Haemorrhagic bronchial casts causing complete ventilatory failure in a COVID‐19 patient on ECMO

Coronavirus disease 2019 (COVID‐19) was identified as causing an unusual pneumonia in Wuhan in late 2019 and rapidly evolved to a pandemic. We present a case of an otherwise well 55‐year‐old female patient who had seemingly mild symptoms when she presented to the emergency department, and then rapidly deteriorated with progressive ventilatory deficit requiring intubation, ventilation, and extracorporeal membrane oxygenation (ECMO). We present the surprise finding of haemorrhagic endobronchial casts in the airways causing a complete ventilatory failure, managed by cryobiopsy and argon plasma coagulation (APC) leading to improved ventilation. To our knowledge, this is the only patient placed on ECMO for COVID‐19 infection in Australia and we would like to highlight the complications and challenges when trying to manage pulmonary haemorrhagic casts whilst on ECMO

Prehospital extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest : a systematic review and meta-analysis

Objectives: To evaluate the available published evidence of the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in the prehospital setting on clinical outcomes in patients with out-of-hospital cardiac arrest. Design: A systematic review and meta-analysis designed according to the Preferred Reporting Items for Systematic Reviews an Meta-Analyses guidelines. Setting: In the prehospital setting. Participants: All randomized control trials (RCTs) and observational trials using pre-hospital ECPR in adult patients (>17 years). Interventions: Prehospital ECPR. Measurements and Main Results: The study authors searched Medline, Embase, and PUBMED for all RCTs and observational trials. The studies were assessed for clinical, methodologic, and statistical heterogeneity. The primary outcome was survival at hospital discharge. The study outcomes were aggregated using random-effects meta-analysis of means or proportions as appropriate. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence. Four studies were included, with a total of 222 patients receiving prehospital ECPR (mean age = 51 years [95% CI 44-57], 81% of patients were male (CI 74-87), and 60% patients had a cardiac cause for their arrest (95% CI 43-76). Overall survival at discharge was 23.4% (95% CI 15.5-33.7; I2 = 62%). The pooled low-flow time was 61.1 minutes (95% CI 45.2-77.0; I2 = 97%). The quality of evidence was assessed to be low, and the overall risk of bias was assessed to be serious, with confounding being the primary source of bias. Conclusion: No definitive conclusions can be made as to the efficacy of prehospital ECPR in refractory cardiac arrest. Higher quality evidence is required

The Prolonged Use of VV ECMO Support in COVID-19: A Case Report

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery

The Prolonged Use of VV ECMO Support in COVID-19: A Case Report

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery

Cardiogenic Shock Challenges and Priorities: A Clinician Survey

Background: Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia\u27s geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described. Method: We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities. Results: There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required. Conclusions: Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department

Abstract Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims to provide perfusion to the patient whilst the underlying cause of arrest can be addressed. ECPR use has increased substantially, with varying survival rates to hospital discharge. The best outcomes for ECPR occur when the time from cardiac arrest to implementation of ECPR is minimised. To reduce this time, systems must be in place to identify the correct patient, expedite transfer to hospital, facilitate rapid cannulation and ECMO circuit flows. We describe the process of activation of ECPR, patient selection, and the steps that emergency department clinicians can utilise to facilitate timely cannulation to ensure the best outcomes for patients in refractory cardiac arrest. With these processes in place our survival to hospital discharge for OHCA patients is 35%, with most patients having a good neurological function

Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach

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Corrigendum to “Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study” [Resuscitation 192 (2023) 109989]

The authors regret, that an acknowledgement to Dr George Perrett for his contribution to the development of this paper was missing from the original article. The authors would like to apologise for any inconvenience caused.</p

Corrigendum to “Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study” [Resuscitation 192 (2023) 109989] (Resuscitation (2023) 192, (S0300957223003039), (10.1016/j.resuscitation.2023.109989))

The authors regret, that an acknowledgement to Dr George Perrett for his contribution to the development of this paper was missing from the original article. The authors would like to apologise for any inconvenience caused