Clinical Voices May 2022

May 31, 2022

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This month we feature articles on ECMO for patients with severe COVID-19, new guidance for CLABSI prevention in the NICU, oxygen therapy for PTSD, and more. Plus, watch the new President’s Video and read a soaring flight nurse's story.

Small Study on ECMO for Patients With Severe COVID-19

ECMO might be a lifesaving resource.

Nearly all members of a small cohort of patients with severe COVID-19 treated with venovenous extracorporeal membrane oxygenation (ECMO) recovered lung function and survived one year post-discharge.

One-Year Outcomes With Venovenous Extracorporeal Membrane Oxygenation Support for Severe COVID-19,” in The Annals of Thoracic Surgery, a retrospective review of 30 cases at a single site, finds that 26 patients (86.7%) survived at a median follow-up of 10.8 months, with 25 (92.6%) regaining normal breathing.

“With appropriately selected patients and aggressive management strategies, the use of ECMO support in patients with severe COVID-19 can result in exceptional early survival that, in this cohort, was sustained at 1 year after ECMO cannulation,” the study notes.

A New York City hospital’s ICU evaluated 80 of its 415 patients with COVID-19 for ECMO between March and May 2020. Of the 30 patients cannulated, 26 were male with a median age of 42, and all were on mechanical ventilation prior to ECMO.

The selectivity in offering ECMO was based on early initiation in patients with good survival odds, “thereby limiting the amount of time the lungs were subjected to the recognized deleterious effects of high airway pressure, respiratory rates, and levels of oxygenation.”

Study limitations include selection bias, which exists in all ECMO studies, because they have not yet randomized ECMO vs. medical therapy, the study notes. It also acknowledges a focus on patient selection to use ECMO as a “potentially lifesaving resource” and “chose to avoid using ECMO as salvage therapy.”

The study adds that data published on other patients treated with ECMO produced very different results, with much lower survival rates and limited data, in part because ECMO was used as salvage therapy. “These discordant outcomes likely reflect differences in patient selection, patient management, and a willingness to continue support in the setting of single-organ dysfunction.”

After COVID-19, Cardiovascular Risks Can Persist

What are the long-term cardiovascular risks for patients who had COVID-19?

Even if they weren’t hospitalized, patients who recover from COVID-19 may have increased cardiovascular risks a year later, including dysrhythmias, heart failure, inflammatory and ischemic heart disease, thromboembolic disease and cerebrovascular disorders.

The COVID Heart – One Year After SARS-CoV-2 Infection, Patients Have an Array of Increased Cardiovascular Risks,” in JAMA: The Journal of the American Medical Association, reports that COVID-19 can lead to long-term heart risks regardless of other factors, such as age, race, sex, smoking, diabetes and preexisting cardiovascular disease.

Patients who were hospitalized or admitted to ICUs were linked to higher risks, but risks were also evident among those who recovered at home. COVID-19 may result in serious, lifelong cardiovascular consequences, adds senior study author Ziyad Al-Aly, chief of research at the VA St. Louis Health Care System.

“The risks reported in our paper may appear small but given the large number of people with COVID-19 in the US and globally, these numbers will likely translate into millions of people with heart disease in the US and many more around the world,” Al-Aly notes in the article. “We need to realize this now and make sure we are prepared and ready to address the needs of these patients.”

The findings are from a study in Nature Medicine analyzing data from nearly 154,000 U.S. veterans in the VA system with COVID-19 who survived at least 30 days. Compared with the contemporary control group, at the one-year mark, COVID-19 was associated with “45.29 incidents of any prespecified cardiovascular outcome” and “23.48 incidents of major adverse cardiovascular events.”

In a related article on TCTMD, Khurram Nasir, a cardiology specialist at Houston Methodist Hospital, notes the findings emphasize the need for preventive cardiology. “Especially (for patients who’ve) had prior COVID, I would be paying more attention to them and having a greater due diligence” when it comes to risk assessment and management.

New Recommendations for CLABSI Prevention in NICU Patients

The guidance should be used in conjunction with population information, patient needs and CLABSI rates.

The Centers for Disease Control and Prevention (CDC) has issued new evidence-based recommendations to prevent and control central line-associated bloodstream infections (CLABSIs) in neonatal ICUs.

Recommendations for Prevention and Control of Infections in Neonatal Intensive Care Unit Patients: Central Line-associated Blood Stream Infections,” on the CDC website, offers definitive recommendations on 10 questions, conditional recommendations for eight and no recommendation on four, along with evidence summaries to support each conclusion. For 14 questions (some multifaceted), the CDC provides supporting evidence, level of confidence, benefits, risks and harms, resource use and more.

The guidance says facilities should use the recommendations in conjunction with their own population information, patient needs and CLABSI rates. “Efforts to develop evidence-based recommendations for CLABSI-prevention in NICUs are complicated by the heterogeneity in settings and the populations they serve,” notes the CDC in the introduction, adding that infection prevention alone cannot always be the primary guide for clinical decisions.

Areas with clinical recommendations include central line catheter types, insertion sites, minimizing the number of times central line hubs are accessed, removing umbilical artery and umbilical venous catheters, removing peripherally inserted central catheters, and use of bundled interventions. “At the unit level, factors such as patient acuity, patient mix, central venous catheter utilization, and length of stay impact CLABSI rates and may shape prevention efforts,” adds the CDC in the introduction.

SHEA Neonatal Intensive Care Unit (NICU) White Paper Series: Practical Approaches for the Prevention of Central Line-Associated Bloodstream Infections,” in Infection Control & Hospital Epidemiology,” includes question-and-answer guidance based on consensus expert opinions. The paper addresses 11 questions in detail, including strategies “above and beyond the elements suggested by CDC.”

TBI Linked to Higher Mortality for Post-9/11 Veterans

TBI is associated with increased risks of mental health issues and mortality.

Compared with the total U.S. population, post-9/11 military veterans die at higher rates across multiple causes of death, and the disparities are especially severe for veterans with traumatic brain injury (TBI).

Association of Traumatic Brain Injury With Mortality Among Military Veterans Serving After September 11, 2001 ,” in JAMA: The Journal of the American Medical Association, finds that despite historically low combat fatality rates in Iraq and Afghanistan, today’s veterans face numerous long-term health risks and a higher mortality burden compared with the total U.S. population. The study involved more than 2.5 million veterans who served and received care during the Global War on Terrorism.

“After 20 years of war, it is vital to focus attention on what puts veterans at risk for accelerated aging and increased mortality, as well as how it can be mitigated,” the study notes.

The analysis of data collected from the Department of Defense Military Health System and other sources estimates that 3,858 excess deaths occurred among military veterans from 2002 through 2018, including 2,285 veterans with mild TBI, 1,298 others with moderate to severe TBI – and about 275 who were not exposed to it.

“In our cohort, excess deaths were observed from accident, suicide, cancer, and homicide, although suicide and accidental deaths were by far the biggest contributors,” the study notes, adding that those deaths were concentrated among veterans ages 18 to 44.

The study suggests that TBI exacerbates mortality risks and has been associated with increased risk of mental health issues, including PTSD, anxiety and depression. The findings also indicate that TBI is linked to long-term health risks, including mortality due to cardiovascular disease and other chronic conditions.

A related article in 2 Minute Medicine adds that while the study is strengthened by its large sample size, the data lacks enough detail to investigate how TBI leads to increased health and mortality risks. Further research is warranted.

Oxygen Therapy Could Be ‘New Avenue’ Against PTSD

HBOT improved veterans’ symptoms of treatment-resistant PTSD.

Hyperbaric oxygen therapy (HBOT) helped reduce treatment-resistant post-traumatic stress disorder (PTSD) symptoms and related depression for veterans, while improving brain function.

Hyperbaric Oxygen Therapy Improves Symptoms, Brain’s Microstructure and Functionality in Veterans With Treatment Resistant Post-Traumatic Stress Disorder: A Prospective, Randomized, Controlled Trial,” in PLOS ONE, involved 35 Israeli military veterans who had combat-associated PTSD for at least four years. Fourteen veterans received 60 daily HBOT sessions lasting 90 minutes each, while 15 others completed the control group. Four of the 18 veterans assigned to the HBOT group and two of 17 from the control group did not complete the study protocol.

According to the study, the sessions led to strong improvements in PTSD symptoms measured by clinician-administered questionnaires and in brain plasticity evaluated by MRI diffuse tensor imaging. “HBOT improved both the brain function and brain microstructure in regions typically involved in PTSD pathogenesis.”

A related article in The Times of Israel reports that after therapy, about half of the veterans in the treatment group were no longer considered to have PTSD. Currently, hyperbaric oxygen isn’t used for significant PTSD treatments, but scientists involved in the study say it could open a new avenue for patients with the disorder.

“Today we understand that treatment-resistant PTSD is caused by a biological wound in brain tissues, which obstructs attempts at psychological and psychiatric treatments,” study author Shai Efrati, Sagol Center for Hyperbaric Medicine and Research in Israel, says in the article. Oxygen therapy, he adds, “induces reactivation and proliferation of stem cells, as well as generation of new blood vessels and increased brain activity, ultimately restoring the functionality of the wounded tissues.”

The study lists several limitations, including its small size of 35 randomized patients. “Even though the results are significant, larger scale clinical trials are required to confirm the findings presented,” the study adds.

Telehealth Critical Care Program Helps Fill Pandemic Gaps

NETCCN offers telemedicine support for facilities with limited resources.

The National Emergency Tele-Critical Care Network (NETCCN) provides critical care consulting, remote monitoring and telemedicine support for hospitals with limited capacity.

Organizations funded by the Department of Health and Human Services (HHS) and Department of Defense (DOD) offer remote support through NETCCN to facilities that cannot manage COVID-19 surges with their in-house capabilities. “HHS, DOD and Vendors Partner for Critical Care via Telehealth,”,” in Healthcare IT News, notes that facilities in many states, including Texas, Florida, Georgia, Alabama and Louisiana, have received support to fill gaps in critical-care coverage during the pandemic.

The NETCCN program helps systems and providers access critical care teams via mobile devices during disaster situations. “The simple act of supporting local clinicians and care teams without critical-care knowledge, skills or abilities – with expertise from remote tele-critical-care specialists enables these caregivers to provide more support to patients than would otherwise be possible,” notes the NETCCN website.

NETCCN has several partner organizations, including Avel eCARE of Sioux Falls, South Dakota, which services over 450 systems and facilities. Support includes relief for local teams, expertise and real-time coaching in unfamiliar situations, and patient monitoring in and out of hospitals, the article adds.

Many solutions are available. For instance, a facility with a PPE shortage used NETCCN to monitor in-patients from a central nursing station. “This option gave the staff a quick way to talk to a patient or check vitals remotely, allowing patients to rest uninterrupted and helping the facility preserve their limited PPE supply.”

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