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Objectives: Assessment of the literature on the ProtekDuo cannula when used as venopulmonary (V-P) extracorporeal membrane oxygenation (ECMO) in ARDS secondary to COVID-19. Method(s): Systematic literature search in EMBASE, Medline (Pubmed) and NHS library using appropriate keywords as well as PICOS and PRISMA approach. Result(s): We found 285 publications, of which 5 publications met the search criteria and were included in this review. A total of 194 patients with COVID-19 related ARDS had a ProtekDuo placed to establish venovenous (V-V) ECMO and right ventricular (RV) support. Patients treated with the ProtekDuo cannula had survival rates between between the studies of 59 and 89%, with a significant survival compared to an invasive ventilation group or when compared to dual site V-V ECMO or other double lumen ECMO cannulas. One of the studies focused on extubation and early discontinuation of ventilator support, which the authors achieved in 100% of ProtekDuo patients. The incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) was significantly reduced in the ProtekDuo versus other groups. Conclusion(s): The ProtekDuo displayed lower mortality rates, AKI occurrence and CRRT need as compared to other respiratory support modalities and has shown to be a game changer for ECMO support in patients suffering from COVID-19 ARDS. Many authors suggested the ProtekDuo for first line use in these patients.
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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).
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SESSION TITLE: Not the Normal Host: Infections Still Matter SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Utilization of ECMO support for refractory cardiogenic, and respiratory failure has increased exponentially over the last 20 years. The advent of miniaturized and portable machines has led to a shift of cannulation strategies in the operating room/cath lab to the bedside. Transitioning to bedside cannulation has been previously reported as safe, with minimal risk for mortality or catheter site infections. However, bedside cannulations in the critically ill crashing patient raises concern for sterility. The aim of this study was to assess the risk of ECMO cannula site infections in bedside vs operating room/catheterization suite. METHODS: It is a retrospective single institution case series review of 52 adult and pediatric patients who were required either Veno-Venous (VV) or Veno-Arterial (VA) ECMO. Data gathering was used to quantify the rate of catheter site infections after initiation of extracorporeal support. Catheter site infections were defined as localized erythema, fluctuance, or purulence from the cannula site within 7 days of of ECMO cannula placement. RESULTS: A total of 42 (81%) pts had bedside cannulation, and the other 10 (19%), were done in IR suite/cath lab. The total number of catheter site infections was 1 (2.4%) in the bedside cannulation group. There were no infections in the non-bedside cannulation groups. 13 (30%) of the bedside cannulations, and 3 (30%) of the non-bedside cannulation group were on antibiotics during or prior to cannula insertion. CONCLUSIONS: Current literature suggests that the prevalence of infections on ECMO is 10-12%,. Traditionally, this has predisposed most cannulations to be performed in the surgical setting rather than at bedside. During the recent COVID pandemic, the frequency of bedside cannulation for ECMO had increased and was not associated with significant morbidity, and mortality. The risk of infection from the catheter site had also been determined to be minimal to none. From the data gathered above, it can be safely assumed that the risk of catheter site infection with bedside cannulation is minimal. However, the major contributing factor to decreased infection risk appears to be meticulous cannula site nursing care. The current ECMO nursing protocol utilized at our hospital required twice daily dressing changes with stringent chlorhexidine cleanses prior to redressing. The only case of catheter site infection we experienced was when this protocol was deviated. CLINICAL IMPLICATIONS: Utilizations of bedside ECMO cannulation techniques carries minimal risk for catheter site infections. It is important to state that nursing driven protocols for cannula site dressing changes, has one of the biggest implications on the risk of catheter site infections. Therefore, with the employment of appropriate nursing protocols, the concern for catheter site infections should not preclude the decision to proceed with bedside cannulation. DISCLOSURES: No relevant relationships by Ajit Alexander No relevant relationships by Melodie Blackmon Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, value=Consulting fee No relevant relationships by ANIBAL DOMINGUEZ no disclosure on file for Jonathan Eaton;No relevant relationships by Laurie Grier No relevant relationships by Rajkamal Hansra No relevant relationships by Prathik Krishnan No relevant relationships by Nathaniel LSUHSC-Shreveport No relevant relationships by Alex Manuel No relevant relationships by Jonathan Packer No relevant relationships by arunima sharma no disclosure on file for Chris Trosclair;No relevant relationships by Gregory Vo No relevant relationships by Robert Walter
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Introduction: Massive pulmonary embolism is a rare complication following Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) decannulation. Management can be challenging. The authors present a case that required VV-ECMO re-cannulation and catheterdirected thrombolysis. Main body: 58-year-old gentleman, background of hypertension and asthma, admitted with severe respiratory failure secondary to COVID-19 pneumonitis. Due to lack of improvement with conventional ARDS treatment, he was referred and retrieved on VV-ECMO. After being off sweep gas for more than 24 hours he was decannulated on day 7. Five hours after decannulation the patient acutely deteriorated. He became tachycardic, hypotensive and hypoxic. A bedside TTE showed severely dilated and impaired right ventricle. The patient was started on milrinone and nitric oxide. Nevertheless, he deteriorated further and became profoundly hypoxic and hypercapnic, and a decision was made to start him on VV-ECMO. A TOE was done to guide cannulation and showed a thrombus in the RV and in the left pulmonary artery. Next day, a CT-pulmonary angiogram (CTPA) was done which showed saddle-shaped pulmonary embolism, with a large occlusive clot in the left main pulmonary artery causing complete non-perfusion of the left lung. After a multi-disciplinary team discussion, the patient had catheterdirected thrombolysis, with some haemodynamic improvement. Within 48 hours, TTE was repeated showing no significant improvement on RV function. CTPA showed very mild decrease of the clot burden. Decision was made to repeat catheter-directed thrombolysis and partial thrombectomy. Repeated imaging revealed decrease in the size of the left main pulmonary artery thrombus. It is thought that the massive pulmonary embolism could have been caused by showering of ECMO cannulas-related thrombi, which were dislodged during decannulation. Patient remained on VV-ECMO for 32 days and was decannulated successfully afterwards and was discharged home on apixaban and long-term pulmonary hypertension follow-up. Conclusion: ECMO cannulas related thrombi are not uncommon complications because of prolonged stay and coagulopathy related to ECMO circuit. However, massive embolism is rarely seen. The use of echocardiography was paramount on the differential diagnosis. In this TTE study, the right ventricle looks significantly dilated with severely impaired both longitudinal and radial functions. Additionally noted septal flattening in systole indicating RV pressure overload, diastolic notching of RVOT doppler trace consistent with significantly raised pulmonary artery pressure and mild to moderate tricuspid regurgitation. Otherwise, the left ventricle is small and has preserved function. (Figure Presented).
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Purpose: Percutaneous cannulation for Veno-Venous (V-V) and Veno-Pulmonary Arterial (V-PA) ECMO has transformed our approach to extracorporeal support, particularly in the Covid-19 era. Along with the increase in percutaneous cannulation comes an increase in complications, some necessitating replacement of the cannula. We present a novel technique to exchange cannulas using the same site with minimal blood loss and time off support. Method: All procedures were performed in the hybrid OR with fluoroscopy and transesophageal echocardiography (TEE). A 4 Fr. dilator was placed posteromedial to the existing cannula with pressure directed toward the cannula to enter the vein. A wire was placed through the dilator to facilitate directing the wire into the PA or IVC, ultimately advancing the wire into the RPA (V-PA) or IVC (V-V). The ECMO circuit was clamped and both limbs transected. The existing cannula was removed simultaneously with the new cannula being placed over the wire into either PA or IVC (V-PA or V-V respectively). The cannula was deaired, reconnected to the ECMO circuit, and flow reestablished. Results: 8.1% (19/234) of our V-V or V-PA patients required replacement of the percutaneous cannula. 63% were due to RV failure diagnosed by echocardiography and 32% were for cannula migration below the pulmonary valve into the RV. Our technique was universally successful with a mean blood loss of 20cc, <1.5 minutes off ECMO, and no complications. Summary: The described technique is effective in replacing percutaneous V-V and V-PA ECMO cannulas using the original site with minimal time off support and blood loss. (Figure Presented).
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Background: Patients with severe COVID-19 related respiratory failure may require veno-venous extracorporeal membrane oxygenation (VV ECMO). After decannulation, patients on VV ECMO have historically had high percentages of cannula-associated deep vein thrombosis (CaDVT). Due to their hypercoagulable state and prolonged course on VV ECMO, we hypothesized that patients with COVID-19 would experience a higher rate of CaDVT when compared to their non-COVID-19 counterparts. We also described the association between location and size of cannula in the development of CaDVTs. Methods: This was a single center retrospective review of patients ≥ 18 years old who were treated with VV ECMO and decannulated from January 1, 2014, to January 10, 2022. Patients who were placed on VV ECMO due to trauma and patients who were cannulated for veno-arterial ECMO were excluded. Patients were managed in a dedicated Lung Rescue Unit and anticoagulated with a heparin infusion at a goal partial thromboplastin time (aPTT) of 45-55 or 60-80 depending on the presence of clotting complications. Post-decannulation venous duplexes were performed 24 hours after decannulation and if positive for DVT, performed again in 2 weeks. Univariate and multivariate analyses were conducted to analyze our primary outcome of the development of CaDVT. Results: A total of 291 patients met our inclusion criteria: 76 COVID-19 VV ECMO patients and 215 non-COVID-19 VV ECMO patients. Decannulated COVID-19 VV ECMO patients had a significantly higher body mass index (BMI) (35.8, 32.9, p= 0.03) and length of ECMO run (hours) (660, 312, p< 0.001) than their non-COVID-19 counterparts. Most decannulated patients in both groups received post-decannulation duplexes (96%, 99%, p= 0.45). COVID-19 and non-COVID-19 patients decannulated from VV ECMO both experienced high incidences of CaDVT on initial post-decannulation ultrasound (95%, 88%, p= 0.13). COVID-19 patients were more likely to have multiple CaDVTs (32%, 11%, p< 0.001). Patients with COVID- 19 experienced a higher rate of right common femoral CaDVT (47%, 17%, p< 0.001) and a higher percentage of 25 French drainage cannula CaDVT (48%, 18%, p< 0.001). COVID-19 VV ECMO patients had a significantly higher incidence of persistent CaDVT on repeat ultrasound (78%, 56%, p= 0.03). A logistic regression was performed with all decannulated patients. Age, BMI, hours on ECMO, COVID-19 status, and size and location of ECMO cannulas did not predict the presence of DVT. Conclusion: Both COVID-19 and non-COVID-19 VV ECMO patients had high rates of CaDVTs. The utilization of VV ECMO in COVID-19 respiratory failure was associated with a higher incidence of CaDVTs on repeat ultrasound as compared to patients with non-COVID-19 related respiratory failure. Regular post-decannulation screening, treatment, and follow up imaging should be performed. Further investigation into the effect of anticoagulation strategy is needed. (Table Presented).
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Case series: Extracorporeal membrane oxygenation (ECMO) use for severe acute respiratory distress syndrome due to coronavirus disease 2019 (COVID-19) patients has increased during the second wave of the pandemic. However, there are many complications associated with the management of ECMO in critically ill COVID- 19 patients. We report a case series of challenges and strategies for managing critically ill COVID-19 patients on ECMO support for severe ARDS. Seven COVID-19 patients required VV ECMO of which three were women and four were men of median age of 43 years. Among seven, three cases (42%) recovered. We experienced multiple challenges and complications in the management of the patients, being a non-ECMO centre with limited resources, in heavy workload during the second wave of the pandemic. All the patients required multiple invasive procedures like placement of invasive lines, frequent bronchoscopies for bronchial toileting. Displacement of both ECMO cannulas required repositioning under ultrasound guidance, four patients underwent percutaneous tracheostomy on ECMO. Three patients had ECMO-oxygenator failure that required the exchange of a new ECMO circuit. ACT was monitored for the management of anticoagulation. A challenging task is to achieve a balance between bleeding and thrombotic events, for which anticoagulation had to be stopped for the acceptable ACT, required transfusion of multiple blood products for correcting coagulopathy. One patient developed HIT antibodies and managed with bivalirudin for the management of anticoagulation which was challenging in titrating the drug dose and ACT. Two patients had an intracranial haemorrhage on ECMO support, managed conservatively despite anticoagulation. Pseudoaneurysm of femoral vein diagnosed and managed with ultrasound-guided thrombin injection. Four patients got decannulated from ECMO. One patient had unexplained severe haemolysis immediately after initiation of ECMO, unfortunately, he could not recover. Management of VV ECMO in resource-limited, non-ECMO centre in a pandemic is challenging. Mortality depends on various factors, despite expertise, advanced critical care management in COVID- 19 ARDS and ECMO. Increased use of VV ECMO during the second wave of pandemic reported significant changes in strategies for management of challenges, though further studies are still required for the best outcome.
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Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the disease entity COVID- 19. Initially, reports showed children had generally mild disease, with few requiring hospitalization. However, as of December 2021 in Arkansas, USA, children and young adults aged 24 years and younger accounted for approximately 166,000 cases with over 1,800 hospitalizations and 27 deaths (3 deaths under age 17). Comparatively, there have been over 6 million cases nationally in children and young adults, with over 1,000 deaths. Bacterial, viral, and fungal co-infections are known complications of viral respiratory illnesses that can lead to increased mortality. There have been multiple reports in adults on the incidence and type of co-infections seen with COVID-19, but few in pediatric patients. Adult data shows that co-infections are present in approximately 13-45% of patients with COVID-19, most commonly with bacterial pathogens of Mycoplasma pneumoniae and Haemophilus influenzae. Methods: We describe four patients with acute SARS-CoV-2 infection, requiring intubation, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), all of whom had methicillin-sensitive Staphylococcus aureus(MSSA) infections discovered within 24 hours of escalating respiratory support. This case series was determined as exempt by the Institutional Review Board at our institution. Results: Our cohort includes 4 patients with a median age of 18 years (range 16-19 years), all of whom required ECMO for acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia. The median time from intubation to ECMO cannulation was 139 hours (range 3-319 hours). All patients received targeted COVID-19 therapy with dexamethasone, remdesivir, and either tociluzimab or baricitinib during their hospitalization. These patient also all had culture positive MSSA infections from blood and mini-BAL cultures. Three of the four patients had a positive culture within 24 hours of requiring ECMO and one patient had a positive culture within 24 hours of requiring intubation. All of the patients were initially placed on venovenous (V-V) ECMO and three (75%) later required transition to venoarterial venous (VA-V) ECMO for worsening hemodynamics. All were initially cannulated with dual site femoral-internal jugular configuration. Femoral arterial cannulas were used for the transition to VA-V. Complications encountered during ECMO for these patients included GI bleeding (n=1), atrial flutter requiring cardioversion (n=1), lower extremity compartment syndrome (n=1), and dislodgement of a venous ECMO cannula (n=1). One patient received a tracheostomy while on ECMO. The median ECMO duration was 19.35 days (range 11-48.5 days). All patients were successfully decannulated from ECMO and all were discharged from the hospital alive, except one who is still requiring inpatient rehabilitation services. Discussion: We describe 4 pediatric patients with acute SARS-CoV-2 respiratory infections who were found to have MSSA co-infection within 24 hours of escalating respiratory support, all of whom eventually required ECMO support. In a recently published study, Pickens, et al reported that 25% of recently intubated adult COVID-19 patients have a bacterial co-infection. Limited data is available in pediatric patients. Staphylococcus aureus infections are among the most common bacterial infections worldwide. They are responsible for over 100,000 infections in the United States each year and lead to increased morbidity and mortality. All of our patients received immunemodulating therapies with either tociluzimab or baricitinib, which carry the risk of secondary infections due to immunosuppressive effects. Clinicians should maintain a high index of suspicion and be aware of the possibility of secondary bacterial infections in COVID- 19 patients, especially in those treated with immune-modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with SARS-CoV-2, as seen in our cohort. More investigation s needed to further describe co-infections in patients with COVID- 19 and to identify risk factors for the development of co-infections.
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Introduction: Dual-lumen cannula is used for extracorporeal membrane perfusion (ECMO) to support patients with ARDS due to COVID-19 as a bridge to lung recovery. It tends to be a longer support and there are several factors that can degrade the physical structure of the ECMO cannula and put the cannula at risk for breakage. Case Report: A 63-year-old woman was admitted to the hospital with COVID-19 pneumonia. Two days later, she was intubated and VV-ECMO was initiated due to treatment-resistant acute respiratory failure;a 28Fr CrescentTM dual-lumen cannula (Medtronic, MN) was inserted through the left subclavian vein and connected to a centrifugal oxygen pump with a centrifugal oxygenator. Within six weeks after onset, the patient was unable to be weaned from the ventilator and was transferred to our center with ECMO connected for consideration of lung transplantation. Two days after transfer, the patient developed acute aphasia, altered mental status, disturbed consciousness, and left arm seizures. A suction sound was heard from the left subclavian cannula insertion site and the ECMO bubble detector alarmed, but local inspection, chest X-rays, and CT scans of the brain and chest showed no obvious abnormalities. The patient was reintubated for encephalopathy and subsequently underwent a tracheostomy. The patient regained normal neurological function over the next 7 days. However, the air bubble sensor alarmed and suction sound was heard at the cannulation site again, and air bubbles were seen in the oxygenator. Due to concerns about air entrapment and cannula failure, we changed to a dual-canal VV-ECMO configuration using a right internal cervical and a left femoral cannula. The removed cannula had a 2 cm fracture distal to the skin insertion site. After resumption of ECMO, no new neurological episodes occurred. While awaiting lung transplantation, the patient died due to sepsis and multiple organ failure. An autopsy revealed a possible cause of cerebrovascular disease patent foramen ovale and air embolism to the brain. If a patient has been on ECMO for a long time and the bubble sensor warns of air detection, cannula breakage and impending air embolism should be suspected clinically, even if the defect is not found on examination and is not evident on imaging. If the COVID-19 epidemic continues, increased transport events may increase ECMO cannula breakage.