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| ABSTRACT |
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| Year : 2022 | Volume
: 6
| Issue : 5 | Page : 21-31 |
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Abstract
| Date of Web Publication | 04-Feb-2023 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2543-1854.369157
How to cite this article:
. Abstract. Saudi Crit Care J 2022;6, Suppl S1:21-31 |
| Abstract 1 | |  |
| Association of Pre-Intubation Non-Invasive Mechanical Ventilation and the Hospital Mortality of Critically Ill COVID-19 Patients Received Extracorporeal Membrane Oxygenation Support: A Retrospective Cohort Study | | |
Saeed Alghamdi1, Ali Albagshi1, Mada Alghamdi1, Hassan S.Alkhalaf1, Ahmad F. Mady1,2, Mohammad Alodat1, Waleed Aletreby1, Razan S. Albreak1, Basel H. Almuabbadi1, Huda A. Mhawish1, Moayed Alshowaish1
1Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia, 2Tanta University Hospital, Tanta, Egypt
E-mail: [email protected]
Introduction: Decision-making is crucial for optimal patient management, particularly for individuals with life-threatening respiratory failure. This includes an appropriate selection for patients requiring ECMO support with a favorable outcome. The length of noninvasive mechanical ventilation (NIV) duration before the commencement of ECMO therapy may influence patient outcomes. The overwhelmed institutions during the COVID-19 pandemic and the associated limited mechanical ventilator capacity obligate healthcare providers to overuse the NIV with maximum settings for a longer course before intubation than we used to do before the pandemic. Uncertainly, NIV duration is thought to be associated with mortality risk in those with life-threatening respiratory failure. A clinically relevant threshold exists for estimating the maximal time for NIV that indicates poor outcome; therefore, there is an urgent need for more high-quality research to understand the risk of antecedent NIV time pre-ECMO on patient outcome.[1]
Objective: This study aims to determine the association between the length of pre-intubation non-invasive mechanical ventilation and hospital mortality following ECMO support.
Methodology: A retrospective, observational study of patients who received ECMO in King Saud Medical City between 1 January 2020 and 1 October 2022. The cohort includes all patients who received ECMO and were admitted to the ICU. Patients were divided according to the use of NIV before ECMO into two groups: patients who received NIV before intubation and those who never received it before intubation.
Outcomes: The primary outcome is hospital mortality, while the secondary outcomes include ICU length of stay and ventilator-free days (VFD). Additionally, we explored hospital mortality if NIV was used for three or less days compared to more than three days.
Results: 61 patients were included, the mean age was 39.7 (±12.6), and 43 (70.5%) males. 37 patients received NIV before ECMO for a different course duration, while 24 were immediately intubated upon hospitalization. Both groups were comparable demographically, as presented in [Table 1]. In the NIV group, 20 (54.1%) patients died compared to 14 (58.3%) in the immediate intubation group. No statistically significant difference in mortality (95% CI: 20% to 30%; p = 0.7). ICU LOS for the NIV and Intubation groups were 36.5 (± 25.5) and 35.7 (± 27.6), respectively, with no significant difference (95% CI: -14.5 to 13; 0.7). The NIV group had a longer VFD of 10.9 (± 17.3) compared to 7 (± 15.1) for the intubation group with no statistical significance (95% CI: -12.7 to 4.8; 0.4) [Table 2]. In a subgroup analysis of the NIV group, 27 patients received NIV for three or less days, out of which 15 patients died (56%), whereas ten patients received NIV for more than three days, out of which 5 patients died (50%). No statistical significance was observed (95% CI: 31% to 42%; p = 0.8) [Table 3]. | Table 1: Characteristics of patients receiving noninvasive mechanical ventilation compared to those who did not
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 | Table 2: Outcomes of patients receiving noninvasive mechanical ventilation compared to those who did not
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 | Table 3: Subgroup analysis of patients who receive noninvasive mechanical ventilation with different outcomes related to noninvasive mechanical ventilation days
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Conclusion: Days on NIMV before endotracheal intubation should be cautiously discussed on selecting COVID-19 patients for ECMO support until high-quality research exists enough to reach a solid conclusion.
Keywords: COVID-19, ECMO, mechanical ventilation, non-invasive, pre-intubation
| Reference | | |
- Ahmad Q, Green A, Chandel A, Lantry J, Desai M, Simou J, et al. Impact of noninvasive respiratory support in patients with COVID-19 requiring V-V ECMO. ASAIO J 2022;68:171-7.
| Abstract 2 | | |
| Case Report: Prolonged VV ECMO (135 days) Support in a Patient with Severe ARDS Secondary to COVID-19 | | |
H. Alziadey, Ismail Alenezi, W. Alqassem, M. Rajab
Prince Mohamed Bin Abdul-Aziz Hospital, Riyadh, Saudi Arabia
E-mail: [email protected]
Background: During the COVID-19 pandemic, venovenous extracorporeal membrane oxygenation (VV ECMO) has been shown to be effective in selected cases of severe ARDS refractory to Conventional therapy. Despite increasing reports of successful prolonged use of VVECMO in COVID-19 (more than 21 days), the safety and length of treatment beyond which native lung recovery is possible are still to be defined. We report a case of prolonged VV ECMO duration in a patient with severe COVID-19 (135 days, 3228 hours).
Case Presentation: A 40-year-old man, previously healthy, was admitted to the hospital with a cough, fever, severe shortness of breath, and desaturation. COVID-19 tested positive. He was intubated after non-invasive ventilation failure and was persistently hypoxic despite maximum Conventional ARDS management. He was referred to us within 24 hours of intubation, femorojugular VV ECMO was commenced, and the patient was retrieved to our ECMO center by Airplane. After initial stabilization, a percutaneous bedside tracheostomy was done on Day 19, and he failed the first decannulation trial on Day 73. The ECMO circuit was changed ten times during his course due to oxygenator failure, severe consumption, and hemolysis. Eventually, he was weaned off and decannulated after 135 days on ECMO, discharged from the ICU at D 164, and discharged from the hospital at D 212. He left the hospital fully conscious, requiring further rehabilitation due to generalized muscle weakness.
Conclusion: While providing advanced and complex therapeutic interventions like ECMO during a pandemic is challenging due to resource constraints; it is more difficult when an ECMO patient's course is lengthy, and the probability of futility becomes the main driver of moral stress. However, this case shows that native lung recovery is still possible after more than four months of VV ECMO support, as long as the risk of complications from ECMO is kept to a minimum and reasonable rehabilitation efforts are kept up.
Keywords: Long-term ECMO, prolonged ECMO
| Abstract 3 | | |
| Extracorporeal Membrane Oxygenation for Hemodynamic Support of Refractory Ventricular Tachycardia | | |
Tarek Mohamed Tantawy, Rawan Alghamdi, Mohammed Anwar Aboughanima, Yousif Abdelfattah Elshoura
Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
E-mail: [email protected]
Introduction: Background Ventricular tachycardia refractory to pharmacological therapy or electrical cardioversion is a complex clinical situation. It can affect organ perfusion and lead to acute decompensation and multi-organ failure that may lead to death. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide circulatory support in patients with drug-refractory ventricular tachycardia. We report our experience using VA-ECMO for patients with VT storm following recent myocardial infarction going for the procedure, including device insertion or VT ablation at our center.
Methodology: Case summary In our case report, we describe the course of two patients (40 and 45 years old) who had a late presentation with acute myocardial infarction treated with percutaneous coronary. Unfortunately, frequent recurrent attacks of ventricular tachycardia refractory to electrical shock and antiarrhythmic drugs, including amiodarone and lidocaine, complicated their hospital course.
Result: They became hemodynamically unstable, and the decision was made to insert VA ECMO for stabilization. They were supported on VA ECMO for around 3-4 weeks; during this period, they had on-and-off attacks of ventricular tachycardia. Eventually, with the ECMO support, one patient underwent ICD insertion, and no more arrhythmia was observed; the other patient underwent ventricular ablation; however, the arrhythmia didn't settle until he was started on sotalol. After the resolution of the VT attacks, the two patients were weaned off from ECMO, remained stable, and were discharged home within two weeks.
Conclusion: VA ECMO is life-saving in patients with refractory or recurrent ventricular arrhythmias. ECMO provides hemodynamic support allowing time for VT management, such as revascularization of ischemic myocardium, VT ablation attempts, or pharmacological rhythm control.
| Abstract 4 | | |
| Extracorporeal Membrane Oxygenation in Pregnant Women: Case Series | | |
Ayed Aboud Abu Jaflah, Marwa Ali Alanazi, Ziad Ali Alamri, Elham Saeed Aljuaid, Adel Ali Alkenani, Waleed Aletreby, Huda A. Mhawish, Rayan Alshaya, M. Saleh, Saima Akhtar, Zohdi S. Farea
Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
E-mail: [email protected]
Introduction: Extracorporeal membrane oxygenation (ECMO) is a supportive treatment that provides circulatory and ventilatory support as a bridge to organ recovery. Extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women.[1],[2] Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Increasing evidence supports the ECMO use as a bridge to babies throughout pregnancy and attests to its favorable outcomes.[3],[4] These case series aim to report maternal and fetal complications and outcomes associated with peripartum ECMO.
Methodology: A descriptive analysis of 7 patients as a case series who required ECMO support in pregnancy and postpartum at KSMC, Riyadh, Saudi Arabia, between January 2020 and January 2022.
Result: Our case series includes seven patients with a median age of 35 years (24–42 years), five of them are pregnant at the time of ECMO, and two are postpartum. Two were in the second trimester, and three were in the third trimester. All patients were COVID-19 positive, and all patients had ARDS. In addition, six patients received venovenous ECMO support, and one required VA ECMO due to cardiogenic shock. All patients were successfully decannulated from ECMO; however, the required days of ECMO range from 6 - 48 days. Two of the five pregnant patients delivered usually, and three underwent cesarean sections. All newborns are alive post-delivery. All mothers survived home discharge with their babies except one who developed Intra uterine fetal death and spontaneously aborted in ICU [Table 1]. | Table 1: Descriptive analysis of COVID-19 pregnant ladies during extracorporeal membrane oxygenation
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Conclusion: Our case series demonstrates a promising outcome for pregnant ladies with severe ARDS and preserving pregnancy in experienced ECMO centers.
Keywords: ARDS, COVID-19, ECMO, peripartum, pregnancy
| References | | |
- Fiore A, Piscitelli M, Adodo DK, Thomas C, Dessap AM, Bagate F, et al. Successful use of extracorporeal membrane oxygenation postpartum as rescue therapy in a woman with COVID-19. J Cardiothorac Vasc Anesth 2021;35:2140-3.
- Barrantes JH, Ortoleva J, O'Neil ER, Suarez EE, Beth Larson S, Rali AS, et al. Successful treatment of pregnant and postpartum women with severe COVID-19 associated acute respiratory distress syndrome with extracorporeal membrane oxygenation. ASAIO J 2021;67:132-6.
- Larson SB, Watson SN, Eberlein M, Simmons JS, Doerschug KC, Leslie KK. Survival of pregnant coronavirus patient on extracorporeal membrane oxygenation. Ann Thorac Surg 2021;111:e151-2.
- Tambawala ZY, Hakim ZT, Hamza LK, Al Rayes M. Successful management of severe acute respiratory distress syndrome due to COVID-19 with extracorporeal membrane oxygenation during mid-trimester of pregnancy. BMJ Case Rep 2021;14:e240823.
| Abstract 5 | | |
| Veno-Arterial Extracorporeal Membrane Oxygenation and Levosimendan in Aluminum Phosphide-Induced Cardiogenic Shock | | |
Bassant Abdelazeim, Mahmoud Saad, Ahmed Said, Mohamed Yosri, Nermin Zawilla1, Akram Abdelbary
Departments of Critical Care and 1Toxicology and Occupational Medicine, Cairo University Hospitals, Cairo, Egypt
E-mail: [email protected]
Background: Patients with aluminum phosphide-induced severe circulatory and cardiogenic shock represent a major challenge in the absence of specific antidotes. Conventional therapeutic approaches are only sometimes successful and have high mortality rates. In limited studies, VA-ECMO support alone provided mortality benefits; however, early successful weaning is desirable. Levosimendan efficiently enhances myocardial function, facilitating VA-ECMO weaning success. In this study, we describe the efficiency of levosimendan in aluminum phosphide-intoxicated patients receiving VA-ECMO support.
Case Presentation: We report three female patients, aged 17, 32, and 15 years, referred to our center from the toxicology department with aluminum phosphide-induced cardiotoxicity and refractory cardiogenic shock. Given the escalating doses of noradrenaline and adrenaline, the depressed ejection fraction below 10%, the velocity time integral (VTI) of 2-4 cm, and the ventricular arrhythmias, they were connected to VA-ECMO for hemodynamic support. After a failed weaning trial of VA-ECMO within 100 and 102 hours from ingestion, the first two patients received levosimendan as adjuvant therapy, while the third received it 60 hours after ingestion due to persistently depressed cardiac function. Cardiac contractility recovered with decreasing doses of vasopressors in all three patients who were weaned successfully 24, 48, and 68 hours after the initiation of levosimendan with a total ECMO run of 164, 138, and 108 hours, respectively. The first two patients had average ejection fractions and good functional capacities on discharge. However, the third patient died 24 hours after decannulation due to reperfusion injury and multi-organ failure. None of the patients suffered adverse events attributed to levosimendan.
Conclusion: Levosimendan may represent a potential treatment option for aluminum phosphide-induced cardiogenic shock, improving contractility and accelerating VA-ECMO weaning. Further studies are still required.
| Abstract 6 | | |
| Rapid Establishment of the ECMO Program during the COVID-19 Pandemic | | |
Manaa Al Yami, Khalid Asiri, Abdulrahman Al Yami, Ahmed Al Haidar, Hasan Massloom, Islam Seada
King Khalid Hospital, Najran, Saudi Arabia
E-mail: islamsada2[email protected]
Introduction: Extracorporeal membrane oxygenation (ECMO) is used to manage patients with refractory cardiogenic shock or acute respiratory failure. Because of the COVID-19 pandemic in 2020, the number of cases and centers providing adult extracorporeal membrane oxygenation (ECMO) increased.[1],[2],[3]
Objective: Analysis of our experience.
Methodology: As ad hoc support, we quickly developed and implemented an organized ECMO program at King Khalid Hospital. The program provided care for patients within the ICU from March 2020 until now. It started with preparing policies and strategies, followed by training a multidisciplinary team of doctors, nurses, RT specialists, and perfusionists, then starting the service with continuous training and improvement, including workshops, hands-on training, and lectures. Also, we had great support from the MOH ECMO team for training and supervision. Finally, we became an ELSO center, the 4th center in Saudi Arabia, and designated this year as a silver-level ELSO center of excellence award.
Results: 85 patients were treated with venovenous and venoarterial ECMO, with a survival rate to decannulation of 75% and a survival rate to intensive care unit discharge of 55%. All these patients are initiated and managed by our ECMO team; we have 20 cases of retrieval in which we used air, ground, or both. Complications included hemothorax in six patients, heparin-induced thrombocytopenia in three patients, oxygenator failure in three cases, oozing from cannulation sites in 10 cases, oral cavity bleeding in four cases, from a tracheostomy site in another four cases, and renal impairment or failure in 39% of cases.
Conclusion: The findings suggest that a rapidly developed ECMO program for safe services with outcomes comparable to those described in the literature is feasible. Key components are an institutional commitment, a physician champion, dedicated leadership, a multidisciplinary team, and organized training.
Keywords: ECLS, ECMO, new center
| References | | |
- MacLaren G, Combes A, Bartlett RH. Contemporary extracorporeal membrane oxygenation for adult respiratory failure: Life support in the new era. Intensive Care Med 2012;38:210-20.
- Shekar K, Mullany DV, Thomson B, Ziegenfuss M, Platts DG, Fraser JF. Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: A comprehensive review. Crit Care 2014;18:219.
- Rabie AA, Azzam MH, Al-Fares AA, Abdelbary A, Mufti HN, Hassan IF, et al. Implementation of new ECMO centers during the COVID-19 pandemic: Experience and results from the Middle East and India. Intensive Care Med 2021;47:887-95.
| Abstract 7 | | |
| Point-of-Care Ultrasound to Detect Thrombus Formation within the Extracorporeal Circuit | | |
Youssef Quizad, Grace Van Leeuwen, Elisabetta Giacomini, Andrew Duward
CICU, Sidra Medicine, Doha, Qatar
E-mail: [email protected]
Introduction: Circuit thrombosis (CT) is a potentially serious complication of Extracorporeal membrane oxygenation (ECMO) and can lead to ineffective ECMO flow and its adverse consequences. CT can be assessed by external circuit inspection or biochemical tests such as plasma-free Hb and D-Dimers. We describe the use of Point-of-care ultrasound (POCUS) to demonstrate cannula patency and thrombus.
Methodology: We used Sonosite HSL25x Intraoperative Probe 6 - 13 MH, scanning the cannula longitudinally and storing the images in the USB drive. We provide an example of a 10 kg patient with cardiomyopathy on LVAD support using the Xenios DP3 centrifugal pump (1/4-inch circuit).
Result: The images [Figure 1] demonstrated real-time, non-invasive thrombus detection by POCUS in the return limb of the circuit. | Figure 1: Real time non-invasive thrombus detection by POCUS in the return limb of the circuit
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Conclusion: POCUS provides a simple and accurate manner to assess circuit thrombus on ECMO or LVAD.
| Abstract 8 | | |
| Optimizing High Flow Nasal Cannula in Patient with Respiratory Failure to Improve Oxygenation thus Avoiding Escalation to More Invasive Support in KFAFH – Jeddah | | |
Fouad Hamid Almutairi
Department of Critical Care, KFAFH, Jeddah, Saudi Arabia
E-mail: [email protected]
Introduction: A heated humidifier high-flow nasal cannula provides oxygen and positive airway pressure to hypoxic and respiratory distress patients. It may reduce the need for Non-Invasive ventilation or Invasive ventilation and provide support post-extubation. In children, at the high flow of 2 L/kg/min using appropriate nasal prongs, a positive distending pressure of 4.8 cmH20 is achieved, while in adults, there is a change of 1 cmH20 of positive pressure in each 10 L/min. flow rate. This improves functional residual capacity, thereby reducing the work of breathing minimizing Oxygen dilution, and washing out dead pharyngeal space. This process improvement will pave the way to review the indications in adult and pediatric patients. In this study, the main indication of HFNC for adults is hypoxemic respiratory failure due to COVID-19 pneumonia, post-extubation, and acute pulmonary edema. For pediatric patients, the most common indications are bronchiolitis, bacterial/viral pneumonia, and bronchial asthma.
Methodology: The data were collected using the HFNC checklist and ISBAR (Introduction Situation Background Assessment Recommendation). Hand over tool from January to October 2022. Patient data from all age groups were collected with the criteria of 1. Weaned off from HFNC and remained admitted in the ward and/or discharged home; 2. Failed from HFNC and hooked to NIV and/or mechanically intubated. In the schematic diagram of patients treated with HFNC, there was a total of 107 patients enrolled in the study, and 70 of those patients were weaned successfully from HFNC, while 37 patients failed and were either intubated or hooked to NIV.
Result: Based on the data collected using our ISBAR tools from January to October 2022, 107 patients used HFNC as treatment; 70 were weaned off from HFNC and continuously received oxygen therapy, while 37 patients failed to be weaned in HFNC. Instead, they were either hooked to CPAP/BiPAP or mechanically intubated. January and February 2022 showed the lowest percentage of successful treatment to HFNC, 50%, and 45%, respectively, and from June – October, the success rate of using HFNC as treatment increased from 70 – 77%. These are the months we started HFNC as a treatment for pediatric patients with bronchiolitis. This was also when the nasal interface for our pediatric patients became available at any size, and more healthcare workers were trained in this modality. New policy and procedure guidelines were also implemented, and we maximized the use of our available Airvo-2 and inspired O2 Flo HFNC machines [Figure 1]. | Figure 1: Percentage rate of Patient successfully weaned and failed weaned off from HFNC in KFAFH - Jeddah
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Conclusion: High-flow nasal cannulas in managing acute respiratory failure became popular and a trend in all hospitals, especially during COVID-19, where most of the patients are being treated for acute respiratory failure. However, healthcare workers (doctors, nurses, and respiratory therapists) need the training to familiarize themselves with these new modalities. Many factors affect this treatment's success, including the patient's age and diagnosis.
| Abstract 9 | | |
| A Tale of Three Pumps and a Mechanical Heart | | |
Tarek Elsayed Omran, Cornilia Carr, Lateef Wani, Imad Mahmoud, Rula Taha, Bassam Shouman, Amr Salah, Abdelaziz Alkhulaifi
Hamad Hospital, Heart Hospital, Doha, Qatar
E-mail: [email protected]
Introduction: Left ventricular assist device (LVAD) implantation is an established treatment for end-stage heart failure as a destination therapy or bridge to transplantation. The underlying diagnosis is dilated cardiomyopathy in most patients, but ischemic cardiomyopathy represents about 30% of the total. Temporary mechanical circulatory support (tMCS) devices could bridge patients to more definitive therapeutic modalities, and so on, a venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, some patients may experience deterioration in cardiovascular functions that requires re-cannulation after weaning from VA-ECMO. In addition, the result of performing concomitant cardiac procedures with LVAD implantation remains undefined due to the small number of reported cases.
Methodology: A 43-year-old man (smoker) presented with chest pain, electrocardiogram (ECG) changes suggesting postero-lateral myocardial infarction, and high serum troponin levels. He then suffered a cardiac arrest (ventricular fibrillation). When he failed to have a return of spontaneous circulation, as per our hospital protocol, he was evaluated and accepted for resuscitation with tMCS. A CentriMag™ Circulatory Support System (Abbott Laboratories, USA) was introduced through the left femoral artery and the right femoral vein. The cardiorespiratory collapse was reversed by tMCS via the CentriMag™ within a short time (12 min) with a 3.5 L/min blood flow.
Result: The patient was weaned the first time after fulfilling our criteria, but 8 hours later, he collapsed and needed to re-insert ECMO again. Our patient underwent ECMO three times, with the last subclavian artery being used to initiate ECMO, with iatrogenic Type A aortic dissection. The decision to take the patient for concomitant surgery for LVAD insertion and repair of type A dissection. The patient was weaned off cardiopulmonary bypass relatively smoothly after de-airing the heart and the pump. The patient stayed in the intensive care unit for two weeks, then in the ward for 4 weeks, and was discharged home. Four months post-LVAD, his functional status is excellent and independent.
Conclusion: We have shown that tMCS could have more than one reason for failure and could be complicated by aortic dissection. Implantation of long-term MCS and dissection repair could provide the desired outcome.
| Abstract 10 | | |
| The Use of Veno-Arterial Extracorporeal Membrane Oxygenation in High-Risk Percutaneous Cardiac Intervention Procedures: A Prospective Case-Control Study | | |
Hany Z. Mohamed, Alia Abd El Fatah, Helmy El Ghawaby, Akram Abdelbary, Wael Samy
Department Critical Care, Cairo University, Cairo, Egypt
E-mail: [email protected]
Introduction: Veno-arterial ECMO use is increasing with favorable outcomes and advantages in high-risk PCI. It supports hemodynamics and maintains the perfusion to various organs, especially the brain, that may be compromised due to existing complications during the procedure.
Objectives: The study is designed to assess the outcomes of using V-A ECMO on PCI procedures.
Methods: A prospective interventional study on patients with viable ischemic myocardium, syntax score >22. Patients with scarred myocardium and those who refused CABG were excluded. In addition, hemodynamic support will be done during elective high-risk PCI procedures by connecting patients on V-A ECMO (Fem-Fem configuration), compared to patients with high-risk PCI without mechanical circulatory support.
Results: In a case-control study, 20 patients were identified; 10 patients underwent high-risk PCI with V-A ECMO support (intervention group), and ten patients underwent high-risk PCI without V-A ECMO support (control group). In the intervention group, the mean age was 59, and the mean EF was 30.9%. Five people with diabetes, six hypertensives, four patients with left main LM lesions, an average of 3.9 stents, one patient with VT during PCI, six patients needing vasopressors and inotropic support, seven patients requiring surgical decannulation, three patients using a vascular closure device, four patients needing invasive mechanical ventilation during PCI, eight patients having complete revascularization in one session, ten patients being successfully weaned off V-A ECMO support just after PCI, average ECLS duration of 2.5 hours, and all successfully discharged home within a week.
Conclusion: V-A ECMO provided practical support to the hemodynamics during high-risk PCI, minimizing complications during the procedure and maintaining perfusion. However, high-quality studies are needed to confirm the benefits of ECMO over conventional treatment.
| Abstract 11 | | |
| ECMO as a Life-Saving Modality in Near-Fatal Asthma, the Najran Experience | | |
Mana Al Yami, Ahmed Al Haidar, Ali Swedan, Islam Seada
King Khalid Hospital, Najran, Saudi Arabia
E-mail: [email protected]
Introduction: The use of extracorporeal membrane oxygenation (ECMO) in cases of near-fatal asthma has increased, but the benefits of this therapy have yet to be thoroughly investigated.[1] However, its use in severe asthma is limited to case reports or a case series.[2]
Objective: To analyze our experience implementing VV ECMO as a lifesaving modality in near-fatal asthma. Severe and fatal asthma Three patients presented with severe hypercapnia and severe respiratory acidosis, and intubation was done in the ER; two of them developed cardiac arrest while managing asthma. The time of arrest was between 2 and 4 minutes. While the other two patients were arrested in the emergency department and CPR was done, ROSC was obtained in 5 and 18 minutes, respectively. Vigorous asthma management in the form of muscle relaxants, sedation, PRVC ventilation, and aggressive therapy for bronchial asthma was started for all five patients. Still, their condition was worsening, and no improvement was obtained. An ECMO consultation was done in the emergency department, and VV ECMO was started for those patients. The Fem-Jag configuration was used with gradual correction of hypercapnia, and normalization of ABG was obtained later with the continuity of conventional asthma treatment. The mean time of the ECMO run was 128.3 hours. Four patients were extubated before ECMO decannulation, and one decannulated while on the ventilator. Ventilator settings were significantly improved after ECMO initiation in all patients. Weaning from ECMO was successful in all five patients, and 4 were discharged home. Unfortunately, one patient with prolonged cardiac arrest before initiation developed irreversible brain damage and died later in the ICU.
Conclusion: ECMO is lifesaving in patients with severe fatal bronchial asthma for whom conventional therapy failed, and it is associated with a good outcome; however, more high-quality research is required.
Keywords: Asthma, ECMO, status asthmaticus
| References | | |
- Yeo HJ, Kim D, Jeon D, Kim YS, Rycus P, Cho WH. Extracorporeal membrane oxygenation for life-threatening asthma refractory to mechanical ventilation: Analysis of the Extracorporeal Life Support Organization registry. Crit Care 2017;21:297.
- Chang CL, Yates DH. Early extracorporeal membrane oxygenation (ECMO) is used for severe refractory status asthmaticus. J Med Cases 2011;2:124-6.
| Abstract 12 | | |
| Thyroid Storm-Induced Refractory Cardiogenic Shock and Multiorgan Failure Managed by Veno-Arterial Extra Corporal Membrane Oxygenation Support and Thyroidectomy: A Single-Center Experience | | |
Mugahid Eltahir1,2, Hamza Chaudhry3, Eizzuldein Abdulslam1,2, Hani Jauni1,2, Ibrahim Fawzy Hassan1, 2, 3, Ahmed Labib1, 2, 3, Ayman El Menyar3
Departments of 1Internal Medicine and 2Medical ICU, Hamad General Hospital, Hamad Medical Corporation, 3Weill Cornell Medicine, Doha, Qatar.
Introduction: A thyroid storm is a life-threatening condition.[1] In addition to specific therapy directed against the thyroid hormones, supportive therapy in an intensive care unit (ICU) and recognition and treatment of any precipitating factors are essential since the mortality rate of thyroid storm is substantial (10 to 30 percent).[2],[3],[4],[5],[6],[7] Administration of beta-blockers in patients with thyroid storm who have poor heart function and signs of heart failure may lead to circulatory collapse with multiorgan failure and even cardiac arrest, which may lead to cardiac arrest. In cases of severe and refractory hemodynamic collapse, antithyroid medication may be contraindicated due to multiorgan failure, especially liver involvement. Extracorporeal membrane oxygenation (ECMO) can be used in such cases to achieve hemodynamic stability as a rescue measure until the normalization of the thyroid hormone and improvement of the symptoms are performed by medical therapy. In patients with thyroid storm and fulminant multi-organ failure, therapeutic plasma exchange (TPE) is an effective salvage therapy for lowering circulating hormones and stabilizing patients in preparation for an urgent thyroidectomy.[8] The challenges of the institution of plasma exchanges with ongoing ECMO support, dialysis, and timing of thyroidectomy are still to be explored.
Methods and Results: We summarized our experience with 4 cases of life-threatening thyroid storms leading to circulatory collapse and multiorgan failure in patients who needed VA-ECMO support, renal replacement therapy, and underwent therapeutic plasma exchange as part of a planned urgent thyroidectomy [Table 1]. | Table 1: Summary of patients, clinical signs, laboratory investigations, and outcomes
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Learning points: (1) Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis. (2) Early recognition and appropriate treatment of thyroid storm are essential to improve outcomes. (3) Supportive therapy in an intensive care unit (ICU) setting is essential since the mortality is high. (4) Severe cardiovascular symptoms and death from cardiovascular collapse may occur after beta-blocker administration. (5) Extracorporeal membrane oxygenation (ECMO) should be considered a supportive treatment in patients who develop severe refractory cardiovascular symptoms. 6. Plasma exchange (TPE) as an effective salvage therapy for lowering circulating hormones and stabilization of patients in preparation for urgent thyroidectomy in patients with fulminant multi-organ failure. (6) Urgent thyroidectomy for definitive therapy should not be delayed for thyroid hormone to normalize and symptoms to improve.
Conclusion: Our limited experience showed that in patients with life-threatening thyroid storms, and multiple organ failures, VA-ECMO could be utilized as a bridge to stabilization, definitive surgical intervention, and post-operative endocranial management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial. Could this be the case in other endocrinal emergencies such as pheochromocytoma?
Keywords: Cardiogenic shock, ECMO, plasmapheresis, thyroid storm, thyroidectomy
| References | | |
- Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003;4:129-36.
- Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012;22:661-79.
- Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: A case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract 2015;21:182-9.
- Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical features and hospital outcomes in thyroid storm: A retrospective cohort study. J Clin Endocrinol Metab 2015;100:451-9.
- Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors associated with mortality of thyroid storm: Analysis using a national inpatient database in Japan. Medicine (Baltimore) 2016;95:e2848.
- Bourcier S, Coutrot M, Kimmoun A, Sonneville R, de Montmollin E, Persichini R, et al. Thyroid storm in the ICU: A retrospective multicenter study. Crit Care Med 2020;48:83-90.
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- Koh H, Kaushik M, Loh JK, Chng CL. Plasma exchange and early thyroidectomy in thyroid storm requiring extracorporeal membrane oxygenation. Endocrinol Diabetes Metab Case Rep 2019;2019:1-6.
| Abstract 13 | | |
| ECMO for Polytrauma Patients: A Blessing in Disguise! | | |
Maytham N. Almusawi, Hassan Alkhalaf, Modi Alqahtani, Abdul Rahman Alhadhif, Mohammed Alsanan1, Alqahtani Faisal, Faisal Alshammari, Mohammed A. Alshammeri2, Waleed Alatrby3, Demetrios Karakitsos3, Rehab E. Yousif3, Mohammed A. Abu Jafilah, Ghassan Al Ramahi4
Resident Critical Care, 1Resident Trauma Department, 2Critical Care Nursing Department, 3Consultant Critical Care, 4Consultant Trauma Department, King Saud Medical City, Riyadh, Saudi Arabia
E-mail: [email protected]
Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) for polytrauma patients has widely increased in the last decade. Earlier, polytrauma and ECMO did not mix; it was one of the main contraindications to patient selection, owing to the risk of bleeding and the therapeutic anticoagulation used during the ECMO run. However, the renascence on ECMO material became more compatible with patient blood, allowing ECMO run-off heparin. This pushes the boundaries of ECMO use, opens new frontiers, and increases the pool of patients who may benefit from this super-advanced life support. We aimed to evaluate the outcomes of a group of polytrauma patients who received ECMO in a tertiary hospital.
Methods: All patients were admitted to King Saud Medical City ECMO center from 1 June 2020 to 01 January 2022. We stratified patients according to primary diagnosis into two groups Non-trauma ECMO and trauma ECMO groups. Propensity score matching (1:2) was done between the two groups; then we compared the matched groups for the primary outcome of in-hospital mortality.
Results: The total number of patients included in this study was 61 unmatched trauma and non-trauma, 53 to 8 patients, respectively. Post-matching trauma to non-trauma 8 to 16 patients. The mean age was 37.5 (± 16.7) to 62.5 (±16.7), p-value 0.6. No significant difference between in-hospital mortality of matched trauma to non-trauma patients (3, (37.5%): 10, (62.5%), p-value 0.2), matched trauma patients, mean ECMO days 24.6 (±25.4) to 36.7 (±32.3) respectively, Trauma patients stayed at the hospital, ICU much more days than non-trauma patients and higher ventilator-free days VFD [Table 1]. | Table 1: Demographics and outcomes of matched trauma and nontrauma patients
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Conclusion: ECMO use in trauma patients was previously thought to be harmful; however, our study is underpowered and suggests that ECMO may play a role in reducing hospital mortality comparable to ECMO use in non-trauma patients of the same severity with no adverse effects. Nevertheless, more high-quality research is needed for a more significant number of patients.
Keywords: ARDS, ECMO, polytrauma
| Abstract 14 | | |
| Combined Use of VA-ECMO and Impella (ECpella) in Patients with Acute Coronary Syndrome and Cardiogenic Shock | | |
Mada Alzahrani, Mubark Aldossari, Hatem Aloui1, Wasim S. Alzayer, Shahzad Ahmad, Omar Ramadan, Mohamed I. Alotaibi, Basheer Abdulrahman, Mohammed A. Alshammeri
Department of Critical Care, 1The Heart Center, King Saud Medical City, Riyadh, Saudia Arabia
E-mail: [email protected]
Introduction: In a patient with cardiogenic shock (CS), VA-ECMO maintains end-organ perfusion; however, it may increase left ventricle (LV) afterload, increasing wall stress and oxygen demand of the LV, leading to myocardial ischemia and, ultimately, impairing CS recovery. Therefore, the term “ECpella” refers to Impella and VA-ECMO support in cardiopulmonary resuscitation (CS) to provide optimal hemodynamic support while reducing LV afterload and unloading the LV. In this case, we will describe how ECpella was used to successfully manage a patient who presented with CS during percutaneous coronary intervention PCI due to Acute Coronary Syndrome ACS.
Case Présentation: The patient was a 33-year-old Filipino male with known HTN who presented to the emergency department with late presentation anterior ST-segment elevation myocardial infarction STEMI; the patient was conscious, oriented, and HD hemodynamically stable; the ECG revealed anterior ST-segment elevation and positive troponin results; and the transthoracic/cardiac ECHO revealed left ventricular hypertrophy, mitral regurgitation (MR), and EFs of 40-45%. A coronary angiogram showed triple vascular disease. Cardiac MRI showed MI involving the right coronary artery (RCA), left anterior descending LAD, and left circumflex LCX (EF 26%). Percutaneous coronary intervention PCI was performed on the RCA, LAD, and LCX; inotropes (noradrenaline, adrenaline, and dopamine) were started at the maximum dose, and the decision was made to support him on VA ECMO in addition to Impella. Day 1 HD unstable on three inotropes, patient intubated on Fio2:80% PEEP: 8 mmHg, troponin 4.1, developed AKI, DIC, liver dysfunction, radiological chest X-ray: bilateral infiltration. On day 3, showed improvement, patient on three inotropes decreased adrenaline dose to 0.07 mcg/Kg/min with HD stable, Fio2: 40% PEEP: 8 mmHg, troponin 2.1, showed a slight improvement in coagulation profile and lactate 3.4 mmol/L. On day 4, there was a significant improvement; the patient was on two inotropes, normal lactate 1.1 mmol/L, improved liver function, then decided to remove Impella. On day 6, patient HD was stable without inotropes, low setting mechanical ventilation MV, chest X-ray normal, normal lactate, liver function, and coagulation profile. ECHO showed LV moderate dilatation, EF: 20-25%, VTI: 13.4 cm, and stroke volume: 39 ml; compared to the previous study, there was an improvement in LV EF, and eventually, the decision was taken to remove VA ECMO. On day 10 patient extubated on dexmedetomidine for agitation, he was HD stable on nasal canula 2 L. On day 13, discharged from ICU to the ward. On day 16 patient was discharged home [Figure 1].
Conclusion: Combined VA ECMO and Impella (ECpella) in patients with CS were associated may improve survival and patient outcome. We advocate early unloading guided by echocardiographic and hemodynamic monitoring.
Keywords: ACS, CS, ECpella, impella, VA ECMO
| Abstract 15 | | |
| A novel Approach to ECMO Troubleshooting (Hypoxia) Management Utilizing Two ECMO Circuits in Parallel, A Case Report | | |
Najd A. Al-Howimil, Prabhagaran G. Franklin, Mariam G. Alenezi, Ameera A. Sharif, Razan S. A. Albreak, Abdullah Ba-Lhamar, Ahmed N. Balshi, Nasir N. Mahmood
Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
E-mail: [email protected]
Introduction: The improvements in ECMO management over the last decade were in response to the innovation and breakthroughs in ECMO material biocompatibility and miniaturization; however, there needs to be more high-quality ECMO research to support and look for the best management approaches. Troubleshooting, particularly patient hypoxia while on ECMO, the most common one that necessitated algorithmic management escalation, till reaching to insertion of another cannula to increase the pump flow, which, if failed, probably may lose the patient if he did not tolerate hypoxia or develop brain insult from prolonged hypoxia herein, we present a challenging case that failed to be managed with all previously mentioned approaches and how.
Case Presentation: A 25-year-old male, morbidly obese, weighing 130 kg, standing 170 cm, with a BMI of 45 kg/m2, and known epilepsy, presented to the emergency department with burns involving 30% of the involved upper limbs, head, and neck, as well as inhalation injury and worsening respiratory distress. Patients developed hypoxia on oxygen therapy and non-invasive positive pressure ventilation after aggressive fluid resuscitation, with decreased consciousness. He was endotracheally intubated, placed on lung protective mechanical ventilation with a fraction of inspired oxygen [FiO2] of 100%, and admitted to the intensive care unit (ICU) on August 25, 2021. He was on a high ventilator setting and had severe refractory hypoxia saturation of 60% (partial pressure of oxygen to fraction inspired oxygen ratio (Pao2:Fio2 52 mmHg). Hence, the team decided to support the patient on V-V ECMO. On 8/29/2021, ECMO cannulation was successful with an access cannula in the left femoral vein (23 FR) and a return on IJV (21 FR). Unfortunately, the hypoxia improved; however, oxygen saturation remained low, the best Pao2/FIO2 ratio was obtained on the highest setting, excluding all possible causes of hypoxia on ECMO, the membrane oxygenator worked efficiently, pump flow reached 6 L/min, and cardiac output was controlled. Hemoglobin Hb was optimized to 11.4 d/l. Adding another oxygenator to the circuit was ignored due to possible hemolysis that cannot be tolerated, and planned to add another ECMO circuit with a new pump and console to run concurrently with the old one, draining blood by two different pumps and passing it into the suitable internal jugular vein cannula with a 25-Fr cannula, called a “dual” or “parallel” ECMO run. Both pumps' RPMs (rounds per minute) were adjusted equally for the two circuits. Patient hypoxia improved, and oxygen saturation picked up above 90% while the mechanical ventilator setting was adjusted to the lowest. (ABG: Ph 7.43, PcO2 39.8, Po2 70.2, SPO2 93%). Eight days later, we weaned one of the ECMO circuits and explant one of the access cannulas while preserving patient oxygen saturation. Unfortunately, during ICU post-weaning of one of the circuits, the patient's course was further challenged by severe recurrent, hardly controlled, ventilator-associated pneumonia (VAP) with MDRO infection and severe septic shock that required vasopressors; a blood culture showed candida aureus, covered by antifungal treatment. Also, the patient developed AKI and required multiple sessions of dialysis. The oxygenator was changed five times during the run, and the patient eventually tolerated the weaning trial of sweep gas, and hemodynamics improved on low mechanical ventilator support. The patient completed an 80-day ECMO run and was successfully decannulated. A few days later, he was discharged from the ICU and eventually from the hospital in good general condition.
Conclusion: We reported a rare, feasible approach to ECMO troubleshooting management with very few reported cases or case series in the literature; however, further high-quality research is required to support this finding.
Keywords: Anticoagulation, ECMO, point of care anticoagulation
| Abstract 16 | | |
| Independent Lung Ventilation IDL during Extracorporeal Membrane Oxygenation | | |
Mohammed Alalawi, Adi Alsahli, Jehan Kattan, Rasha Dakhakhni, Waleed Aletreby, Ahmed F. Dodin, Saad M. Altamimi, Rehab E. Yousif, Zohdi Saif Farea
Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
E-mail: [email protected]
Introduction: Independent lung ventilation is an infrequently used strategy in the intensive care unit. However, it can be beneficial in unique selective patients, such as those with unilateral pulmonary pathology. Independent lung ventilation allows for separating each lung individually and isolating each lung content, thus preventing lung content from reaching another lung. In theory, it may help avoid spilling content in the non-diseased lung, thus, maintaining healthy lungs and providing adequate oxygenation. In addition, it allows for targeted interventions. Here, we describe an adult female with a unilateral hydatid cyst requiring venovenous extracorporeal membrane oxygenation who showed improvement in the non-diseased lung after independent lung ventilation.
Discussion: Hydatid cysts can present in a single lung; thus, intensivists aim to prevent further spilling of content to the other lung, maintain adequate oxygenation and ventilation, and prevent secondary damage until definitive surgical management can be provided, including pneumonectomy/lobectomy. This is achieved through a single lung ventilation strategy; this strategy presents a challenge to intensivist as different lung has different compliance and driving pressure; thus different setting, the application of standard intubation is not ideal because it will allow for hydatid cyst content to be spilled into the other lung thus risking and compromising healthy lung and secondary damage to lung and hypoxia, Independent lung ventilation furthermore provides adequate lung protection from barotrauma targeting different plateau in different lungs allow for more control in the settings.
Conclusion: Our case demonstrates an improvement with independent lung ventilation with ECMO.
Keywords: Dual-lumen endotracheal tube, ECMO, hydatid cyst, independent lung ventilation
| Abstract 17 | | |
| Lifesaving Starts with BLS and Ends with ECPR | | |
Esraa Amer, Ahmed Al Haidar, Samer Al Karak, Islam Seada
King Khalid Hospital, Najran, Saudi Arabia
E-mail: [email protected]
Introduction: The incidence of unexpected in-hospital and out-of-hospital cardiac arrests is high.[1]
(ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient. (ECPR) is becoming a way to improve a patient's chances of survival by increasing blood flow to vital organs. This is done by using extracorporeal membrane oxygenation (ECMO) while doing regular CPR and stabilizing the patient.[2]
Objective: Case report analysis.
Methodology: Case report of a patient who survived after 45 minutes of cardiac arrest and with whom all modalities of life support were used in King Khalid Hospital, Najran, Saudi Arabia.
Results: A 24-year-old male developed cardiac arrest after choking while sitting with his friends. Immediately, they started CPR using the BLS protocol while the ambulance was called. The patient was transferred to a primary health care center, where he was intubated, and ACLS was initiated while the patient was being transported to our hospital. The patient was received in the emergency department after 15 minutes of asystole. CPR was continued for another 10 minutes due to VT, during which DC shock was used twice. Then ROSC was achieved with unstable hemodynamics and shallow blood pressure, even though all available inotropes were used. ECMO consultation was done, and VA ECMO was started within 30 minutes of ROSC. Later, the patient was decannulated. Home from the hospital in good general condition and was referred to the EPS clinic for follow-up.
Conclusion: ECPR can improve survival and decrease hospital mortality, but this should be done with good CPR, starting with BLS and ACLS.
Keywords: ECLS, ECMO, ECPR
| References | | |
- Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics: 2020 update: A report from the American Heart Association. Circulation 2020;141:e139-596.
- Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021;161:115-51.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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