• A dedicated veno-venous extracorporeal membrane oxygenation unit during a respiratory pandemic: Lessons learned from covid-19 part I: System planning and care teams

      Dave, Sagar; Shah, Aakash; Galvagno, Samuel; George, Kristen; Menne, Ashley R.; Haase, Daniel J.; McCormick, Brian; Rector, Raymond; Dahi, Siamak; Madathil, Ronson J.; et al. (MDPI AG, 2021-04-02)
      Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic. © 2021 by the authors.
    • A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management

      Shah, Aakash; Dave, Sagar; Galvagno, Samuel; George, Kristen; Menne, Ashley R; Haase, Daniel J; McCormick, Brian; Rector, Raymond; Dahi, Siamak; Madathil, Ronson J; et al. (MDPI AG, 2021-04-21)
      (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.
    • Evidence of SARS-CoV-2-Specific T-Cell-Mediated Myocarditis in a MIS-A Case

      Vannella, Kevin M; Oguz, Cihan; Stein, Sydney R; Pittaluga, Stefania; Dikoglu, Esra; Kanwal, Arjun; Ramelli, Sabrina C; Briese, Thomas; Su, Ling; Wu, Xiaolin; et al. (Frontiers Media S.A., 2021-12-09)
      A 26-year-old otherwise healthy man died of fulminant myocarditis. Nasopharyngeal specimens collected premortem tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Histopathological evaluation of the heart showed myocardial necrosis surrounded by cytotoxic T-cells and tissue-repair macrophages. Myocardial T-cell receptor (TCR) sequencing revealed hyper-dominant clones with highly similar sequences to TCRs that are specific for SARS-CoV-2 epitopes. SARS-CoV-2 RNA was detected in the gut, supporting a diagnosis of multisystem inflammatory syndrome in adults (MIS-A). Molecular targets of MIS-associated inflammation are not known. Our data indicate that SARS-CoV-2 antigens selected high-frequency T-cell clones that mediated fatal myocarditis.
    • EVTM After COVID

      Kundi, Rishi; Morrison, Jonathan; Scalea, Thomas (Orebro University Hospital, 2021-01-01)
    • Mortality Risk Assessment in COVID-19 Venovenous Extracorporeal Membrane Oxygenation

      Tabatabai, Ali; Ghneim, Mira H; Kaczorowski, David J; Shah, Aakash; Dave, Sagar; Haase, Daniel J; Vesselinov, Roumen; Deatrick, Kristopher B; Rabin, Joseph; Rabinowitz, Ronald P; et al. (Elsevier Inc., 2021-01-21)
      Background: 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. Methods: 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. Results: 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. Conclusions: 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. © 2021
    • The Role of a Statewide Critical Care Coordination Center in the Coronavirus Disease 2019 Pandemic-and Beyond

      Galvagno, Samuel M; Naumann, Andrew; Delbridge, Theodore R; Kelly, Melissa A; Scalea, Thomas (Wolters Kluwer Health, 2021-10-28)
      Objective: Public health emergencies, like the coronavirus disease 2019 pandemic, can cause unprecedented demand for critical care services. We describe statewide implementation of a critical care coordination center designed to optimize ICU utilization. To describe a centralized critical care coordination center designed to ensure appropriate intensive care resource allocation. Design: A descriptive case series of consecutive critically ill adult patients. Setting: ICUs, emergency departments, freestanding medical facilities in the state of Maryland and adjacent states, serving a population of over 6,045,000 across a land area of 9,776 sq mi (25,314 km2). Patients: Adults requiring intensive care. Interventions: Consultation with a critical care physician and emergency medical services clinician. Measurements and main results: Number of consults, number of patient movements to higher levels of critical care, and number of extracorporeal membrane oxygenation referrals for both patients with and without coronavirus disease 2019. Over a 6-month period, critical care coordination center provided 1,006 critical care consultations and directed 578 patient transfers for 58 hospitals in the state of Maryland and adjoining region. Extracorporeal membrane oxygenation referrals were requested for 58 patients. Four-hundred twenty-eight patients (42.5%) were managed with consultation only and did not require transfer. Conclusions: Critical care coordination center, staffed 24/7 by a critical care physician and emergency medical service clinician, may improve critical care resource use and patient flow. This serves as a model for a tiered regionalized system to ensure that the demand for critical care services may be met during a pandemic and beyond.