Coronavirus Discussion Thread

[E tank]

Some of the patients we are seeing are having significant cardiac complications that could be Cytokine Storm, Myocarditis, or Kakotsubo like cardiomyopathy requiring VA. Others primarily need VV but may be on high pressor requirments that preclude VV. Generally pressor requirments go down once VV is initiated due to improved oxygenation however some are still crashing so VA is safer. Some are post arrest.

Some of it is chicken or the egg, do they just happen to be COVID positive or is COVID an instigating factor for MI or worsening HF

I think early on, folks were using VA too soon or inappropriately (ie not VV at the outset) and ending up dealing with north/south syndrome.

 

[VentMonkey]

Good stuff shared by the in-hospital/ nursing folks. Certainly way out of my comfort zone. I’d say I’m out of touch. Thanks all.

 

[Jim37F]

A local Coast Guard Cutter almost had an outbreak. A Crewman was sick, they took him off just as they left for patrol, and then the guy tested positive for COVID-19, but since he wasn't on board none of the other Coasties tested positive.

Early action helps Coast Guard keep coronavirus at bay in Hawaii

As fallout continues from the outbreak of COVID-19 aboard the aircraft carrier USS Theodore Roosevelt — with nearly 600 infected and one crew member dead — the Coast Guard appears to have had a close call, but that’s all, with the virus on the Honolulu-based cutter Midgett.

www.staradvertiser.com

 

[Jim37F]

But otherwise, sure looks like the curve is flattening out here. Like last week we were getting 30 new cases each day, today only 5 new cases.

Hawaii’s coronavirus cases rise by only 5 to a total of 504, health director Bruce Anderson says

UPDATE: 4 p.m.

www.staradvertiser.com

 

[Peak]

Emphasis on the word planning. ECMO is bridging to somewhere right (even if its recovery) but every path takes time? What is your group's plan during the height of your pandemic if you are taking in these VA patients now?

We certainly are not currently doing VA, even the phrase "STEMI activation" is more or less non-existent.

We only offer ECMO to patients who we believe are likely to benefit, we are pretty strict on the 80/80 rule across the age span. We do not believe in long term ECLS, patients must have a reversible condition of some kind.

Supposedly we are in the height of our pandemic.

What are you doing about LV venting? Re-circ is an issue, but can be mitigated, and max achievable Pa02 is less than VA however VV is still an extremely useful modality.

We start everyone on a pretty high dose of milrinone to decrease SVR and ward off failure.

We run pretty high flows but try to minimize pressure. We will start nicardipine, labetalol, and nitro drips to keep us at the bottom end of goal pressure.

We can place impellas in patients who are large enough, but this is very rare. We don't really see any dialated failure in our patients on ECMO though.

 

[Phillyrube]

Sailor dies from Covid-19 and almost 600 test positive after outbreak on USS Theodore Roosevelt

Death of first US active duty military member comes 11 days after captain was fired for voicing concerns over safety of his crew on ship off Guam

www.theguardian.com

He was a Chief. Dang Wuhan virus.

 

[Akulahawk]

But otherwise, sure looks like the curve is flattening out here. Like last week we were getting 30 new cases each day, today only 5 new cases.

Hawaii’s coronavirus cases rise by only 5 to a total of 504, health director Bruce Anderson says

UPDATE: 4 p.m.

www.staradvertiser.com

As long as we ALL continue to stay generally away from each other for a while, even after a "go back to work" is declared, we won't overload the hospitals. That's mostly what the "social distancing" was all about. My hospital ED is down about 40% of daily volume, mostly from people that usually see us for their PCP needs. That also means our general acuity level is up and we actually have the beds in-hospital to support those patients so they don't spend much time holding in the ED. That also means people are sometimes waiting too long and they get way sick before they come in.

 

[E tank]

We start everyone on a pretty high dose of milrinone to decrease SVR and ward off failure.

We run pretty high flows but try to minimize pressure. We will start nicardipine, labetalol, and nitro drips to keep us at the bottom end of goal pressure.

If you have to work so hard to suppress native cardiovascular function why not just do VV?

 

[Peak]

If you have to work so hard to suppress native cardiovascular function why not just do VV?

VV ECMO doesn't allow for as much flow across the membrane decreasing the amount of gas exchange. It also means that if we needed to transition from VV to VA that we would need to do additional surgery, or patients who needed VA to start would need additional surgery to transition to VA.

 

[VFlutter]

VV ECMO doesn't allow for as much flow across the membrane decreasing the amount of gas exchange. It also means that if we needed to transition from VV to VA that we would need to do additional surgery, or patients who needed VA to start would need additional surgery to transition to VA.

Do you only do central cannulations? Your program is primarily Peds and CHD, correct? It sounds like your specific programs preference is heavily towards VA however may not translate elsewhere.

Converting pVV to pVA is pretty straight forward and actually ends up being a better set up, VVA

Choosing good components, including an oxygenator with an adequate rated flow, and multi-stage or triple cannulation there is really no downside to VV ECMO with normal cardiac function. And single access cannula are amazing for longer term VV awaiting transplant.

 

[E tank]

VV ECMO doesn't allow for as much flow across the membrane decreasing the amount of gas exchange. It also means that if we needed to transition from VV to VA that we would need to do additional surgery, or patients who needed VA to start would need additional surgery to transition to VA.

Yes, the accepted oxygenation parameters are lower with VV, but that doesn't mean they aren't acceptable and therapeutic, otherwise no one would do VV.

These are adults we're talking about? How often do these patients need to be taken to the OR for cannulation? Bedside perc access not a thing where you are? How often does a pt. need transitioning from VV to VA?

 

[VFlutter]

To bring it back to the topic on hand I do think it is prudent to err on the side of VA for COVID patients as anecdotally we are frequently encountering patients who develop severe shock or cardiac dysfunction quickly and unexpectedly.

 

[FiremanMike]

Anyone paying attention to Sweden?

Voluntary social distancing, no lockdown, schools still in session, et.. 1400 deaths in a population of 10.9 million..

Would love to hear your thoughts..

 

[akflightmedic]

Anyone paying attention to Sweden?

Voluntary social distancing, no lockdown, schools still in session, et.. 1400 deaths in a population of 10.9 million..

Would love to hear your thoughts..

You mean a country that values human life over profit (from the very top down)? A socialist system that has one of the highest quality of life ratings with access to healthcare, high employment, and many other elements of a civil, proper society which tries to ensure no one suffers?

Yeh, 'Murika is so far from that.

 

[Peak]

Do you only do central cannulations? Your program is primarily Peds and CHD, correct? It sounds like your specific programs preference is heavily towards VA however may not translate elsewhere.

Converting pVV to pVA is pretty straight forward and actually ends up being a better set up, VVA

Choosing good components, including an oxygenator with an adequate rated flow, and multi-stage or triple cannulation there is really no downside to VV ECMO with normal cardiac function. And single access cannula are amazing for longer term VV awaiting transplant.

Yes, the accepted oxygenation parameters are lower with VV, but that doesn't mean they aren't acceptable and therapeutic, otherwise no one would do VV.

These are adults we're talking about? How often do these patients need to be taken to the OR for cannulation? Bedside perc access not a thing where you are? How often does a pt. need transitioning from VV to VA?

We do neo through adults, CHD and non-CHD. We predominantly do neck and chest cannulation, leg cannulation is pretty rare as we have seen quite a bit of complications from it.

I think the biggest difference between our program and most others is that we don’t see ECMO as a long term intervention. We don’t us ECMO as a bridge to transplant,and we don’t put people on that we don’t think have a good chance of coming off. We are very strict on the 80/80 criteria, and don’t offer it simply because a person is crashing and it is the last thing left to do.

Some patients are cannulated at the bedside, some are done in OR. Regardless cardiac or general surgery come in to cannulate (with the rest of the OR team), and we treat the room as an OR. Compared to most adult CVICUs and MICU/SICUs we consider sterile technique much more strictly, and everyone in the room needs to be in surgical scrubs, do a two minute hand wash with the appropriate sponge, and so on whether they are actually going to scrub in, circulate, or whatever else

Due to a large number of factors we encourage patients who are at the point of lung transplant to either consider palliative care or to move out of state. We used to do lung transplants in the past but outcomes just aren’t that great across multiple local transplant centers.

Simply put I can easily flow 150-180 mL/kg/min of IWB on VA, I can’t get close to that with almost any VV setup.

 

[E tank]

To bring it back to the topic on hand I do think it is prudent to err on the side of VA for COVID patients as anecdotally we are frequently encountering patients who develop severe shock or cardiac dysfunction quickly and unexpectedly.

I guess that's my question...I've not read anything at all about recommendations for "just in case" VA ecmo for patients that only need vv. It isn't a casual decision going to ecmo in the first place, let alone determining which mode to use.

 

[E tank]

Simply put I can easily flow 150-180 mL/kg/min of IWB on VA, I can’t get close to that with almost any VV setup.

....12 L/min in a 70 kg pt? Is that really a thing in your covid unit? We are talking covid patients here.

 

[Peak]

Anyone paying attention to Sweden?

Voluntary social distancing, no lockdown, schools still in session, et.. 1400 deaths in a population of 10.9 million..

Would love to hear your thoughts..

From the data it looks like they are just starting to build cases, and their growth doesn’t seem entirely dissimilar from other countries. Rate of critical illness and death among those tested appear inline with most other counties. I’m not familiar with how many patients they are actually testing, what the criteria to get tested is, et cetera.

So far my experience has been that patients seem to fall into and stay in a few categories. Mild to moderate symptoms that don’t need to come in, moderate to high symptoms that require hospitalization, those that require critical care but have a good clinical course, and those who are on maximized support and have a awful course of illness.

I think the availability of resources is going to most greatly affect those who only require basic hospitalization or have good critical care courses, these are the patients that actually need medical access for survival.

Provided that the system is not overwhelmed (NYC, Italy) I don’t think the specific type of healthcare system as long as it is modern is going to greatly affect survival rates. It seems that those who truly crash in the unit all seem to have the same outcome regardless of specific treatment courses. I suspect that those who turn it around with whatever novel drug trial would likely have done so anyway, though possibly over a longer period of time.

 

[Peak]

....12 L/min in a 70 kg pt? Is that really a thing in your covid unit? We are talking covid patients here.

We have yet to offer ECMO to a COVID patient (so far all of our patients have either done well enough to not need ECMO or their chronic health status makes them very unlikely to recover), but yes we have flowed that high on acute respiratory disease without cardiac component before.

 

[FiremanMike]

You mean a country that values human life over profit (from the very top down)? A socialist system that has one of the highest quality of life ratings with access to healthcare, high employment, and many other elements of a civil, proper society which tries to ensure no one suffers?

Yeh, 'Murika is so far from that.

Do you believe those items influence the fact their lack of oppressive lockdown is not showing a significant increase in infection/mortality?

FYI Their recorded cases in Sweden started at the beginning of March, which is about when our numbers became trackable, so in terms of viral introduction, they aren't that far behind us (if you believe covid didn't enter the US before late February..)