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TOPIC: Critical Care TYPE: Original Investigations PURPOSE: In 2020, ELSO published guidelines to assist providers with patient selection for ECMO in COVID ARDS. A BMI > 40 was listed as a relative contraindication for ECMO support without any supporting data in this specific patient population. Two major reports on ECMO patients from France and the ELSO database that included a total of 1118 patients with COVID ARDS, all with BMIs of 40 to be ECMO candidates. We aim to demonstrate the outcomes and feasibility of using ECMO in ARDS patients with extreme obesity METHODS: Data was collected from the ELSO database outlining outcomes of patients cannulated at Advent Health-Orlando for ECMO due to COVID ARDS between March 2020 – April 2021. The data included only patients with a BMI > 40. Data collected included age, length of stay, survival, discharge disposition, and expiration RESULTS: We have cannulated a total of 33 morbidly obese patients (BMI >40). 19/33 (57%) have survived and transitioned to either home, long-term acute care facility, rehab, or original referring hospital. 11/33 (33%) expired while on ECMO, 1/33 (3%) expired post-ECMO, resulting in an overall mortality of (12/33) 36%. The average LOS for all patients was 39.9 days. The survival group had an average LOS of 46.1 days. The average age for our cohort was 41 years CONCLUSIONS: It is our experience at Advent Health Orlando, that providing ECMO support to patients with BMI >40 has similar outcomes to patients who are not morbidly obese, our 59% survival rate compares to 60% in the ELSO historical database. Our 36% mortality rate compared to a range of 31-37% reported in the recent literature for COVID ARDS. Based on our results, we suggest that BMI > 40 be removed as a relative contraindication to ECMO. We also urge other centers to re-consider denying morbidly obese patients ECMO support based on the assumption that they may have a worse outcome than the rest of the population CLINICAL IMPLICATIONS: Based on our data, we demonstrate patients with COVID-19 ARDS with BMI > 40 benefited from ECMO support. In order to effectively ventilate morbidly obese patients, higher plateau pressures are required and may result in barotrauma and hemodynamic compromise. Supporting obese patients with ECMO to maintain protective lung settings can ultimately lead to better long-term outcomes. More data is needed to fully assess the survivability and overall quality of life in morbidly obese patients who are placed on ECMO, however, while this information is collected, we hope that the medical community will start offering the same opportunities to all patients regardless of weight DISCLOSURES: No relevant relationships by Nicholas Cavarocchi, source=Web Response No relevant relationships by Sergio Ramirez, source=Web Response No relevant relationships by Mai Vo, source=Web Response

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: ECMO has long been used in the ICU as a salvage or bridge therapy for selected ICU patients. There had been a variety of cannulas available in the market. We report 2 cases with positive outcomes associated with the use of jugular dual lumen cannula. CASE PRESENTATION: An obese 42-year-old obese female, with PMH of hypothyroidism and ulcerative colitis, was admitted for acute hypoxic respiratory failure due to COVID-19. Patient underwent conventional treatment at the time (dexamethasone, remdesivir, convalescent plasma and antibiotics) for COVID-19 but was ultimately intubated on day 8 due to profound hypoxia requiring VV ECMO on day 10. She remained on full ECMO support until day 56. Her FiO2 was eventually weaned down to 21% but she continued to require a sweep of 3L secondary to profound muscular weakness and obesity. After transitioning to the jugular dual lumen cannula on day 75 for long-term ECMO, her sedation was weaned down, that allowed participation of physical therapy. She was decannulated on day 94 and was discharged to LTAC on day 100. A 48-year-old female was tested positive for COVID-19 after being exposed 12 days before. Due to worsening symptoms, she eventually sought care at the hospital. Despite the standard treatment, her respiratory status continued to worsen. She was intubated on Day 2 before receiving full support on VV ECMO on day 6. Despite effort to wean down to FiO2 of 21%, she still required a sweep of 1L. After being transitioned to a jugular dual lumen cannula on day 71, she was weaned off of sedation and able to participate in therapy. She was eventually decannulated on day 79, and discharged to a rehab facility on day 85 to continue her recovery. DISCUSSION: Transition from a dual cannula ECMO system to a single cannula ECMO system allowed increased mobility and participation of physical therapy while in the ICU for patients requiring extended time on ECMO. Study has suggested a reduction of up to 35% in muscle mass among ECMO patients by day 20 of their cannulation. In an economic study performing on transplant patients, a 73% reduction in post-transplant ICU cost was reported for those who underwent rehabilitation while being supported on ECMO. Both studies demonstrated the potential benefits with promoting early rehabilitation for ECMO patients. Regarding the technique involved, there was a recent report of a similar transition without any ECMO interruption, allowing the patient uninterrupted time on ECMO while benefiting from early rehab. CONCLUSIONS: We present two cases of severe COVID-19 patients with an extended period of time on VV ECMO became severely debilitated. They were transitioned to a jugular dual lumen cannula, allowing early participation in rehab, resulting in their eventual discharge. These cases demonstrated these cannulas were valuable tool to reduce patients' reliance on support, before being transitioned off of ECMO. REFERENCE #1: Hayes K, Holland AE, Pellegrino VA, Mathur S, Hodgson CL. Acute skeletal muscle wasting and relation to physical function in patients requiring extracorporeal membrane oxygenation (ECMO). J Crit Care. 2018;48:1-8. doi:10.1016/j.jcrc.2018.08.002 REFERENCE #2: Bain JC, Turner DA, Rehder KJ, et al. Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation. Respir Care. 2016;61(1):1-7. doi:10.4187/respcare.03729 REFERENCE #3: Chan EG, Chan PG, Harano T, Sanchez PG. Transition of femoral-jugular to dual-stage left subclavian without discontinuation of extracorporeal membrane oxygenation. J Card Surg. 2020;35(10):2794-2797. doi:10.1111/jocs.14881 DISCLOSURES: No relevant relationships by Vernon Chan, source=Web Response No relevant relationships by Marina Dolina, source=Web Response

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Black and Hispanic patients are reported to have higher mortality rates associated with COVID-19 than White patients. There is a paucity of data exploring the effects of extracorporeal membrane oxygenation (ECMO) in COVID-19 patients in respect to race. This study examines differences in outcome between White and Minority COVID-19 patients treated with ECMO in a community hospital. METHODS: This is a retrospective observational study of all patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 who were treated with ECMO at a tertiary cardiovascular care center between March and December 2020. Patients were stratified into two groups: White and Minority patients. The Minority group was composed entirely of Blacks and Hispanics. Patient demographics, hemodynamics, lab values, treatments, outcomes, and complications were recorded. The primary outcome of interest was mortality. The secondary outcome was rate of ECMO-related complications. RESULTS: We identified 23 consecutive COVID-19 patients with ARDS treated with ECMO, of which 7 (30.5%) were White and 16 (69.5%) were Minorities. 6 White and 13 Minority patients were treated with veno-venous ECMO, with the remaining patients in each group treated with veno-arterial ECMO. There was no significant difference in baseline demographics between groups. Minority patients were found to have a lower mortality rate than White patients (62.5% vs 85.7%, p