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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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Introduction: Acute respiratory disease, Coronavirus Disease 2019 (COVID-19) is an infectious and potentially fatal respiratory disease. Increase in the inflammatory response, hypoxia, immobilisation are suggested mechanisms of procoagulant state. Deep Vein Thrombosis (DVT) and pulmonary emboli are common and often silent. Venous duplex ultrasound help in determination of the presence, extent, age of the thrombus and its attachment to venous wall. Aim: To evaluate the prevalence of DVT by colour doppler ultrasound in lower limbs of mild to severe clinical categories of COVID-19 patients. Materials and Methods: A time-bound, hospital-based prospective cohort study was conducted in the Department of Radiodiagnosis, MY Hospital, Indore, Madhya Pradesh, India, between March 2021 and February 2022. Study comprised 2200 cases of COVID-19 positive patients with elevated D-dimer levels i.e., >0.5 ng/mL and colour doppler imaging for lower limb. The clinical (co-morbidities, clinical severity) and radiological data (compressibility, colour flow) were studied and analysed using Statistical Package for the Social Sciences (SPSS) software version 25.0. Results: In the present study, there were 1144 (53%) males and 1056 (47%) females. Out of 2200 patients, 792 (36%) patients showed presence of DVT. The most prevalent age group was 36-55 years having 506 (63.9%) patients. Majority of DVT positive patients were suffering with hypertension and diabetes i.e., 261 (33%) and 372 (47%) patients, respectively. Most commonly affected vein in DVT was Common Femoral Vein (CFV) in 704 (88.9%) patients. Superficial veins thrombosis was also associated with DVT affecting Short Saphenous Vein (SSV) in 439 (55.4%) patients and Great Saphenous Vein (GSV) in 221 (27.9%) patients. Conclusion: There was a high prevalence of DVT among COVID-19 positive patients. Colour doppler ultrasound has provided an excellent aid in the diagnosis of DVT.
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History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.
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Funding: None. Synopsis: 61-year-old male who initially presented to an outside facility with streptococcal pneumoniae meningitis and bacteremia. Of note, he had history of COVID-19 pneumonia a month prior. On hospital day 15, he reported sudden onset lower back pain prompting imaging which demonstrated a contained rupture of an infrarenal aortic aneurysm that had significantly evolved in comparison to admission imaging where his infrarenal aorta had the largest dimension measuring 2.9cm. We present the successful application of neoaortoiliac system (NAIS). Method(s): Proceeding with midline laparotomy we encountered dense adhesive disease due to his history of surgery for colon cancer. After adhesiolysis, we exposed the aorta and aneurysm with severe surrounding inflammatory changes. 20cm of femoral vein was harvested, reversed, and joined for a span of 4cm using an Endo GIA 45mm vascular load to create our neoaorta. Proximal and distal clamp zones were developed. Upon entering the aneurysm, a foul smell was encountered, revealing that the noxious process had destroyed the posterior wall of the aorta and paraspinal tissues. Our neoaorta was anastomosed in end-to-end fashion to the infrarenal aorta and subsequently to the common iliac arteries. Flow was initially restored to the hypogastric arteries and then the external iliac arteries. The retroperitoneum was closed over our repair and covered with omentum. Result(s): On post-operative day 2, he had hematochezia;intraoperatively, the IMA was noted to be 1mm in size, though had brisk back-bleeding and was ultimately ligated. A flexible sigmoidoscopy revealed ischemic sloughing of the sigmoid colon near his previous anastomosis from his colon cancer resection though no transmural necrosis. He remains on high-dose ceftriaxone to complete a 6-week course and metronidazole for 10 days due to his sigmoid mucosal ischemia per infectious disease recommendations. He is now post-operative day 10 and remains in the ICU. Conclusion(s): Mycotic aortic aneurysms constitute 1-1.8% of aortic aneurysms. The standard of treatment is aggressive debridement of involved aortic wall and periaortic tissue, in-situ or extra-anatomic reconstruction, coverage with an omental flap and long-term antibiotic therapy. NAIS is resistant to infection and aneurysmal dilation, however, is a time-consuming procedure with a mean completion time of 8 hours. Dorweiler et al. demonstrated that vascular reconstruction with femoral vein in infected aortoiliofemoral fields has a mortality of 9-10% with negligible rate of late complications (graft stenosis, thrombosis, and dilation) and that venous morbidity after femoral vein harvest is well tolerated. Clagett et al. demonstrated that NAIS fashioned from greater saphenous vein had a failure rate requiring intervention of 64% compared to 0% for those constructed with deep femoral vein. Lastly, it is important to note that our patient was previously COVID-19 positive. This case demonstrates that the sequela of COVID-19 may have been a significant factor in our patient's pathophysiology. As we continue to learn about the effects of COVID-19 on vascular pathology, we must keep a large repertoire of operative techniques at hand in order to treat complex presentations of vascular emergencies. [Formula presented] [Formula presented] [Formula presented] Institution: Orlando Health, Orlando, FLCopyright © 2022
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Background: Literature describing triggers of GFAP astrocytopathy (GFAP-A) is limited. We report a case of GFAP-A in a patient with recent messenger ribonucleic acid (mRNA) severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) vaccination and discuss the possible pathogenesis. Case description: A 45-year-old gentleman presented with features of meningoencephalitis 31 days after the first dose and 4 days after the second dose of mRNA SARS-CoV-2 vaccination. He sequentially developed brainstem/cerebellar, autonomic and cord dysfunction. Cerebrospinal fluid was positive for GFAP autoantibody. Clinical improvement occurred after intravenous methylprednisolone and immunoglobulins. Conclusion(s): Although we are uncertain of a causal link of GFAP-A to mRNA vaccine, indirect activation of an underlying dysregulated immune milieu is plausible.Copyright © 2021 The Author(s)
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Background: The occurrence of deep vein thrombosis (DVT) in COVID-19 pneumonia has raised wide concern recently, but few studies have reported the incidence of DVT in other types of pneumonia. We evaluate the prevalence, risk factors and treatment of DVT in the elderly inpatients with pneumonia. Method(s): A cohort of 550 elderly inpatients (>= 75 years old) with pneumonia between 2017 and 2021 were reviewed. They were divided into DVT group and non-DVT groups on the basis of whether pneumonia was combined with new-found DVT. Clinical data were collected retrospectively. Patients with DVT were divided into anticoagulant group and non-anticoagulant groups on the basis of whether they received anticoagulant therapy. Result(s): Ninety-seven patients were included in the DVT group;453 in the non-DVT group. The incidence of DVT was 17.64%. Hospital stays were significantly longer for DVT patients than for non-DVT counterparts (p = 0.005). Coronary heart disease, heart failure, hyperlipidemia, bed rest, and elevated D-dimer were independent risk factors for DVT (p < 0.05). The rate of anticoagulant therapy in DVT group was 63.92% (62/97 cases). Follow-up showed that the continuous anticoagulant treatment rate was 48.39% (30/62 cases) at 3 months and 30.65% (19/62 cases) at 6 months. Conclusion(s): Elderly inpatients with pneumonia are at high risk of DVT. The combination of DVT and pneumonia may lead to prolonged hospitalization. Coronary heart disease, heart failure, hyperlipidemia, bed rest and elevated D-dimer are independent risk factors for DVT in these patients. The rate of regular anticoagulant treatment is low because of the high risk of bleeding.Copyright © 2022, Taiwan Society of Geriatric Emergency & Critical Care Medicine.
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Background: VITT involves thrombocytopenia and thrombosis post-initial anti-SARS-CoV-2 adenoviral vaccination. Most patients are found to have platelet-activating antibodies to the chemokine, platelet factor 4 (PF4) in the absence of heparin. VITT antibodies differ from those in heparin-induced thrombocytopenia (HIT), in which PF4 is bound to heparin. Distinct epitope sites on PF4 for VITT and HIT antibodies were defined (PMID34233346). We noted that the VITT antigenic site is conserved in mouse (m) PF4, and in the platelet-specific chemokine neutrophil-activating peptide 2 (NAP2), both human and mouse. We observed that VITT antibodies bind strongly to NAP2. In an active patient with VITT, we found that VITT antibodies circulate as immune complexes containing either PF4 or NAP2. Importantly, VITT antibodies plus NAP2 activates platelets. Aim(s): We tested in a passive-immunization murine model with VITT antibodies the ability to induce neutrophil-endothelial activation as an indicator of a prothrombotic state and identify the chemokines involved. Method(s): We studied two systems: A femoral vein and a cremaster venule model, using confocal intravital imaging and labeled neutrophils. VITT antibodies were infused into mice transgenic for FcgammaRIIA and lacking PF4 (FcgammaRIIA+/mPF4-/-). Result(s): This led to an immediately reduced neutrophil rolling by ~80% (14-3 m/sec) (Figure 1A,B). Subsequent infusion of PF4 slowed neutrophil rolling by another ~80% (3-0.6 m/sec). In contrast, VITT antibodies did not slow neutrophil speed in FcgammaRIIA+/ mPF4-/-/ mNAP2-/-mice (Figure 1C). Conclusion(s): These data suggest that both NAP2 and PF4 contribute to thrombosis in VITT and may explain the pathogenesis of VITT in patients with no detectable anti-PF4 antibodies. VITT may be prothrombotic because it involves co-activation of neutrophils via NAP2 by way of CXCR2 and FcgammaRIIA. Targeting NAP2 pathobiology may enhance understanding of the pathogenesis of VITT and lead to new therapeutics.
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SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Deep vein thrombosis (DVT) formation is widely recognized as Virchow's Triad of hypercoagulability, venous stasis, and endothelial injury. Based on this definition, congenital aberrations of the inferior vena cava (IVC) such as atresia or coarctation classify as major risk factors to incite a DVT (1). A congenital IVC anomaly with evidence of post-COVID-19 vaccination hypercoagulability (2) suggests a risk association with thrombotic episodes. We present a case of congenital IVC interruption with development of a DVT nine days after Pfizer COVID-19 booster administration. While it is known that IVC anomalies may contribute to DVT development (1), there is scarce data identifying a COVID-19 mRNA vaccine as a direct source of massive DVT in a young adult. CASE PRESENTATION: A 28 year old male with a history of repaired coarctation of the aorta presented with severe right thigh pain that began days after the Pfizer COVID-19 booster. Four days prior, an outpatient ultrasound (US) was negative for DVT. Physical exam revealed a dusky right foot with good distal pulses. Sensation was intact throughout. The left lower extremity (LE) had no edema or tenderness. An US of the right LE showed a DVT extending from the common femoral vein to the posterior tibial vein and DVT of the greater saphenous and deep femoral vein. Left LE US showed an anterior tibial DVT. Attempted thrombolysis was made with tissue plasminogen activator therapy and thrombectomy. Given the patient's atretic IVC anatomy, some residual clot remained in the common iliac vein, and was treated with anticoagulation therapy. After two extensive surgical lyses and aggressive medical lysis, the DVT's were resolved and the patient slowly improved. Upon follow up, he is feeling much better with no further pain. Ultimately this patient will require lifelong anticoagulation and may require an IVC stent to prevent future thrombotic events. DISCUSSION: Coarctation of the aorta is a common congenital heart defect and is often coupled with additional cardiovascular anomalies (1). In our patient, imaging showed a small and near-occluded IVC, which predisposed him to vasculitic events. There is no literature describing a massive DVT in a young adult patient within days of an mRNA COVID-19 vaccine. While these thrombotic events are rare (2), this report portrays one case in which the Pfizer COVID-19 mRNA vaccine may have prompted a vascular event in a susceptible patient. CONCLUSIONS: It has been previously established that congenital IVC anomalies may contribute to increased risk of DVT (1). In this case, we observe an association of the mRNA COVID-19 vaccine with massive DVT in a young male. While this is not meant to discourage patients with congenital IVC anomalies from receiving the COVID vaccine series, it prompts the need for open discussion with healthcare providers to discuss possible adverse effects. Reference #1: Chee, Y.-L., Culligan, D.J. and Watson, H.G. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. British Journal of Haematology. 2001;114:878-880. doi.org/10.1046/j.1365-2141.2001.03025.x Reference #2: Bilotta C, Perrone G, Adelfio V, et al. COVID-19 Vaccine-Related Thrombosis: A Systematic Review and Exploratory Analysis. Front Immunol. 2021;12:729251. doi:10.3389/fimmu.2021.729251 Reference #3: Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. The Lancet. 2001;357(9254):441. doi.org/10.1016/S0140-6736(00)04010-1 DISCLOSURES: No relevant relationships by Melanie Krongold no disclosure on file for Majed Samarneh;No relevant relationships by Elena Tran No relevant relationships by Lakshmi Sheetala Vijaya
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SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Heparin is the preferred anticoagulant for use in pregnancy while on extracorporeal membrane oxygenation (ECMO) (1). Alternatives to heparin in this patient population are not well studied as heparin-induced thrombocytopenia is rare in pregnancy. Parenteral non-heparin anticoagulants available in the United States include the direct thrombin inhibitors argatroban and bivalirudin, both of which are utilized in ECMO. Guidelines recommend avoidance of these agents in pregnancy if at all possible (2). Whereas case reports support the safe use of argatroban in pregnancy, to our knowledge, there are no known documented reports of bivalirudin use in this patient population (3). Here we describe the successful use of bivalirudin during pregnancy. CASE PRESENTATION: A 25 year old G2P1 was transferred to our institution at 28 weeks gestation for further management of acute hypoxic respiratory failure secondary to COVID-19. On hospital day 2 the patient was urgently placed on venovenous (VV) ECMO for refractory hypoxemia, high dead space with acidosis, and the inability to provide adequate gas exchange and lung protection with mechanical ventilation alone. Following ECMO cannulation with a 25f cannula in the right femoral vein and a 21f cannula in the right internal jugular vein, she was anticoagulated with heparin at a rate of 12 units/kg/hr. This was titrated to target a PTT goal of 60-80 seconds. On ECMO day 2, the TEG demonstrated a markedly hypocoagulable state, and the heparin nomogram called for increasing heparin dosing based on PTT. Given the already high dose of heparin that the patient was on (32.9 units/kg/hr), the decision was made to switch from heparin to bivalirudin to prevent over anticoagulation and reduce bleeding risk. Bivalirudin was titrated to a goal PTT of 50-60 seconds, with an initial rate of 0.15 mg/kg/hr (dose range 0.15-0.22 mg/kg/hr). Therapy was continued and on ECMO day 11, at 29w6d the patient delivered via cesarean section. Bivalirudin was discontinued 2.5 hours prior to the surgical procedure which resulted with no fetal bleeding complications. The patient was decannulated from ECMO on day 20 and was later discharged from the hospital. The newborn is developing well and meeting age adjusted milestones. DISCUSSION: Bivalirudin was selected based on institutional experience and the pharmacokinetic properties of the drug (half-life of 25 minutes) as we considered a situation where an emergent delivery may be indicated. Bivalirudin successfully prevented clotting of the circuit with no maternal or fetal bleeding complications during its use. CONCLUSIONS: Our case report describes a multidisciplinary approach to managing a pregnant patient on ECMO requiring anticoagulation using an alternative medication to heparin. This is the first documented use of bivalirudin in pregnancy. Reference #1: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.4 August 2017. Ann Arbor, MI, USA www.elso.org. Reference #2: Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl): e691S–736S Reference #3: Young SK, Al-Mondhiry HA, Vaida SJ, et al. Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature. Pharmacotherapy 2008;28: 1531–6. DISCLOSURES: No relevant relationships by Jacqueline Finger No relevant relationships by Caitlin Gluck No relevant relationships by Cameron Hypes No relevant relationships by John Rathbun
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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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Staphylococcal aureus infection in children is a major public health problem globally. It causes a varied spectrum of clinical disease including bacteremia, endocarditis, skin and soft tissue infection, pleuro-pulmaonry and osteo-articular infection. Deep vein thrombosis (DVT) is a known complication of staphylococcal infection. We report a case series which included, 10-year old boy developed DVT, septic pulmonary emboli and Methicillin-resistant Staphylococcal aureus (MRSA) bacteremia following a furuculosis and 13 year old girl with thrombosis of internal and external jugular vein, cavernous sinus with pulmonary emboli and MRA bacteremia. Both patients are previously healthy showed complete recovery after aggressive appropriate antibiotics, anticoagulants and supportive care. The high index of suspicion of DVT in MRSA infection is needed, prompt diagnosis and aggressive appropriate therapies improve the outcomes and minimize the complications.
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Background: Extracorporeal membrane oxygenation (ECMO) is a form of cardio-pulmonary life support used for patients with respiratory and/or cardiac failure. Hybrid ECMO is a sophisticated circuit to match the exact hemodynamic demands in patients who are refractory to traditional ECMO settings. Case: A 43-year-old male presented with dyspnea for four days. On physical examination, he exhibited increased work of breathing and decreased breath sounds bilaterally. Pulse oximetry was 70% on room air, minimally improved to 75% on maximum high flow nasal cannula. He was found to be COVID-19 positive and demonstrated diffuse bilateral lung consolidation on CT chest consistent with severe acute respiratory distress syndrome. Patient was intubated but continued to show poor oxygenation with P/F ratio of 71 (Normal: >400). Veno-Venous (VV) ECMO was started with cannulations into the right femoral vein (RFV) and right internal jugular vein (RIJV);this resulted in an initial improvement of partial pressure of oxygen (pO2) in arterial blood gas. However, within a few days, pO2 started to decrease with visual evidence of recirculation of oxygenated blood into the venous drainage line. A transthoracic echocardiography revealed severe pulmonary artery (PA) hypertension secondary to respiratory failure with PA pressure of 116mmHg (Normal: 18-25mmHg). This prompted a revision of the ECMO circuit to offload the right ventricle. Revised circuit included a cannula in the RFV for venous drainage and oxygenated venous return through two pathways: cannula in the RIJV (approximately 1 liter return), and a third cannula inserted through the left subclavian vein terminating into the main PA (approximately 4 liters return). Hereon, patient was able to maintain adequate pO2 for the remainder of his hospital stay until he was transferred to a lung transplant center. Conclusion: Our case illustrates the clinical sophistication of hybrid VV-PA ECMO-especially in patients with PA hypertension and impending right-sided heart failure. As respiratory failure secondary to COVID-19 becomes more prevalent, hybrid ECMO may provide a practical solution to protect the right heart in the journey to lung transplant.
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The SARS-CoV-2 (COVID-19) pandemic has been an ongoing healthcare battle for nearly 2 years. According to CDC data, as of January 2022, there have been over 60 million cases of COVID-19 with over 800,000 lives lost, in the United States alone. Patients less than 18 years of age account for approximately 15% of these cases and only 0.14% of all deaths. The Extracorporeal Life Support Organization (ELSO) COVID-19 data registry has been tracking the use of Extracorporeal Membrane Oxygenation (ECMO) since the start of the pandemic. Internationally, there have been 12,133 confirmed positive cases of COVID-19 requiring ECMO, of these, 330 (2.8%) have been patients under the age of 18. In North America, there have been 7,780 confirmed positive COVID-19 patients requiring ECMO support, of which, 272 (3.5%) have been pediatric patients. Of these 272 pediatric patients, the median age is 12 with a median BMI of 29 (IQR of 18 to 40) and an in-hospital mortality of 32%. We present the case of a 14-year-old, morbidly obese (BMI 48), adolescent male who presented in the early fall of 2021 with COVID-19. The patient developed a cough and dyspnea and was positive for COVID-19 two days prior to presentation. On the day of presentation, was initially taken to the emergency department at an outside institution where he was found to be profoundly hypoxic requiring up 60L of high-flow nasal cannula. After resuscitation and stabilization, he was transferred to our institution for a higher level of care. He continued to be tachypneic, lightheaded and febrile. Over the next 24 hours he required increasing respiratory support pressures and despite escalating support, he remained hypoxic and required intubation. After intubation the patient transiently improved, however, over the next 48 hours he developed worsening hypoxia with elevated airway pressures leading to a right-side pneumothorax and significant pneumomediastinum. Given the risk of ongoing barotrauma with worsening pneumomediastinum and isolated severe hypoxia with maintained cardiac function, the decision was made to initiate V-V ECMO. Due to the severity of hypoxia and predicted flow requirements, he was initially cannulated using a dual site, ultrasound guided percutaneous technique at the bedside. The right femoral vein was accessed for drainage and the left internal jugular vein was accessed for infusion to preserve the right internal jugular vein for future dual lumen cannula placement. Cannula placement was confirmed with x-ray and echocardiography. Over the next two weeks the patient stabilized on V-V ECMO, and flow requirements were weaned to less than 5 L/min. With the stabilization on V-V ECMO the decision was made to transition to an ambulatory configuration. Due to the patient's size and experience of our adult colleagues with the earlier phase of the COVID-19 pandemic, the Protek Duo (TandemLife, Pittsburgh PA) dual lumen cannula was used. The patient was taken to the cardiac catheterization suite where he underwent fluoroscopy guided placement of the Protek Duo cannula with drainage from the right atrium and infusion into the main pulmonary artery. This stepwise application of the Protek Duo oxygenated right ventricular assist device (OxyRVAD) in a morbidly obese adolescent with COVID-19 pneumonia, allowed increased participation in therapy. The increased mobility and right heart support aided his recovery to decannulation and eventual hospital discharge. As the COVID-19 pandemic shows no signs of slowing down and has proven to be adept at mutating to increase transmissibility, it is more important than ever to continue to evolve our practices to battle this disease.
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Background: For patients with acute respiratory distress requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO), there are several cannulation strategies that may be used. The typical cannulation strategy for VV ECMO is either femoral-femoral or a femoral-internal jugular due to the advantage of using larger vessels to access and can typically be done at the bedside under ultrasound and x-ray guidance. However, there is concern for limited mobility and an increased risk of infection due to the location of the cannulas. VV ECMO with a dual-lumen cannula placed via the subclavian approach is an effective cannulation strategy. Case Review: 38-year-old male with a past medical history of childhood asthma and depression. He was hospitalized for respiratory failure due to COVID-19 and intubated on hospital day 2. Despite heavy sedation, paralytics, and prone positioning, his P/F ratio remained less than 50 with peak pressures in the 40s. The multidisciplinary team decided to proceed with cannulation for VV ECMO on day four of intubation. He was cannulated using a 25 French multistage cannula via the left common femoral vein and a 21 French single-stage return cannula via the right common femoral vein. He underwent a tracheostomy on ECMO day four and was able to tolerate weaning of the ventilator over the next few days. Despite only requiring a sweep gas flow of 0.5L/min on ECMO day six, the patient had worsening oxygenation and was unable to achieve a blood flow of more than 3L/min due to chatter. The chest x-ray (CXR) revealed the drainage cannula was now too high and his PaO2 decreased from 101 to 50 despite the same ventilator settings. The drainage cannula was pulled back 6cm at the bedside and flows were increased from 3L/min to 4 L/min with an increase in the PaO2 to 83. On ECMO day seven, oxygenation remained suboptimal and the CXR demonstrated a worsening pneumomediastinum, so the decision was made to transition the patient to a dual-lumen cannula in order to optimize ECMO flow and allow for more aggressive weaning of the ventilator. By ECMO day 12, he was weaned off sedation, out of bed with physical therapy, tolerating CPAP and able to Facetime with his family. ECMO support was utilized to allow for more aggressive ventilator weaning given the pneumomediastinum and increase rehab and nutrition. On ECMO day 16, he was weaned off sweep while on a T-piece with 20L 60%. He remained off sweep for 24 hours and tolerated physical therapy without requiring additional support. By day 17, he was decannulated at bedside. Discussion: By transitioning the ECMO cannulation strategy to optimize oxygenation, facilitate weaning of mechanical ventilation and allow for increased mobility, patients may be decannulated at a higher functional status than if they continued with the original cannulation strategy. Since 2020, our institution has performed 137 dual-lumen subclavian cannulations for patients on VV ECMO with a survival rate of 63%.
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ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.
ABSTRACT
Introduction: The invasion of lung tissue by a commensal like aspergillus after severe viral infection has been known.[1] But coronavirus has multiple fangs like immune dysfunction, precipitates new onset diabetes and hypercoagulability.[2] We hereby present a case of long COVID with pulmonary aspergillosis and deep vein thrombosis (DVT). Case Study: A 46 year old male presented with one and half month history of fever, cough with expectoration, hemoptysis. He had tested positive for COVID and diabetes two months before and had required intensive care treatment. The Chest Xray [Figure 1a] showed left upper lobe opacity. Chest CT Scan [Figure 2] showed cavity with central hypodense component within anterior segment of left upper lobe (bird's nest appearance). BAL from that segment grew aspergillus. The patient was started on voriconazole, hemoptysis was controlled and subsequently discharged. But 15 days later, he was readmitted with hemoptysis and left side calf pain and swelling. Lower limb venous doppler showed thrombosis of parts of Left Superficial femoral vein and popliteal vein. CTPA (CT Pulmonary Angiography) didn't show any filling defect. Patient was started on anticoagulation. After 8 weeks patient improved with significant clearing of lung lesion on chest X Ray [Figure 1b]. Discussion: Studies from Wuhan, China, reported secondary fungal infections in 35.3% critically ill patients.[3] Our patient, apart from other risk factors had received corticosteroids and the dose was more than 0.3 mg/kg/d and the duration was upto 4 weeks.[4] Conclusion: Post COVID cases with hemoptysis should be investigated properly considering the multiple pathogenic pathways that are implicated by this virus.
ABSTRACT
BACKGROUND: During coronavirus disease 2019 (COVID-19) pandemic, Helmet Continuous Positive Airway Pressure (h-CPAP) has been widely used to treat Acute Hypoxemic Respiratory Failure (AHRF). In COVID-19 patients undergoing h-CPAP a simple short peripheral catheter could be insufficient. According to the European Recommendations for Proper Indication and Use of Peripheral venous access consensus, a stable peripheral Vascular Access Device is indicated for intravenous treatment compatible with the peripheral route scheduled for more than 1 week. OBJECTIVE: The aim of this prospective study was to evaluate the performance and the potential complications of superficial femoral midline catheters (SFMC) inserted in the Superficial Femoral Vein by direct Seldinger technique with peripheral tip (Arrow®, Teleflex; 20 cm length four FR single lumen and seven FR dual lumen) in AHRF COVID-19 patient. Complications were divided in early (accidental puncture of superficial femoral artery (APSFA); accidental saphenous nerve puncture (ASNP); bleeding) and late (Catheter Related Thrombosis (CRT); Catheter-Related Bloodstream Infections (CRBSI); Accidental Removal (AR); persistent withdrawal occlusion (PWO)). METHODS: From 1st October 2020 to 30th June 2021 we conducted a prospective observational study in COVID-19 sub-intensive wards at Luigi Sacco Hospital (Milan). RESULTS: Hundred seventy five SFMC (mean dwell time 11.1 ± 9.8 days) were implanted in COVID-19 patients, 107 (61.1%) during h-CPAP treatment (10.5 ± 8.9 days), the remaining 68 (38.9%) in patients with severe disease. We recorded two minor immediate/early complications (APSFA without sequelae) and no major complications.The long-term follow-up registered four CRBSI (2.3%-2.5/1000 catheters days (CD)), five CRT (2.9%: 2.6/1000 CD), 22 AR (12.6%; 11.4/1000 CD), 38 PWO (36.5%), 34 of which occurred due to fibroblastic sleeve (32.7%). CONCLUSIONS: SFMC proved to be safe, easy and time-saving. It could be implemented, after a careful benefits and risks evaluation, in particular settings such as h-CPAP, delirium, bleeding risk factors and palliative care patients.
ABSTRACT
Introduction Heterozygous Factor V Leiden (FVL) mutation is the most common inherited thrombophilia, most common in people of Northern European descent and in some Middle Eastern population. It increases risk of developing a deep venous thrombosis (DVT) by 5-to 7-fold, and is considered a weak risk factor, and most people never develop blood clots. Case report 19-year-old woman presented with left lower quadrant abdominal pain, left groin pain, chest tightness and shortness of breath that had started 1 week prior to presentation. Patient had tested positive for COVID-19 six months but had only minor symptoms and recovered without needing treatment. She had completed 2nd dose of Moderna Covid vaccine two weeks ago and had been using oral contraceptive pills (OCP) for two years. Family history was significant for a paternal uncle with history of blood clots. Physical exam revealed swelling and erythema in left lower extremity up to groin area. Doppler ultrasound showed an acute DVT in the left external iliac vein, common femoral vein, deep femoral vein, superficial femoral vein, and proximal popliteal vein. Spiral computed tomography imaging of chest showed pulmonary emboli (PE) in the segmental branches of the pulmonary arteries with mild dilation of the right ventricle. Cardiac echogram (TTE) showed intact right ventricular function. Patient underwent mechanical aspiration thrombectomy with extirpation of DVT, but the procedure was complicated by PEA arrest requiring CPR for about 50-60 mins. During episode, bedside TTE showed evidence of right ventricular dilation and RV strain concerning for a massive PE. She was cannulated for V-A ECMO then underwent therapeutic hypothermia, and was successfully decannulated after six days. Patient eventually recovered and was neurologically intact. She was discharged home on warfarin and aspirin. Hypercoagulable work-up was remarkable for heterozygous FVL mutation R506Q. Both her father and mother were found to have heterozygous FVL mutation and her sister was found to have homozygous FVL mutation. Discussion People with FVL have additional risk factors that contribute to the development of DVT, and FVL alone does not increase the risk of developing arterial thrombosis, heart attacks and strokes. DVTs in heterozygous FVL population are considered provoked DVTs requiring anti-coagulation for a definite period, like that in general population. Curiously, patients with severe COVID-19 infection requiring ventilator support were found to have factor V levels high above the normal reference range and were found to have elevated risk for blood clots. Use of OCPs, and perhaps a recent COVID infection, although mostly asymptomatic, might have contributed to hypercoagulability in our patient. FVL mutation is not considered a contraindication to having COVID vaccination and patients with hereditary clotting disorders are recommended to have the vaccine.
ABSTRACT
Case Report Between December 2019 and May 2021, there were around 200 million cases of COVID-19, with more than 3.5 million deaths all over the world. In the United States alone, there were more than thirty million cases, with around six hundred thousand deaths attributed to COVID-19. Incidents of hypercoagulability after receiving different types of COVID-19 vaccine have been reported. The incidence of deep vein thrombosis (DVT) is about 1 in 1000, and about 50% of these patients with DVT develop pulmonary embolism (PE). The incidence of DVT affecting the upper extremity exceedingly rare with an approximate incidence of 1 in 10,000. While patients receiving anticoagulation are still at risk of DVT, data on apixaban reflects a 98% protection from recurrent thrombosis. Hypercoagulability including DVT and PE is always a rising concern in patients with COVID-19 pneumonia. We are reporting a case of a hypercoagulability state in 73-year-old lady after receiving first and second dose of Pfizer vaccine;despite being on apixaban. she has a past medical history of COPD on 2 L home oxygen. She presented with acute hypoxic respiratory failure few days after receiving the first dose of COVID-19 Pfizer vaccine. Imaging revealed right interlobar pulmonary embolism and right superficial femoral vein thrombosis without any provoking factors. She improved clinically and was discharged on apixaban. Few months later she came in with right upper extremity DVT, 7 days after receiving a second dose of Pfizer vaccine. Transesophageal Echo revealed a round mass in the left atrial appendage, which was likely a thrombus, she was discharged on warfarin. Incidence venous thromboembolism is about 1 in 1000 individuals in the United States. Several factors can increase the hypercoagulable state. SARS-COV-2 is hypothesized to increase the risk of thromboembolism by infecting cell expressing surface receptors of ACE-2 by binding the SARCOV-2 spike protein and activating cell pyroproptosis which activates neighboring cells inflammatory response and then activate coagulation pathway. BioNTECH mRNA vaccine induces immune response by engulfing S protein mRNA into the cell to produce spike protein and induce antibody production against SARS-COV-2 spike protein. At this time, this is the Third reported Vaccine related VTE after reporting a Pfizer BioNTech vaccine induced DVT on January 2021 After ruling out other causes of VTE in this case as well as the time between receiving the vaccine and the onset of symptoms, vaccine-induced thrombosis is the most likely cause for our patient's thrombosis, including venous thrombosis, pulmonary embolism, and left atrial appendage thrombosis. The mechanism remains unknown but may possibly be due to enhanced immune response to the vaccine. In patients at increased risk of thrombosis, BioNTech mRNA vaccination may induce Intravascular Coagulation, venous thromboembolism, possibly due to enhanced immune response to spike protein production.