Percutaneous femoral venoarterial (VA) or jugular venovenous (VV) extracorporeal membrane oxygenation (ECMO) can result in delivery of hypoxic blood to the brain, coronaries, and upper extremities. Additionally, VA‐ECMO by percutaneous femoral artery cannulation may compromise perfusion to the lower limbs. Use of near‐infrared spectroscopy (NIRS) detects regional ischemia and warns of impending hypoxic damage. We report the first known series with standardized monitoring of this parameter in adults on ECMO. This is an institutional review board‐approved single institution retrospective review of patients with NIRS monitoring on ECMO from July 2010 until June 2011. Patients were analyzed for drops in NIRS tracings below 40 or >25% from baseline. VA‐ECMO and VV‐ECMO were initiated by percutaneous cannulation of the femoral vessels and the internal jugular vein, respectively. Sensors were placed on the patients' foreheads and on the lower limbs. NIRS tracings were recorded, analyzed, and correlated with clinical events. Twenty patients were analyzed (median age: 47.5 years): 17 patients were placed on VA‐ECMO, and three patients on VV‐ECMO. The median duration on ECMO was 7 days (range 2–26). One hundred percent of patients had a significant drop in bilateral cerebral oximetry tracings resulting in hemodynamic interventions, which involved increasing pressure, oxygenation, and/or ECMO flow. In 16 patients (80%), these interventions corrected the underlying ischemia. Four patients (20%) required further diagnostic intervention for persistent decreased bilateral and/or unilateral cerebral oximetry tracings, and were found to have a cerebrovascular accident (CVA). Six (30%) patients had persistent unilateral lower limb oximetry events, which resolved upon placement or replacement of a distal perfusion cannula. No patient was found to have either lower limb ischemia or a CVA with normal NIRS tracings. Use of NIRS with ECMO is important in detecting ischemic cerebral and peripheral vascular events. This allows for potential correction of the underlying process, thus preventing permanent ischemic damage.

Background‘Non-compressible’ haemorrhage is the leading cause of preventable battlefield death, often requiring surgical or radiological intervention, which is precluded in the pre-hospital environment. One-fifth of such bleeds are junctional and therefore potentially survivable. We examine the use of the Abdominal Aortic Junctional Tourniquet - Stabilized (AAJTS) among UK Combat Medical Technicians (CMTs) as a device to control junctional haemorrhage with external compression of the abdominal aorta—compression of junctional haemorrhage previously considered ‘non-compressible.’ This follows animal studies showing that the AAJTS achieves control of haemorrhage and improves physiological parameters.MethodsCMTs were selected and applied the AAJTS to each other following a 1-hour training package. A consultant radiologist-operated hand-held ultrasound monitored flow changes in the subjects’ common femoral artery. CMTs were then surveyed for their opinions as to utility and function.Results21 CMTs were screened and 17 CMTs participated with 34 total applications (16 day and 18 low-light). 27/34 (79%) achieved a successful application. The median application time was 75 s in daylight and 57 s in low-light conditions. There was no significant difference in Body Mass Index (p=0.23), median systolic blood pressure (p=0.19), nor class of CMT (p=0.10) between successful and unsuccessful applications. Higher systolic blood pressure was associated with longer application times (p=0.03). Users deemed the device easy to use (median score 4.4 on a 5-point Likert scale).ConclusionCMTs can use AAJTS successfully after a 1-hour training session in the majority of applications. Application was successful in both daylight and low-light conditions. Self-reported usability ratings were high.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is known to be associated with low-grade inflammation, oxidative stress and ectopic fat/metabolic syndrome. There are studies showing increased prevalence of Non-alcoholic fatty liver disease/Non-alcoholic steatohepatitis (NASH) in patients with COPD. This study is to compare and evaluate the outcome of acute exacerbation of COPD in patients with NASH compared to non-NASH population. Methods: We used the 2018 National Inpatient Sample (NIS) database. Using ICD-10 codes, we queried the database for adults with diagnosis of acute exacerbation of COPD with and without NASH. The primary outcome was odds of mortality and secondary outcome was mean length of stay. Results: A total of 892220 AE of COPD discharges, 2150 discharges had diagnosis of NASH. The NASH group were relatively young (66.8 years vs 70.3 years), more female (67.9% vs 52.7%), more total hospital cost ($83263 vs $74340) and obese (43.2% vs 20.8%) however with less smokers (27.2% vs 35.3%), less pulmonary embolism (0.2% vs 1.7%). There was total of 160 deaths (7.4%) in NASH cohort versus 45950 (5.1%) in non-NASH cohort. Using univariate regression analysis, we found that the unadjusted mortality was higher in patients with NASH compared to the non-NASH patients and was statistically significant [Odds ratio (OR) 1.47, 95% CI (1.02 -2.13), p-value 5 0.03]. After adjusting for age, gender, race, Charlson index, hospital location, ACS, pneumonia, pulmonary embolism, obstructive sleep apnea, pulmonary hypertension, pleural effusion, respiratory failure, mechanical ventilation, atrial fibrillation/flutter using multivariate regression analysis revealed a similar result with increased odds of mortality among NASH patients compared to non-NASH patients and was statistically significant [OR 1.52 95% CI (1.03-2.23), p-value 5 0.031].The mean length of stay was longer for patients in NASH group compared to non-NASH group, however after adjusting using multivariate regression analysis, it wasn't statistically significant (OR 1.4, CI:0.34 -5.65; p-value: 0.63). The disposition of discharge was near evenly distributed among different groups. Conclusion: Our study showed increased mortality among patients with NASH presenting for AE of COPD compared to patients with non-NASH. This was also associated with increased hospital cost without statistically significant longer length of stay. Further studies would be needed to assess the burden of disease on COPD patients and the subsequent outcome.