ABSTRACT
Acquired von Willebrand syndrome (AVWS) contributes to bleeding during extracorporeal membrane oxygenation (ECMO) support. Although it is recognized that AVWS rapidly resolves after ECMO decannulation, this approach may often be clinically unsuitable. In such cases, optimal AVWS management during ECMO support is not well established. We report our approach to managing AVWS in a patient on veno-venous (VV) ECMO for 59 days. A 19-year-old male developed hypoxemic respiratory failure from SARS-CoV-2 pneumonia. Following intubation, he progressed to VV-ECMO support for refractory hypoxemia and was started on bivalirudin for systemic anticoagulation. Two days later, he developed refractory gastrointestinal and oro-nasopharyngeal bleeding despite blood product transfusions and discontinuing bivalirudin. He was started on pantoprazole along with infusions of octreotide and aminocaproic acid. Upper endoscopy on ECMO day 5 revealed an ulcerative bleeding vessel in the duodenum that was clipped. Recurrent mucosal bleeding precluded resumption of systemic anticoagulation. On ECMO day 23, AVWS was diagnosed based on elevated von Willebrand factor (VWF) activity (207%, normal 55-189%) and antigen (234%, normal 50-210%) levels with abnormally low VWF high-molecular-weight multimers. Factor VIII complex was administered twice over the following week. Between doses, the ECMO circuit was exchanged to empirically mitigate suspected shear-related VWF consumption from the fibrin burden, and a repeat endoscopy controlled additional intestinal bleeding with local hemostatic agents. He received 36 units of red blood cells, 2 units of platelets, 2 units of plasma, and 7 pooled units of cryoprecipitate over 31 days leading into these combined interventions. In the 28 days afterwards, he received 3 units of red blood cells, 3.5 pooled units of cryoprecipitate, and no additional platelets or plasma. Our patient was maintained off systemic anticoagulation for 54 of 59 days of VV-ECMO support without any thrombotic complications occurring. With no subsequent clinical evidence of bleeding, repeat VWF testing was done two months post-decannulation and showed near-normal VWF activity (54%) and normal multimer distribution. Our patient rehabilitated well without any neurologic deficits and on discharge was requiring supplemental oxygen with sleep and strenuous activity. Avoiding systemic anticoagulation, repleting VWF, maintaining circuit integrity, and providing local hemostasis, when possible, may be a safe and effective management strategy of AVWS on ECMO support when decannulation is not a viable option.
ABSTRACT
Silver has been in medicine for hundreds of years and has proven antimicrobial properties. It was widely used until the Second World War, when antibiotics emerged. Silver nitrate (SN) sticks (75% silver nitrate and 25% potassium nitrate) are currently employed as a topical haemostatic agent for various cutaneous surgical procedures. In the initial phase of the COVID-19 pandemic, faced with a limited supply of personal protective equipment, we used SN stick haemostasis for several skin surgical procedures (including excisions). COVID-19-related guidance from the Trust recommended the avoidance of electrocautery owing to the generation of surgical plume;hence, SN stick haemostasis seemed a pragmatic option. Four female patients with a mean age of 67 years (range 48-75) presented with swelling, erythema and pain at the surgical site within a week of the procedure. Three had ellipse excisions for suspected melanoma and squamous cell carcinomas, and one had a shave excision for possible seborrhoeic keratosis. Postsurgical wound infection was suspected, but repeated microbiological swabs did not grow any pathogens. All patients failed to respond to broad-spectrum oral antibiotics, even after two courses. The inflammatory changes took up to 4 weeks to settle, with topical corticosteroids used for wound healing. On contact with moisture, SN sticks deliver free silver ions that form an eschar as they bind to the tissue and occlude vessels. The longer the tip contacts the tissue, the greater the degree of the resultant caustic action. It is widely used in clinical practice, especially wound care (overgranulation, epibole and delayed healing). A 2020 review found an increased incidence of postoperative pain along with pigmentary changes in surgical wounds treated with SN sticks vs. aluminium chloride hexahydrate and ferric subsulfate. In skin surgery, SN is used to cauterize superficial wounds after curettage and shave excision. It does not generate aerosol and, in a pandemic setting, this particular feature can be valuable. However, the potential to cause aseptic skin inflammation that mimics postoperative infection is noteworthy. There are no evidence-based guidelines for its use in dermatology. We believe that the SN is an effective haemostatic agent but can induce significant tissue inflammation in some patients, particularly if it is used in excisions when the cauterized tissue is closed. If SN-induced haemostasis for excision was to be adopted in clinical practice, our experience suggests that larger studies and guidelines are recommended.
ABSTRACT
The proceedings contain 7 papers. The topics discussed include: pediatric burn care: how burn camps survived and thrived during the coronavirus pandemic;a retrospective chart review to determine hypophosphatemia incidence and phosphorus supplementation requirements in patients with severe thermal cutaneous injuries receiving high-volume hemofiltration;setting the standard: using the aba burn registry to benchmark risk adjusted mortality;burn injury from smoking electronic cigarettes while on supplemental oxygen;focused wound care handoff improves burn center physician-nursing communication and wound care education;modified frailty index is an independent predictor of death in the burn population: a secondary analysis of the transfusion requirement in burn care evaluation (TRIBE) study;and topical hemostatic agents in burn surgery: a systematic review.
ABSTRACT
In response to the COVID-19 pandemic and the UK governance restrictions to prevent the spread of the virus, several policies have been adopted to balance the delivery of uninterrupted healthcare services and the risk of COVID-19 exposure. In a very short period, methods of providing healthcare in the UK has changed dramatically and efficiently. At the haemophilia unit (HU) of Birmingham Children's hospital (BCH), most face-to-face consultations were replaced by remote consultations. On the other hand, accessibility of the haemophilia team was increased and improved by the introduction of a dedicated mobile phone and an email address for the HU. In cases of emergencies, families were encouraged to contact the HU to discuss injuries/ bleeding, and medical advice was given based on remote assessment by either video consultation or reviewing emailed injuries'pictures. Families were supplied at home with extra haemostatic agents to be used in case of breakthrough bleeding events, and their administration was monitored through the Haemtrack system. These approaches not only limited the risk of exposure to the virus, but also saved time and resources of the healthcare system. We conducted a retrospective study at HU of BCH. The study aimed to compare haemophilia patients'attendance before and after the pandemic. At the same time, patients'satisfaction towards healthcare services was measured in order to identify the effect of decreased attendance and assess the success of the new management approaches. Attendance was categorised into either planned or unplanned. Planned attendances were for treatment/prophylaxis, education, vaccines and regular clinic reviews. Unplanned attendances were either at the HU or the emergency department for management of injuries and breakthrough bleeding events. Patients'satisfaction was measured using a validated questionnaire. The questionnaire was sent to all caregivers of haemophilia patients through a text message. Baseline attendance (January 2019-January 2020 inclusive, before the pandemic) was compared to those during the pandemic (April 2020-April 2021 inclusive, after lockdown measures legally came into force). Total attendance during the pandemic was reduced by 46.6% compared to total attendances before the pandemic. Also, planned attendances were reduced by 43.9%, and unplanned attendances were reduced by 56.9%. More details are described in (Table 1). No adverse events have been reported because of the decreased number of attendances. On analysing patients'satisfaction questionnaire, 80% of patients reported positive experiences despite reduced attendance, while 20% did not respond to the questionnaire. None of the caregivers reported negative experiences. Our results highlight that those remote consultations, due to COVID-19 precautions, were effective in reducing attendances with appropriate patients'satisfaction and without major adverse events. There is no doubt that there was a tremendous strain on healthcare services during the peak of the pandemic. However, on the long term, we can conclude that this pandemic has also positively impacted healthcare systems through the introduction of telemedicine and remote consultations. Despite the ease of COVID-19 restrictions, at the HU we continue to use same approaches beyond the pandemic as part of the new normal. Further studies post restrictions ease are essential to obtain robust evidence and create effective service transformation..