Aakash Shah1, Sagar Dave2, Samuel Galvagno3, Kristen George2, Ashley R Menne4, Daniel J Haase4, Brian McCormick5, Raymond Rector5, Siamak Dahi1, Ronson J Madathil1, Kristopher B Deatrick1, Mehrdad Ghoreishi1, James S Gammie1, David J Kaczorowski6, Thomas M Scalea2, Jay Menaker7, Daniel Herr2, Ali Tabatabai8, Eric Krause9. 1. Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA. 2. Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA. 3. Program in Trauma, Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA. 4. Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA. 5. Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA. 6. Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. 7. Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA 94143, USA. 8. Program in Trauma, Department of Medicine, Division of Pulmonary and Critical Care, School of Medicine, University of Maryland, Baltimore, MD 21201, USA. 9. Department of Surgery, Division of Thoracic Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA.
Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
(1) Background: COVID-19acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically illpatients.
Authors: Sagar B Dave; Ronald Rabinowitz; Aakash Shah; Ali Tabatabai; Samuel M Galvagno; Michael A Mazzeffi; Raymond Rector; David J Kaczorowski; Thomas M Scalea; Jay Menaker Journal: Perfusion Date: 2022-06-02 Impact factor: 1.581