key: cord-0921236-k0a3u9xg authors: JWA, Hayanga; HK, Hayanga; A, Dhamija; J, Fugett; C, Cook; D, Powell; P, McCarthy; IM, Olfert; V, Badhwar; A, Toker title: Extracorporeal Support to Treat E-cigarette or Vaping Product Use-associated Lung Injury (EVALI) During a COVID Pandemic date: 2020-05-24 journal: JTCVS techniques DOI: 10.1016/j.xjtc.2020.05.015 sha: 7dd7b3681c39704371b9fd5981e4a52f7a31be9d doc_id: 921236 cord_uid: k0a3u9xg nan Hayanga JWA 1 , Hayanga HK 1 , Dhamija A 1 , Fugett J 1 , Cook C 1 , Powell, D 1 , McCarthy P 1 , 3 Olfert IM 2 , Badhwar V 1 , Toker A. was tilted leftward to alleviate pressure on the IVC. The neonate in breech presentation was 55 delivered safely by cesarean section immediately post-cannulation in the ICU within 90 minutes 56 of the patient's arrival. APGAR of 9. Anticoagulation, although administered during initiation 57 of ECMO, was held during the delivery. The patient was extubated on Day 2, tested negative for 58 COVID-19 , was able to nurse her baby on Day 3, decannulated on Day 6, and was discharged 59 Day 7. Further history revealed that, though not a "smoker", she had been an active "vaper" until 60 the day of her hospitalization. It was most plausible that she had sustained e-cigarette or vaping 61 product use-associated lung injury (EVALI). Informed consent was provided by the patient. In a single year, two novel physiological entities have expanded indications for extracorporeal 66 support. 1-3 In this report, we describe the management of a 30-year-old expectant mother who 67 presented in her third trimester with severe acute hypoxic respiratory failure secondary to 68 EVALI. She tested negative for influenza A and B. However, by presenting during the SARS-69 Cov 2 pandemic in a high-risk geographic area, suspicion was heightened, and she was 70 transferred from with the presumptive diagnosis of COVID-19. 71 Dual corollaries warrant consideration in the acute setting. First, there is growing evidence that 72 vaping impairs lung and host immunity. 4 As such, healthy young adults who may not otherwise 73 experience severe respiratory symptoms to seasonal flu or novel viral outbreaks are now likely to 74 become a new 'at-risk' group. Vaping status should consequently be routinely entered into the 75 medical record and an effort to should be taken to distinguish EVALI from other respiratory 76 illness in the history by eliciting signs of fever, sore throat and/or exposure. Secondly, current 77 opinion regarding safety of vaping during pregnancy remains mixed. 4 Emerging evidence 78 suggests that, like smoking, it poses significant risk to the developing fetus. 4-6 This is due, in 79 part, to the well-known adverse effects of maternal nicotine exposure on fetal outcomes and 80 post-natal development. 6 A single e-cigarette pod (for a JUUL, Sorin, or similar rechargeable 81 device), or disposable e-cigarette stick, can deliver the nicotine equivalent of four packs of 82 cigarettes (i.e. 20-90 mg nicotine), the ill effects of nicotine exposure to the unborn child are thus 83 cause for great concern. Even in the absence of nicotine, in utero exposure to vaping (without 84 nicotine) may also induce vascular impairment and dysfunction in offspring after birth. 7 As 85 such, vaping during pregnancy may have profound impact on vascular health and function and 86 should not be considered 'safe' or 'risk-free'. 8,9 87 In the weeks preceding this admission, the ECMO team had conducted a series of preparedness 89 drills and drafted a checklist for managing suspected COVID-19. (Appendix 1) The drills 90 involved multidisciplinary providers, nurses, perfusionists, respiratory therapists, security and 91 housekeeping in high-fidelity scenarios using mock pumps and mannequins in simulating 92 transport, cannulation and containment. (Figure 2) The drills allowed for a fluid and reproducible 93 response. The patient remained in full airborne precautions until she was confirmed negative and 94 volunteered the history of active vaping once extubated and communicative. 95 The repeated drills allowed us to identify commonly overlooked features delineated below. 97 • Need for a pre-transportation huddle to anticipate hurdles and barriers. 98 • Need for environmental services crew to cordon off and disinfect hallways and elevators. 99 • Need for personal protective equipment for two sets of teams. 100 • Need for receptacles for contaminated equipment and clothing. 101 • Consider IRB exemption to permit compassionate use of trial drug, Remdesivir (Gilead 102 Science, Foster City, CA). 103 • Use designated telephone (and/or whiteboard) from which the teams inside patient's 104 room may communicate without having to break the negative pressure seal. 105 • Cordon off the main room door and use signage. 106 The concurrent novelty and mimicry proffered by EVALI is likely to render it a potential 108 differential diagnosis in the midst of a COVID-19 pandemic and the ensuing diagnostic dilemma 109 will likely test the level of preparedness for dealing with this deadly virus. Lung injury associated with e-cigarette or 115 vaping product use Severe E-cigarette, or Vaping, Product Use Associated Lung 117 Injury Requiring Venovenous Extracorporeal Membrane Oxygenation Preparing for the Most Critically Ill Patients With 120 COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation Electronic nicotine delivery systems and pregnancy: 123 Recent research on perceptions, cessation, and toxicant delivery Modulation of neural regulators of energy homeostasis, and 126 of inflammation, in the pups of mice exposed to e-cigarettes Maternal nicotine exposure and fetal programming of vascular 129 oxidative stress in adult offspring Utero Exposure to Electronic Cigarettes Causes 134 Chronic exposure to electronic cigarettes 137 results in impaired cardiovascular function in mice JUUL and Combusted Cigarettes Comparably Impair 140 Endothelial Function. Tob Regul Sci. 2020 Use simplest mode of cannulations that does not require the OR 248  Control contacts and enforce visitation policy  Storage and supplies to be thoughtfully sequestered 250