when ECMO alone failed to provide sufficient oxygenation.

Coronavirus Disease 2019 Causing Infection of Transplanted Lung Allograft: A Pitfall of Prolonged Shedding of Severe Acute Respiratory Syndrome Coronavirus-2 Pretransplant.

Coronavirus disease 2019 (COVID-19) pandemic has led to considerable morbidity and mortality across the world. Lung transplant is a viable option for a few with COVID-19-related lung disease. Whom and when to transplant has been the major question impacting the transplant community given the novelty of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe a pitfall of presumed prolonged shedding of SARS-CoV-2 in a patient with COVID-19 associated acute respiratory distress syndrome leading to COVID-19 pneumonia after lung transplant. This raises concerns that replication-competent SARS-CoV-2 virus can persist for months post-infection and can lead to re-infection of grafts in the future.

Percutaneous debulking of tricuspid valve endocarditis in severe COVID-19 pneumonia after prolonged venovenous extracorporeal membrane oxygenation with right-ventricular support: a case series.

Background: Over the past 2 years, the utilization of venovenous extracorporeal membrane oxygenation (VV-ECMO) for the treatment of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) has increased. While supporting respiratory function, VV-ECMO requires large-bore indwelling venous cannulas, which risk bleeding and infections, including endocarditis. Case summary: We describe two adults hospitalized for COVID-19 pneumonia who developed ARDS and right-ventricular failure, requiring VV-ECMO and ProtekDuo cannulation. After over 100 days with these devices, both patients developed tricuspid valve vegetations. Our first patient was decannulated from ECMO and discharged, but re-presented with a segmental pulmonary embolism and tricuspid mass. The Inari FlowTriver system was chosen to percutaneously remove both the tricuspid mass and pulmonary thromboembolism. Pathological examination of the mass demonstrated Candida albicans endocarditis in the setting of Candida fungemia. Our second patient developed a tricuspid valve vegetation which was also removed with the FlowTriever system. Pathological examination demonstrated endocarditis consistent with Pseudomonas aeruginosa in the setting of Pseudomonas bacteremia. Both patients experienced resolution of fungemia and bacteremia after percutaneous vegetation removal. After ECMO decannulation and percutaneous debulking, both patients experienced prolonged hospital stays for ventilator weaning and were eventually discharged with supplemental oxygen. Discussion: VV-ECMO and right-ventricular support devices are invasive and create various risks, including bloodstream infection and infective endocarditis. Percutaneous debulking of valvular vegetations associated with these right-sided indwelling devices may be an effective means of infection source control. It is unclear whether prolonged use of VV-ECMO provides a mortality benefit in COVID-19 ARDS.

A Dedicated Expert ECMO-Team and Strict Patient Selection Improve Survival of Patients with Severe SARS-CoV-2 ARDS Supported by VV-ECMO.

The SARS-CoV-2 pandemic has overwhelmed health care systems worldwide since its first wave. Intensive care units have been under a significant amount of pressure as patients with the most severe form of the disease presented with acute respiratory distress syndrome (ARDS). A proportion of them experienced refractory acute respiratory failure and had to be supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO). The present retrospective study reports the experiences of our ECMO center in the management of COVID-19 patients with refractory ARDS. Patient characteristics and outcomes are presented through the different waves of the pandemic. A cohort study was conducted on patients with refractory ARDS due to COVID-19 infection who were admitted to the intensive care unit (ICU) at the Geneva University Hospital and supported with VV-ECMO between 14 March 2020 and January 2022. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit of the hospital and the Swiss Society of Intensive Care Medicine. Among the 500 ARDS patients admitted to our ICU, 41 patients with a median age of 57 (52−63) years, a body mass index (BMI) of 28 (26−32) kg/m2, and a SAPS II score of 57 (47−67), and 27 (66%) of whom were men required VV-ECMO. None of the patients were vaccinated. The time of ventilation, including noninvasive ventilation (NIV) and mechanical ventilation (MV), and the time of MV before ECMO were 7 (4−11) days and 4 (1−7) days, respectively. The time under ECMO was 20 (10−27) days. The ICU and hospital lengths of stay were 36 (21−45) days and 45 (33−69) days, respectively. The survival rate for patients on ECMO was 59%. Comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter ventilation duration before ECMO (NIV + MV: 5.5 (1.3−9) vs. 9 (6.5−13.5) days, p = 0.0026 and MV alone: 1.6 (0.4−5.5) vs. 5.8 (5−8) days, p < 0.0001). The management of patients on ECMO by an experienced ECMO team dedicated to this activity was associated with improved survival (78% vs. 28%, p = 0.0012). Between the first wave and the following waves, patients presented with a higher incidence of ventilator-associated pneumonia (100% vs. 82%, p = 0.0325) but had better survival rates (74% vs. 35%, p = 0.024). The present study suggests that both the prompt insertion of VV-ECMO to control refractory hypoxemia and the involvement of an ECMO team improve the survival of COVID-19 patients.

The role of ECMO in COVID-19 acute respiratory failure: Defining risk factors for mortality.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV ECMO) utilization increased substantially during the COVID-19 pandemic, but without patient selection criteria. METHODS: We conducted a retrospective review of all adult patients with COVID-19-associated ARDS placed on VV ECMO at our institution from April 2020 through June 2022. RESULTS: 162 patients were included (n = 95 Pre-Delta; n = 58 Delta; n = 9 Omicron). The frequency of ECMO duration greater than three weeks was variable by pandemic period (17% pre-Delta, 41% Delta, 22% Omicron, p = 0.003). In-hospital mortality was 60.5%. Age ≥50 years (RR 1.28, 95% CI 1.01, 1.62), ≥7 days of respiratory support (1.39, 95% CI 1.05, 1.83) and pre-cannulation renal failure requiring dialysis (RR 1.42, 95% CI 1.13, 1.78) were associated with mortality. CONCLUSIONS: In this cohort of VV ECMO patients with COVID-19, older age, a longer duration of pre-ECMO respiratory support, and pre-ECMO renal failure all increased the risk of mortality by approximately 30%.

Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO.

BACKGROUND: Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure. OBJECTIVE: To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support. METHODS: We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation. RESULTS: We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs 13.4 mcg/kg/day, P = 0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs 53.5 mg/kg/day, P < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01). CONCLUSION AND RELEVANCE: Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.

Severe Air Leak Syndrome Associated with Sars-Cov-2 and Corona-Oc43 Infections

BACKGROUND AND AIM: Air leak syndrome is an uncommon complication for viral infections in pediatric patients and has been associated with pneumothoraces, empyemas, necrotizing pneumonias, barotrauma, and other underlying lung diseases. We present a case series of three patients with Coronavirus infections that developed severe air leak syndrome, two of which were placed on venovenous-extracorporeal membrane oxygenation (VV-ECMO). METHOD(S): Patient 1 (Pt1) is a 6-month-old male with a history of prematurity presenting with fever, cough, and respiratory failure with severe air leak syndrome requiring VV-ECMO support with SARS-CoV2. Patient 2 (Pt2) is a previously healthy 19-month-old female presenting with fever, cough, and respiratory failure with multiple pneumatoceles and pneumothoraces in the setting of coronavirus-OC43 requiring VV-ECMO support. Patient 3 (Pt3) is a previously healthy 25-day-old infant presenting with shock, cyanosis, apnea, multiple pneumothoraces and pneumatoceles, and subsequent respiratory failure with SARS-CoV2. RESULT(S): Pt1 and Pt2 developed multiple pneumothoraces with tension physiology and severe hypoxemia from necrotizing pneumonia with severe air leak, requiring multiple chest tubes, JET ventilation, and ultimately VV-ECMO support (see Figure 1). Pt3 developed multiple loculated pneumothoraces that necessitated surgically-placed chest tubes for decompression and JET ventilation for a 3+ week course. CONCLUSION(S): These cases highlight severe air leak syndromes as an infrequent and life-threatening complication correlated with Coronavirus infections. Viral illnesses such as SARS-CoV2 and Corona-OC43 and their associated multiorgan system disease have more recently impacted a larger number of pediatric patients and must be further evaluated to better understand underlying etiologies and compare management strategies. (Figure Presented).

Evaluation of urinary cysteinyl leukotrienes as biomarkers of severity and putative therapeutic targets in COVID-19 patients.

BACKGROUND: Cysteinyl leukotrienes (CysLT) are potent inflammation-promoting mediators, but remain scarcely explored in COVID-19. We evaluated urinary CysLT (U-CysLT) relationship with disease severity and their usefulness for prognostication in hospitalized COVID-19 patients. The impact on U-CysLT of veno-venous extracorporeal membrane oxygenation (VV-ECMO) and of comorbidities such as hypertension and obesity was also assessed. METHODS: Blood and spot urine were collected in "severe" (n = 26), "critically ill" (n = 17) and "critically ill on VV-ECMO" (n = 17) patients with COVID-19 at days 1-2 (admission), 3-4, 5-8 and weekly thereafter, and in controls (n = 23) at a single time point. U-CysLT were measured by ELISA. Routine markers, prognostic scores and outcomes were also evaluated. RESULTS: U-CysLT did not differ between groups at admission, but significantly increased along hospitalization only in critical groups, being markedly higher in VV-ECMO patients, especially in hypertensives. U-CysLT values during the first week were positively associated with ICU and total hospital length of stay in critical groups and showed acceptable area under curve (AUC) for prediction of 30-day mortality (AUC: 0.734, p = 0.001) among all patients. CONCLUSIONS: U-CysLT increase during hospitalization in critical COVID-19 patients, especially in hypertensives on VV-ECMO. U-CysLT association with severe outcomes suggests their usefulness for prognostication and as therapeutic targets.

Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation.

Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).

Venovenous Extracorporeal Membrane Oxygenation Support in Patients with COVID-19 Respiratory Failure: A Multicenter Study.

Objective: The COVID -19 pandemic presents a high mortality rate amongst patients who develop severe acute respiratory distress syndrome (ARDS). The purpose of this study was to evaluate the outcomes of venovenous ECMO in COVID-19-related ARDS and identify the patients that benefit the most from this procedure. Methods: Adult COVID-19 patients with severe ARDS requiring VV-ECMO support at four academic insititutions between March and October 2020 were included. Data were collected through retrospective chart reviews. Bivariate and multivariable analysis were performed with the primary outcome of in-hospital mortality. Results: Fifty-one consecutive patients underwent VV-ECMO with a mean age of 50.4 years; 64.7% were male. Survival to hospital discharge was 62.8%. Median ICU and hospitalization duration were 27.4 (IQR:17-37) and 34.5 days (IQR:23-43), respectively. Survivors and non-survivors had a median ECMO cannulation time of 11 days (IQR 8-18) and 17 days (IQR: 12-25). The average post decannulation length of stay was 17.5 days (IQR: 12.4-25) for survivors and 0 days for non-survivors (IQR 0-6 days). Only one non-survivor was able to be decannulated. Clinical characteristics associated with mortality between non-surviors and survivors included increasing age (p=0.0048), hemorrhagic stroke (p=0.0014), and post operative dialysis (p=0.0013)were associated with mortality in a bivariate model and retained statistical significance in a multivariable model. Conclusion: This multicenter study confirms the effectiveness of VV-ECMO in selected critically ill patients with COVID-19-related severe ARDS. The survival of these patients is comparable to non-COVID-19-related ARDS.

Prone positioning in ARDS patients supported with VV ECMO, what we should explore?

BACKGROUND: Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. MAIN BODY: The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. CONCLUSION: For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.

Adhered ECMO cannula in COVID-19 related severe acute respiratory failure.

BACKGROUND: Crescent cannula adhesion in the setting of COVID-19 respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support is a novel complication. The objective of this case presentation is to highlight this rare complication and to explore potential predisposing factors and our management strategies. CASE PRESENTATION: We present the case of a 25 y.o. patient with COVID-19 respiratory failure requiring ECMO support for 16-days in which a 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein. Attempts to remove the cannula at the bedside failed due to immobility of the cannula. Ultrasound of the right neck was unremarkable, so he was taken to the hybrid OR where both TEE and fluoroscopy were unrevealing. An upper sternotomy was performed, and the superior vena cava and proximal jugular vein were dissected revealing a 2 cm segment of the distal SVC and proximal jugular vein that was densely sclerosed and adherent to the cannula. The vessel was opened across the adherent area at the level of the innominate vein and the cannula was then able to be withdrawn. The patient suffered no ill effects and had an unremarkable recovery to discharge. CONCLUSIONS: To date, there have been no reports of crescent cannula adhesion related complications. In patients with COVID-19 respiratory failure requiring ECMO, clinicians should be aware of widespread hypercoagulability and the potential of unprovoked, localized venous sclerosis and cannula adhesion. We report our technique of decannulation in the setting of cannula adhesion and hope that presentation will shed further light on this complication allowing clinicians to optimize patient care.

An Early Catch: Multisystem Inflammatory Syndrome in Adults (MIS-A) in a Young Adult Male With COVID-19 Exposure.

While severe acute respiratory syndrome (SARS) is the most common presentation of coronavirus disease 2019 (COVID-19) infection, several short- and long-term complications from COVID-19 infection are also being recognized. One such complication with life-threatening consequences is known as multisystem inflammatory syndrome in adults (MIS-A). While the phenomenon of multisystem inflammatory syndrome in children (MIS-C) is more recognized, the pathophysiology of both presentations remains a mystery currently. Several theories have been put forward however no consensus has been established yet. We present the case of a 20-year-old male who was admitted to the intensive care unit for a multisystem illness characterized by severe biventricular failure, profound shock, and acute liver and kidney injuries. The severity of illness necessitated the treatment with mechanical ventilation, extracorporeal membrane oxygenation (ECMO), vasopressors, and continuous veno-venous hemofiltration (CVVH). The patient was treated with one dose of intravenous immune globulin (IVIG). In association with the foregoing treatment, the patient made dramatic recovery and came off pulmonary, hemodynamic, and renal support within a week and made remarkably quick and full recovery. This case highlights a rare presentation of a COVID-19 complication that requires prompt recognition, supportive care, and empiric treatment that led to a favorable outcome in this case.

Impaired Pharmacokinetics of Amiodarone under Veno-Venous Extracorporeal Membrane Oxygenation: From Bench to Bedside.

BACKGROUND: Adjusting drug therapy under veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging. Although impaired pharmacokinetics (PK) under VV ECMO have been reported for sedative drugs and antibiotics, data about amiodarone are lacking. We evaluated the pharmacokinetics of amiodarone under VV ECMO both in vitro and in vivo. METHODS: In vitro: Amiodarone concentration decays were compared between closed-loop ECMO and control stirring containers over a 24 h period. In vivo: Potassium-induced cardiac arrest in 10 pigs with ARDS, assigned to either control or VV ECMO groups, was treated with 300 mg amiodarone injection under continuous cardiopulmonary resuscitation. Pharmacokinetic parameters Cmax, Tmax AUC and F were determined from both direct amiodarone plasma concentrations observation and non-linear mixed effects modeling estimation. RESULTS: An in vitro study revealed a rapid and significant decrease in amiodarone concentrations in the closed-loop ECMO circuitry whereas it remained stable in control experiment. In vivo study revealed a 32% decrease in the AUC and a significant 42% drop of Cmax in the VV ECMO group as compared to controls. No difference in Tmax was observed. VV ECMO significantly modified both central distribution volume and amiodarone clearance. Monte Carlo simulations predicted that a 600 mg bolus of amiodarone under VV ECMO would achieve the amiodarone bioavailability observed in the control group. CONCLUSIONS: This is the first study to report decreased amiodarone bioavailability under VV ECMO. Higher doses of amiodarone should be considered for effective amiodarone exposure under VV ECMO.

COVID-19 Hasta Takibindeki ECMO Uygulamalarımız

Amaç: Ağır COVID-19 pnömonisi sonrası gelişen ARDS’de ekstrakorporeal membran oksijenasyon (ECMO) yöntemi, akciğer iyileşmesine zaman tanımak ve dolaşım dolaşım desteği sağlamak amacıyla kullanılmaktadır. Bu olgu serisi ile, yoğun bakımımızda uygulanan venö-venöz ve venöarteriyel ECMO tecrübesi paylaşılacaktır. Olgu: Yoğun bakımımızda altı VV-ECMO ve iki VA-ECMO olmak üzere toplam sekiz ECMO uygulaması yapıldı. Hastaların beşi erkek, üçü kadın hasta idi. Yaş ortalaması 49,1 (31-70) yıl olarak hesaplandı. Hastaların tümü aşısızdı. Komorbidite olarak bir hastada romatoid artrit, bir hastada multipl skleroz ve hipertansiyon, bir hastada astım, bir hastada hipertansiyon vardı. Hastaların tümü obezdi (VKÍ >30). Hastaların hepsinde prone pozisyonuna dirençli hipoksemi mevcuttu (PaO2/FiO2<70), ECMO kararı için hesaplanan Murray Skorları tüm hastalarda dört bulundu. Hastalara ortalama olarak entübasyonun dördüncü gününde ECMO başlandı. Hastaların altısına, izole olarak hipoksi mevcut olduğu için VV-ECMO;ikisine laktat artışı ve dirençli hipotansiyon olması nedeniyle VA-ECMO başlandı. Ortalama ECMO süresi 16 gün olarak (16 saat - 39 gün) bulundu. Standart olarak;VV-ECMO için, sağ juguler ven ve sağ femoral ven;VA-ECMO için sağ femoral arter ve sol femoral ven tercih edildi. Tüm hastaların ACT (activated clotting time) takipleri yapıldı ve 150-200 sn. arasında tutuldu. Bir hastada (taburcu olan) Heparin Induced Thrombocytopenia (HIT) gelişti. Bir hastada dirençli A. baummanii, bir hastada Aspergillus spp. üremesi tespit edildi. ECMO tedavisi altında takipte iken üç hastada anizokori tespit edildi. Bu hastalardan biri bilgisayarlı tomografiye transport için uygun olup yaygın parankimal kanama gösterildi (Şekil 1). Bir hastanın ECMO cihazı ani olarak kapandı, 45 dakika manuel olarak sirkülasyon sağlandı. En uzun süre ECMO tedavisi alan hasta taburcu edilirken, diğer yedi hasta vefat etti. Sonuç: ECMO uygulaması kendisine ait komplikasyonları olan, yüksek maliyetli, tecrübe ve eğitimli personel gerektiren bir yöntemdir. Bir tedavi seçeneği değil, iyileşmeye giden bir köprüdür. Hangi hastada, ne zaman uygulanması gerektiği tecrübe gerektiren bir uygulamadır. Geri döndürülebilir kliniği olan hastalarda doğru zamanda karar verilmesi önemlidir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Şiddetli COVID-19 ARDS’li Bir Hastada Ínvaziv Mekanik Ventilasyon Yerine Ekstrakorporeal Membran Oksijenasyonu Uygulaması: Fully Awake ECMO

Amaç: Mekanik ventilasyon ile yeterli oksijenasyonun sağlanamadığı COVID-19 hastalarında VV-ECMO kurtarma tedavisi olarak uygulanabilir. Son zamanlarda, bazı seçilmiş olgularda rutin uygulamada yeri olmamasına rağmen P-SILI’yi önlemek adına “fully awake ECMO” uygulaması gündeme gelmiştir. Yoğun bakımda uyanık VV-ECMO uyguladığımız 42 yaşında hasta sunulmuştur. Olgu: Bilinen kronik hastalığı olmayan 42 yaş erkek hasta SARS-CoV-2 PCR pozitifliği (delta varyant) ile yoğun bakıma kabul edildi (Şekil 1). Öncesinde 24 gün serviste takip edildi. Yoğun bakımda HFNC ve aralıklı NIMV uygulandı. Ancak YBÜ kabulünün 6. gününde direçli hipoksi nedeni ile uyanık VV-ECMO kararı alındı. Hastaya entübe edilmeden noninvaziv destek altında (PS: 0, PEEP: 8,TV: 800 mL, SS: 35) fentanyl infüzyonu 2,5 mcg/kg/dk ile sol femoral venden 23 F drenaj kanülü, sağ internal juguler vene 21F dönüş kanülü yerleştirildi. Blood flow: 3,2 lt/dk, sweep gas: 4 lt/dk FiO2 : %100 ile VV-ECMO uygulaması başlatıldı. Başlar başlamaz periferik oksijen saturasyonu %98 olan hastanın hipoksik solunumsal kompansasyon yanıtı azaldı 4/dk solumaya başladı. Opioid alan hastanın solunum depresyonu naloksan ile revers edildi. Hemen ardından GKS: 15, HFNC ile takibe alındı, entübasyon ihtiyacı olmadı, hasta 21. gün ECMO’da ekstübe halde takip edildi. ECMO altında mobilize edildi. (Şekil 2). 14. gününde ECMO FiO2 desteği kapatıldı, süpürücü 5 l/dk, HFNC FiO2 : %70, akım 40 lt/dk ile izlenirken kan gazında kompanse respiratuvar asidozu gelişti. 23. gününde ateş, idrarda Trichosporon asahii görüldü ve tedavisine vorikonazol eklendi. ECMO’nun 21. gününde dekanüle edilen hasta, 3 gün dekanüle halde izlendi. Yoğun bakım takibinin 32. gününde hasta Trichosporon asahii fungemisi nedeni ile septik şok tablosu sonucu kaybedildi. Sonuç: “Fully awake ECMO” stratejisi, hastanın aktif tedaviye katılımını ve mobilizasyonunu mümkün kılar ve ağır sedasyon, paralizi ve uzun süreli MV ile ilişkili komplikasyonları önleyebilir. Bununla birlikte, ECMO ile ilişkili risklerin dikkatli bir şekilde izlenmesi önemlidir ve bu strateji deneyimli ECMO merkezlerinde çok sayıda hasta ile deneyimlenmelidir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Nebulized in-Line Endotracheal Dornase Alfa and Albuterol Administered to Mechanically Ventilated COVID-19 Patients: A Case Series

Mechanically ventilated patients with COVID-19 have a mortality of 2453%, in part due to distal mucopurulent secretions interfering with ventilation. DNA from neutrophil extracellular traps (NETs) contribute to the viscosity of mucopurulent secretions and NETs are found in the serum of COVID-19 patients. Dornase alfa is recombinant human DNase 1 and is used to digest DNA in mucoid sputum. Here, we report a single-center case series where dornase alfa was co-administered with albuterol through an in-line nebulizer system.

Venovenous extracorporeal life support circuit exchange: Tips and pitfalls.

Extracorporeal life support is a well-known therapy for acute respiratory failure. Its use has increased exponentially in recent years, even more since the beginning of the SARS-CoV-2 pandemic. Patients with COVID-19 may need long-term extracorporeal life support runs. They also suffer coagulation derangements that cause a prothrombotic state. Both situations may increase the need for exchanges of extracorporeal life support circuits. Extracorporeal life support circuit exchange should be performed as quickly and as safely as possible because patients may be completely dependent on it.