Maintaining Mobility in a Patient Who Is Pregnant and Has COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Case Report.

OBJECTIVE: Mobilization while receiving life support interventions, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO), is a recommended intensive care unit (ICU) intervention to maintain physical function. The purpose of this case report is to describe a novel approach to implementing early mobility interventions for a patient who was pregnant and receiving ECMO while continuing necessary infectious disease precautions because of diagnosed coronavirus disease-19 (COVID-19). METHODS: A 27-year-old woman who was pregnant was admitted to the ICU with COVID-19 and rapidly developed acute respiratory failure requiring 9 days of ECMO support. After a physical therapist consultation, the patient was standing at the bedside by hospital day 5 and ambulating by hospital day 9. RESULTS: The patient safely participated in physical therapy during ICU admission and was discharged to home with outpatient physical therapy follow-up after 14 days of hospitalization. CONCLUSION: Early mobility is feasible during ECMO with COVID-19, and active participation in physical therapy, including in-room ambulation, may facilitate discharge to home. Innovative strategies to facilitate routine activity in a patient who is critically ill with COVID-19 require an established and highly trained team with a focus on maintaining function. IMPACT: Early mobility while intubated, on ECMO, and infected with COVID-19 is feasible while adhering to infectious disease precautions when it is performed by an experienced interdisciplinary team.

Saddle Up: Anticoagulation for Extracorporeal Membrane Oxygenation in a Pulmonary Embolism and Ischemic Stroke-A Case Report.

This case describes an anticoagulation strategy in a postpartum patient on venoarterial extracorporeal membrane oxygenation (VA ECMO) for a pulmonary embolism (PE) with a concurrent ischemic stroke. After receiving systemic lysis, the patient had impending cardiovascular collapse, right heart strain, worsening clinical picture, prompting VA ECMO cannulation and subsequent cautious management of the patient's anticoagulation. There have been no similar cases published describing an ECMO anticoagulation strategy and management for this complex clinical situation. By withholding a heparin bolus and delaying initiation of a heparin drip for 24 hours, thromboelastogram (TEG) R-time and partial thromboplastin time (PTT) could be closely monitored while the patient began to recover.

Novel Utilization of the Bridge During Weaning Off Venoarterial ECMO: The Hoffman Clamp Method.

Standard practice for weaning patients off venoarterial extracorporeal membrane oxygenation (ECMO) occurs by decreasing pump flows until idle flow is achieved. This method is limited in its use because it is difficult to assess a patient's true potential to successfully come off ECMO when supported by idle flow. We have developed a weaning technique that uses a Hoffman clamp on the bridge to decrease blood flow to the patient beyond idle flow. This method was used to wean eight patients from venoarterial ECMO. No patients weaned with this technique required emergent reinstitution of ECMO. The Hoffman clamp technique has allowed us to safely wean patients off ECMO support while maintaining integrity of the circuit.

Improper renal dosing in long-term care facilities.

OBJECTIVES: With advancing age, physiologic changes occur that affect drug metabolism. Possibly the most predictable function decline in geriatric population is renal function. METHODS: The prescribing habits of physicians and the attention given to patient renal function was investigated. Data was collected from two nursing facilities in southeastern Georgia. RESULTS: Based on two models of prescribing habits and using logistic regression estimates, we concluded that physicians do not follow recommendations for dose adjustment of renally excreted medications in these two facilities. CONCLUSION: We recommend that physicians consider evaluating current medications and establishing a base line for renal function and degree of decline.