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1.
ASAIO Journal ; 68:146, 2022.
Article in English | EMBASE | ID: covidwho-2032192

ABSTRACT

Background: Revised guidelines clarify indications for extracorporeal membrane oxygenation (ECMO) support in patients with COVID-19-related acute respiratory distress syndrome (ARDS). Commercially available ECMO analytics software records granular perfusion data continuously throughout the run. To date, electronic-medical record (EMR) clinical data has not been integrated with ECMO perfusion data and analyzed with machine learning-based algorithms to improve patient care. Methods: Retrospective chart review was performed on all SARS-CoV2 positive patients cannulated to veno-venous ECMO at an urban highvolume regional referral center from March 1st, 2020, through December 31st, 2021. Categorical data including patient demographics, clinical outcomes, and laboratory data (complete blood count, basic metabolic panel, arterial blood gas, lactate, anticoagulation assays) and vital signs (pulse, arterial line blood pressure, oxygen saturation) were collected for the entirety of the ECMO run. Time-series perfusion data (arterial flow normalized to body surface area (BSA), sweep gas, delta pressures normalized to arterial flow) were captured every 60-120 seconds. We constructed a predictive long-short term memory (LSTM) predictive model that integrated clinical and time-series data using an extended machine learning (ML) framework with neural network. Primary outcome was successful ECMO decannulation. Data were truncated to discrete and relative timepoints (7, 14, 21 days, or percent of the run). Receiver operating characteristic (ROC) curves show the model's diagnostic accuracy. Results: 42 patients were included in the analysis (30 male, 12 female). Mean age was 43.9 (SD=11.5) years old, and mean duration of ECMO run was 36.2 (SD=30.1) days. 24 patients were successfully decannulated and 4 are currently supported on ECMO. When provided the complete data, the LSTM model showed an area under the ROC curve >0.95, demonstrating strong diagnostic accuracy in predicting successful ECMO decannulation (Figure 1A). When data were truncated to only the first two weeks of the ECMO run, the area under the ROC curve was 0.93 (Fig. 1B). Patterns of arterial flow normalized to BSA and sweep gas normalized to flow also appear different in patients with divergent clinical outcomes (Fig 2). Conclusion: Characterizing key determinants of ECMO support may offer intensive care unit healthcare teams potentially lifesaving information in real-time. Our machine-learning model successfully integrates clinical and perfusion data from the mind's eye of a clinician managing the care of a patient supported with ECMO. We have identified critical variables with the most meaningful impact on the mechanics of ECMO support. Our model may also help predict patient outcomes into and offer clinicians opportunities for interventions to improve care. (Figure Presented).

2.
ASAIO Journal ; 68:140, 2022.
Article in English | EMBASE | ID: covidwho-2032190

ABSTRACT

Background: Timing of tracheostomy in COVID-19 patients supported with extracorporeal oxygenation membrane (ECMO) remains unclear. This study aims to compare the short-term outcomes in early (≤7 days from ECMO insertion) (ET) versus late (LT) tracheostomy. Methods: Charts of COVID-19 patients with tracheostomy from 2020 to 2021 were reviewed, retrospectively. Primary endpoint was in-hospital mortality. Secondary endpoints were analgesics/sedatives doses, length of treatment (LOT), and initiation of physiotherapy (PT). Results: Eight patients with ET were compared to six patients with LT. Mean age was 41.4±12.5 (ET) and 49.5±6.9 (LT) years. In both groups, 50% were male with comparable BMI. Twelve patients received venovenous (VV) and two received veno-arterial (VA) ECMO. Tracheostomy post ECMO cannulation was performed in 12 [ET:6(75%);LT:6(100%)] patients, whereas in the remaining two patients, it was performed immediately after initiation of ECMO support. Average duration of ECMO support was 48.0±21.3 (ET) than 42.2±27.0 (LT) days, P=0.34. Requirement of sedatives before [ET:6.4±4.6;LT:9.3±5.3;P=0.15] and after [ET:21.6±11.9;LT:12.2±14.0;P=0.11] along with analgesics before [ET:6.3±4.9;LT:7.0±6.5;P=0.41] and after [ET:19.0±6.9;LT:14.8±15.5;P=0.28] tracheostomy was comparable. No difference was observed in the LOT during sedatives/ analgesics dosing after tracheostomy. However, the LOT before tracheostomy was significantly longer in sedatives [ET:2.9±3.1;LT:11.8±6.2, P<0.01] and analgesics [ET:2.9±2.8;LT:9.8±3.5, P<0.01], explained by the longer interval between ECMO insertion and tracheostomy in LT group. Compared to LT, number of days from ECMO insertion to first PT session was significantly shorter in ET patients [ET:13.6±5.6;LT:26.5±4.5, P<0.01]. In-hospital mortality rate was 21.4% [ET:1(13%);LT:2(33%), P=0.33] patients with comparable ICU stay [ET:56.9±18.6;LT:50.2±26.4, P=0.30] between groups. Conclusion: Although the advantages of ET to reduce the requirement of analgesics and sedatives amongst COVID19 patients supported with ECMO were like LT group, ET was associated with early initiation of PT and improved survival.

3.
ASAIO Journal ; 68:66, 2022.
Article in English | EMBASE | ID: covidwho-2032186

ABSTRACT

Background: SARS-CoV-2 (i.e., COVID-19) has brought extracorporeal membrane oxygenation (ECMO) into the forefront of critical care. Its unique pathophysiology has added a level of complexity to ECMO therapy, particularly, the hematologic manifestations. Here we detail the spectrum and outcomes of bleeding complications in ECMO for COVID-19 and identify potential contributing factors. Methods: All patients who received ECMO for SARS-CoV-2 pneumonia severe acute respiratory distress syndrome at our institution between March 1, 2020 and April 12, 2021 were reviewed. Patient characteristics, laboratory results, and overall outcomes were recorded. Bleeding events were reviewed with regard to the type/location and intervention required. Severity was graded according to the degree of intervention for treatment (1 [conservative or minor] - 3 [major, life-threatening, or operative]). Laboratory results and patient characteristics were compared between patients with bleeding events and those without to identify factors associated with bleeding risk. Results: Fifty-four patients (mean age 53.2 years, 61.1% female, 51.9% Caucasian) underwent ECMO cannulation for SARSCoV-2 pneumonia at our institution. Thirty-eight (70.4%) received veno-pulmonary artery ECMO. The mean duration of support was 33.2 days with an in-hospital mortality of 42.6%. 68.5% of patients experienced at least one bleeding event during their ECMO course with 92 bleeding events (n=23 [grade 1], n=31 [grade 2], n=38 [grade 3]) over 1804 cannulation days. The most common types of bleeding types were nasal/oropharyngeal (n=30, 32.6%), pulmonary (n=18, 19.6%), and gastrointestinal (n=11, 12.0%). Eight (16.0%) patients required operative intervention and 11 (20.3%) died as a result of a bleeding event, mainly due to intracranial hemorrhages (n=5, 9.3%). There was no difference in the mean cumulative function for bleeding events between different ECMO support modalities (p=0.85) which demonstrated a linear pattern over time. Factors that increased the risk of bleeding included patient cumulative volume balance (OR 1.22 per 1000 mL increase from admission, p<0.001) while higher platelet count (OR 0.83 per 50x103/uL increase, p=0.03) was protective. Conclusion: ECMO for SARS-CoV-2 pneumonia is associated with a diverse and unique profile of bleeding complications. The incidence of bleeding complications is linearly related to cannulation duration. Certain patient factors may affect the risk of bleeding while on ECMO.

4.
ASAIO Journal ; 68:66, 2022.
Article in English | EMBASE | ID: covidwho-2032185

ABSTRACT

Background: The COVID-19 pandemic has led to a significant increase in the use of Veno-venous extracorporeal membrane oxygenation (VV ECMO) as a bridge to various outcomes including transplantation or recovery. Unlike other etiologies of acute respiratory distress syndrome (ARDS), utilization of VV ECMO in COVID-19 has been associated with longer duration of ECMO support requirements. Our team sought to evaluate outcomes associated with prolonged duration of ECMO support in this patient population. Methods: Single-center retrospective review of patients who were placed on ECMO due to COVID-19 associated ARDS. Specifically examining outcomes-mortality, transplantation and discharge rates-of patients requiring VV ECMO support more than 50 days in duration. Data collected between February 15,2020 to February 15, 2022. Results: Reviewed outcomes in 18 patients who required VV support for >50 days. Twenty three percent (n=4) mortality rate within cohort. Three patients (16%) continue to require ECMO support at time of submission. Sixty-one percent (n=11) patients were discharged, of which sixteen percent (n=3) required a lung transplant (Table). Summary: Prolonged VV ECMO at our center was associated with comparable outcomes to the national ELSO pulmonary ECMO cohort. With availability of device and staffing, prolonged ECMO runs can potentially be justified in a highly selected patient population (Table Presented).

5.
ASAIO Journal ; 68:65, 2022.
Article in English | EMBASE | ID: covidwho-2032184

ABSTRACT

Objectives: The purpose of this study was to compare the outcomes of chest tubes (CT) inserted via three approaches in COVID-19 patients undergoing extracorporeal membrane oxygenation (ECMO): open thoracostomies (OT), percutaneously at bedside (PERC), and percutaneously by interventional radiology (PERC IR). Methods: We conducted an institutional review board - approved retrospective study of all COVID-19 patients who required CT placement while undergoing ECMO in our institution from February 2020 till February 2022. Insertions prior to ECMO cannulation or after decannulation, and those related to post-operative lung transplantation during ECMO were excluded from our analysis. Depending on the insertion approach, eligible CT insertion events were divided in three groups: OT, PERC and PERC IR. Data regarding patients' demographics and CT characteristics, clinical indications and associated complications for each group were collected and analyzed. Bleeding related to CT insertion was diagnosed based on requirement of blood transfusion, cessation of anticoagulation and/or ongoing bloody CT output. Results: Study criteria were met by 43 patients, with 35 (83.7%) of male sex. Mean age was 45 years. Mean BMI was 31.6 kg/m2. Forty patients (93.0%) had COVID-related acute respiratory distress syndrome as primary diagnosis. All patients but one had been receiving therapeutic anticoagulation which was held prior to CT insertion. Eighty-seven CT insertion events were recorded, of which 34 (39.1%) comprised the OT group, 20 (23.0%) the PERC group, and 33 (37.9%) the PERC IR group. Table 1 demonstrates a descriptive comparison of CT and insertion data among the three groups. Table 2 depicts the major outcomes among the three groups. Conclusions: For COVID-19 patients on ECMO, insertion of CTs percutaneously by IR is associated with significantly fewer bleeding episodes, transfusions, thoracic consults and explorations in the operating room compared to bedside OT or percutaneous CTs. One third of the percutaneously placed CTs by IR required tube upsizing in the IR suite, a rate still lower compared to the overall CT manipulations or repeat interventions required for CTs inserted via OT or percutaneously at bedside. (Table Presented).

6.
ASAIO Journal ; 68:64, 2022.
Article in English | EMBASE | ID: covidwho-2032183

ABSTRACT

Background: Patients requiring extracorporeal membrane oxygenation (ECMO) frequently necessitate tracheostomy due to prolonged mechanical ventilation. SARS-CoV-2 infection has been associated with different coagulation disorders and may increase the risk of bleeding in high risk patients such as those requiring ECMO. Here, we aim to determine if SARS-CoV-2 increases the risk of bleeding after tracheostomy in ECMO patients. Methods: A retrospective review of all patients requiring ECMO at our institution between March 20 of 2020 and December 31 of 2021 was conducted. Patients requiring tracheostomy after ECMO were included. Demographics, COVID-19 status, tracheostomy approach and post-procedure bleeding events were collected. Statistical analysis was performed using student T-test for nominal variables and Chi-Square test for categorical variables. Results: A total of 267 patients required ECMO during the defined study period. Of these, 112 patients had tracheostomy placement and were included for analysis. Seventy-five percent (84/112) of tracheostomies were done percutaneously and 25% (28/112) were done using surgical open technique. Mean age was 46.2 years ±14.3, 68% were male, mean BMI was 29.9Kg/m2 ±5.5. Seventy patients (63%) had COVID-19. The remaining 42 (37%) required ECMO due to polytrauma, cardiogenic shock, and respiratory failure after other operations such as heart and lung transplant. Of the 112 tracheostomies performed, 34% (38/112) had severe bleeding after tracheostomy placement requiring blood transfusion or additional interventions to control the bleeding. Of the 70 patients with COVID-19, 47% had severe bleeding compared to 12% in the non-COVID-19 group (p=<0.001) (Table). Conclusion: The rate of severe bleeding after tracheostomy was significantly higher in patients with COVID-19 compared with those that did not have SARS-CoV-2 infection. COVID-19 status should be considered before tracheostomy in ECMO patients as it may increase the risk of bleeding complications (Table Presented).

7.
ASAIO Journal ; 68:63, 2022.
Article in English | EMBASE | ID: covidwho-2032181

ABSTRACT

Background: In patients with COVID-19 and respiratory failure, class 3 obesity (body mass index > 40 kg/m2) has been associated with worse survival. Obese patients on mechanical ventilation with progressively more severe acute respiratory syndrome (ARDS) may be offered venovenous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The impact of morbid obesity on the outcome of COVID-19 patients supported with VV ECMO has been underexplored. Methods: This is a multicenter, retrospective observational cohort analysis of critically ill adults with COVID-19 ARDS requiring advanced mechanical ventilation with or without VV ECMO. Data was collected from 236 international institutions forming the COVID-19 Critical Care Consortium international registry. Patients were admitted between January 2020 to December 2021. Included patients were stratified by ECMO status and a BMI threshold at 40 kg/m2. Median values with interquartile range (IQR) were used to summarize continuous variables and multi-state analysis was used to explore the effect of Class 3 obesity on the study endpoints of patient survival to discharge or death. Results: Complete data was available on 8851 of 9059 patients on mechanical ventilation, of which 767 patients required VV ECMO. For the entire study group, older age and male gender were associated with an increased risk of death. The demographics and comorbidities of the higher BMI (H >40 kg/m2) and lower BMI (L ≤40 kg/m2) cohorts were similar with the exception of age and weight. Patients with a higher BMI were younger. The median age of the H, non-ECMO cohort was 56 years (46-64), and the H, ECMO cohort was 41 years (35-51) versus the L, non-ECMO cohort of 64 years(55-71), and the L, ECMO cohort of 53years (45-60). Patients requiring VV ECMO had higher SOFA scores, experienced longer ICU and hospital lengths of stay, and a longer duration of total mechanical ventilation. Table The median time to intubation was longer in the mechanical ventilation only group (2 versus 0 days). Predictors for requiring ECMO included younger age, higher BMI and male gender. Risk factors for death included advancing age (every 10 years), male gender and increasing BMI (every 5kg/m2). The association between BMI and a higher rate of death was reduced in the mechanical ventilation only group (HR 0.92, 95% confidence interval 0.85 to 0.99). Conclusion: In patients with severe ARDS due to COVID-19 requiring mechanical ventilation, the likelihood of progressing to VV ECMO therapy or experiencing death is impacted by age, gender and higher BMI. The cohort of COVID-19 patients that ultimately required ECMO appear to be sicker at time hospital admission owing to the shorter time until mechanical ventilation. It appears the association between increasing BMI and death differs among the ECMO and mechanical ventilation alone cohorts. We would advocate for a prospective study to determine the benefit of VVECMO for the obese patient requiring VV-ECMO for COVID-19 ARDS. (Figure Presented).

8.
ASAIO Journal ; 68:62, 2022.
Article in English | EMBASE | ID: covidwho-2032180

ABSTRACT

Background: Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly being utilized to manage critical COVID-19 associated ARDS (CCAA) in patients who fail medical optimization and mechanical ventilatory support. The aim of this study was to determine the probability of weaning patients from ECMO over time and whether a subset of patients should be considered for lung transplantation. Additionally, we investigated when lung transplant should be considered after VV ECMO support. Methods: 49 patients with CCAA who required ECMO between January 2020 and September 2021 were investigated. Baseline patient demographics, clinical, laboratory, and follow-up data were compared. The change in probability of ECMO weaning based on duration of ECMO support was studied using a univariate analysis. Additionally, patients who received lung transplantation following VV ECMO for COVID-19 during this same period were studied to compare outcomes to those of patients with only VV ECMO support. Cox proportion hazard analysis was performed to determine predictors of survival in patients who required greater than 28 days of ECMO support. Yuden index was used to determine change in probability of survival with time on ECMO. Results: Of 49 patients, 17 (35%) received lung transplants and 32 (65%) remained on ECMO for >28 days. The probability of weaning patients from ECMO was highest within the first 10 days (60%);beyond 40 days, it was 5.1% (Fig. A). The probability of successfully weaning patients from ECMO significantly decreased over time and ECMO support greater than 28 days (Yuden index, Hazard ratio: 1.09, 95% CI;1.00-1.03) was associated with a significantly increased risk of mortality. Additionally, both survival to hospital discharge (p<0.001, Fig. B) and post-discharge survival (p<0.001, Fig. C) were significantly greater in those who were weaned from ECMO prior to 28 days than those who were weaned after 28 days. In those who could not be weaned from ECMO, lung transplantation (HR:0.47, p<0.01, 95% CI 0.17-0.94), ECMO duration (HR:1.09, p=0.01, 95% CI 1.00-1.03) and higher BUN levels (HR:1.02, p<0.01, 95% CI 1.01- 1.46) prior to ECMO initiation were independent predictors of survival. ECMO support of greater than 8 days was associated with a statistically significant increase in mortality compared to those who received fewer than 8 days of support (Yuden index, HR 1.96, CI 1.06-5.51). Furthermore, the projected survival of patients on ECMO support for greater than 8 days was substantially worse than those requiring fewer than 8 days of support (Fig. C and D). Conclusion: This study suggests that survival and accompanying lung recovery is more probable in patients who require a short duration of ECMO support whereas those who require longer durations, particularly exceeding 28 days, is associated with a lower rate of survival. (Figure Presented).

9.
ASAIO Journal ; 68:61-62, 2022.
Article in English | EMBASE | ID: covidwho-2032179

ABSTRACT

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).

10.
Frontiers in Pediatrics ; 10, 2022.
Article in English | EMBASE | ID: covidwho-2009893

ABSTRACT

Coronavirus disease 2019 (COVID-19) was first reported to the World Health Organization (WHO) in December 2019 and has since unleashed a global pandemic, with over 518 million cases as of May 10, 2022. Neonates represent a very small proportion of those patients. Among reported cases of neonates with symptomatic COVID-19 infection, the rates of hospitalization remain low. Most reported cases in infants and neonates are community acquired with mild symptoms, most commonly fever, rhinorrhea and cough. Very few require intensive care or invasive support for acute infection. We present a case of a 2-month-old former 26-week gestation infant with a birthweight of 915 grams and diagnoses of mild bronchopulmonary dysplasia and a small ventricular septal defect who developed acute respiratory decompensation due to COVID-19 infection. He required veno-arterial extracorporeal membrane oxygenation support for 23 days. Complications included liver and renal dysfunction and a head ultrasound notable for lentriculostriate vasculopathy, extra-axial space enlargement and patchy periventricular echogenicity. The patient was successfully decannulated to conventional mechanical ventilation with subsequent extubation to non-invasive respiratory support. He was discharged home at 6 months of age with supplemental oxygen via nasal cannula and gastrostomy tube feedings. He continues to receive outpatient developmental follow-up. To our knowledge, this is the first case report of a preterm infant during their initial hospitalization to survive ECMO for COVID-19.

11.
Clinical obstetrics and gynecology ; 2022.
Article in English | MEDLINE | ID: covidwho-2008650

ABSTRACT

In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.

12.
Indian Journal of Critical Care Medicine ; 26:S104-S105, 2022.
Article in English | EMBASE | ID: covidwho-2006394

ABSTRACT

Aim and background: Infection due to SARS-CoV-2 may lead to an atypical ARDS, requiring in the most severe cases VV ECMO. The management of persistent severe hypoxemia under VV ECMO requires a multistep clinical approach including prone positioning which could improve oxygenation. Objective: To assess the synergistic effect of prone ventilation and VV-ECMO in addition to lung-protective ventilation to improve patient outcomes in severe ARDS. Materials and methods: Fortis hospital has been an established ECMO center prior to the COVID-19 pandemic but has now become a primary referral center for ECMO retrieval of critically ill patients. In the past 10 months, we had 19 ECMO patients. All patients who underwent ECMO insertion had CT imaging done on the day of ECMO insertion. Patients with inhomogeneous lung opacities on imaging were postulated to potentially benefit from proning on ECMO. We would like to present a case series of 3 patients (2 retrievals and 1 in-house) subjected to prone ventilation immediately after initiation of VV ECMO in view of ARDS with refractory hypoxia, high driving pressures, and Murray score of >3. Femoro-jugular configuration of VV ECMO was used with adequate anticoagulation. All patients were subjected to proning and supining with a dedicated team of 8-10 members including a senior intensivist and airway expert at the head end and perfusionist taking care of the ECMO circuit along with 6 support staff on side of the patient and 1-2 staff for placing/removing the head support, chest, and pelvic bolsters. All patients received immunomodulation with methylprednisolone for the persistent maladaptive hyperinflammatory states. Ventilatory parameters on conventional lung-protective ventilation were compared to parameters on ECMO at the initiation of proning and after completion of prone sessions. Any complications associated with proning were noted. Results: We describe 3 patients with severe COVID-19 bronchopneumonia with refractory hypoxemia who received prone ventilation on VV ECMO. The median age of patients was 40 years with 1 male and 2 female patients. The median time from symptom onset to mechanical ventilation was 7 days and from mechanical ventilation to VV ECMO initiation was 1.5 days. The median duration on VV-ECMO was 5 days with a duration of prone sessions lasting 18 hours. The mean driving pressure has reduced by 17.6% with an improvement in compliance by 26.3%. The paO2 and P/F ratio improved by 63.2% and 260%, respectively, on ECMO support and these changes were sustained post-ECMO decannulation. None of the patients had any major complications associated with proning. The median duration of hospital stay was 30 days. Days to discharge were prolonged due to sepsis from secondary infection. All 3 patients survived to hospital discharge with minimal to no oxygen requirement, mobilized to an adequate functional capacity to perform activities of daily living. Conclusion: ECMO is often used in patients with severe ARDS and refractory hypoxemia to improve oxygenation and survival. Prone positioning concurrently with ECMO in selected patients can further aid in optimizing alveolar recruitment and reducing ventilator-induced lung injury, which ultimately may be associated with a reduction in-hospital mortality.

13.
Indian Journal of Critical Care Medicine ; 26:S9, 2022.
Article in English | EMBASE | ID: covidwho-2006321

ABSTRACT

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.

14.
Journal of Clinical Oncology ; 40(16), 2022.
Article in English | EMBASE | ID: covidwho-2005665

ABSTRACT

Background: Patients with multiple myeloma (MM), an age-dependent neoplasm of antibody-producing plasma cells, have compromised immune systems due to multiple factors that may increase the risk of severe COVID-19. The NCATS' National COVID Cohort Collaborative (N3C) is a centralized data resource representing the largest multi-center cohort of ∼12M COVID-19 cases and controls nationwide. In this study, we aim to analyze risk factors associated with COVID-19 severity and death in MM patients using the N3C database. Methods: Our cohort included MM patients within the N3C registry diagnosed with COVID-19 based on positive PCR or antigen tests or ICD-10-CM. The outcomes of interest include all-cause mortality (including discharge to hospice) during the index encounter, and clinical indicators of severity (hospitalization/ED visit, use of mechanical ventilation, or extracorporeal membrane oxygenation/ECMO). Results: As of 09/10/2021, the N3C registry included 690371 cancer patients, out of which 17791 were MM patients (4707 were COVID-19+). The mean age at diagnosis was 65.9yrs, 57.6% were >65yo, 46.4% were females, and 21.8% were Blacks. 25.6% had a Charlson Comorbidity Index (CCI) score of ≥2. 55.6% required an inpatient or ED visit, and 3.65% required invasive ventilation. 11.4% developed acute kidney injury during hospitalization. Multivariate logistic regression analysis showed histories of pulmonary disease (OR 2.2;95%CI: 1.7-2.8), renal disease (OR 1.8;95%CI: 1.4-2.4), and black race (p<0.001) were associated with higher risk of severity. Interestingly, smoking status was significantly associated with a lower risk of severity (OR 0.7;95%CI: 0.5-0.9). Further, protective association was also observed between COVID-19 severity and blood or marrow transplant (BMT) (OR 0.52;95%CI: 0.4-0.7), daratumumab therapy (OR 0.64;95%CI: 0.42- 0.99) and COVID-19 vaccination (OR 0.28;95%CI: 0.18-0.44). IMiDs were associated increase in the risk of COVID-19 severity (OR 2.1;95%CI: 1.6-2.7). 2.3% of N3C-myeloma COVID-19+ patients died within the first 10 days, while 4.95% died within 30 days of COVID-19 hospitalization. Overall, the survival probability was 90.5% across the course of the study. Multivariate cox proportional hazard model showed that CCI score ≥2 (HR 4.4;95%CI: 2.2-8.8), hypertension (HR 1.6;95%CI: 1.02- 2.4), IMiD (HR 2.6;95%CI: 1.8-3.8) and proteasome inhibitor (HR 1.6;95%CI: 1.1-2.5) therapy were associated with worse survival. COVID-19 vaccination (HR 0.195;95%CI: 0.09-0.45) and BMT (HR 0.65;95%CI: 0.4-0.995) were associated with lower risk of death. Conclusions: We have identified previously unpublished potential risk factors for COVID-19 severity and death in MM as well as validated some published ones. To the best of our knowledge, this is the largest nationwide study on multiple myeloma patients with COVID-19.

15.
Pediatrics ; 149, 2022.
Article in English | EMBASE | ID: covidwho-2003108

ABSTRACT

Background: The COVID-19 pandemic has been shown to have a compounding effect on families across various social and healthcare needs. However, the impact of social determinants of health (SDOH) on COVID-19 disease severity in children is unknown. Our objectives were to describe the SDOH in children with SARS-CoV-2 infection and determine their association with severity of the infection Methods: This prospective observational study was supported by the National Institutes of Health RADx program and conducted in the emergency department (ED) of two large children's hospitals. Children ≤ 18 years of age with symptoms due to SARS-CoV-2 infection (positive RT PCR test, serology or epidemiological link) were enrolled between 03/29/2021 and 05/30/2021. Data collected from electronic medical records included demographics, clinical features, treatment, disposition, and outcomes. Severe cases were defined as the following within 30 days of test positivity: diagnosis of Multisystem inflammatory syndrome in children or Kawasaki disease, requirement for oxygen > 2L, inotropes, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death. Following informed consent, caregivers were surveyed via an electronic device on previously validated PhenX questions. Aligned with the Healthy People 2020 SDOH framework, caregivers reported on economic stability, education, social and community context, health and health care, and neighborhood and built environment. Stata was used to analyze descriptive statistics, and unadjusted comparisons between groups were assessed using two sample t-tests for continuous variables and Fisher's exact test for categorical variables due to small sizes. Results: A total of 107 children (mean age 6.9 (±5.9) years, 44.9% males), with SARS-CoV-2 infection were enrolled, and 85 caregivers (79.4%) completed the survey (71.4% Black). In this sample, 97% of children were RT PCR positive, 3% had an epidemiological link, and 23 (27.1%) were categorized as severe. Almost half of caregivers (47.6%) reported employment or income loss due to COVID-19. The three most common SDOH needs identified were that of childcare (22.0%), housing instability (22.0%), and food insecurity (21.7%). Children with severe COVID-19 were significantly more likely to have a caregiver who was single, including never married, separated/divorced, and widowed (82.6% vs. 52.5%;Table 1). Although not statistically significant, children with severe COVID-19 tended to have higher levels of social needs including housing instability, poor caregiver mental health, and lower levels of social support compared to children with nonsevere infection (Table 2). Conclusion: Our preliminary data on SDOH suggest that among children with SARS-CoV-2 infection, housing instability, food insecurity and childcare needs are particularly prevalent. Children with severe SARS-CoV-2 infection were more likely to have single caregivers. Family structure may influence severe COVID-19 in children and programming and supports for single parent households should be considered. Larger studies in the ED setting will help confirm these findings and to direct resources to address these social needs.

16.
Journal of General Internal Medicine ; 37:S506, 2022.
Article in English | EMBASE | ID: covidwho-1995821

ABSTRACT

CASE: A 31-year-old woman G4P2204 was admitted with respiratory failure. Her hemoglobin was 9.7 g/dl, D-dimer 1349 ng/mL feu, procalcitonin 0.44 ng/ mL, CRP 91.4 mg/L, normal white count and nasal RT-PCR positive for COVID-19. Chest x-ray showed bilateral patchy airspace opacities. She underwent emergent C-section, was intubated and placed on mechanical ventilation, received Remdesivir, dexamethasone, vancomycin and piperacillintazobactam. On day 11, she developed bilateral pneumothorces and had chest tubes placed. She had new elevation in white blood count (16,000/ul) and inflammatory markers. She was put on extracorporeal membrane oxygenation (ECMO). Computed Tomography ( CT) chest on day 15 showed large multiloculated cavity. She underwent bronchoscopy with bronchoalveolar lavage cultures positive for Mucorales. She had CT abdomen-pelvis, CT head and nasal endoscopy without evidence of invasive disease. She was started on amphotericin B and posaconazole. She had tracheostomy on day 21 and underwent successful ECMO weaning and decannulation on day 35. Chest tubes were removed. Amphotericin B was discontinued. She was discharged on nasal cannula and oral posaconazole and continued to improve. IMPACT/DISCUSSION: There are 6 other cases reported in literature with isolated pulmonary mucormycosis associated with SARS-CoV-2. All of these patients had clinical improvement before deteriorating again with SARS Cov-2 treatment. The timeline of new imaging findings like cavities, changing opacities, pleural effusions or bronchopleural fistula was usually 2 to 3 weeks from diagnosis of SARS-CoV-2 pneumonia. On analysis 5/7 of these patients were not diabetic, 6/7 received steroids, 3/7 received Tocilizumab and 4/7 received Remdesivir. 2 patients received surgical intervention with medical management although it did not change the outcome. Unfortunately despite aggressive medical and surgical treatment, there were poor outcomes. 4/7 patients died, 1/7 was permanently ventilator dependent and 2/7 survived. The diagnosis of isolated pulmonary mucormycosis is challenging. This might be secondary to hesitance of invasive diagnostic tests like bronchoscopy, lack of rapid diagnostic tests and fewer autopsies. Amphotericin B, posaconazole and isavuconazole remain the main treatment options along with surgical debridement of necrotic tissue. The pathology of mucormycosis in COVID-19 has been attributed to impaired T-cell function, impaired phagocytosis and more availability of fungal heme oxygenase which facilitates iron uptake for its metabolism. Glucocorticoids, IL-6 inhibitors and monoclonal antibodies further increase the risk of secondary infections. CONCLUSION: Mucormycosis is a lifethreatening disease with high morbidity and mortality. Based on our case and literature review, it is important to have high index of suspicion for pulmonary mucormycosis in patients who are recently treated with immunosuppressants for SARS-CoV-2 pneumonia and suddenly deteriorate after treatment.

17.
European Review for Medical and Pharmacological Sciences ; 26(15):5618-5623, 2022.
Article in English | EMBASE | ID: covidwho-1988909

ABSTRACT

The Coronavirus illness 2019 (COVID-19) was first observed to induce fever, dry cough, pneumonia, and dyspnea in the lower respiratory tract. Atypical manifestations, including digestive problems and cardiac symptoms, were also observed. The rate of mortality in the older population is greater than in the younger group, as well as in individuals suffering from comorbidities. Oxygen supplementation through a face-mask, non-invasive ventilation, mechanical ventilation, and extracorporeal membrane oxygenation ECMO are some of the available supportive techniques. Hyperbaric oxygen treatment (HBOT) is thought to boost tissue oxygenation by increasing plasma soluble oxygen levels. HBOT also reduces inflammatory responses in COVID-19 patients, minimizing the negative impacts of the cytokine storm. Because the existing data on the efficacy of HBOT in COVID-19 patients is limited, the purpose of this article is to review the possible mechanisms of HBO, as well as data available on potential advantages, side effects and uses in the treatment of COVID-19 patients.

18.
Indian Journal of Critical Care Medicine ; 26(8):896-897, 2022.
Article in English | EMBASE | ID: covidwho-1979539
19.
Indian Journal of Critical Care Medicine ; 26(8):970-973, 2022.
Article in English | EMBASE | ID: covidwho-1979534

ABSTRACT

Ab s t r ac t Introduction: Acute respiratory distress syndrome (ARDS) is an uncommon complication of hemophagocytic lymphohistiocytosis (HLH). Non-specific findings that mimic other diseases make timely diagnosis and treatment challenging. We present a rare case of severe ARDS and multiorgan failure from secondary HLH due to peripheral T-cell lymphoma. Case presentation: A middle-aged female presented with dry cough and fever for three days. On presentation, the patient was febrile to 105°F and hypoxic to 88% on room air. Chest X-ray showed bilateral interstitial infiltrates. Laboratory investigations showed lymphopenia and elevated inflammatory markers. The viral panel, including coronavirus disease-2019 (COVID-19), influenza, and respiratory syncytial virus (RSV), was negative. Her respiratory status progressively worsened, requiring invasive mechanical ventilation for ARDS. Despite lung-protective ventilation, prone positioning, and the use of paralytic agents, the patient continued to remain hypoxic, necessitating extracorporeal membrane oxygenation (ECMO) support. The patient was started on antibiotics and high-dose steroid. Thereafter, she developed a leukemoid reaction, and the ferritin level started rising;raising suspicion for lymphophagocytosis. During this time, she also developed acute liver and kidney failure and required multiple vasopressors and renal replacement therapy. Eventually, a diagnosis of mature peripheral T-cell lymphoma was established. Subsequently, her respiratory status and multiorgan failure significantly improved, and ECMO was explanted after 2 weeks. She was started on etoposide and steroid, and eventually discharged after 6 weeks. Discussion: This is the first case describing a successful implementation of ECMO in an adult diagnosed with ARDS secondary to mature peripheral T-cell lymphoma;allowing for recovery of respiratory status, which was compromised during the initial cytokine storm and provided time to establish the diagnosis and initiate appropriate treatment of secondary HLH mature due to peripheral T-cell lymphoma, and in the end, prevented a fatality. We believe that ECMO may be appropriately instituted in rapidly deteriorating patients with an unknown illness refractory to conventional therapy, to allow for end-organ recovery, to reach a diagnosis, and to administer appropriate therapy.

20.
Fundamental and Clinical Pharmacology ; 36:49-50, 2022.
Article in English | EMBASE | ID: covidwho-1968107

ABSTRACT

Introduction: Acute Respiratory Distress Syndrome (ARDS) became a leading cause of ICU admission since the COVID-19 outbreak. Refractory ARDS can benefit from Veno-Venous Extra Corporeal Membrane Oxygenation (VV ECMO). Amiodarone is used for treating cardiac arrhythmias and shockable cardiac arrest during cardiopulmonary resuscitation (CPR). Data about amiodarone under VV ECMO are still lacking. In a previous work led on a model of ARDS in pigs ongoing CPR, we showed a pharmacokinetics impairment of amiodarone under VV ECMO. We aimed to establish a PK modelling of amiodarone concentrations. Material and methods: Nonlinear mixed effects modelling approach was used to analyse plasma concentrations. Impact of VV ECMO on amiodarone pharmacokinetic profile were investigated. Using our final model, different dosing schemes for amiodarone (10 000 Monte Carlo simulations) were simulated in animals on ECMO VV. Results: A two-compartment model with first-order absorption and elimination was able to accurately describe amiodarone plasma concentrations. Interindividual variability was retained for clearance and central volume of distribution. Amiodarone PK parameters were influenced by the ECMO covariable. All parameters were well estimated. Goodness of fit plots comforted the accuracy of the model. Predicted-corrected visual predictive check of the final model was satisfactory. Simulated amiodarone exposure showed that amiodarone 600 mg bolus is required under VV ECMO to achieve similar AUC observed in the control group. Discussion/Conclusion: In our model of ARDS in pigs with cardiac arrest and benefiting from CPR and VV ECMO, a two-compartment model with first-order absorption and elimination was able to accurately describe amiodarone plasma concentrations. VV ECMO significantly modified both central distribution volume and amiodarone clearance. From Monte-Carlo simulation, we showed that a 2-fold increase of amiodarone doses should be considered to reach efficient drug exposure under VV ECMO.

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