Use of novel oxygenated right ventricular assist device hybrid ECLS for adolescents with refractory hypoxemic respiratory dailure due to Covid-19 pneumonia

Objectives: To describe institutional experience using Oxygenated Right Ventricular Assist Device (OxyRVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU), including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular (RV) dysfunction or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to Cardiohelp systems with built in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult critical care colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia. (Figure Presented).

Use of Novel Oxygenated Right Ventricular Assist Device Hybrid ECLS for Adolescents with Refractory Hypoxemic Respiratory Failure due to Covid-19 Pneumonia

Objective: To describe institutional experience using Oxygenated Right Ventricular Assist Device Oxy-RVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU) including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular dysfunction (RV) or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to CardiohelpTM systems with built-in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients were cannulated directly to Oxy-RVAD ECLS support. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult-focused colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia.

The Warburg Effect And Complex Thermomics Inform Phenotypic Expression

Introduction: As technology reveals biological complexity, integration of vast clinical and multi-omic data utilizing artificial intelligence promises to clarify confusion. We have utilized challenge tests to inform algorithmic graphs recognizing heat as foundational for understanding phenotypic variation. Thermomics, describing complex thermic influences that are difficult to objectively quantify thereby compromising application to AI, are readily included in practice-derived models. Methods: For the past 45 years cases have been evaluated with oral calcium challenge and immersion in water while observing changes in urinary composition. Between 2001 and 2010 respiratory gas exchange following a high carbohydrate meal combined with pulsatile insulin revealed metabolic variance that combined with basic, translational and clinical data of others informed generation of algorithmic graphs. COVID 19 served to clarify the effect of ACE2 disruption by predicting divergent phenotypic expression mediated by calciotropic hormones. Results: Extraction of O2 from glucose, a consequence of fatty acid synthesis producing R/Q > 1 is modeled as foundational for metabolic evolution. This Warburg effect, recognized in proliferating malignant cells, was observed at the systemic level in humans and, modeled as mediated by hypoxia inducible factors regulating glucose uptake and suppression of beta-oxidation. Higher order orchestration is governed by a signaling structure including PTH, PTHrP, FGF23, Klotho, prolactin, growth hormone, IGFs, insulin, SGLT2, thyroid, adrenal and vit D while salt inducible kinase contributes to understanding of terrestrial adaptation. Inclusion of thermomics leads to prediction of a favorable effect of sub-cutaneous adipose beiging on CNS function mediated by circulating Klotho as a constraint on FGF23 in amelioration of Long COVID by phentermine that is also effective in hypophosphatasia where the exercise induced beiging, induced by irisin is known to be dependent upon alkaline phosphatase. The post-exertional malaise of Myalgic Encephalomyelitis, where exercise induces elevation in R/Q and reduced work capacity, has informed modeling of the systemic Warburg effect. The models are further validated with mechanistic explanation for recent reports of marked increases of R/Q in human Paget's disease and CEBPb expression dependence mimicking Alzheimer's and limiting life span in mice. Conclusions: The value of practice is demonstrated by the ability to model thermomics even when difficult to quantify. The work is validated by explanation of old conundrums, discovery of treatment for unresolved problems, facilitation of case-based discovery and integration of emerging data from basic sciences. The Warburg effect when recognized as foundational to biology, contributes to a General Theory of Metabolism applicable to effective personalization of care.Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.