We describe rapid spread of multidrug-resistant gram-negative bacteria among patients in dedicated coronavirus disease care units in a hospital in Maryland, USA, during May-June 2020. Critical ...illness, high antibiotic use, double occupancy of single rooms, and modified infection prevention practices were key contributing factors. Surveillance culturing aided in outbreak recognition and control.
Limited literature regarding the incidence of cannula-associated deep vein thrombosis (CaDVT) after veno-venous extracorporeal membrane oxygenation (VV ECMO) exists. The purpose of this study was to ...identify the incidence of post decannulation CaDVT and identify any associated risk factors. Forty-eight patients were admitted between August 2014 and January 2016 to the Lung Rescue Unit were included in the study. Protocolized anticoagulation levels (partial thromboplastin time PTT 45-55 seconds) and routine post decannulation DVT screening were in place during the study period. Forty-one (85.4%) patients had CaDVT. Of those with CaDVT, 31 (76%) patients were treated with full anti-coagulation therapy. Thirty-four (76%) patients with right internal jugular (RIJ) cannulation had CaDVT at cannula site. Twenty-five (61%) patients had CaDVT in the lower extremity (18 associated right femoral vein cannulation and 7 left femoral vein cannulation). Eighteen (44%) patients had both upper and lower extremity CaDVT. Overall, patients with CaDVT tended to be older, have a higher body mass index (BMI), and on ECMO longer (p = NS). Mean PTT during time on ECMO between patients that did and did not have CaDVT did not differ. No clinical evidence of pulmonary embolism (PE) was seen.
A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane ...oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators.
A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses.
Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality.
These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.
The purpose of this study was to evaluate survival to hospital discharge for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) when stratified by age. We performed a retrospective ...study at single, academic, tertiary care center intensive care unit for VV ECMO. All patients, older than 17 years of age, on VV ECMO admitted to a specialized intensive care unit for the management of VV ECMO between August 2014 and May 2018 were included in the study. Trauma and bridge-to-lung transplant patients were excluded for this analysis. Demographics, pre-ECMO and ECMO data were collected. Primary outcome was survival to hospital discharge when stratified by age. Secondary outcomes included time on VV ECMO and hospital length of stay (HLOS). One hundred eighty-two patients were included. Median P/F ratio at time of cannulation was 69 56-85, and respiratory ECMO survival prediction (RESP) score was 3 1-5. Median time on ECMO was 319 180-567 hours. Overall survival to hospital discharge was 75.8%. Lowess and cubic spline curves demonstrated an inflection point associated with increased mortality at age >45 years. Kaplan-Meier analysis demonstrated significantly greater survival in patients <45 years of age (p = 0.0001). Survival to hospital discharge for those <age 45 years was 84.6%. Comparatively, survival to hospital discharge for those ≥45 years was significantly lower (67.0%; p = 0.009), as was survival for those 55 years (57.1%; p = 0.001) and patients age ≥65 years (16.7%; p = 0.003). Patients 65 years of age and older treated with VV ECMO support for respiratory failure have low rates of survival to discharge. We have shown that age is an independent predictor of survival to discharge and beginning at age 45 years, in-hospital mortality increases incrementally. Moving forward we believe criteria and scoring systems for VV ECMO should include age as a variable.
Introduction
The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients ...requiring VV ECMO.
Methods
Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians interquartile range (IQR) were reported. A
p
value ≤0.05 was considered statistically significant.
Results
Eighteen patients required VV ECMO during the study period. Median age was 28.5 years (IQR 24–43). Median injury severity score (ISS) was 27 (IQR 21–41); median PaO
2
/FiO
2
(P/F) prior to ECMO cannulation was 61 (IQR 50–70). Median time from injury to cannulation was 3 (IQR 0–6) days. Median duration of ECMO was 266 (IQR 177–379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (
p
= 0.03), longer intensive care unit length of stay (ICU LOS) (
p
< 0.0004), hospital LOS (
p
< 0.000004), and time on the ventilator (
p
< 0.0003). Median time of injury to cannulation was significantly longer in patients who survived to discharge (
p
= 0.01). There was no difference in P/F ratio prior to cannulation (
p
= ns).
Conclusion
We have demonstrated improved outcome of patients requiring VV ECMO following injury compared to historical data. Although shorter time from injury to cannulation for VV ECMO was associated with death, select patients who meet criteria for VV ECMO early following injury should be referred/transferred to a tertiary care facility that specializes in trauma and ECMO care.
Background
Paroxysmal sympathetic hyperactivity (PSH) occurs in a subset of patients with traumatic brain injury (TBI) and is associated with worse outcomes. Sepsis is also associated with worse ...outcomes after TBI and shares several physiologic features with PSH, potentially creating diagnostic confusion and suboptimal management of each. This is the first study to directly investigate the interaction between PSH and infection using robust diagnostic criteria.
Methods
We performed a retrospective cohort study of patients with TBI admitted to a level I trauma center intensive care unit with hospital length of stay of at least 2 weeks. From January 2016 to July 2018, 77 patients diagnosed with PSH were 1:1 matched by age and Glasgow Coma Scale to 77 patients without PSH. Trauma infectious diseases subspecialists prospectively documented assessments corroborating diagnoses of infection. Extracted data including incidence, timing, classification, and anatomical source of infections were compared according to PSH diagnosis. We also evaluated daily PSH clinical feature severity scores and systemic inflammatory response syndrome (SIRS) criteria and compared values for patients with and without confirmed infection, stratified by PSH diagnosis.
Results
During the first 2 weeks of hospitalization, there were no differences in rates of suspected (62%) nor confirmed (48%) infection between patients with PSH and controls. Specific treatments for PSH were initiated on median hospital day 7 and for confirmed infections on median hospital day 8. SIRS criteria could identify infection only in patients who were not diagnosed with PSH.
Conclusions
In the presence of brain injury-induced autonomic nervous system dysregulation, the initiation and continuation of antimicrobial therapy is a challenging clinical decision, as standard physiologic markers of sepsis do not distinguish infected from noninfected patients with PSH, and these entities often present around the same time. Clinicians should be aware that PSH is a potential driver of SIRS, and familiarity with its diagnostic criteria as proposed by the PSH assessment measure is important. Management by a multidisciplinary team attentive to these issues may reduce rates of inappropriate antibiotic usage and misdiagnoses.
The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) in adults with respiratory failure has steadily increased during the past decade. Recent literature has demonstrated variable ...outcomes with the use of extended ECMO. The purpose of this study is to evaluate survival to hospital discharge in patients with extended ECMO runs compared with patients with short ECMO runs at a tertiary care ECMO referral center. We retrospectively reviewed all patients on VV ECMO for respiratory failure between August 2014 and February 2017. Bridge to lung transplant, post-lung transplant, and post-cardiac surgery patients were excluded. Patients were stratified by duration of ECMO: extended ECMO, defined as >504 hours; short ECMO as ≤504 hours. Demographics, pre-ECMO data, ECMO-specific data, and outcomes were analyzed. One hundred and thirty-nine patients with respiratory failure were treated with VV ECMO. Overall survival to discharge was 76%. Thirty-one (22%) patients had extended ECMO runs with an 87% survival to discharge. When compared with patients with short ECMO runs, there was no difference in median age, body mass index (BMI), body surface area (BSA), partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) (P/F), and survival to discharge. However, time from intubation to cannulation for ECMO was significantly longer in patients with extended ECMO runs. (p = 0.008). Our data demonstrate that patients with extended ECMO runs have equivalent outcomes to those with short ECMO runs. Although the decision to continue ECMO support in this patient population is multifactorial, we suggest that time on ECMO should not be the sole factor in this challenging decision.
The use of venovenous extra corporeal membrane oxygenation (VV ECMO) for acute respiratory failure (ARF)/acute respiratory (ARDS) has increased since 2009. Specialized units for patients requiring VV ...ECMO are not standard and patients are often cohorted with other critically ill patients. The purpose of this study was to report the outcome of adult patients admitted in 2015 to the lung rescue unit, which, to our knowledge, is the first intensive care unit in the United States that has been specifically created to provide care for patients requiring VV ECMO.
Data were collected on all patients admitted to the lung rescue unit on VV ECMO between January 1, 2015, and December 31, 2015. Demographics, medical history, pre-ECMO data, indication for VV ECMO as well as duration of ECMO and survival to decannulation and discharge were recorded. Means (± standard deviation) and medians (interquartile range IQR) were reported when appropriate.
Forty-nine patients were enrolled. Median age was 48 years (IQR, 32-57). Median PaO2/FIO2 ratio before cannulation was 66 (IQR, 53-86). Median ventilator days before cannulation was 2 (IQR, 1-4). Median time on VV ECMO for all patients was 311 hours (IQR, 203-461). Thirty-eight (78%) patients were successfully decannulated with 35 (71%) patients surviving to hospital discharge.
The use of VV ECMO for ARF/ARDS is increasing. We have demonstrated that a dedicated multidisciplinary intensive care unit for the purpose of providing standardized care with specialized trained providers can improve survival to discharge for patients that require VV ECMO for ARF/ARDS.
Therapeutic, level V.
The purpose of this study was to evaluate the incidence of continuous renal replacement therapy (CRRT) in patients supported with veno-venous extracorporeal membrane oxygenation (VV ECMO). Secondary ...outcomes included mortality and the need for hemodialysis on hospital discharge. We performed a retrospective cohort study of all patients admitted to a specialty unit on VV ECMO between August 2014 and August 2018. Trauma and bridge to lung transplant patients were excluded. Demographics, comorbidities, pre-ECMO, ECMO, and renal replacement therapy outcome data were collected and analyzed with parametric and nonparametric statistics as appropriate. One hundred eighty-seven patients were enrolled. Median age was 45 (32, 55) years; precannulation pH, 7.21 (7.12, 7.30); PaO2/FiO2 ratio, 69 (56, 86); respiratory ECMO survival prediction score, 3 (0, 5); sequential organ failure assessment score, 12 (10, 14); and creatinine, 1.45 (0.93, 2.35) mg/dL. Overall survival to hospital discharge was 74.6%. Ninety-four (50.3%) patients had CRRT while on VV ECMO. Median time on CRRT was 14 (7, 21) days with 59 (61.4%) of these patients surviving to hospital discharge. Four (6.8%) patients, none with documented preexisting renal disease, required hemodialysis on discharge. CRRT patients had a statistically higher precannulation sequential organ failure assessment score, creatinine, total bilirubin and lower precannulation pH, respiratory ECMO survival prediction score, and platelet count compared with non-CRRT patients. Survival was 61.4% vs. 88.1% (p < 0.001). More than half of our patients received CRRT while on VV ECMO. CRRT was used in a more critically ill patient population and was associated with higher in-hospital mortality. However, for patients who survived to hospital discharge, the majority have full renal recovery.
PDF
