Cannula associated deep vein thromboses in COVID-19 patients supported with VV ECMO.

BACKGROUND: VV ECMO is increasingly used as a rescue strategy for hypercarbic and hypoxic respiratory failure refractory to conventional management, and more than 14,000 patients with COVID-19 related respiratory failure have been supported with VV ECMO to date. One of the known complications of VV ECMO support is the development of cannula-associated deep vein thromboses (CaDVT). The purpose of this study was to identify the incidence of CaDVT in COVID-19 patients supported with VV ECMO as compared to non-COVID-19 patients. We hypothesized that due to the hypercoagulable state and longer duration of VV ECMO support required for patients with COVID-19, a higher incidence of CaDVT would be observed in these patients. METHODS: This is a single center, retrospective observational study. About 291 non-trauma adult patients who were cannulated for VV ECMO and managed at our institution from January 1, 2014 to January 10, 2022 were included. The primary outcome was the presence of CaDVT 24 h after decannulation in COVID-19 versus non-COVID-19 patients. Our secondary outcome was continued presence of DVT on follow up imaging. CaDVT were defined as venous thrombi detected at prior cannulation sites. RESULTS: Both groups had a high incidence of CaDVT. There was no significant difference in the incidence of CaDVT in COVID-19 patients compared to non-COVID-19 patients (95% vs 88%, p = 0.13). Patients with COVID-19 had an increased incidence of persistent CaDVT on repeat imaging (78% vs 56%, p = 0.03). CONCLUSION: Given the high number of post-decannulation CaDVT in both groups, routine screening should be a part of post ECMO care in both populations. Repeat venous duplex ultrasound should be performed to assess for the need for ongoing treatment given the high incidence of CaDVT that persisted on repeat duplex scans.

Body mass index does not impact survival in COVID-19 patients requiring veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: With the increased demand for veno-venous extracorporeal membrane oxygenation (VV ECMO) during the COVID-19 pandemic, guidelines for patient candidacy have often limited this modality for patients with a body mass index (BMI) less than 40 kg/m2. We hypothesize that COVID-19 VV ECMO patients with at least class III obesity (BMI ≥ 40) have decreased in-hospital mortality when compared to non-COVID-19 and non-class III obese COVID-19 VV ECMO populations. METHODS: This is a single-center retrospective study of COVID-19 VV ECMO patients from January 1, 2014, to November 30, 2021. Our institution used BMI ≥ 40 as part of a multi-disciplinary VV ECMO candidate screening process in COVID-19 patients. BMI criteria were not considered for exclusion criteria in non-COVID-19 patients. Univariate and multivariable analyses were performed to assess in-hospital mortality differences. RESULTS: A total of 380 patients were included in our analysis: The COVID-19 group had a lower survival rate that was not statistically significant (65.7% vs.74.9%, p = .07). The median BMI between BMI ≥ 40 COVID-19 and non-COVID-19 patients was not different (44.5 vs 45.5, p = .2). There was no difference in survival between the groups (73.3% vs. 78.5%, p = .58), nor was there a difference in survival between the COVID-19 BMI ≥ 40 and BMI < 40 patients (73.3, 62.7, p= .29). Multivariable logistic regression with the outcome of in-hospital mortality was performed and BMI was not found to be significant (OR 0.99, 95% CI 0.89, 1.01; p = .92). CONCLUSION: BMI ≥ 40 was not an independent risk factor for decreased in-hospital survival in this cohort of VV ECMO patients at a high-volume center. BMI should not be the sole factor when deciding VV ECMO candidacy in patients with COVID-19.

Advances in Trauma Ultrasound.

Bedside ultrasound assessment has become a routine aspect of care in trauma resuscitation and the critical care setting. Although early research was focused on its role in blunt trauma, it has shown utility in the assessment of penetrating trauma by rapidly identifying hemopericardium and facilitating appropriate intraoperative management. In addition, ultrasound is a reliable test in identifying hemopneumothorax or diaphragmatic injuries. The Rapid Ultrasound in Shock and Hypotension and the Focused Rapid Echocardiographic Examination can diagnose etiologies of shock and guide resuscitation in the critically ill patient. Finally, the role of transesophageal echocardiography is expanding in the trauma setting as more research emerges.

Extracorporeal Life Support for Trauma.

The utilization of extracorporeal membrane oxygenation (ECMO) in trauma mirrors wider trends toward increased utilization of ECMO throughout various forms of critical illness. ECMO can safely be performed on trauma patients with or without anticoagulation. Most of the trauma ECMO cases are for the management of post-traumatic respiratory failure, but they can be used for certain cases of circulatory failure as well. Cannulation of patients for ECMO is technically feasible in the hands of surgeons and intensivists involved in the care of trauma patients. A sound understanding of the ECMO circuit components can help troubleshoot system malfunctions. Emerging technologies may combine extracorporeal circulatory support with endovascular hemorrhage control to prolong the viable survival of exsanguinating patients.

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

Systemic thrombolysis for refractory cardiac arrest due to presumed myocardial infarction.

The empiric usage of systemic thrombolysis for refractory out of hospital cardiac arrest (OHCA) is considered for pulmonary embolism (PE), but not for undifferentiated cardiac etiology [1, 2]. We report a case of successful resuscitation after protracted OHCA with suspected non-PE cardiac etiology, with favorable neurological outcome after empiric administration of systemic thrombolysis. A 47-year-old male presented to the emergency department (ED) after a witnessed OHCA with no bystander cardiopulmonary resuscitation (CPR). His initial rhythm was ventricular fibrillation (VF) which had degenerated into pulseless electrical activity (PEA) by ED arrival. Fifty-seven minutes into his arrest, we gave systemic thrombolysis which obtained return of spontaneous circulation (ROSC). He was transferred to the coronary care unit (CCU) and underwent therapeutic hypothermia. On hospital day (HD) 4 he began following commands and was extubated on HD 5. Subsequent percutaneous coronary intervention (PCI) revealed non-obstructive stenosis in distal LAD. He was discharged home directly from the hospital, with one-month cerebral performance category (CPC) score of one. He was back to work three months post-arrest. Emergency physicians (EP) should be aware of this topic since we are front-line health care professionals for OHCA. Thrombolytics have the advantage of being widely available in ED and therefore offer an option on a case-by-case basis when intra-arrest PCI and ECPR are not available. This case report adds to the existing literature on systemic thrombolysis as salvage therapy for cardiac arrest from an undifferentiated cardiac etiology. The time is now for this treatment to be reevaluated.

Operative Hysteroscopy Intravascular Absorption Syndrome Causing Hyponatremia with Associated Cerebral and Pulmonary Edema.

Operative hysteroscopy intravascular absorption syndrome is an iatrogenic syndrome caused by absorption of hypo-osmolar distension medium during hysteroscopy, which can lead to rapid hyponatremia with resulting cerebral and pulmonary edema. We present a case of a 47-year-old female who underwent hysteroscopic myomectomy at an outpatient ambulatory surgical center who was brought to the emergency department with dyspnea, hypoxia, and altered mental status. Workup showed hyponatremia with cerebral edema on computed tomography of the head and pulmonary edema on chest radiograph. The patient improved after resuscitation with intravenous saline and supplemental oxygen, and she was discharged home the next day.

Bilateral Posterior Native Hip Dislocations after Fall from Standing.

We present a case of bilateral posterior native hip dislocations after a fall from standing. This exceedingly rare diagnosis is classically associated with younger patients whose bones are strong enough to dislocate rather than fracture in the setting of a high-momentum collision. We present an unusual case of an 88-year-old male with native hips who sustained a low-energy collision after falling from standing and was found to have bilateral posterior hip dislocations without associated pelvis or femur fractures.