Combining information technology and human research efforts to lessen personnel burden and costs One success story

Objectives: Develop a coding system to extract EHR data and establish research validity to lessen need for manual data extraction Methods: As part of a data collection project for COVID + patients requiring ICU care, we established data elements able to be extracted from the Epic electronic health record (EHR). Collaboration between Information Technology (IT), research and clinical personnel established where data elements were located within the EHR and what data could be extracted with minimal manual assistance and uploaded to a research database. Coding was developed using Structured Query Language (SQL) with best practices (includes indexes, execution plans, optimized range keys, avoiding large reads inside read-write transactions as instructed by the Epic consultant). Accuracy of extracted data was evaluated by manual validation of data against Epic records via random selection of patient data within the cohort. Result(s): From July-December 2022, coding was developed which extracted over 130 fields of data from 3093 COVID patients across 5 INOVA ICU sites (demographic, physiologic, lab, interventions, outcome). Prior efforts at data extraction of these elements from research personnel (ZS) who previously performed this task noted an average of 4 hours/patient to complete coded fields. Coded data was also noted to be more accurate when accessed by the same personnel to manually extracted fields. Assuming 4 hrs/pt, manual extraction would require 12,372 hours, which equates to over 6 full time human research personnel. Data coding required 446 hours. Coded data extraction can be almost immediate once fields requested are established, decreasing personnel costs and effort significantly. Conclusion(s): Reduction in need for manual data collection using automated coding extraction can reduce costs, personnel time and enhance research efforts. Sharing coding mapping to other EPIC sites or use of similar methods may improve timeliness of ongoing data extraction and will be useful to develop earlywarning and patient-centered care algorithms to improve care.

Coagulation Disorders and Management

Coronavirus Disease-19 (COVID-19), caused by SARS-CoV-2 infection, is associated with a rise in inflammatory markers which can result in altered coagulation system activation and regulation. During COVID-19, a remarkable tendency towards venous thrombosis and thrombo-embolism has been widely reported, especially in the critically ill patients. Thus, to limit this clinically relevant events, various strategies of venous thrombo-prophylaxis and anticoagulation have been studied. On the other hand, arterial thrombosis seems to play a less relevant role the clinical picture of COVID-19, as much as bleeding complications, which are mostly correlated to anticoagulation management. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Pediatric Covid-19 Mortality: Twosided Challenges from Health Resource Disparity

BACKGROUND AND AIM: The COVID-19 pandemic impacted high (HICs) and low to high- middle income countries (LHMICs) disproportionately. We sought to investigate factors contributing to disparate pediatric COVID-19 mortality. METHOD(S): We used the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) COVID-19 database, and stratified country group defined by World Bank criteria. All hospitalized patients aged less than 19 years with suspected or confirmed COVID-19 diagnosis from January 2020 through April 2021 were included. RESULT(S): A total of 12,860 patients with 3,819 cases from HICs and 9,041 cases from LHMICs were included in this study. Of these, 8,961 (73.8%) patiens were confirmed cases and 2444 (20.1%) were suspected COVID19. Overall in-hospital mortality was 425 (3.3%) patients, with 4.0% mortality in LHMICs (361/9041), which was higher than 1.7% mortality in HICs (64/3819);adjusted HR (aHR) 4.74, 95%CI 3.16-7.10, p<0.001. There were significant differences between country income groups in the use of interventions, with higher use of antibiotics, corticosteroid, prone position, high flow nasal cannula, and invasive mechanical ventilation in HICs, and higher use of anticoagulants and non-invasive ventilation in LHMICs. Infectious comorbidities such as tuberculosis and HIV/AIDS were shown to be more prevalent in LHMICs [2 (0.0%) vs 171 (1.9 %), 1 (0.0%) vs. 149 (1.6%) patients, respectively]. Mortality rates in children who received mechanical ventilation in LHMICs were higher compared with children in HICs [89 (43.6%) vs. 17 (7.2%) patients, aHR 12.0, CI95% 7.2-19.9, p<0.001]. CONCLUSION(S): Various contributing factors to COVID-19 mortality identified in this study may reflect management differences in HICs and LHMICs. (Figure Presented).

Length of Pre-Ecmo Mechanical Ventilation Is Not Associated with Mortality in Patients with Covid-19

INTRODUCTION: Previous studies suggest that delayed initiation of extracorporeal membrane oxygenation (ECMO) is associated with higher patient mortality. Hence, we hypothesized that prolonged invasive mechanical ventilation (IMV) prior to ECMO was associated with higher mortality in patients with COVID-19. METHOD(S): The COVID-19 Critical Care Consortium, a prospective international multicenter registry, was queried for all patients with COVID-19 infection who received IMV and ECMO. Patients who were intubated prior to transfer to a study site were excluded. The primary variable was number of days on IMV prior to ECMO initiation and study endpoint was death or discharge from the study site. Cox proportional hazards model for the time between ECMO initiation and death was built using covariates including age, gender, selected comorbidities, and time intervals from ICU admission to IMV and IMV to ECMO initiation. RESULT(S): Between 1/1/2020 and 6/6/2022, A total of 593 patients from 107 study sites and 25 countries were included in the analysis. In this cohort, the median age was 50 (Interquartile range [IQR]: 40-58) years. Obesity and hypertension were prevalent among 220 (38.4%) and 223 (38.8%) of the patients, respectively. Twenty-four (4.2%) patients had chronic pulmonary disease. Prior to ECMO initiation, patients spent a median of 3.68 (IQR: 1.36-8.07) days in the ICU and a median of 2.49 (IQR: 0.88-5.65) days on IMV. Overall mortality was 47.2% with 3.9% patients' status not finalized or unknown. According to the final survival model, the number of days on IMV prior to ECMO initiation was not associated with mortality. The hazard ratios for 0, 3, 7, and 14 days of pre-ECMO IMV were 0.94 (95% confidence interval [CI]: 0.83 to 1.07), 1.02 (95% CI: 0.97 to 1.08), 1.09 (95% CI: 0.92 to 1.3) and 1.09 (95% CI: 0.83 to 1.42), respectively. Other noticeable contributory factors in the model included age and gender. CONCLUSION(S): Among patients with COVID-19 who received ECMO, the length of pre-ECMO IMV was not associated with hospital mortality. Further studies evaluating the ventilator settings before and after ECMO initiation are needed.

Hemorrhagic, coagulopathic, and thrombotic (HECTOR) complications among critically-ill patients with COVID-19: An International COVID-19 critical care consortium study

Background: Hemorrhage, coagulopathy and thrombosis (HECTOR) are reported complications of coronavirus disease 2019 (COVID-19) however, more information is needed on the prevalence of these complications and their associated outcomes in intensive care unit (ICU) settings. Aim(s): To determine the prevalence and outcomes of HECTOR complications in ICU patients with COVID-19. Method(s): Observational cohort study spanning 229 ICUs across 32 countries. Patients >=16 years admitted for severe COVID-19 from 1st January 2020, through 31st December 2021 were included. Patient characteristics and clinical data were collected. Survival analysis estimated the instantaneous impact of HECTOR complications on ICU-mortality and discharge. Result(s): HECTOR complications occurred in 1,735 (14%) of 11,972 study-eligible patients. Acute thrombosis occurred in 1,249 (10%) patients, including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial infarction, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic stroke. Hemorrhagic complications were reported in 582 (4.9%) patients, including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, and 77 (13%) with pulmonary hemorrhage. Disseminated intravascular coagulation occurred in 11 (0.09%) patients. Univariate analysis identified diabetes, hypertension, cardiac and kidney disease and ECMO as statistically-significant risk factors for HECTOR complications. Patients with versus without HECTOR complications suffered higher ICU-mortality at 28 days (25%vs.13%, p < 0.001), 90 days (32%vs.15%, p < 0.0001) and overall (44%vs.36%, p < 0.001). Among ICU survivors, the ICU stay was longer (median days 19vs.12, p < 0.001). ICU mortality was similar between patients with and without HECTOR complications (HR = 1.01, 95%CI 0.92-1.12, p = 0.783) where an increased hazard of ICU mortality with hemorrhage (HR = 1.26, 1.09-1.45, p = 0.002) was balanced by a reduced hazard of thrombosis (HR = 0.88, 0.79-0.99, p = 0.03). Kaplan-Meier curves are presented in the Figure. Conclusion(s): HECTOR events are frequent complications of severe COVID-19 in ICU patients. Hemorrhagic, but not thrombotic complications are associated with increased ICU-mortality.

Comparison of New Viscoelastic Coagulation Monitor with Standard of Care Thromboelastography for Anticoagulation Monitoring during 72-Hour Extracorporeal Life Support

Introduction: Management of coagulation remains the foremost challenge during extracorporeal life support (ECLS). Thromboelastography (TEG) and other viscoelastic clotting tests have shown utility for assessing coagulation status in trauma and ECLS patients and have also been utilized in COVID 19 patients. However, with few exceptions, these methods are performed in a laboratory setting, not at the bedside, and rely on cumbersome, non-portable equipment. The Viscoelastic Coagulation Monitor (VCM;Entegrion;Durham, NC) is a portable device/test developed for use at the bedside and outside hospitals to assess clot formation and lysis using a small sample of whole blood. Blood coagulation is activated by contact with the glass surface on the cartridge, and measurements are derived pertaining to clot formation, stability, and lysis - similar to metrics obtained by the TEG 5000 (Haemonetics;Boston, MA). In a recent study, the relationship of VCM results and heparin dose administered in 36 COVID-19 patients was investigated;however, use of VCM for ECLS with application of heparinase has not been reported. We investigated efficacy of the VCM for coagulation monitoring during 72 hours of continuous ECLS in swine and hypothesized that the VCM with heparinase correlates with TEG heparinase. Methods: Female Yorkshire swine (n=3, 53.4±1.6kg) were anesthetized, mechanically ventilated, and systemically heparinized. Blood samples were collected at baseline, post ECLS, 6, 24, 48, and 72-hours post ECLS initiation. For the VCM, 350μL of whole blood was added to a 0.05 IU heparinase vial, mixed, and then added to a VCM cartridge. For TEG, 340μL of citrated whole blood was added to 20μL 0.2 M CaCl2, and samples were activated with a kaolin reagent. Heparinase cups (Haemonetics;Boston, MA) were used for testing. Spearman correlation was performed to compare standard VCM metrics (clotting time [CT], clot formation time [CFT], alpha, maximum clot firmness [MCF], clot retraction/fibrinolysis [LI30]) to the respective TEG metrics (reaction time [R], clot formation time [K], alpha, maximum amplitude [MA], clot retraction/fibrinolysis [LY30]), and also to other conventional coagulation measurements such as prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (FIB), and platelet count (PLT) for each timepoint. A p-value of 0.05 was used for significance. Results: All VCM metrics significantly correlated with the respective TEG measurements (see Table 1). Both VCM and TEG show the same positive and negative correlation relationships for clot formation time, clot kinetics, and clot retraction with conventional coagulation tests (see Table 2). Additionally, clotting time and maximum clot firmness did not show moderate or significant correlation with conventional tests. Prothrombin time did not correlate with any values. Conclusion: The VCM is comparable to TEG in assessing coagulation status in heparinized swine and can be used during austere care with ECLS application. In the next round of experiments, we will validate the VCM in clinically-relevant trauma with and without ECLS.

Extracorporeal corporeal membrane oxygenation: indications, technical considerations, and future trends

The extracorporeal membrane oxygenation (ECMO) device was initially developed with the goal of providing extended support in patients experiencing cardiac failure. However, ECMO technology has evolved, and now provides a means to successfully manage patients experiencing cardiac and/or pulmonary failure until such time as the patient's body is able to either heal, or undergo transplantation. In addition, it has been used in the management of multisystem organ dysfunction. The life-saving utility of this therapy for critically ill patients has prompted world-wide implementation particularly in resource-rich settings. Innovations in instrumentation, broad clinical implementation, extensive utilization of blood and blood components, and the catastrophic nature of potential complications, have collectively prompted the evolution of a tremendous body of research. In this comprehensive review we briefly describe the early development of the ECMO device and technology, in addition to outlining the function of the device as it now commonly utilized including veno-arterial (VA) vs. veno-venous (VV) and rapid deployment ECMO. This review will also delineate the rationale for ECMO use, common clinical indications, and specialized techniques, in addition to the approaches necessary for their successful implementation. As systemic anticoagulation is frequently utilized to support patients on ECMO, the review also contains an extensive review of anticoagulation management, blood component utilization, and potential hematologic complications of ECMO. The review includes a discussion of more recent trends including the use of ECMO in COVID-19 patients, and the performance of tandem plasma exchange. Finally, areas of current controversy and needed research will be highlighted. © 2022 The authors.

Extracorporeal survival scores perform poorly in the covid-19 patients

Introduction: Over the last two decades several ECMO survival predictions scores have been developed, with varying internal and external validation. We sought to evaluate the performance of six widely available scores on both our local COVID-19 database and a large international multicenter dataset. Methods: Using an institutional dataset encompassing 15 hospitals in a bi-state region and an international dataset of 42 countries, International Severe Acute Respiratory and emerging Infections Consortium (ISARIC), we evaluated the performance of ECMOnet, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP), PRedicting dEath for SEvere ARDS on VV-ECMO (PRESERVE), Sequential Organ Failure Assessment (SOFA), Roch and PREdiction of Survival on ECMO Therapy-Score (PRESET) scores in identifying ECMO survival for COVID-19 patients. Results: We identified a total of 67 local and 1,014 ISARIC COVID-19 patients supported on ECMO, with a mortality rates of 48% and 51% respectively. In the local cohort all scores demonstrated poor overall performance with area under the receiver operative curve (AUROC) values between 0.53-0.61;ECMOnet 0.54, RESP 0.53, PRESERVE 0.59, Roch 0.53, PRESET 0.61 and SOFA 0.59. The ISARIC database contained fewer variables, allowing 4 scores to be evaluated. Again, all scores demonstrated poor performance in identifying non-survivors with AUROC between 0.55-0.66;ECMOnet 0.59, Roch 0.66, PRESET 0.55 and SOFA 0.59. Conclusions: Current ECMO prediction scores have poor accuracy and limited clinical utility when applied to both local and international databases of COVID-19 patients. Future work should focus on developing clinically applicable models to identify COVID-19 patients most likely to benefit from ECMO.

Long covid syndrome: Why efforts like aftercor are needed

Introduction: The AFTERCOR study was developed by the COVID-19 Critical Care Consortium (>7000 intensive care unit [ICU] and >400 extracorporeal membrane oxygenation [ECMO] patients currently) to enhance understanding of occurrence and progression of long-term dysfunction post-COVID-19. Design: Prospective longitudinal (24 months) study of ICU survivors of COVID-19 to describe recovery of the following aspects: a) health-related quality of life b) dynamics of organ dysfunction and recovery and c) pulmonary function. Countries involved Italy, Spain, Ireland, Austria, South Africa, Australia, USA, Argentina, Brazil, Colombia. Protocol specifics available at https://www.aftercorstudy.com. Inclusion Criteria: 1) COVID-19 infection requiring ICU admission;2) informed consent;3) age ≥18 years. Exclusion Criteria: 1) pregnancy;2) pre-COVID paralysis;3) history of pulmonary resection;4) prior lung transplant;5) inability to perform 6-min walk test or participate in interview. Methods: Goal enrollment is 1000 patients. Follow-up visits are at 3, 6, 12, 18 and 24-month post-ICU discharge. Assessments include: 1) Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36);2) Montreal Cognitive Assessment;3) any subsequent admission 4) St. George's Respiratory Questionnaire;5) Pulmonary function testing;6) chest radiography;7) 6-minute-walk test;8) Patient Health Questionnaire 9 (PHQ-9) and 9) full blood count and biochemistry. CT chest at 6 months and repeat ECHO at 3, 12 and 24 months if performed during COVID-19 hospitalization. If results are normal, subsequent testing will not be performed. Summary: The AFTERCOR study represents a comprehensive evaluation for long-term effects from COVID-19. Interested centers are sought and invited to participate.

An appraisal of respiratory system compliance in mechanically ventilated COVID-19 patients

Rationale Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous smallcase series or studies conducted at a national level.Methods We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe the impact of CRS on the ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide.Results We enrolled 318 COVID-19 patients enrolled into the study from January 14th through September 31th, 2020 in 19 countries and stratified into two CRS groups. CRS was calculated as: tidal volume/[airway plateau pressure-positive endexpiratory pressure (PEEP)] and available within 48h from commencement of MV in 318 patients. Patients were mean±SD of 58.0±12.2, predominantly from Europe (54%) and males (68%). Median CRS (IQR) was 34.1 mL/cmH2O (26.5-45.5) and PaO2/FiO2 was 119 mmHg (87.1-164) and was not correlated with CRS. Female sex presented lower CRS than in males (95% CI:-13.8 to-8.5 P<0.001) and higher body mass index (34.7±10.9 vs 29.1±6.0, p<0.001). Median (IQR) PEEP was 12 cmH2O (10-15), throughout the range of CRS, while median (IQR) driving pressure was 12.3 (10-15) cmH2O and significantly decreased as CRS improved (p<0.001). No differences were found in comorbidities and clinical management between CRS strata. In addition, 28-day ICU mortality and hospital mortality did not differ between CRSgroups.Conclusions This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV-predominantly males or overweight females, in their late 50s-admitted to ICU during the first international outbreaks. Phenotypes associated with different CRS upon commencement of MV could not be identified.

Neuromuscular blocking agents in critically-ill COVID-19 patients requiring mechanical ventilation

RATIONALE. Neuromuscular blocking agents (NMBA) are used in patients with moderate to severe acute respiratory distress syndrome. NMBA have also been used in COVID-19 patients who required mechanical ventilation (MV), but their benefit-to-risk ratio remains uncertain.METHODS. We investigated the effects associated with the use of NMBA in COVID-19 patients who required MV from January 1, 2020 to October 31, 2020 in 153 hospitals across 6 continents, comprising the COVID-19 Critical Care Consortium. Cox proportional hazards analysis was conducted to study the impact of NMBA on 28-day intensive care unit (ICU) mortality. Hospital/ICU lengths of stay were appraised. We performed a propensity score (PS) matching analysis to control confounding factors.RESULTS. 1227 patients were eligible for analysis, among those 598 (48.7%) received NMBA for 2 days or longer, with a median time from ICU admission to commencement of NMBA therapy of 0 day (IQR 0-1 days). The median duration of NMBA therapy was 2 days (N=789, IQR 1-5). In comparison with standard of care, treatment with NMBA was more frequent in obese (31% vs. 39%, P = 0.03) and diabetic patients (2% vs. 8%, P <0.01) and less frequent in patients with hypertension (52% vs. 46%, P =0.04) or cardiac diseases (21% vs. 14%, P =0.003). Upon commencement of MV, patients who underwent NMBA therapy vs those who did not presented a PaO2/FiO2 of 136.1±69.2 vs. 162.7 ±125.8 (p<0.01), required more often ECMO (10% vs 5.2%, p <0.01) and prone position (25.1% vs 6.2%, p <0.01). Unadjusted 28-day all-cause mortality was similar (58.2% vs. 62.4%, P =0.134) between patients without or with NMBA therapy, respectively, but length of MV (3 days [2-5] vs. 6 [3-12] P <0.01) and ICU stay (8 days [4-14] vs. 13 [7-19] P <0.01) were prolonged. After PS matching, NMBA therapy was strongly associated with 28-day ICU mortality (adjusted HR 3.18, 95% CI 2.65-3.81, P <0.01). CONCLUSION. Use of NMBA in COVID-19 patients requiring MV is associated with increased 28-day mortality, delayed discontinuation of MV and prolonged ICU stay.

Factors associated with mortality in patients with COVID-19 requiring mechanical ventilation: An international cohort study from 139 intensive care unit across 6 continents

Rationale: Patients with COVID-19 commonly develop severe hypoxemic respiratory failure and require invasive mechanical ventilation (MV). The disease burden and predictors of mortality in this population remain uncertain. Methods: Prospective observational cohort study from 139 intensive care units of the international COVID-19 Critical Care Consortium. Patients enrolled from January 14th through November 31st 2020 were included in the analysis. Patient's characteristics and clinical data were assessed. Multivariable Cox proportional hazards analysis was conducted to identify indipendent predictors of mortality within 28 days from commencement of MV. Results: 1578 patients on MV were included into the analysis. Mean±SD age was 59 years±13 and patients were predominantly males (66%). 542 Patients (34.4%) died within 28 days from commencement of MV. Nonsurvivors were slightly older (mean age±SD 62±13 vs. 59±13) and presented more frequently hypertension, chronic cardiac disease and diabetes. Median (IQR) PaO2/FiO2 upon commencement of MV was 96 (68-135) and 111 (81-173) in patients who did not survive vs. survivors, respectively (p=0.04). ECMO (13% vs 25%, p<0.01), inhaled nitric oxide (11% vs 15%, p=0.02) and recruitment manoeauvres (26% vs 31%, p<0.01) were used less frequently in patients who did not survive. Independent risk factors associated with 28-day mortality included age older than 70 years (hazard ratio [HR], 2.83;95% CI, 1.32-6.07), higher creatinine levels upon ICU admission (HR, 1.20;95% CI, 1.03-1.40), and lower pH within 24h from commencement of MV (HR, 0.12;95% CI, 0.02-0.62), while a shorter period (day) from early symptoms to hospitalisation reduced mortality risks (HR, 0.96;95% CI, 0.93-0.99). Conclusions: Our findings from a large international cohort of critically-ill COVID-19 patients on mechanical ventilation emphasises that elderly patients, not promptly admitted to the hospital, and who present higher creatinine levels and acidosis are at higher risk of mortality.

Prone position during veno-venous extracorporeal membrane oxygenation for COVID-19

Objective: Prone positioning for severe acute respiratory distress syndrome (ARDS) is associated with improved outcome. It is unclear whether prone positioning during Venovenous extracorporeal membrane oxygenation (VV ECMO) has survival benefit. The study investigated the impact of prone positioning on survival during VV ECMO support for COVID-19 acute respiratory failure. Methods: An observational analysis of VV ECMO patients using the COVID-19 Critical Care Consortium (COVID Critical) international registry. We used a multi-state survival model to compare the outcomes of patients treated with or without prone positioning during ECMO. Results: There were 213 COVID-19 patients at 67 participating institutions who were supported with VV ECMO from February 19, 2020, to October 31, 2020. Proning was used in 160 patients (75%) before initiation of ECMO and in 67 patients (31%) during ECMO. Prone positioning during ECMO support was associated with reduced mortality (hazard ratio 0.33, 95% CI, 0.15 to 0.73). Conclusions: Our study highlights that prone-positioning during VV ECMO support for refractory COVID- 19-related ARDS is associated with reduced mortality. Given our observational study design, a randomized controlled trial of prone positioning on VV ECMO is needed to confirm these findings.

Characteristics and outcomes of patients with COVID-19 admitted to intensive care units-a report from the global COVID-19 critical care consortium

Objective: SARS-CoV-2 has been reported in almost all countries around the world, and a significant proportion of critically ill patients with COVID-19 require care in the intensive care unit (ICU). There have been few observational cohorts including patients in ICU across different countries. We present summary data from a global critical care consortium. Methods: The COVID-19 Critical Care Consortium/ ECMOCARD (COVID-19 CCC/ECMOCARD) is an ongoing international multicenter observational study including more than 377 hospitals in 53 countries. Clinical and treatment characteristics are collected for patients with COVID-19 requiring ICU admission. Results: Data from 2,670 patients with COVID-19 admitted between January 28 and December 19, 2020 were summarized - 182 from Africa, 516 from Asia, 72 from Oceania, 710 from Europe, 343 from Latin America, and 847 from North America. The median (IQR) age was 59 (49 to 68) years, and 909 (34%) were female. 1,283 (49%) patients had hypertension and 830 (32%) had diabetes mellitus. The time from symptom onset to hospital admission was 7 (3 to 10) days, and 1,360 (51%) patients were admitted to ICU on the same day as hospital admission. Upon ICU admission, the heart rate was 95 (80 to 110) beats/min, respiratory rate was 26 (20 to 33) breaths/ min, and oxygen saturation was 93 (89 to 96) %. Details of arterial blood gases and ICU interventions are tabulated. Amongst survivors, ICU length of stay (LOS) was 13 (7 to 25) days, and hospital LOS was 24 (14 to 39) days. As of 31 December 2020, 1,358 (51%) patients were discharged from ICU, and 1,219 (46%) patients survived to hospital discharge. Among 963 (36%) patients who died in hospital, 837 (87%) died within 28 days of ICU admission. Conclusions: The COVID-19 CCC/ECMO offers a unique global perspective of characteristics and outcomes of patients with COVID-19 requiring admission to the ICU.

In an international collaboration, social media's role in managing a critically ill patient supported veno-venous extracorporeal membrane oxygenation and lessons learned

Objective: To describe a case of a critically ill patient with acute refractory respiratory failure and ARDS managed via a commonly used social media site (WhatsApp) between an International center with ECLS capability and a well-experienced ECLS center-based thousands of miles away in the United States. Methods: A case report. Covid19, a pandemic declared by WHO, ushered in innovation and new technologies, such as video patient conference calls, telemedicine appointments. The impact of social media has also played a considerable role in linking clinicians globally with using platforms such as Zoom or Microsoft Teams to enhance patient care and management. Results: A 41 yr male was admitted to a tertiary hospital in Hyderabad, India, with worsening acute hypoxic respiratory failure, ARDS secondary to influenza pneumonia amidst a devastating pandemic(tested negative for SARS-CoV-2 infection). Tertiary hospital in Hyderabad, being an ECLS capable center but limited by experience in long-term venovenous ECMO management, sought assistance from Allegheny General Hospital, Pittsburgh PA, via a professional media platform LinkedIn. A WhatsApp group was created. The two centers dynamically exchanged 24/7 basis protocols on analgo-sedation, anticoagulation, and veno-venous ECMO weaning, including the critically ill patient's daily care goals. The fruits of 21 days of aggressive VV ECMO support, consideration for an early tracheostomy resulted in a successful trial off ECLS and active pulmonary -physical rehabilitation care placement. The patient returned to the community with an improved physical and mental condition. Conclusions: We describe a unique International collaboration between an ECMO capable center with less experience in managing ECMO and a large ELSO certified center of excellence via a social media platform in the successful outcomes of a critically ill patient ARDS supported by veno venous ECMO. Issues of patient confidentiality and liability, linking of resources are areas of ongoing needed conversation.