Predictors of Respiratory Support Use in Emergency Department Patients With COVID-19-Related Respiratory Failure.

BACKGROUND: Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support. METHODS: We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED. RESULTS: A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold. CONCLUSIONS: High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

Implementing Automated Prone Ventilation for Acute Respiratory Distress Syndrome via Simulation-Based Training.

BACKGROUND: Prone position ventilation (PPV) is recommended for patients with severe acute respiratory distress syndrome, but it remains underused. Interprofessional simulation-based training for PPV has not been described. OBJECTIVES: To evaluate the impact of a novel interprofessional simulation-based training program on providers' perception of and comfort with PPV and the program's ability to help identify unrecognized safety issues ("latent safety threats") before implementation. METHODS: A prospective observational quality improvement study was done in the medical intensive care unit of an academic medical center. Registered nurses, physicians, and respiratory therapists were trained via a didactic session, simulations, and structured debriefings during which latent safety threats were identified. Participants completed anonymous surveys before and after training. RESULTS: A total of 73 providers (37 nurses, 18 physicians, 18 respiratory therapists) underwent training and completed surveys. Before training, only 39% of nurses agreed that PPV would be beneficial to patients with severe acute respiratory distress syndrome, compared with 96% of physicians and 70% of respiratory therapists (P < .001). Less than half of both nurses and physicians felt comfortable taking care of prone patients. After training, perceived benefit increased among all providers. Comfort taking care of proned patients and managing cardiac arrest increased significantly among nurses and physicians. Twenty novel latent safety threats were identified. CONCLUSION: Interprofessional simulation-based training may improve providers' perception of and comfort with PPV and can help identify latent safety threats before implementation.

Pediatric VAD Discharge and Outpatient Care.

The advancement of pediatric ventricular assist devices (VADs) has enabled pediatric centers to discharge VAD patients home and integrate them back into their communities. Creating standard work flow processes to ensure the educational needs of the patient, family, and community are met will enable programs to successfully manage VAD patients at home. Utilizing multidisciplinary teams to support these patients while hospitalized will greatly contribute to the patients and families readiness for discharge. Defining mutual goals and expectations for patients, families, and the VAD team will promote a superior discharge and outpatient experience.

Acquired von Willebrand Syndrome: An Under-Recognized Cause of Major Bleeding in the Cardiac Intensive Care Unit.

BACKGROUND: Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit. METHODS: Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children's National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis. RESULTS: Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient. CONCLUSIONS: Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.

Simulation for neonatal extracorporeal membrane oxygenation teams.

Extracorporeal membrane oxygenation (ECMO) is a highly technical and complex method of life support. Patient and circuit emergencies on ECMO are rare, but in these cases, prompt and correct actions to address the crisis are needed to prevent morbidity and mortality. ECMO simulation programs have gained popularity in recent years, as they provide a standardized educational experience for all members of the inter-professional care team. In addition to providing a context in which to solidify knowledge of ECMO support, participants are also able to focus on vital technical and behavioral skills that are not highlighted in other training methodologies. ECMO simulation can also be used for quality improvement, clinical and educational research, and assessment/credentialing. Multi-organizational international collaboratives have formed, and are working to standardize ECMO education training across institutions; simulation will play an essential role in this process.

Extracorporeal fetal support: a new animal model with preservation of the placenta.

BACKGROUND: Previous models of support for premature sheep fetuses have consisted of cesarean delivery followed by catheterization of umbilical or central vessels and support with extracorporeal membrane oxygenation (ECMO). The limitations of these models have been insufficient blood flow, significant fetal edema, and hemorrhage related to anticoagulation. METHODS: We performed a gravid hysterectomy on 13 ewes between 135 and 145days gestational age. The uterine vessels were cannulated bilaterally and circulatory support was provided via ECMO. Successful transition was defined as maintenance of fetal heart rate for 30minutes after establishing full extracorporeal support. Circuit flow was titrated to maintain mixed venous oxygen saturation (SvO2) of 70-75%. RESULTS: Seven experiments were successfully transitioned to ECMO, with an average survival time of 2hours 9minutes. The longest recorded time from cannulation to death was 6hours 14minutes. By delivering a circuit flow of up to 2120ml/min, all but one of the transitioned uteri were maintained within the desired SvO2 range. CONCLUSION: We report a novel animal model of fetal ECMO support that preserves the placenta, mitigates the effects of heparin, and allows for increased circuit flow compared to prior techniques. This approach may provide insight into a technique for future studies of fetal physiology.

Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey.

OBJECTIVE: The objective of this study was to determine current practices of anticoagulation in patients on extracorporeal membrane oxygenation. DESIGN: Internet-based cross-sectional survey distributed between November 2010 and May 2011. SETTING: Extracorporeal Life Support Organization-registered extracorporeal membrane oxygenation centers internationally. PARTICIPANTS: : Extracorporeal membrane oxy genation medical directors and coordinators. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 121 responses from extracorporeal membrane oxy genation medical directors and coordinators at 187 Extracorporeal Life Support Organization centers with access to the survey. Eighty-four of 117 (72%) respondents reported having a written institutional extracorporeal membrane oxy genation protocol for both anticoagulation and blood product management at their institutions. Sixty-nine of 117 (59%) respondents reported use of tip-to-tip or partially heparin-bonded circuits. Unfractionated heparin was used at all centers; only 8% of respondents indicated use of alternative anticoagulation medications in the six months prior to the survey. The preferred method of anticoagulation monitoring was the serial measurement of activated clotting time, as reported by 97% of respondents. In this survey, 82% of respondents reported antithrombin III testing, 65% reported anti-factor Xa testing, and 43% reported use of thromboelastography during extracorporeal membrane oxy genation. Goal ranges for these three tests and interventions triggered by out-of-range values were found to be variable. CONCLUSIONS: Extracorporeal membrane oxy genation anticoagulation management policies vary widely by center. The majority of extracorporeal membrane oxy genation programs employ activated clotting time as the preferred anticoagulation monitoring tool. The coagulation system is also monitored using more specific markers such as antithrombin III, anti-factor Xa, and thromboelastography by a large number of centers. Future research is needed to elucidate optimal anticoagulation management and improve outcomes.