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Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity.An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated.One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P .01). Abnormal NPi (3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82).Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Multisystem Inflammatory Syndrome is a rare condition characterized by fever and multisystem organ failure that presents in those with a history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We present a case of a 37-year-old man with multisystem inflammatory syndrome in adults (MIS-A) to portray this complication of SARS-CoV-2 infection. CASE PRESENTATION: A 37-year-old man with a prior medical history of obesity and mild COVID-19 infection one month prior to admission was evaluated for persistent headaches, fever, and myalgias. The patient presented with leukocytosis, elevated inflammatory markers, a positive COVD-19 PCR, and a chest x-ray that was negative for pulmonary disease. Once admitted, he developed hypotension due to cardiogenic shock with vasoplegia, and decompensated into multiorgan system failure requiring vasopressor and ventilatory support. Corticosteroids and antibiotics were started, and transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 30% with global hypokinesis. The patient was transferred to a tertiary care center, where a follow up TTE revealed an EF of 20%, requiring ionotropic therapy and left ventricular mechanical support with an Impella. The patient's inflammatory markers continued to rise, with a D-Dimer greater than 20 ug/mL, lactate dehydrogenase greater than 4,000 U/L, and ferritin greater than 40,000 U/L, and progressed to acute renal failure. The patient underwent continuous veno-venous hemofiltration, plasma exchange, and tocilizumab, eventually requiring veno-arterial extracorporeal membrane oxygenation for further hemodynamic support. However, due to continued decompensation, the patient expired despite maximal mechanical and pharmacologic support. DISCUSSION: Multisystem inflammatory syndrome in adults (MIS-A) has been described as cardiogenic shock with elevated inflammatory markers in the setting of a positive SARS-CoV-2 test without severe respiratory illness(1). While SARS-CoV-2 infections have been known to cause myocarditis on initial presentation(2), such a significant cardiogenic and vasodilatory shock refractory to both mechanical and pharmacologic support 1-month post-infection is extremely rare in adults, especially in this acuity. However, this presentation has been documented in children (MIS-C) who have had prior SARS-CoV-2 infection (3) with multi-organ inflammation. Treatment is supportive, including the use of corticosteroids, tocilizumab, intravenous immunoglobulin, and circulatory support, but further research is necessary to determine the pathophysiology behind this inflammatory response. CONCLUSIONS: Multisystem inflammatory syndrome in adults is a rare and severe inflammatory complication for those post-SARS-CoV-2 infection. Further research needs to be completed to distinguish the pathophysiology behind this response to optimize treatment. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(40):1450-1456. Published 2020 Oct 9. doi:10.15585/mmwr.mm6940e1 REFERENCE #2: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020;17(9):1463-1471. doi:10.1016/j.hrthm.2020.05.001 REFERENCE #3: Abrams JY, Oster ME, Godfred-Cato SE, et al. Factors linked to SEVERE outcomes IN multisystem Inflammatory syndrome in children (MIS-C) in the USA: A retrospective surveillance study. The Lancet Child & Adolescent Health. 2021;5(5):323-331. doi:10.1016/s2352-4642(21)00050 DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Pedro Mogrovejo, source=Web Response No relevant relationships by Christian von Gizycki, source=Web Response

Patients requiring mechanical circulatory support (MCS) constitute a heterogeneous group whose needs have guided the development of a broad range of MCS devices. Appropriate patient and device selection are important for maximizing the potential benefit of these therapies. Currently available devices can be deployed percutaneously or surgically implanted. They can also be configured for left, right, or biventricular support and remain in place for hours to years, offering varying levels of flow. In the critical care setting, patients with the highest acuity have the worst outcomes when receiving an implantable long-term ventricular assist device (VAD); therefore, shorter-term devices should be considered for stabilization and optimization prior to implantation of a long-term device. In this focused review for the critical care clinician, we discuss important considerations for identifying VAD candidates, identifying the range of devices available to support them, bridging strategies that may improve outcomes for patients who are critically ill, and identifying areas of ongoing research.