Faculty Bibliography

Thrombotic complications of the novel coronavirus (COVID-19) are a concerning aspect of the disease, due to the high incidence in critically ill patients and poor clinical outcomes. COVID-19 predisposes patients to a hypercoagulable state, however, the pathophysiology behind the thrombotic complications seen in this disease is not well understood. Several mechanisms have been proposed and the pathogenesis likely involves a host immune response contributing to vascular endothelial cell injury, inflammation, activation of the coagulation cascade via tissue factor expression, and shutdown of fibrinolysis. Treatments targeting these pathways may need to be considered to improve clinical outcomes and decrease overall mortality due to thrombotic complications. In this review, we will discuss the proposed pathophysiologic mechanisms for thrombotic complications in COVID-19, as well as treatment strategies for these complications based on the current literature available.

BACKGROUND:Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices. METHODS:We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible. RESULTS:The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents. CONCLUSION:Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.

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For the last few decades, the immunochromatographic assay has been used for the rapid detection of biological markers in infectious diseases in humans and animals The assay, also known as lateral flow assay, is utilized for the detection of antigen or antibody in human infectious diseases. There are a series of steps involved in the development of these immuno-chromatographic test kits, from gold nano colloids preparation to nitrocellulose membrane coating (NCM). These tests are mostly used for qualitative assays by a visual interpretation of results. For the interpretation of the results, the color intensity of the test zone is therefore very significant. Herein, the study was performed on a malaria antigen test kit. Several studies have reported the use of gold nanoparticles (AuNPs) with varying diameters and its binding with various concentrations of protein in order to optimize tests. However, none of these studies have reported how to fix (improve) test zone band intensity (color), if different sized AuNPs were synthesized during a reaction and when conjugated equally with same amount of protein. Herein, different AuNPs with average diameter ranging from 10 nm to 50 nm were prepared and conjugated equally with protein concentration of 150 µg/mL with K_D = 1.0 × 10^-3. Afterwards, the developed kits' test zone band intensity for all different sizes AuNPs was fixed to the same band level (high) by utilization of an ultraviolet-visible spectrophotometer. The study found that the same optical density (OD) has the same test zone band intensity irrespective of AuNP size. This study also illustrates the use of absorption maxima (λ max) techniques to characterize AuNPs and to prevent wastage of protein while developing immunochromatographic test kits.

INTRODUCTION/BACKGROUND:During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS:We conducted a cross sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. In order to participate in the study, hospitals were required to meet one of the following criteria: a) development of a formal plan for a central venous access line team during the pandemic, b) implementation of a central venous access line team during the pandemic, c) placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice, or d) management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS:Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2,657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis® catheters and non-tunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of hospitals. Less than 50% (24, 41%) of the participating sites reported managing thrombosed central lines in COVID-patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS:Implementation of a dedicated central venous access line team during a pandemic or other healthcare crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed healthcare system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained ICU, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future healthcare crises.

Rigid bronchoscopy for chronic foreign body removal can cause rare but life-threatening complications in the form of tension pneumothorax. A two-year-old child who developed sudden cardiac arrest during the procedure required urgent chest tube insertion. Integrated team effort with effective communication prevented devastating neurological sequelae from hypoxic ischemic encephalopathy.

Extracorporeal membrane oxygenation (ECMO) has become an integral treatment option for patients as a bridge to transplant, management of post cardiotomy cardiogenic shock, and for rescue after cardiopulmonary arrest. Significant strides in ECMO technology and management cannot, however, replace the importance of maintaining and following a comprehensive safety checklist. We herein report a case of massive air entrainment from an inadvertently disconnected port of a central venous catheter (CVC) in the neck which culminated in an airlock of the ECMO circuit. Ascertaining the relative position of the tip of the CVC with respect to the venous cannula on chest X-ray, tightly securing all its ports, and appraising and educating the health-care team can prevent this rare but devastating complication of fatal air embolism.

Mitochondrial Ca²⁺ (_mCa²⁺) uptake mediated by the mitochondrial calcium uniporter (MCU) plays a critical role in signal transduction, bioenergetics, and cell death, and its dysregulation is linked to several human diseases. In this study, we report a new ruthenium complex Ru265 that is cell-permeable, minimally toxic, and highly potent with respect to MCU inhibition. Cells treated with Ru265 show inhibited MCU activity without any effect on cytosolic Ca²⁺ dynamics and mitochondrial membrane potential (ΔΨ_m). Dose-dependent studies reveal that Ru265 is more potent than the currently employed MCU inhibitor Ru360. Site-directed mutagenesis of Cys97 in the N-terminal domain of human MCU ablates the inhibitory activity of Ru265, suggesting that this matrix-residing domain is its target site. Additionally, Ru265 prevented hypoxia/reoxygenation injury and subsequent mitochondrial dysfunction, demonstrating that this new inhibitor is a valuable tool for studying the functional role of the MCU in intact biological models.