OBJECTIVES The COVID-19 pandemic has caused hospitals around the world to quickly develop not onl... more OBJECTIVES The COVID-19 pandemic has caused hospitals around the world to quickly develop not only strategies to treat patients but also methods to protect health care and frontline workers. STUDY DESIGN Descriptive study. METHODS We outlined the steps and processes that we took to respond to the challenges presented by the COVID-19 pandemic while continuing to provide our routine acute care services to our community. RESULTS These steps and processes included establishing teams focused on maintaining an adequate supply of personal protection equipment, cross-training staff, developing disaster-based triage for the emergency department, creating quality improvement teams geared toward updating care based on the most current literature, developing COVID-19-based units, creating COVID-19-specific teams of providers, maximizing use of our electronic health record system to allocate beds, and providing adequate practitioner coverage by creating a computer-based dashboard that indicated the need for health care practitioners. These processes led to seamless and integrated care for all patients with COVID-19 across our health system and resulted in a reduction in mortality from a high of 20% during the first peak (March and April 2020) to 6% during the plateau period (June-October 2020) to 12% during the second peak (November and December 2020). CONCLUSIONS The detailed processes put in place will help hospital systems meet the continuing challenges not only of COVID-19 but also beyond COVID-19 when other unique public health crises may present themselves.
medRxiv (Cold Spring Harbor Laboratory), Jul 29, 2020
doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by pee... more doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Extracorporeal membrane oxygenation is considered a relative contraindication for patients with s... more Extracorporeal membrane oxygenation is considered a relative contraindication for patients with severe neurological injury manifested by fixed and dilated pupils. The inability to provide adequate cardiopulmonary support while attempting to treat the underlying neurologic disease results in a fatal outcome. The impairment of cerebral perfusion, compounded by the underlying neurologic condition, results in signs of brainstem dysfunction often equated with a fatal prognosis. As a result, these patients are not considered to be candidates for initiation of extracorporeal membrane oxygenation. We present a case series of three patients with complex neurologic conditions with fixed and dilated pupils, who received extracorporeal membrane oxygenation. All three patients achieved a significant neurologic recovery. Two survived with a cerebral performance category scale of 1, and the third succumbed to multi-organ failure after achieving a Glasgow Coma Scale of 11T. The decision to initiate extracorporeal membrane oxygenation should be based upon the pathophysiology of the underlying neurologic condition and not solely upon isolated clinical findings. Extracorporeal membrane oxygenation use is normally reserved for patients with reversible underlying processes, and a neurologic exam with fixed and dilated pupils is often interpreted as an irreversible neurologic injury. The implementation and success of extracorporeal membrane oxygenation in this patient population require understanding of complex neurologic diseases, rapid recognition of neurocardiogenic shock, and expeditious initiation of cardiopulmonary support in carefully selected patients. The patients described demonstrate that fixed and dilated pupils are not a contraindication for extracorporeal support in select patients.
The Leeds Beckett repository holds a wide range of publications, each of which has been checked f... more The Leeds Beckett repository holds a wide range of publications, each of which has been checked for copyright and the relevant embargo period has been applied by the Research Services team. We operate on a standard take-down policy. If you are the author or publisher of an output and you would like it removed from the repository, please contact us and we will investigate on a case-by-case basis.
The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cann... more The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cannula and noninvasive ventilation before the initiation of extracorporeal membrane oxygenation (ECMO) is unknown. We reviewed data of patients with coronavirus disease 2019 (COVID-19) treated with V-V ECMO at two high-volume tertiary care centers. Survival analysis was used to compare the effect of duration of RS on liberation from ECMO. A total of 78 patients required ECMO and the median duration of RS and invasive mechanical ventilation (IMV) before ECMO was 2 days (interquartile range [IQR]: 0, 6) and 2.5 days (IQR: 1, 5), respectively. The median duration of ECMO support was 24 days (IQR: 11, 73) and 59.0% (N = 46) remained alive at the time of censure. Patients that received RS for ≥3 days were significantly less likely to be liberated from ECMO (HR: 0.46; 95% CI: 0.26–0.83), IMV (HR: 0.42; 95% CI: 0.20–0.89) or be discharged from the hospital (HR: 0.52; 95% CI: 0.27–0.99) compared to patients that received RS for <3 days. There was no difference in hospital mortality between the groups (HR: 1.12; 95% CI: 0.56–2.26). These relationships persisted after adjustment for age, gender, and duration of IMV. Prolonged duration of RS before ECMO may result in lung injury and worse subsequent outcomes.
Background: The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogeni... more Background: The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock in pregnant and postpartum patients remains limited by concerns of bleeding, hemolysis, and fetal risks. This case series examines the underlying characteristics and management strategies for this high-risk population. Methods: All pregnant and post-partum patients who underwent VA ECMO in the cardiovascular intensive care unit between January 1, 2016 and November 1, 2019, were included in this retrospective study. Management of maternal and fetal O2 delivery, left ventricular (LV) unloading, anticoagulation, and ECMO circuit characteristics were evaluated. Results: Five patients required veno-arterial ECMO for restoration of systemic perfusion. Three patients developed peripartum cardiomyopathy, one septic cardiomyopathy, and one acute right ventricular (RV) failure. The median age was 30.6 years, with median gestational age in pregnant patients of 31 weeks. Maternal and fetal survival to discharge was 80%. Bleeding was the primary complication, with two patients requiring blood transfusions; one requiring interventional radiology (IR) embolization and the other requiring surgical intervention to control bleeding. One patient was successfully delivered on VA ECMO. No fetal complications were directly attributed to VA ECMO. Conclusions: VA ECMO can be employed successfully in obstetric patients with cardiogenic shock with appropriate patient selection. Further research is needed to determine if VA ECMO provides a survival advantage over traditional management strategies in this vulnerable population.
INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a high rate of thrombotic co... more INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a high rate of thrombotic complications related to an acute inflammatory state D-dimer has been established as a marker of disease severity in COVID-19 Despite a paucity of data, D-dimer concentration has been used by institutions to identify candidates for intensified anticoagulant treatment for prevention and mitigation of the thrombotic complications associated with COVID-19 Thromboelastography (TEG) maximum amplitude (MA) has been validated as a marker of hypercoagulability with previous research defining hypercoagulability by a TEG MA ≥ 68 mm We examined the relationship between common clinical laboratory parameters and hypercoagulability as represented by TEG MA METHODS: We performed a single center retrospective analysis of consecutive patients who received ECMO for the treatment of COVID-19 with simultaneous TEG, coagulation, and inflammatory markers (D-dimer, fibrinogen, ferritin, and C-reactive protein) drawn during hospitalization TEG MA values and inflammatory markers were compared in patients with and without a thrombotic complication during admission Correlation tests were performed to identify the coagulation and inflammatory markers that may predict hypercoagulability as defined by elevated TEG MA RESULTS: 168 TEGs were available in 24 patients C-reactive protein and fibrinogen were significantly higher in patients that developed a thrombotic event versus those that did not (p=0 038 and p=0 043 respectively) There was no difference in D-dimer between groups (p=0 312) D-dimer was negatively correlated with TEG MA (p 441 mg/dL had high diagnostic accuracy (sensitivity of 91 2%, specificity of 85 7%) for the detection of MA ≥ 68 mm CONCLUSIONS: In critically ill patients with COVID-19, D-dimer had an inverse relationship with hypercoagulability as measured by TEG MA D-dimer elevation may reflect severity of COVID-19 related sepsis rather than designate patients likely to benefit from anticoagulation Fibrinogen concentration may represent a more useful marker of hypercoagulability in this population
The use of extracorporeal support is expanding quickly in adult respiratory failure. Extracorpore... more The use of extracorporeal support is expanding quickly in adult respiratory failure. Extracorporeal gas exchange is an accepted rescue therapy for severe acute respiratory distress syndrome (ARDS) in select patients. Extracorporeal carbon dioxide removal is also being investigated as a preventative, preemptive, and management platform in patients with respiratory failure other than severe ARDS. The non-ARDS patient population is much larger, so the potential for rapid growth is high. This article hopes to inform decisions about the use of extracorporeal support by increasing understanding concerning the past and present practice of extracorporeal gas exchange.
The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly def... more The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly defined. We sought to determine clinical characteristics and outcomes of patients with COVID-19 managed with invasive mechanical ventilation in an appropriately resourced US health care system. Methods Outcomes of COVID-19 infected patients requiring mechanical ventilation treated within the Inova Health System between March 5, 2020 and April 26, 2020 were evaluated through an electronic medical record review. Results 1023 COVID-19 positive patients were admitted to the Inova Health System during the study period. Of these, 164 (16.0%) were managed with invasive mechanical ventilation. All patients were followed to definitive disposition. 70/164 patients (42.7%) had died and 94/ 164 (57.3%) were still alive. Deceased patients were older (median age of 66 vs. 55, p <0.0001) and had a higher initial d-dimer (2.22 vs. 1.31, p = 0.005) and peak ferritin levels (2998 vs. 2077, p = 0.016) compared to survivors. 84.3% of patients over 70 years old died in the hospital. Conversely, 67.4% of patients age 70 or younger survived to hospital discharge. Younger age, non-Caucasian race and treatment at a tertiary care center were all associated with survivor status. Conclusion Mortality of patients with COVID-19 requiring invasive mechanical ventilation is high, with particularly daunting mortality seen in patients of advanced age, even in a well-resourced
Journal of the American College of Cardiology, 2020
Communications orales donc être envisagée comme traitement alternatif pour les patients non éligi... more Communications orales donc être envisagée comme traitement alternatif pour les patients non éligibles pour la RH. Déclaration de liens d'intérêts Les auteurs n'ont pas précisé leurs éventuels liens d'intérêts.
Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, char... more Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.
Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure mo... more Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure most typically caused by cigarette smoking, but can also be caused by medications, illicit drugs, infections and environmental exposures. There is growing evidence that disease severity varies and not all patients require mechanical ventilation or even supplemental oxygen. To compare patients with AEP treated at Landstuhl Regional Medical Center (LRMC) to those in other published series, and to provide recommendations regarding diagnosis and treatment of AEP. A retrospective chart review was completed on forty-three cases of AEP which were identified from March 2003 through March 2010 at LRMC, Germany. Tobacco smoking was reported by 91% of our patients. Only 33% of patients in our series had a fever (temperature > 100.4 °F) at presentation. Peripheral eosinophilia (>5%) was present in 35% on initial CBC, but was seen in 72% of patients during their hospital course. Hypoxemia, as mea...
INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung ... more INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung disease caused by immune reactions to inhaled agents. Known offending agents include agricultural dust, aerosolized contaminated water, bird droppings, and mold, among others. Diagnosis is made when clinical suspicion is high, and with the aid of high-resolution CT scan, bronchioalveolar lavage (BAL), lung biopsy, and at times, antigenic panels.
The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure has be... more The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure has been increasing steadily. Evidence suggests that ECMO performed at higher volume centers is associated with improved mortality and regionalization of ECMO centers has been advocated by The International ECMO Network. The process of accepting, retrieving, and successfully transporting a critically ill patient requiring ECMO is a complex endeavor best performed by a specialized ECMO transport team. Transport of the most critically ill patients is best performed on ECMO and can be safely performed with careful planning, teamwork, and a highly trained team.
OBJECTIVES The COVID-19 pandemic has caused hospitals around the world to quickly develop not onl... more OBJECTIVES The COVID-19 pandemic has caused hospitals around the world to quickly develop not only strategies to treat patients but also methods to protect health care and frontline workers. STUDY DESIGN Descriptive study. METHODS We outlined the steps and processes that we took to respond to the challenges presented by the COVID-19 pandemic while continuing to provide our routine acute care services to our community. RESULTS These steps and processes included establishing teams focused on maintaining an adequate supply of personal protection equipment, cross-training staff, developing disaster-based triage for the emergency department, creating quality improvement teams geared toward updating care based on the most current literature, developing COVID-19-based units, creating COVID-19-specific teams of providers, maximizing use of our electronic health record system to allocate beds, and providing adequate practitioner coverage by creating a computer-based dashboard that indicated the need for health care practitioners. These processes led to seamless and integrated care for all patients with COVID-19 across our health system and resulted in a reduction in mortality from a high of 20% during the first peak (March and April 2020) to 6% during the plateau period (June-October 2020) to 12% during the second peak (November and December 2020). CONCLUSIONS The detailed processes put in place will help hospital systems meet the continuing challenges not only of COVID-19 but also beyond COVID-19 when other unique public health crises may present themselves.
medRxiv (Cold Spring Harbor Laboratory), Jul 29, 2020
doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by pee... more doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Extracorporeal membrane oxygenation is considered a relative contraindication for patients with s... more Extracorporeal membrane oxygenation is considered a relative contraindication for patients with severe neurological injury manifested by fixed and dilated pupils. The inability to provide adequate cardiopulmonary support while attempting to treat the underlying neurologic disease results in a fatal outcome. The impairment of cerebral perfusion, compounded by the underlying neurologic condition, results in signs of brainstem dysfunction often equated with a fatal prognosis. As a result, these patients are not considered to be candidates for initiation of extracorporeal membrane oxygenation. We present a case series of three patients with complex neurologic conditions with fixed and dilated pupils, who received extracorporeal membrane oxygenation. All three patients achieved a significant neurologic recovery. Two survived with a cerebral performance category scale of 1, and the third succumbed to multi-organ failure after achieving a Glasgow Coma Scale of 11T. The decision to initiate extracorporeal membrane oxygenation should be based upon the pathophysiology of the underlying neurologic condition and not solely upon isolated clinical findings. Extracorporeal membrane oxygenation use is normally reserved for patients with reversible underlying processes, and a neurologic exam with fixed and dilated pupils is often interpreted as an irreversible neurologic injury. The implementation and success of extracorporeal membrane oxygenation in this patient population require understanding of complex neurologic diseases, rapid recognition of neurocardiogenic shock, and expeditious initiation of cardiopulmonary support in carefully selected patients. The patients described demonstrate that fixed and dilated pupils are not a contraindication for extracorporeal support in select patients.
The Leeds Beckett repository holds a wide range of publications, each of which has been checked f... more The Leeds Beckett repository holds a wide range of publications, each of which has been checked for copyright and the relevant embargo period has been applied by the Research Services team. We operate on a standard take-down policy. If you are the author or publisher of an output and you would like it removed from the repository, please contact us and we will investigate on a case-by-case basis.
The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cann... more The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cannula and noninvasive ventilation before the initiation of extracorporeal membrane oxygenation (ECMO) is unknown. We reviewed data of patients with coronavirus disease 2019 (COVID-19) treated with V-V ECMO at two high-volume tertiary care centers. Survival analysis was used to compare the effect of duration of RS on liberation from ECMO. A total of 78 patients required ECMO and the median duration of RS and invasive mechanical ventilation (IMV) before ECMO was 2 days (interquartile range [IQR]: 0, 6) and 2.5 days (IQR: 1, 5), respectively. The median duration of ECMO support was 24 days (IQR: 11, 73) and 59.0% (N = 46) remained alive at the time of censure. Patients that received RS for ≥3 days were significantly less likely to be liberated from ECMO (HR: 0.46; 95% CI: 0.26–0.83), IMV (HR: 0.42; 95% CI: 0.20–0.89) or be discharged from the hospital (HR: 0.52; 95% CI: 0.27–0.99) compared to patients that received RS for &lt;3 days. There was no difference in hospital mortality between the groups (HR: 1.12; 95% CI: 0.56–2.26). These relationships persisted after adjustment for age, gender, and duration of IMV. Prolonged duration of RS before ECMO may result in lung injury and worse subsequent outcomes.
Background: The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogeni... more Background: The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock in pregnant and postpartum patients remains limited by concerns of bleeding, hemolysis, and fetal risks. This case series examines the underlying characteristics and management strategies for this high-risk population. Methods: All pregnant and post-partum patients who underwent VA ECMO in the cardiovascular intensive care unit between January 1, 2016 and November 1, 2019, were included in this retrospective study. Management of maternal and fetal O2 delivery, left ventricular (LV) unloading, anticoagulation, and ECMO circuit characteristics were evaluated. Results: Five patients required veno-arterial ECMO for restoration of systemic perfusion. Three patients developed peripartum cardiomyopathy, one septic cardiomyopathy, and one acute right ventricular (RV) failure. The median age was 30.6 years, with median gestational age in pregnant patients of 31 weeks. Maternal and fetal survival to discharge was 80%. Bleeding was the primary complication, with two patients requiring blood transfusions; one requiring interventional radiology (IR) embolization and the other requiring surgical intervention to control bleeding. One patient was successfully delivered on VA ECMO. No fetal complications were directly attributed to VA ECMO. Conclusions: VA ECMO can be employed successfully in obstetric patients with cardiogenic shock with appropriate patient selection. Further research is needed to determine if VA ECMO provides a survival advantage over traditional management strategies in this vulnerable population.
INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a high rate of thrombotic co... more INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a high rate of thrombotic complications related to an acute inflammatory state D-dimer has been established as a marker of disease severity in COVID-19 Despite a paucity of data, D-dimer concentration has been used by institutions to identify candidates for intensified anticoagulant treatment for prevention and mitigation of the thrombotic complications associated with COVID-19 Thromboelastography (TEG) maximum amplitude (MA) has been validated as a marker of hypercoagulability with previous research defining hypercoagulability by a TEG MA ≥ 68 mm We examined the relationship between common clinical laboratory parameters and hypercoagulability as represented by TEG MA METHODS: We performed a single center retrospective analysis of consecutive patients who received ECMO for the treatment of COVID-19 with simultaneous TEG, coagulation, and inflammatory markers (D-dimer, fibrinogen, ferritin, and C-reactive protein) drawn during hospitalization TEG MA values and inflammatory markers were compared in patients with and without a thrombotic complication during admission Correlation tests were performed to identify the coagulation and inflammatory markers that may predict hypercoagulability as defined by elevated TEG MA RESULTS: 168 TEGs were available in 24 patients C-reactive protein and fibrinogen were significantly higher in patients that developed a thrombotic event versus those that did not (p=0 038 and p=0 043 respectively) There was no difference in D-dimer between groups (p=0 312) D-dimer was negatively correlated with TEG MA (p 441 mg/dL had high diagnostic accuracy (sensitivity of 91 2%, specificity of 85 7%) for the detection of MA ≥ 68 mm CONCLUSIONS: In critically ill patients with COVID-19, D-dimer had an inverse relationship with hypercoagulability as measured by TEG MA D-dimer elevation may reflect severity of COVID-19 related sepsis rather than designate patients likely to benefit from anticoagulation Fibrinogen concentration may represent a more useful marker of hypercoagulability in this population
The use of extracorporeal support is expanding quickly in adult respiratory failure. Extracorpore... more The use of extracorporeal support is expanding quickly in adult respiratory failure. Extracorporeal gas exchange is an accepted rescue therapy for severe acute respiratory distress syndrome (ARDS) in select patients. Extracorporeal carbon dioxide removal is also being investigated as a preventative, preemptive, and management platform in patients with respiratory failure other than severe ARDS. The non-ARDS patient population is much larger, so the potential for rapid growth is high. This article hopes to inform decisions about the use of extracorporeal support by increasing understanding concerning the past and present practice of extracorporeal gas exchange.
The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly def... more The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly defined. We sought to determine clinical characteristics and outcomes of patients with COVID-19 managed with invasive mechanical ventilation in an appropriately resourced US health care system. Methods Outcomes of COVID-19 infected patients requiring mechanical ventilation treated within the Inova Health System between March 5, 2020 and April 26, 2020 were evaluated through an electronic medical record review. Results 1023 COVID-19 positive patients were admitted to the Inova Health System during the study period. Of these, 164 (16.0%) were managed with invasive mechanical ventilation. All patients were followed to definitive disposition. 70/164 patients (42.7%) had died and 94/ 164 (57.3%) were still alive. Deceased patients were older (median age of 66 vs. 55, p <0.0001) and had a higher initial d-dimer (2.22 vs. 1.31, p = 0.005) and peak ferritin levels (2998 vs. 2077, p = 0.016) compared to survivors. 84.3% of patients over 70 years old died in the hospital. Conversely, 67.4% of patients age 70 or younger survived to hospital discharge. Younger age, non-Caucasian race and treatment at a tertiary care center were all associated with survivor status. Conclusion Mortality of patients with COVID-19 requiring invasive mechanical ventilation is high, with particularly daunting mortality seen in patients of advanced age, even in a well-resourced
Journal of the American College of Cardiology, 2020
Communications orales donc être envisagée comme traitement alternatif pour les patients non éligi... more Communications orales donc être envisagée comme traitement alternatif pour les patients non éligibles pour la RH. Déclaration de liens d'intérêts Les auteurs n'ont pas précisé leurs éventuels liens d'intérêts.
Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, char... more Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.
Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure mo... more Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure most typically caused by cigarette smoking, but can also be caused by medications, illicit drugs, infections and environmental exposures. There is growing evidence that disease severity varies and not all patients require mechanical ventilation or even supplemental oxygen. To compare patients with AEP treated at Landstuhl Regional Medical Center (LRMC) to those in other published series, and to provide recommendations regarding diagnosis and treatment of AEP. A retrospective chart review was completed on forty-three cases of AEP which were identified from March 2003 through March 2010 at LRMC, Germany. Tobacco smoking was reported by 91% of our patients. Only 33% of patients in our series had a fever (temperature > 100.4 °F) at presentation. Peripheral eosinophilia (>5%) was present in 35% on initial CBC, but was seen in 72% of patients during their hospital course. Hypoxemia, as mea...
INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung ... more INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung disease caused by immune reactions to inhaled agents. Known offending agents include agricultural dust, aerosolized contaminated water, bird droppings, and mold, among others. Diagnosis is made when clinical suspicion is high, and with the aid of high-resolution CT scan, bronchioalveolar lavage (BAL), lung biopsy, and at times, antigenic panels.
The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure has be... more The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure has been increasing steadily. Evidence suggests that ECMO performed at higher volume centers is associated with improved mortality and regionalization of ECMO centers has been advocated by The International ECMO Network. The process of accepting, retrieving, and successfully transporting a critically ill patient requiring ECMO is a complex endeavor best performed by a specialized ECMO transport team. Transport of the most critically ill patients is best performed on ECMO and can be safely performed with careful planning, teamwork, and a highly trained team.
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