ABSTRACT
Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.
ABSTRACT
Objectives: We sought to evaluate 2-year outcome of V-V ECMO support for COVID-19 related severe respiratory failure in our center. Method(s): Retrospective analysis of 41 consecutive patients (73% male, mean age 51.6+/-14.2 years, mean BMI 35.1+/-12.5 kg/m2) with critical hypoxemic and/or hypercapnic refractory respiratory failure (mean P/F ratio 67.9+/-14.3 mmHg, mean pCO2 77.6.0+/-185.7 mmHg, Murray Score 3.71+/-0.4) on V-V ECMO support from October 2020 to January 2022 Results: With mean support duration of 234.4+/-63.2 hours, 29 patients (70.7%) were successfully weaned off. Finally, 19 of them (46.3%) were discharged home with good neurological outcome (CPC 1,2). During followup, 30-day, 6-, 12-, and 24 -month survival rate was 61.3%, 46.2%, 41.9%, and 41,9% respectively. In survivor group shorter symptoms onset to respiratory failure time (4+/-4.7 vs. 7+/-6.7 days, p=0.04), higher P/F ration (86+/-41.5 vs. 65+/-37.5 mmHg, p=0.04) and norepinephrine support (0.03+/-0.06 vs. 0.09+/-0.12 ug/kg/min, p=0.04), and lower IL-6 level (12.3+/-7.5 vs. 25.9+/-8.8 ng/l, p=0.03) p=0.01) were analysed before cannulation. Mean in-ICU stay and in-hospital stay in survivors;groups reached 32.5+/-27.7 days and 42.6+/-35.8 days, respectively. All long-term survivors (17 patients) complained about slight functional health limitation only with normal 6MWT (542.6+/- 89.2 min), near to normal spirometry parameters (FEV/VC 87+/-7.4%, DLCO 63.1+/-13.7%, KCO 82.,1+/-19.4%) and minimal neurological disability (CPC 1-2) Conclusion(s): 2-year outcome of V-V ECMO support in COVID-19 severe respiratory failure is acceptable even in the scope of low-volume ECMO centre. Reported functional status of long-term survivors was good despite the complicated and prolonged in-hospital stay. (Table Presented).
ABSTRACT
Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).
ABSTRACT
Objectives: Implementation of venovenous extracorporeal membrane oxygenation (VVECMO) allowed survival of patients with severe respiratory failure associated with SARS-CoV-2 infection. However, VVECMO treatment is usually associated with long ICU stays, prolonged sedation, and neuromuscular blockage days. Functional disability, due to delirium and acquired muscle weakness, is frequently an inevitable burden causing long term disability. This study aims to analyse main characteristics of patients under ECMO due to COVID-19 pneumonia, their outcomes and functional status six months after ICU discharge. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients receiving VVECMO for SARS-CoV-2 infection were included. Epidemiological and clinical data were reviewed. Functional status at 6 months after ICU discharge was assessed with modified Rankin Scale (mRS). Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9, mean SAPS II was 35.6+/-13.6. Mean time from intubation to cannulation was 5+/-5.6 days in 91 patients;awake-ECMO was performed in 2 patients. Mean ECMO run duration was 33.1+/-30 days (longest ECMO run was 194 days). A period of awake-ECMO was performed on 36.5% of patients, during 16.4+/-21.2 days. ICU-acquired weakness was diagnosed on 64.5% of patients and delirium on 63.4%. Mortality was 24.7% (23 patients) with only 1 patient deceased in hospital after ICU discharge. At 6 months follow-up, all patients were still alive and most of them (65.1%) were independent on all daily activities (mRS <= 2). Conclusion(s): Patients with severe COVID-19 treated with VVECMO support had very good functional outcomes at six-month follow-up. Despite long ICU length-of-stay, high incidence of delirium and acquired muscle weakness, full recovery at six-month post-ICU discharge was achievable in most patients.
ABSTRACT
Objectives: During COVID pandemic, ECMO support for the patients with ARDS have saved many lives. Although its an important and effective treatment modality, management of ECMO could be done in a few specialized centers. In this study, we share our in- and out-of-city ECMO transport experience of the patients with COVID-ARDS. Method(s): A total of 75 patients (57% male- 43 %female) were included in this study. The decision ECMO support, initiation at referral hospital, and transport process of all of the patients to our centre were performed by our mobile ECMO team. All transports were done by land ambulance Results: Mean age of the patients was 43.4+/-11.5 years. Mean intubation period before ECMO support was 8.5 +/-8.3 days. We transferred 14 patients from the centers within the city and 12 patients from the centers outside the city to our hospital. Mean distance between our center and the referral center was 36,2 kms (max 269- min 1). We did not experience any major complication during transport. A total of 30 patients (38,6 %) were weaned from ECMO and discharged from hospital. Conclusion(s): ECMO support is an advanced treatment modality for pulmonary failure patients. The decision of initiation, cannulation, transport and management should be performed by experienced centers to achive acceptable results.
ABSTRACT
Objectives: Obesity is a condition prone to pose difficulties to a successful extra-corporeal membrane oxygenation (ECMO) support. Not being a contraindication, it yields significant challenges to physicians and may interfere with patient;s outcome. The number of obese patients supported by ECMO has increased during COVID-19 pandemic due to severe illness in this population. We designed a retrospective study in order to identify prognostic factors for 180-day survival in critical COVID-19 obese patients in venovenous ECMO (VV-ECMO). Method(s): Single-center retrospective cohort of critical COVID-19 adult patients in VV-ECMO, obese and overweight (according to WHO classification), admitted in a tertiary hospital;s ICU from April 1st 2020 to May 31th2022. Univariate logistic regression analysis was performed to assess 180-day mortality differences. Result(s): The analysis included 41 patients. The median [interquartile range (IQR)] age was 55 (IQR 45-60) years and 70,7% were male. Median body mass index (BMI) was 36 (IQR 31-42,5) Kg/m2 ;39% of patients had a BMI >=40 kg/m2 . The sampling had 3 (IQR 1,5-4) days of invasive ventilation prior to ECMO and 63,4% were weaned from ECMO-VV support after a median of 19 (IQR 10-34) days. The median ICU length of stay was 31,9 (IQR 17,5-44,5) days. The invasive ventilation period was 30 (IQR 19-49,5) days. The 60, 90 and 180-day mortalities were 41,5%. On the univariate logistic regression analysis we found that higher BMI was associated with higher 180-day survival (odds ratio [OR] 1,157 (1,038-1,291), p 0,009). Younger age, female patients, less invasive ventilation time prior to ECMO and fewer complications at time of ECMO cannulation were associated with higher 180-day survival [respectively, OR 0,858 (0,774- 0,953), p 0,004;OR 0,074 (0,008-0,650), p 0,019;OR 0,612 (0,401-0,933), p 0.022;OR 0.13 (0,03-0,740), p 0,022)]. Conclusion(s): In this retrospective cohort of critical COVID-19 obese adult patients supported by VVECMO, a higher BMI, younger age and female patients were associated with higher 180-day survival. A shorter invasive ventilation time prior to ECMO and fewer complications at ECMO cannulation were also associated with increased survival.
ABSTRACT
Objectives: Besides in-centre ECMO care, the certificated ECMO centre of the University Hospital Regensburg (UKR) offers out-of-centre ECMO initiation with mobile equipment. During the pandemic situation, this treatment was especially meant for patients with critical cardiopulmonary failure in remote hospitals who present themselves as too unstable for interhospital transfer. We evaluated if treatment with outof-centre ECMO initiation could benefit patients;outcome, by comparing this group with a group of COVID-19 patients who received ECMO therapy at the UKR by in-hospital initiation. Method(s): Retrospective single-centre study including 169 patients who received ECMO due to COVID-19- induced cardiopulmonary failure between March 2020 till March 2022. Patients;population was separated into two groups according to the location of ECMO initiation, out-of-centre or in-centre, and into two subgroups by the used ECMO mode, venovenous (VV) or venoarterial (VA). We compared demographics, treatment duration, adverse events and patient;s outcome. The primary endpoint of the investigation was patients;survival to hospital discharge rate or death on ECMO or after ECMO explant. Result(s): Regarding the total study population, 98 (58.0%) of the 169 patients could be discharged from the UKR. Before initiation of ECMO therapy and with regard to complications during the course of intensive care, such as renal failure requiring dialysis or bleeding, there were no relevant differences between the two groups and subgroups. The out-of-centre group showed a significantly higher survival rate with 70 (63.6%) survivors out of 110 externally cannulated patients. Conclusion(s): In the study population, external ECMO cannulation was beneficial in terms of survival, although the reasons did not show significant differences between the groups. A possible approach for the good overall survival of the study groups in international comparison could be the existing centre expertise. (Figure Presented).
ABSTRACT
Objectives: To evaluate the outcomes and risk factors associated with mortality of patients cannulated on ECMO in the context of covid infection during the pandemics in a newly implemented ECMO center Methods: This was a unicentric observational retrospective study performed at Real Hospital Portugues, in Recife, state of Pernambuco, Brazil. All consecutive patients with laboratory confirmed SARS-CoV-2 infection cannulated for VV-ECMO or VA-ECMO for severe ARDS from march 2020 to december 2021 were included retrospectively. Patients recieving ECMO for isolated refratory cardiogenic shock were excluded. Descriptive statistics and association tests were used to analyze characteristics, management and patient outcomes during that period. Result(s): In our cohort of 47 ECMO for covid associated ARDS (CARDS), 39 patients (83%) were admitted by our emergency department. 8 patients (17%) had been transferred from other hospitals as soons as they had been cannulated. 32 patients (68%) were male, median age was 50 years (18-69). Mean body mass index was 31 (21,4-46,3). 37 patients (78%) had at least 1 comorbidity. Major bleeding occurred in 34 (72%) patients. Venous thromboembolism and hemolysis ocurred in 19 (40%) and 13 (23%) patients, respectively. When we compared treatments before ECMO initiation (imunoglobulin, tocilizuman, nitric oxide, neuromuscular blockade and proning), proning was associated with better survival (RR 0,67 IC 0,46-0,97 p 0,029). The mean duration in mechanical ventilation until ECMO cannulation was 9,69 days and mean time in ECMO was 23 days. The 90- day mortality was approximately 72%. Conclusion(s): The only variable associated with a better chance of survival was proning before ECMO. Our mortality (72%) is higher than reported from a recent meta-analysis of 1986 ECMO patients implanted during the first pandemic year(37,1%). However it is similar to a German populational registry of covid patients receiving VV-ECMO (73%). Althought it;s impossible to make causal inferences with such a design and sample sizes, we believe that describing the experience of smaller and newly implemented ECMO centers serves as motivation to improve quality and also to plan for future episodes of pressure on health system.
ABSTRACT
Objectives: To describe institutional experience using Oxygenated Right Ventricular Assist Device (OxyRVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU), including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular (RV) dysfunction or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to Cardiohelp systems with built in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult critical care colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia. (Figure Presented).
ABSTRACT
Objectives: To present an unusual complication related to prolonged ECMO support in a patient with COVID19 induced acute respiratory syndrome (ARDS). Method(s): Clinical chart review of the care process after obtaining the informed consent from the patient. Result(s): A 48-year-old female with COVID-19 infection during second wave of pandemic in August 2021 progressed to severe ARDS. She was put on VV-ECMO support after failing conventional therapy for refractory hypoxemia. Her cannulation configuration included a 25 F venous drainage cannula in the right femoral vein and a 21 F venous return cannula in the right Internal Jugular (IJ) vein. Cannulations were performed using the ;Seldinger technique;under USG guidance, and no difficulties or complications were reported. Her hospital course was notable for delirium, and intermittent bleeding from the cannula sites. After 80 days of support, she showed adequate respiratory improvement which allowed ECMO decannulation. She continued to show improvement, and was eventually discharged after 102 days of total hospital stay. During her 6 weeks follow-up clinic visit a palpable thrill was noted at the jugular ECMO cannula site. A CT angiogram of the neck demonstrated a large venous varix connecting the right IJ and the left common carotid artery with filling from the left common carotid artery. ECMO cannulation site complications such as aneurysm, clots, infections and stenosis are well known. What was unusual in this case is the nature of the aneurysm given that there were no arterial procedures performed on the left side of the neck. She was managed by an ;Amplatzer plug;to the carotid artery at the level of the connection to the varix without any complications. Conclusion(s): Longer duration of ECMO support needs careful follow-up for timely recognition and management of vascular complications. (Figure Presented).
ABSTRACT
Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.
ABSTRACT
Objectives: The objetive of this study is to describe the cases trasferred to an ECMO referral;s centre (Hospital Universitario 12 de Octubre, Madrid (Spain)), to investigate characteristics before ECMO and while the patient was on ECMO, to analyse the presence or not of complications secondary to transfer and cannulation and finally to analyse the ICU outcome. Method(s): This is a Prospective study done from November 1st, 2020 to December 31st, 2022. The cases were accepted either for emergency ECMO cannulation in the hospital of origin and retrieval or for conventional transfer. We analysed basic decriptive variables such as male proportion, age, IMC and etiology of ARDS and variables before ECMO such as prone position, duration of non-invasive ventilation, invasive ventilation and ICU leght of stay before ECMO. We recorded ELSO, SOFA and APACHE Severity Scores. We also analysed several variables on ECMO: if prone position on ECMO was done, median days of ECMO and succesfull weaning from ECMO. We also recorded whether there were complications or not in the transfer and cannulation. Finally ICU survival was examined. Result(s): 31 cases were accepted. 22 (71 %) were male. 29 cases were accepted for emergency ECMO cannulation. Median age was 47 years and IMC 31.1. The etiology of SDRA was COVID 19 infection in 23 cases (74% cases). Lenght of non invasive and invasive ventilation before ECMO were 4 days and 3 days respectively and lenght of ICU admission before ECMO was 2 days. Prone position was 1 day and 2 prone sessions were done before ECMO. Severity scores: APACHE 10 , SOFA 4 , ELSO 3 . On ECMO Prone position was done on 15 cases(48.4%) . Median days on ECMO were 13.5 days. Succesfull weaning from ECMO were achieved on 20 cases(61%), 2 cases remain on ECMO. No complications were seen on transfer or cannulation. ICU Survivors were 16(51.6%). Conclusion(s): After 2 years of experience on ECMO retrieval in the region of Madrid ECMO availability was achieved. Our results are similar than ELSO mortality.
ABSTRACT
Objectives: To describe the IPT collaborative approach for peripartum women with COVID-19 on ECMO and report the intervention outcomes. Method(s): A retrospective electronic health record review was performed from January 2020 through January 2022. All peripartum women on ECMO with COVID19 admitted to the cardiothoracic intensive care unit (CTICU) were included. The IPT came together to coordinate peripartum care and delivery. An algorithm was created to outline the roles and workflow in the care of these patients. The outcomes evaluated included delivery method, timing, and location, maternal survival at discharge, maternal ICU length of stay (LOS), and neonatal survival Results: Thirteen Peropartum women were placed on ECMO (5 antepartum and 8 postpartum, ages 27-42). None had been vaccinated against COVID-19. All received femoral vessel cannulation (11 venovenous and 2 venoarterial). Four patients underwent Caesareansection delivery while on ECMO. Maternal survival to hospital discharge was 84.6%. All neonates survived with COVID-19 negative status. Conclusion(s): The collaborative IPT approach with a structured algorithm facilitated survival outcomes. This report adds to the limited literature on peripartum. ECMO and provides insights to consider in planning for the care of these patients.
ABSTRACT
Objectives: To describe our experience in ECMO for acute myocarditis Methods: Descriptive, retrospective study (2018-2022) of a cohort of 8 patients < 16 years with acute myocarditis who were assisted on ECMO. Result(s): 8 patients were collected, (6 females), with a mean age 7;8 years [range 0;1-13;8]. In 7/8, the reason for cannulation was hemodynamic instability refractory to medical treatment, with a mean inotropic score of 70 [range 10-122]. Sixty-two percent presented cardiorespiratory arrest prior to cannulation and 2 of them needed ECRP. The mean precannulation troponin level was 1498 ng/ml [range 89-6212]. Primary transport was performed in 4 patients. ECMO was peripheral veno-arterial in 100%, jugulo-carotid in 2/8 and femoro-femoral in 6/8. All patients underwent atrioseptostomy. They received treatment with levosimendan, immunoglobulins, corticoids and carnitine. In 4 acute infectious etiology was confirmed (parvovirus, influenza and SARSCoV2), another one was due to PIMS-TS and in 3 no etiology was found. Six patients underwent myocardial biopsy and 5 of them showed inflammatory infiltrates. The mean time on ECMO was 8 days [range 3-14], 2 of them requiring 2 ECMO courses. The mean length of PICU stay was 21 days [range 10-50]. Two were transferred to a heart transplant center. The main complications were arterial hypertension (88%), bleeding (63%), neurological (50%), arrhythmias (38%), coagulopathy (38%) and infectious (38%). One patient required renal replacement therapy. 1 patient died, 2 had moderate neurological sequels. Conclusion(s): ECMO is a therapeutic option in patients with fulminant myocarditis refractory to medical treatment and may help improve their prognosis.
ABSTRACT
Objectives: To present a series of immunosuppressed patients (oncohematological disease, congenital immunosuppression, hematopoietic stem cell (HSCT), and solid organ transplant) assisted on ECMO. Method(s): Descriptive, retrospective study (2011-2020) of a cohort of 9 immunosuppressed patients, supported on ECMO. Medical records were reviewed and demographic, clinical, and analytical variables were collected. Result(s): In our series of 9 patients, 5 were male, the median age was 8 years [RIC 3-11 years]. Considering the underlying disease, 6 were oncologic, 1 liver transplant and 2 with congenital immunodeficiency after HSCT. 4 were under active chemotherapy (median 6 days after the last cycle [RIC 5-188]). 6 were admitted due to acute respiratory failure, 3 due to hemodynamic instability (3/9), (one septic shock). The median PEEP was 12 [RIC 9-15] and FiO2 100% (81-100%). 78% (6) required vasoactive drugs (median inotropic score 35 [RIC 0-75]. 40%. 5 had severe neutropenia and/or plateletopenia in the 24 hours prior to ECMO, and alterations in acid-base balance (median pH 7. 1 [RIC 6.9-7.15]. 5 were on multiorgan failure. TPrimary ECMO transport was performed in 4 patients (44%). Cannulation was peripheral in 80% (57% cervical, 43% femoral) and central in 20%;70% VA-ECMO. Median time of assistance was 15 days [RIC 3.5-31.5] in cardiac ECMO (4), and 29 days [RIC 13.5-42] and in pulmonary ECMO (n=5). The median total time of admission was 45 days [RIC 27-59]. 9 had an infection, 2 COVID after HSCT, and 8 bleeding complications, but only one required surgical revision. Renal replacement therapy was used in 5 (median 9 days [RIC 5-34.5]). Other therapies used were polymyxin hemadsorption(2), intratracheal surfactant(2), plasma exchange(1), infusion of mesenchymal cells(1) and specific memory T lymphocytes(2). 4 patients died, 5 survived decannulation, 2 died later, with an overall survival rate to hospital discharge of 33% (3/9). Conclusion(s): Despite having a worse prognosis, ECMO can increase survival in immunosuppressed patients, in situations that are challenging and require a multidisciplinary approach.
ABSTRACT
Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).
ABSTRACT
Introduction: Children requiring venoarterial (VA) extracorporeal membrane oxygenation for long durations may have increased risk of complications compared to venovenous (VV) ECMO. The purpose of this study was to evaluate the feasibility and safety of conversion from VA to VV ECMO. Method(s): This is a retrospective review of all children requiring VA ECMO who underwent conversion to VV ECMO at a single institution, from 2015- 2022. Indications for and methods of conversion were examined as well as adverse events including re-operation, ischemic complications, renal failure, and mortality. Descriptive statistics were calculated. Result(s): Of 422 pediatric patients on initial VA ECMO, only three children (0.7%) underwent conversion from VA to VV support, ages 10-19: for hypoxic respiratory failure due to COVID19, for cardiac dysfunction following orthotopic heart transplant, and for sepsis with associated left ventricular dysfunction. The indications for conversion were bleeding from cannulation site (n=2, 66%) and an anticipated prolonged ECMO run (n=1, 33%). For all three patients, the method of conversion was cutdown with femoral arterial repair followed by placement of additional jugular venous cannulas (n=2, 66%) or insertion of a singular jugular bicaval venous cannula with removal of the femoral cannulas (n=1, 33%). The median time on VA ECMO prior to conversion was 8 days (range 4-54 days). All 3 patients were managed with renal replacement therapy with 1 patient (33%) progressing to long term dialysis. There were no significant ischemic limb complications although one (33%) patient developed a femoral artery pseudoaneurysm that required re-operation. Two of the three patients (66%) were able to be decannulated at a median of 23.5 days (range 8-39 days) following conversion to VV ECMO and survived to discharge. The other patient was unable to be decannulated after successful conversion and care was withdrawn. Conclusion(s): Based on this small pilot study, conversion to VV ECMO from initial femoral VA ECMO cannulation is safe and feasible. Indications for conversion include coagulopathy and need for extended ECMO run after recovery of cardiac function.
ABSTRACT
Introduction. Midline catheters (MCs) are an option for vascular access alongside the commonly used short peripheral intravenous catheters, centrally and peripherally inserted central catheters.Aim. The aim of this study was to evaluate the solution implemented during the COVID-19 pandemic in a centre where MC access had not been used before.Material and method. It was an observational retrospective evaluation of the 98 medical registries of adult patients.Results. The mean time from hospital admission to midline catheter insertion was 15 days. The most common indications for the catheter implementation were: difficult intravenous access (83%) and expected time hospital stay >6 days (17%). The mean dwell time of the catheters was 9 days. The most common reasons for removal were: the end of intravenous therapy (44%) and catheter blockages (36%).Conclusions. A high level of prematurely removed catheters was observed, despite the existence of a hospital protocol. The high percentage of MCs removed before the end of intravenous therapy may be indicative of the poor quality of care and the need for continuous education of medical staff. The results obtained should be confi rmed in a prospective study planned on their basis in order to identify interventions which are necessary to improve the quality of vascular access care.
ABSTRACT
Objective: To describe institutional experience using Oxygenated Right Ventricular Assist Device Oxy-RVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU) including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular dysfunction (RV) or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to CardiohelpTM systems with built-in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients were cannulated directly to Oxy-RVAD ECLS support. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult-focused colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia.
ABSTRACT
Background There were increased claims of thrombotic events in ICU-bound patients with COVID-19. We designed this observational study to examine implementation of systemic anti-coagulation on arterial catheter patency and its failure and to identify risk factors for arterial catheter failure. Methods A total of 245 COVID-19 subjects were included in this observational study, 48 patients in the non-systemic, (Non-SA), (Prophylactic) anticoagulation cohort, and 197 patients in the systemic (SA), (Therapeutic) anticoagulation group. The first arterial line inserted on ICU admission for every patient was monitored regarding its duration of the patency, number and location of consecutive arterial lines inserted during stay in ICU. Demographics of patients, ICU parameters and risk factors for arterial line failure were followed and analyzed. Results The percentage of arterial line failure was significantly higher in Non-SA group, 45.8% when compared to SA group, 25.9%, P = 0.007. The patients with arterial line failure exhibited higher D-dimer, co-morbidities, diabetic patients, received aspirin and mortality than the patent group, respectively, p = 0.002, p = 0.002, p < 0.0001, p < 0.0001, and p < 0.0001. This group also received higher sedation and prone position on mechanical ventilation and higher vasopressors, respectively, p = 0.034, p < 0.0001, p < 0.0001, and p < 0.0001 when compared to patent group. They had prolonged length of stay in ICU and hospital, respectively, p = 0.001 and p = 0.042. The cumulative incidence of index arterial line failure (Log-rank test 6.95, P = 0.008) with overall percentage was significantly lower in SA group (25.9%) compared to non-SA group (45.8%), respectively, P = 0.007. On Cox-proportional hazard multivariate regression analysis, independent predictors of arterial line failure increased platelets level (HR 1.00, 95% CI 1.00-1.01, P = 0.001), use of ultrasound use in arterial line insertion (HR 4.68, 95% CI 1.75-12.56, P = 0.002), and prone position in ICU (HR 1.94, 95% CI 1.09-3.42, P = 0.023). Conclusion We observed three independent predictors of arterial line failure including platelets level and ultrasound use during arterial catheter insertion and prone position in ICU. Systemic anticoagulation was associated with more patency of arterial catheter than prophylactic therapy group.