TELE-ECMO FOR A YOUNG, ACTIVE DUTY SERVICEMEMBER IN A DOMESTIC COVID-19 HOTSPOT

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Through the Joint Tele-Critical Care Network (JTCCN), the U.S. military has demonstrated that tele-critical care (TCC) services can facilitate the safe delivery of critical care beyond the consulting provider's level of training. While TCC has been described in a variety of scenarios, virtual health support of adult extracorporeal membrane oxygenation (ECMO) management has not been previously reported. We present a case of a young, active duty servicemember with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure refractory to conventional therapy who was cannulated for veno-venous ECMO and successfully managed for 72 hours with TCC support. CASE PRESENTATION: A 39 year-old male Active Duty Service Member (ADSM) presented to Naval Medical Center San Diego (NMCSD) with hypoxemic respiratory failure five days after a positive SARS-CoV-2 PCR test. He was given supportive oxygen therapy, Remdesivir and dexamethasone. On hospital day nine, he was intubated for refractory hypoxemia and the ratio of arterial pO2 to fraction of inspired oxygen (P/F ratio) one hour later was 74. Neuromuscular blockade and prone positioning were initiated. Three days later, the P/F ratio remained less than 100. A request to transfer the patient to a local partner facility for ECMO was declined due to lack of bed availability.The San Antonio Military Medical Center (SAMMC) ECMO Team was consulted via TCC and the patient was placed on veno-venous ECMO, as personnel at NMCSD had previously undergone cannulation training. The NMCSD critical care team had round-the-clock secure video teleconferencing connection to the perfusionists and physician ECMO specialists at SAMMC during this time. After 72 hours of tele-ECMO management without complications, a U.S. Air Force Critical Care Air Transport Team safely transferred the patient 1,276 miles by fixed-wing aircraft to SAMMC for ongoing care. DISCUSSION: As the only certified ECMO center in the Department of Defense and one of the few centers in the world with global air transport capability, SAMMC has partnered with NMCSD to provide short-term ECMO care with TCC support. Previously, this capability had not been demonstrated over a period longer than a few hours. Because this patient's clinical decompensation occurred during the peak of the COVID-19 surge in Southern California, rapid transfer to a local ECMO center was not possible. In this case, JTCCN enabled the provision of lifesaving advanced cardiopulmonary support to an ADSM until aeromedical evacuation could be arranged. CONCLUSIONS: This case serves as proof-of-concept for a hub and spoke model of tele-ECMO support to global military medical facilities, demonstrating the potential to bring sophisticated lifesaving technology to medically-austere environments anywhere in the world. REFERENCE #1: Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations. Mil Med. 2017 May;182(5):e1702-e1707. doi: 10.7205/MILMED-D-16-00277. PMID: 29087914. REFERENCE #2: Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med. 2020 Dec 30;185(11-12):e2055-e2060. doi: 10.1093/milmed/usaa215. PMID: 32885813. REFERENCE #3: Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Feb 26. doi: 10.1097/MAT.0000000000001422. Epub ahead of print. PMID: 33657573. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Phillip Mason, source=Web Res onse No relevant relationships by Jeremy Pamplin, source=Web Response No relevant relationships by Nick Rohrhoff, source=Web Response No relevant relationships by Melissa Rosas, source=Web Response No relevant relationships by Jesse Sherratt, source=Web Response No relevant relationships by Robert Walter, source=Web Response