Refractory Hypoxemia Research Articles

Butorphanol Promotes Macrophage Phenotypic Transition to Inhibit Inflammatory Lung Injury via κ Receptors.

Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by diffuse inflammation of the lung parenchyma and refractory hypoxemia. Butorphanol is commonly used clinically for perioperative pain relief, but whether butorphanol can regulate LPS-induced alveolar macrophage polarization is unclear. In this study, we observed that butorphanol markedly attenuated sepsis-induced lung tissue injury and mortality in mice. Moreover, butorphanol also decreased the expression of M1 phenotype markers (TNF-α, IL-6, IL-1β and iNOS) and enhanced the expression of M2 marker (CD206) in alveolar macrophages in the bronchoalveolar lavage fluid (BALF) of LPS-stimulated mice. Butorphanol administration reduced LPS-induced numbers of proinflammatory (M1) macrophages and increased numbers of anti-inflammatory (M2) macrophages in the lungs of mice. Furthermore, we found that butorphanol-mediated suppression of the LPS-induced increases in M1 phenotype marker expression (TNF-α, IL-6, IL-1β and iNOS) in bone marrow-derived macrophages (BMDMs), and this effect was reversed by κ-opioid receptor (KOR) antagonists. Moreover, butorphanol inhibited the interaction of TLR4 with MyD88 and further suppressed NF-κB and MAPKs activation. In addition, butorphanol prevented the Toll/IL-1 receptor domain-containing adaptor inducing IFN-β (TRIF)-mediated IFN signaling pathway. These effects were ameliorated by KOR antagonists. Thus, butorphanol may promote macrophage polarization from a proinflammatory to an anti-inflammatory phenotype secondary to the inhibition of NF-κB, MAPKs, and the TRIF-mediated IFN signaling pathway through κ receptors.

Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study

BackgroundAlthough COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country.MethodsIn this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete.FindingsBetween March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52–70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7–22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0–7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H2O (8–12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO2) to fractional inspired oxygen (FiO2) was 160 (IQR 111–218), respiratory system compliance 36 mL/cm H2O (29–44), driving pressure 12 cm H2O (10–14), and FiO2 0·60 (0·45–0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01–1·03]), Charlson score (1·16 [1·11–1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10–1·71]), vasopressor use on day 1 (1·29 [1·07–1·55]), D-dimer concentration (1·02 [1·01–1·03]), PaO2/FiO2 on day 1 (0·998 [0·997–0·999]), arterial pH on day 1 (1·01 [1·00–1·01]), driving pressure on day 1 (1·05 [1·03–1·08]), acute kidney injury (1·66 [1·36–2·03]), and month of admission (1·10 [1·03–1·18]) as independent predictors of mortality.InterpretationIn patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere.FundingNone.TranslationFor the Spanish translation of the Summary see Supplementary Materials section.

Ensuring pulmonary artery patency in donor-recipient size mismatch: A collaborative challenge.

The vascular anastomoses of lung transplantation are a growing area of interest. Anastomosing the donor and recipient pulmonary artery (PA) segments is among the most delicate aspects of the surgery, and proper surgical technique is critical to allograft and patient survival. Obstruction of blood flow through the PA may cause graft ischemia, refractory hypoxemia, right ventricular dysfunction, and even death in affected patients.1 However, the importance of the PA anastomoses has yet to be critically examined in the lung transplant literature.

Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India.

PurposeExtracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient’s outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers.MethodsThis is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type.ResultsThree hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37–52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% (p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05–3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75–3.67)).ConclusionsDuring pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-021-06451-w.

Recruitment maneuvers in patients undergoing thoracic surgery: a meta-analysis.

Pulmonary atelectasis is a common postoperative complication that may lead to intrapulmonary shunt, refractory hypoxemia, and respiratory distress. Recruitment maneuvers may relieve pulmonary atelectasis in patients undergoing thoracic surgery. This meta-analysis of randomized controlled trials (RCTs) is to evaluate the effectiveness and safety of recruitment maneuvers in patients undergoing thoracic surgery. We performed a literature search on the PubMed, Embase, and Cochrane Library databases and the ClinicalTrials.gov registry for trials published before April 2021. We investigated postoperative pulmonary atelectasis incidence, intrapulmonary shunt fraction, static lung compliance, and mean arterial pressure. Six RCTs involving 526 patients were reviewed. Patients receiving a recruitment maneuver exhibited a significant decrease in intrapulmonary shunt fraction [weighted mean difference (WMD) - 0.02, 95% CI - 0.03 to - 0.01], improved static lung compliance (WMD 2.16; 95% CI 1.14-3.18), and PaO2/FIO2 ratio (WMD 31.31; 95% CI 12.11-50.52) without a significant difference in mean arterial pressure (WMD - 0.64; 95% CI - 4.92 to 3.64). The incidence pulmonary atelectasis favored recruitment maneuver group, but was not statistically significant (RR 0.55; 95% CI 0.27-1.12). Recruitment maneuvers may be a viable treatment for reducing intra-pulmonary shunt and improving static lung compliance and PaO2/FIO2 ratio without the disturbance of hemodynamics in patients undergoing thoracic surgery.

Gasping on Oxygen: A Case Report on Toxic Methemoglobinemia

Abstract We report the case of a 27-year-old male patient who presented with refractory hypoxemia following the alleged inhalation of an unknown substance. The patient appeared to show worsening cyanosis despite increment of supplemental oxygenation. A drawn sample of the patient’s blood appeared chocolate brown in color, and disparity was noted between the patient’s oxygen saturation (SaO2) in his blood against the pulse oximetry (SpO2) reading. A diagnosis of toxic methemoglobinemia was established following elevated levels of methemoglobin discovered in his blood. The patient was started on methylene blue and instantaneously recovered without any complications. Methemoglobinemia should be suspected in any patient with refractory cyanosis, and early recognition of this condition could be potentially lifesaving.

RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic

BackgroundCOVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and...

Triptolide dose-dependently improves LPS-induced alveolar hypercoagulation and fibrinolysis inhibition through NF-κB inactivation in ARDS mice

BackgroundAlveolar hypercoagulation and fibrinolysis inhibition were associated with the refractory hypoxemia and the high mortality in patient with acute respiratory distress syndrome (ARDS), and NF-κB pathway was confirmed to contribute to the process. Triptolide (TP) significantly inhibited NF-κB pathway and thus depressed accessive inflammatory response in ARDS. We speculate that TP could improve alveolar hypercoagulation and fibrinolytic inhibition in LPS-induced ARDS via NF-κB inactivation. PurposeThe aim of this experiment was to explore the efficacy and potential mechanism of TP on alveolar hypercoagulation and fibrinolysis inhibition in LPS-induced ARDS in mice. Methods50 μl of LPS (5 mg/ml) was inhalationally given to C57BL/6 mice to set up ARDS model. Male mice were randomly accepted with LPS, LPS + TP (1 μg/kg, 10 μg/kg, 50 μg/kg respectively), or with NEMO Binding domain peptide (NBD), an inhibitor of NF-κB. TP (1 μg/kg, 10 μg/kg, 50 μg/kg) were intraperitoneally injected or 10 μg/50 μl of NBD solution were inhaled 30 min before LPS inhalation. A same volume of normal saline (NS) substituted for TP in mice in control. The endpoint of experiment was at 8 hours after LPS stimulation. Pulmonary tissues were taken for hematoxylin-eosin (HE) staining, wet / dry ratio and for lung injury scores (LIS). Tissue factor (TF) and plasminogen activator inhibitor (PAI)-1 in lung tissue were detected by Western-blotting and by quantitative Real-time PCR(qPCR) respectively. Concentrations of TF, PAI-1, thrombin-antithrombin complex (TAT), procollagen peptide type Ⅲ (PⅢP) and activated protein C (APC) in bronchoalveolar lavage fluid (BALF) were measured by ELISA. NF-κB activation and p65-DNA binding activity in pulmonary tissue were simultaneously determined. ResultsLPS stimulation resulted in pulmonary edema, neutrophils infiltration, obvious alveolar collapse, interstitial congestion, with high LIS, which were all dose-dependently ameliorated by Triptolide. LPS also dramatically promoted the expressions of TF and PAI-1 either in mRNA or in protein in lung tissue, and significantly stimulated the secretions of TF, PAI-1, TAT, PⅢP but inhibited APC production in BALF, which were all reversed by triptolide treatment in dose-dependent manner. TP dose-dependently inhibited the activation of NF-κB pathway induced by LPS, indicated by the changes of phosphorylations of p65 (p-p65), p-IKKα/β and p-IκBα, and weakened p65-DNA binding activity. TP and NBD had same efficacies either on alveolar hypercoagulation and fibrinolysis inhibition or on NF-κB signalling pathway in ARDS mice. ConclusionsTP dose-dependently improves alveolar hypercoagulation and fibrinolysis inhibition in ARDS mice through inhibiting NF-κB signaling pathway. Our data demonstrate that TP is expected to be an effective selection in ARDS.

Two Cases of COVID-19 with Refractory Hypoxemia Intubated by a Ventilator-Assisted, Laryngeal Mask Airway-Facilitated Rescue Approach

[b]BACKGROUND[/b] Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a novel respiratory infection responsible for a global pandemic with an associated high rate of critical illness and hypoxemic respiratory failure. Airway management is challenged by refractory hypoxemia and the risk of transmission. Standard techniques for rescue oxygenation and ventilation, and for preoxygenation may increase the risk of transmission to providers. [b]CASE REPORT[/b] Two patients with COVID-19 and refractory hypoxemic respiratory failure, a 60-year-old woman with a history of hypertension and hypothyroidism with COVID-19 pneumonia, and a 72-year-old man with a history of hypertension with COVID-19 pneumonia and pneumothorax were oxygenated prior to intubation with an approach utilizing laryngeal mask airway, ventilator, and localized negative low generated by oropharyngeal suction catheters. This approach improved oxygenation, reduced desaturation, and theoretically reduced the risk of aerosols to the airway team. Both patients were subsequently intubated using video laryngoscopy with reduced peri-intubation desaturation. [b]CONCLUSIONS[/b] Intubation of patients with COVID-19 and hypoxemic respiratory failure during pandemic conditions often occurs in circumstances with limited negative-pressure space and personal protective equipment. We report 2 cases in which an alternative approach to oxygenation reduced desaturation while potentially reducing the risk from aerosols to the airway team, and call for further clinical study and validation. This protocol has the potential to serve as a rescue technique in cases of failed intubation, which theoretically decreases the risks from aerosols for airway teams, and if validated will be translatable to other highly transmissible respiratory pathogens.

Prone transportation to an ECMO center

Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of all intensive care unit admissions and mortality remains exceedingly high ranging from 35 to 46%. Prone positioning has demonstrated benefit as a treatment option in the moderate to severe subset of ARDS patients. Referral to an extracorporeal membrane oxygenation (ECMO) center remains the standard of care for patients with refractory hypoxemia. Transfer of these already critically ill patients is high risk but there is a possibility for improved oxygenation on transport with prone positioning. Currently there is limited data on the safe transportation of prone patients to ECMO centers. Herein we describe a case of an ARDS patient safely transported prone with minimal ad hoc adjustments to standard ambulance transport.

Œdème aigu pulmonaire réfractaire sous ECMO : une place pour l’atrioseptotomie de Rashkind ?

Hydrostatic pulmonary edema is a well-known complication of veinoarterial extracorporeal membrane oxygenation (VA-ECMO) caused by increased left ventricle afterload due to reverse blood flow in the aorta. Several techniques are commonly used for left ventricle venting such as intra-aortic balloon pump, Impella® (Abiomed, Danvers, MA), central surgical cannulation or Rahskind atrial septostomy. We reported two cases of hydrostatic pulmonary edema in patients under VA-ECMO for whom it was decided to perform Rashkind technique. The first is a late anterior myocardial infarction complicated with cardiac arrest and cardiogenic shock. Refractory hypoxemia due to hydrostatic pulmonary edema conducted us to perform atrial septostomy. The second case is a refractory cardiogenic shock due to left main stent thrombosis myocardial infarction. Procedural transesophageal echocardiography revealed a large left atrial thrombus extended to pulmonary veins preventing the procedure. These two cases illustrate the importance and gravity of pulmonary edema induced by VA-ECMO. The first shows that this technique is feasible, allows great left ventricle unloading and improves hypoxemia. The second underlines the interest of performing transesophageal echocardiography to look for pulmonary veins thrombosis that can take part in the elevation of hydrostatic pressure and forbid Rashkind manoeuver.

Neuromuscular blockade management in patients with COVID-19.

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome, and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.

Emergency Management of Refractory Hypoxemia in Mechanically Ventilated Patients with COVID-19 Acute Respiratory Distress Syndrome

Covid-19 disease has had a significant impact on intensive care facilities worldwide. In ventilated patients with Covid-19 ARDS, refractory hypoxemia is a particularly challenging scenario. This article presents a case study and explores a systematic approach to the management of refractory hypoxemia. Current evidence base for Covid-19 medical management is discussed. It is emphasized that one must adhere to evidence based principles of ARDS management.

Une forme sévère de pneumopathie aiguë à éosinophiles liée à l’amoxicilline

Acute eosinophilic pneumonia (AEP) is a rare and potentially severe disorder, characterized by an acute febrile respiratory illness with diffuse pulmonary infiltrates, pleural effusions and an eosinophilic alveolitis identified on broncho-alveolar lavage or lung biopsy. The condition can be idiopathic, or induced by the inhalation of toxic substances, by infections or by medications. The condition tends to respond rapidly to treatment with systemic steroids. We report the case of a 16-year old patient who presented severe acute interstitial pneumonia with eosinophilia (1.17g/L). They had taken a seven-day course of amoxicillin treatment two weeks previously for a dental abscess. The patient initially required respiratory support by mechanical ventilation followed by extracorporeal membrane oxygenation due to severe refractory hypoxemia. After exhaustive investigation a diagnosis of amoxicillin-induced acute eosinophilic pneumonia was made. After steroid treatment was initiated the clinical response was rapidly favorable and remission was achieved. The patient has been advised to avoid beta lactam antibiotics for life. This case illustrates a rare case of severe acute eosinophilic pneumonia induced by amoxicillin.

Patent foramen ovale revealed by COVID-19 pneumonia

BackgroundPlatypnea-orthodeoxia syndrome (POS) is a rare condition characterized by dyspnoea (platypnea) and arterial desaturation in the upright position resolved in the supine position (orthodeoxia). Intracardiac shunt, pulmonary ventilation–perfusion mismatch and others intrapulmonary abnormalities are involved.Case presentationWe report a case of POS associated with two pathophysiological issues: one, cardiac POS caused by a patent foramen ovale (PFO) and second, pulmonary POS due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interstitial pneumonia. POS has resolved after recovery of coronavirus disease 2019 (COVID-19) pneumonia.ConclusionsRight-to-left interatrial shunt and intrapulmonary shunt caused by SARS-CoV-2 pneumonia contributed to refractory hypoxemia and POS. Therefore, in case of COVID-19 patient with unexplained POS, the existence of PFO must be investigated.

Hemodynamic response to milrinone for refractory hypoxemia during therapeutic hypothermia for neonatal hypoxic ischemic encephalopathy.

Characterize the impact of milrinone on arterial pressure of neonates with persistent hypoxemic respiratory failure (HRF) and hypoxic ischemic encephalopathy (HIE) treated with inhaled nitric oxide and therapeutic hypothermia (TH). Retrospective cohort study. Arterial pressure was assessed hourly for 24 h. The primary outcome was change in diastolic arterial pressure (DAP). 56 patients were included [(i) cases: HIE/TH who received milrinone (n = 9), (ii) Milrinone controls (n = 17), (iii) HIE controls (n = 30)]. Baseline demographics, severity of HRF and arterial pressure were comparable between groups. Only milrinone treated patients with HIE/TH had a marked drop in DAP in the first hour, which persisted for more than 12 h despite escalation in inotropes (p = 0.008). Milrinone treated patients with HRF and HIE/TH develop profound reduction in DAP and require escalation of cardiovascular support. The risk benefit profile of milrinone should be considered and pharmacological studies are warranted to evaluate drug metabolism and clearance in this population.

Analysis of COVID-19 Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation at US Academic Centers.

Objective:This study analyzed the outcomes of COVID-19 patients with ARDS who were managed with extracorporeal membrane oxygenation (ECMO) across 155 US academic centers.Summary Background Data:ECMO has been utilized in COVID-19 patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Early case series with the use of ECMO in these patients reported high mortality exceeding 90%.Methods:Using ICD-10 codes, data of patients with COVID-19 with ARDS, managed with ECMO between April and September 2020, were analyzed using the Vizient clinical database. Outcomes measured included in-hospital mortality, hospital and ICU length of stay, and direct cost. For comparative purposes, the outcome of a subset of COVID-19 patients aged between 18 and 64 years and managed with versus without ECMO were examined.Results:1,182 patients with COVID-19 and ARDS received ECMO. In-hospital mortality was 45.9%, mean length of stay was 36.8 ± 24.9 days, and mean ICU stay was 29.1 ± 17.3 days. In-hospital mortality according to age group was 25.2% for 1 to 30 years; 42.2% for 31 to 50 years; 53.2% for 51 to 64 years; and 73.7% for ≥65 years. A subset analysis of COVID-19 patients, aged 18 to 64 years with ARDS requiring mechanical ventilation and managed with (n = 1113) vs without (n = 16,343) ECMO, showed relatively high in-hospital mortality for both groups (44.6% with ECMO vs 37.9% without ECMO).Conclusions:In this large US study of patients with COVID-19 and ARDS managed with ECMO, the in-hospital mortality is high but much lower than initial reports. Future research is needed to evaluate which patients with COVID-19 and ARDS would benefit from ECMO.

Unilateral Pulmonary Edema After Robotically Assisted Mitral Valve Repair Requiring Veno-Venous Extracorporeal Membrane Oxygenation

Unilateral pulmonary edema (UPE) is an uncommon yet potentially life-threatening complication of minimally invasive cardiac surgery (MICS). Most frequently described after robotically assisted mitral valve (MV) repair, it is characterized by right lung edema, hypoxemia, hypercapnia, pulmonary hypertension, and hemodynamic instability beginning minutes-to-hours after separation from cardiopulmonary bypass (CPB). The authors describe a severe case with refractory hypoxemia requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) after robotically assisted MV repair.

POS-049 SUCCESSFUL MULTI ORGAN SUPPORT THERAPY (MOST) IN COVID-19 PNEUMONIA: A CASE REPORT

Patients with severe COVID-19 pneumonia can develop acute respiratory distress syndrome, which triggers respiratory failure. Extracorporeal organ support therapies (ECMO, CRRT, plasmapheresis) can be used as part of adjunctive management in patients with refractory hypoxemia even with the appropriate use of optimal mechanical ventilation (IMV) and pharmacological measures.

12 Outcomes in Ventilated Burn Patients with Acute Respiratory Distress Syndrome: An Evaluation of Early High-PEEP Strategy Using Berlin Criteria.

Abstract Introduction Acute respiratory distress syndrome (ARDS) remains a formidable sequela, complication, and mortality risk in patients with large burns with or without inhalation injury. Alveolar recruitment using higher positive end expiratory Pressures (PEEP) after the onset of ARDS has been tried with varying success. Subsequent studies have identified benefits for several rescue maneuvers in ARDS patients with refractory hypoxemia. A preventive strategy utilizing an early recruitment maneuver, however, has not, to our knowledge, been explored in ventilated burn patients. The purpose of this study was to evaluate the natural progression and clinical outcomes of ARDS severity (mild, moderate, and severe) using Berlin criteria in ventilated burn patients treated with an early high-PEEP ventilator strategy. Methods A single-center retrospective review of burn patients who were mechanically ventilated for more than 48 hours utilizing an early high-PEEP ventilator strategy was performed at our Level 1 trauma and regional burn center. ARDS severity was defined according to the Berlin criteria. Demographic data, as well as respiratory and clinical outcomes were evaluated. Results Eighty-three patients met inclusion criteria and were analyzed. According to the Berlin definition, 42.1% of patients met ARDS criteria on admission and nearly all patients (85.5%) developed ARDS within the first seven days: 28 (34%) mild, 32 (38.6%) moderate, and 11 (13.3%) severe ARDS. The mean percent total body surface area (%TBSA) was 24.6 ± 22.1, with 68.7% of patients diagnosed with inhalation injury. The highest incidence of ARDS was 57.8% on day 2 of admission. Most cases remained in the mild to moderate ARDS category with severe ARDS (2.4%) being less common by hospital day 7. Overall, 30-day in-hospital and inhalation injury mortality rates were 9.6% and 15.8%, respectively. No correlation was observed between plateau pressures (22.8), mean arterial pressures (84.4), or vasopressor requirements; and oxygen requirements down trended quickly over the first 24–48 hours. Conclusions In our study, prophylactic, immediate, high-PEEP in mechanically ventilated burn patients was associated with trends toward decreased severity and more rapid resolution of ARDS in the first week following burn injury. This correlated with lower 30-day in-hospital mortality in this population. This