Gala, J

Abstract Background Ventilated patients in the intensive care unit are often complex and require multiple care team members including bedside nurses, respiratory therapists, advanced practice providers, and physicians. A Quality Improvement initiative was created to address any barriers in communication. Spontaneous breathing trials (SBT) are often used as a surrogate for multidisciplinary communication. Both Respiratory therapist (RT) and provider led spontaneous breathing trial protocols are often performed but not necessarily documented or communicated appropriately. Our primary aim was to increase spontaneous breathing trial documentation from a baseline of 12% to 80% with a counterbalance of not increasing the 24-hour reintubation rate. Methods Using the DMAIC framework, we defined the gap in quality by getting baseline patient data for 3 months including SBT completion rate, SBT documentation rate, time to first SBT, total time on ventilator, 24-hour reintubation rate, and total ICU days. All care team members including providers, RTs, and nurses completed a 10-questions Likert 5-scale survey regarding their views of multidisciplinary communication and SBT completion. We identified the lack of documentation of SBTs and implemented a standardized respiratory therapy shift summary note which included SBT details and major ventilator changes. We then collected the same data over 3 months after implementation. Results Post intervention analysis revealed documentation of daily spontaneous breathing trials improved from 12% to 79%. Pre and post intervention means for patient focused outcomes were statistically unchanged for time to first SBT 26 hours vs 32 hours (p = 0.16), Total ventilator time 5.6 vs 5.4 (p = 0.83), total ICU days 1.9 days vs 2.7 days (p = 0.11), and reintubation rate 14% vs 15%.Survey results showed that there was a statistically significant improvement in overall satisfaction regarding multidisciplinary communication, satisfaction regarding ventilator management discussion on rounds, and if documentation amount was appropriate. Also, there was a significant improvement in the percentage of care team members that were aware of daily SBTs occurring. Conclusion The implementation of RT shift summary greatly improved staff member satisfaction, multidisciplinary discussion during rounds, and awareness of SBT occurrence among providers, RTs, and nurses. While patient centered outcomes were statistically unchanged over this very brief period of observation, having better staff satisfaction and communication may eventually lead to improved outcomes over time and can lead to further analysis to avoid mishaps that can arise from miscommunication. This abstract is funded by: None

Abstract Background Spinal cord ischemia (SCI) is an uncommon but devastating complication of Veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Peripheral femoral cannulation, while rapidly deployable, may compromise spinal cord perfusion. We report a case of thoracolumbar spinal cord ischemia presenting as paraplegia with cauda equina enhancement in a patient on femoral VA-ECMO. Case Presentation A 57-year-old man with nonischemic cardiomyopathy (EF 30%), atrial fibrillation on apixaban, and ICD (2023) suffered a witnessed out-of-hospital cardiac arrest requiring 45 minutes of CPR before return of spontaneous circulation. Peripheral femoral-femoral VA-ECMO was initiated, complicated by left femoral artery injury requiring repair. He was supported with the right axillary Impella 5.5 and listed UNOS Status 1 for heart transplantation. On ECMO day 5, the patient developed acute bilateral lower extremity weakness with preserved sensation and allodynia of the soles. Neurologic exam demonstrated flaccid paralysis below the quadriceps, consistent with a T12 motor level (ASIA C). Given his prolonged low-flow state and ECMO configuration, spinal cord ischemia was suspected. Hemodynamic augmentation and conversion of ECMO drainage from femoral to left subclavian were performed, along with corticosteroids. Following orthotopic heart transplantation on 8/8/2025, MRI of the thoracic and lumbar spine showed thickening, clumping, and enhancement of the cauda equina nerve roots without cord infarction. CSF analysis was negative for infection or inflammation, supporting an ischemic etiology. Despite rehabilitation and neuropathic pain management with pregabalin, lower extremity weakness persisted. He was discharged to inpatient rehabilitation with residual paraplegia. Discussion SCI is a rare neurological complication of femoral VA-ECMO, likely resulting from compromised spinal perfusion due to retrograde aortic flow, vascular injury, or systemic hypoperfusion during cardiac arrest. Post-ischemic cauda equina enhancement may reflect reperfusion-related breakdown of the blood-nerve barrier. Conclusion This case underscores the need for early recognition of spinal cord ischemia in ECMO-supported patients with new-onset paraplegia. Maintaining adequate mean arterial pressure, minimizing femoral arterial compromise, and early reevaluation of cannulation strategy may mitigate irreversible neurologic injury. This abstract is funded by: None