ABSTRACT
Extracorporeal Membrane Oxygenation is a resource intensive therapy;heavily reliant upon specialized equipment, unique disposables, and skilled staff. The Covid-19 pandemic and following events exposed flaws in multiple phases of the care delivery system. The combination of high patient census, acuity, manufacturing delays, and supply chain disruptions led to our center's reassessment of the way in which limited resources are utilized. As a combined pediatric and adult center, we possess the ability to share resources amongst all patient populations. Currently, the majority of our equipment and disposables support a heavier use of Centrimag. We adjusted our general weight guidelines in order to best serve the most patients. (<8kg Sorin Rollerhead, 8-20kg Sorin Revolution, >20kg Centrimag.) Presently, a major challenge is the cessation of production of the -inch Better Bladder. The ECMO Coordinator team collaborated with key physician stakeholders. It was decided that the fluid reservoir and air trap benefits of a bladder outweighed the risks of running without one on our Sorin Rollerhead circuit. We designed a circuit with a 3/8 Bigger Better Bladder. Recognizing the increased risk of clotting with the 3/8 segment, we added a post-oxygenator shunt. This allows for adequate blood flow to maintain circuit integrity, while limiting the amount of flow to the patient. The nationwide nursing shortage is well-known. Though our multidisciplinary ECMO Specialist Team supports nursing and respiratory therapy, the nursing shortage still impacts our staffing models, resulting in the inability to safely staff bedside nurses and ECMO specialists. At times of high census, ECMO patients are cohorted into one geographical location. This allows for a temporary 2:1 staffing model for Centrimag patients. Our goal remains to staff pediatric cases as a 1:1 ECMO Specialist assignment. The ability to obtain this is assessed shift to shift;factoring patient stability, experience of the ECMO specialist, and unit staffing. The collaboration with ICU Nurse Managers, Hospital Supervisors and Central Staffing Office is imperative to the success of staffing model alterations. Our ECMO department has increased its FTEs, implementing a core team to be preassigned to two ECMO beds. The objective is to alleviate the burden on ICU staffing, limiting the number of nurses pulled from staffing grids. In uncertain times, flexibility is vital. It is important to remain vigilant and proactive. Our ECMO program feels that continuous assessment of supplies, equipment, and open communication has been the key to successfully serving our patients.
ABSTRACT
Background and Aims: AKI is a common complication in critically ill patients, during the COVID-19 pandemic, it has been presented directly associated with damage by the virus, due to the severity of the disease and secondary to treatment, that is, secondary to the Crosstalk of organs and the crosstalk of support equipment, such as the extracorporeal oxygenation membrane (ECMO), which has been used in patients with severe respiratory failure. According to the international bibliography, the incidence of AKI in ECMO ranges from 26 to 85% depending on the characteristics of the patient, the percentage that requires KRT is around 45% . Objective(s): Our hospital is a national reference center for ECMO support therapy as for lung transplantation, it is the only center that has an active program, so understanding the epidemiology of AKI associated with ECMO in our population is important, in addition to representing an part of the experience in Latin America. Method(s): Retrospective and Descriptive study. Were included all patients 18y or older connected to ECMO with diagnosis of severe pneumonia for COVID-19 from June 2020 to August 2021. Data was collected in excel and using the ECMO Team platform data that is shared in the ELSO. Descriptive data analysis was performed with SPSS V21 and excel. Result(s): 48 patients were connected to ECMO for COVID-19 severe pneumonia in our center, 39 men. Average Age 49 years (Min 21y, Max 68y), average weight 93 kg (Min 55kg, Max 125kg) 25 patients (52%) with AKI, 22 (45%) requires KRT, 100% CKRT. 10 patients (20%) have kidney recovery function, all them get out form ECMO. From all, 45% patients died, these 45% were still in ECMO. In most of the cases the AKI cause is multifactorial, but the most common cause identified was sepsis, the second nephrotoxicity (antibiotics like vancomycin and colistin) and third hemolysis (as ECMO membrane complication). About the indication of star KRT: 50% fluid overload, 30% acidosis and uremia, 20% anuria. 100% of patients were in ECMO-VV at time CKRT started, all were connected in parallel in ECMO in Post blood pump and return Pre blood pump, with no coagulation problems as long as they have the ECMO anticoagulation, 93% patients with heparin and 7% with argatroban for HIT suspicious. As data to highlight from our population there is the first bilateral lung transplant secondary to covid-19 in Latin America and the longest air transfer in ECMO in the world. Conclusion(s): In our center the AKI, KRT and mortality in patients with ECMO it is much like other centers reported. In COVID-19 there is not yet very clear evidence and more studies should be done. This is the first study in Mexico about ECMO, AKI and COVID- 19.
ABSTRACT
Purpose: Release and circulation of pro-inflammatory cytokines or “cytokine storm,” a pathophysiologic component of severe COVID-19, is associated with thrombosis and clot embolization. Compromised patients often require extracorporeal oxygenation and mechanical circulatory support (MCS), imparting blood flow disturbances and exogenous shear stress, further amplifying thrombotic potential. Central in these processes is the platelet. The dynamic interaction of MCS flow/shear and inflammatory cytokines and their propensity for altering platelet function remains unknown. We hypothesized that platelet function is modified in an MCS + pro-inflammatory cytokine environment. We examined platelet aggregation as a function of time, exposing platelets to COVID-19-associated cytokines under MCS flow in vitro. Methods: An Impella5.5® was affixed in a closed loop and positioned with outflow cannula in a 1-inch tube region, maintained at differential 60mmHg pressure. Alternatively, a CentriMag® was affixed in series with a similar closed loop. Porcine PRP, obtained via centrifugation of fresh, ACD-A anticoagulated whole blood was used as circulating fluid. A cytokine “COVID cocktail” of porcine IL-6 (4.5 ng/mL), IL-1β (0.5 ng/mL), IL-8 (2.7 ng/mL), and TNFα (1 ng/mL) was added to PRP and circulated at 5 L/ min. After 5, 60 and 240min of circulation, platelet samples were taken and measured for aggregation with ADP (20uM), and expression of activation markers (CD62P, AnnV) via flow cytometry. Samples were measured in duplicate from N ≥ 2 pigs per experiment. Results: The addition of COVID Cocktail cytokines led to an increase in overall aggregability of platelets over time. In contrast, the addition of shear via MCS devices led to a decrease in platelet aggregability despite Cytokine addition (Fig 1). Notably, platelet aggregability was more greatly reduced with CentriMag (85% reduction) than with Impella (65% reduction). There was no significant difference in platelet activation (AnnV binding, CD62P exposure) between CentriMag and Impella 5.5 in the cytokine environment. (Figure Presented).
ABSTRACT
The proceedings contain 226 papers. The topics discussed include: identification of biomarkers sensitive to pulsatile and continuous flow for identification of promising continuous flow VAD modulation protocols to mitigate non-surgical bleeding events;comprehensive machine learning analysis of pre-implantation risk factors for right heart failure after LVAD implantation;combining VA-ECMO And Impella (EC-Pella) before reperfusion mitigates left ventricular loading and injury due to VA-ECMO in acute myocardial infarction;platelet function at the intersection of the COVID-19 'cytokine storm' and mechanical circulatory support;a dialysate free portable artificial kidney device;durable right heart mechanical support system: a multi-day proof-of-concept study in pulmonary hypertension sheep;a dual-action nitric oxide-releasing slippery surface coating for extracorporeal organ support: first evaluation at clinically relevant blood flow rate for partial lung support;cannula add-on for pressure and flow measurement in VADs;and comparison of interlaboratory CFD simulations of the FDA benchmark blood pump model.