Hello everyone, my name is Karthik Baluri. I'm an assistant professor for Cardiovascular Critical Care Medicine at Baylor College of Medicine. Today I'm here to talk about our experience with COVID-19 in a critical care aspect. The primary focus for me is to shift it toward perfusion and ECMO. Prior to getting to ECMO, what have we faced? So this is our talk, this is part one. Dr. Chatterjee will be joining me next after with his insight. I will be talking about the pathway to ECMO. So a quick epidemiology, all of us have been inundated with COVID facts, it's all over the news, it's all everyone talks about, we're also facing it as a population. So general mode of transmission, we know that it's respiratory droplets, you know it's contact with infected service, however now recently that's been debated by the CDC. Airborne aerosolized respiratory droplets which can be seen during procedures that we see like in the units like BIPAP or any type of airway related procedures. If you have coronavirus or if you acquire it through these methods it usually takes about four to 14 days for it to have presenting symptoms after which there's a progressive course and there's different outcomes. Overall what the way we control this infection is to contact and droplet spread, prevention with simple masks, eye-face protection, three to six feet of distance, social distancing and different agencies like WHO and CDC have different requirements. Overall this is a very severe disease, however majority of the patients in these statistics range between 60 to 80% only suffer a mild form of it, however there is the component that gets progressively worse and this is about three to six week course for these patients with a severe form of COVID. So how does COVID-19 lead to respiratory failure? The overall aspect of this virus is that it infiltrates, we respond to it and then sequentially we get worse. There's an asymptomatic state followed by our upper airway tract symptoms and then slowly our hypoxia and there are changes in our radiological imaging setting. What are these events that take place? It's a very busy slide but this is a graphic representation of the various cascades and processes involved within our alveoli in our lung. Now the virus binds to everyone's possibly heard about the ACE2 receptor which is lining majority of our alveoli respiratory tracts endothelium, cardiac, myocytes, it's in the brain, it's found in the GI tract, it's a pretty prominent and widespread receptor so it's a potential target but for this sake and for this virus purpose our respiratory tract is pretty much where it sort of shows tropism toward. It attaches, infiltrates our cell and it triggers a massive inflammatory response. Now the inflammatory response for this virus is determined predominantly individually like not everyone has a clear cut cookie cutter response to it. Some people can deal with it and they'll have mild symptoms that'll go away however our problem with respiratory failure starts here. As our host responds to the viral infiltration progressively gets worse it leads us into different situations in which macrophages, antibodies, interferons, interleukins, all these inflammatory modulators start eating away in basic terms at our respiratory tract and our functional unit of the lungs which is our alveolus. This is where oxygen is being transferred from our air that we breathe in into the bloodstream so it's a very vital component to our existence and that's why this is such a severe disease. So just in general these are some of the findings that we've seen. CT has been shown to be a better modality in detecting changes in regards to COVID-19. Certain patterns which are these patterns are present in other disease states however in the clinical context of you acquiring this condition you being tested positive for it or you presenting with exposure to it. If you find these findings it's pretty indicative of potential and progressive respiratory failure. You have ground glass capacities and that's the capacities you see there in the corner. Then you'll see patterns like crazy paving which is like these cobblestone appearance and it's like it's like the roads that you see. Vascular dilatation so this is the other component of your lungs the blood interface you'll see the vascular which are also being affected by this virus. You see something called traction bronchiectasis in which these airways get really stretched and enlarged and ultimately lose their functional purpose. As of May 21st very recently New England Journal of Medicine released an article sort of cataloging the changes of this virus. Gross morphology and microscopic like patho histology. So one new component they've seen a lot is something called endothelitis basically our endothelium which is the cells that line the inside of our blood vessels are just extremely inflamed that's one. The next thing they've seen is micro thrombi and this has been passed along a lot that there's a lot of micro thrombi formation in this alveolar capillary interface areas in which is all of this all of these issues all this inflammation it ultimately leads to one simple thing oxygen that comes into our body needs to get put into our lung because of all this inflammation all this endothelitis these thrombosis and all these other secondary effects to the host's response that that barrier is created and that interface where oxygen can easily be transferred from air that we breathe in put it into our blood is destroyed. The severity of how much this occurs in different times of people is dependent on the host factors that means if you're susceptible to it we don't know exactly which conditions make the certain person susceptible however we do know the general things of age heart disease we see it less in children they say but we see a different form now and other comorbidities associated with this has shown to have a more severe outcome. So what do we do this patient comes in and now you know how this virus affects us and how it infiltrates our lungs how it causes the inflammation in our host system and then ultimately messes up our ability to oxygenate our blood. So over the course of the last three months there's been three major issues that have been associated with COVID and critical care medicine. Number one understanding what it is and that is an ongoing process by doing studies from Wuhan and everywhere else. The next thing that what do we do and how to prepare for it how to protect our own people and staff that's another focus and then the biggest thing was what if we have a increased amount of patients that surpasses our hospital capacity which is the surge which we circumvented. Majority of external factors took place like mitigation strategies we tried containment the contact tracing and stuff like that but these mitigation strategies with social distancing quarantine and everything has led to a slowly flattening of the curve as of now. So our ICU luckily in Houston here in St. Luke's now wasn't inundated we were able to handle the capacity that we got in. However that's just one aspect of this entire thing. The other aspect of this is okay versus another respiratory failure patients such as with COPD or you know pneumonia. How does COVID defer and what do we do? So we've established amongst the collaboration with pulmonary critical care cardiovascular ICU anesthesia surgical ICU group of critical care doctors and administrators everyone's got together and created a agreed to format which basically sets a few rules and protocols and the patient came into our ICUs and how do we treat them. Once again this is important to remember oxygen needs to be delivered to the blood how do we do that. First step we isolate them droplet and make everyone safe health care workers and and the patient himself. We initiate low flow oxygen which one to six leaders of oxygen to see if their oxygen saturations are going up of 92 percent. Time goes by and as this inflammation is occurring in that patient's body he's requiring more and more oxygen. Now we would escalate to something called a non-rebreather mask and this is approximately 15 liters per minute and there's no humidification at this point. Simultaneously this patient would be transferred from a different aspect from a from an investigation room to a critical care isolated unit and that would be happening to that patient. The next major thing is something called heated high flow or heated humidified high flow nasal cannula and it's called vapor thermos brand name. Basically this still is a high liters per minute like 40 liters per minute a lot of oxygen into the body. Now this method is debated whether every institution is different some institutions say don't do it because it increases aerosolization however we believed it worked if long as we were in a negative pressure room make sure all the precautions and barriers are done and this would prevent us in the setting of COVID progressively getting worse and causing further and further impending respiratory failure in these patients to improve oxygenation and maybe pull them out from the edge. If that didn't work then in case by case elected bases we would use BiPAP or CPAP, the mask, the non-invasive positive pressure ventilation. Fine. COVID is eating away at the lungs and all these experimental treatments that are under clinical trials right now like convalescent plasma, remdesivir, tosylizumab. So these treatments will be ongoing parallel but as they're ongoing we can hydroxychloroquine right so as they're going parallel to this we don't see any improvement in oxygenation what else do we have left but to intubate the patient and that's where the ultimate step comes in from the medical ICU and our oxygenation strategies. So when would we intubate this patient? We've tried all of these methods now we're at an oxygen saturation despite maximum level of treatment including flow land, proning the patient that is a completely different topic but proning has been shown to help. We see a O2 less than 65, SAO2 less than 92% on all on high flow nasal cannula. We see the patients in respiratory distress, respiratory rate greater than 30. CO2 is building up, building up and his patients getting more acidotic is pH. Impending respiratory failure with metabolic variations despite maximum capacity to supplement oxygen is when we would intubate this patient. We don't wait that long until it hits that point. A clinical day-to-day decision and patient-by-patient decision is made to intubate the patient. Fine, COVID is continuing to eat away at the lungs we're unable to oxygenate we've intubated to force air into their lungs to get it into their bloodstream. So this acts and this behaves in a radiographic manner as something called ARDS. ARDS has been around for 60 years now. Now the thing with ARDS is it's a broad umbrella term. It basically says that your lungs are supposed to be like balloons but now in the case of COVID or ARDS they're like cement blocks and that's what we have to try to oxygenate. So over time there's been different trials and strategies that have been accepted. Now one of these strategies, PEEP, which is positive and respiratory pressure is the amount of pressure you push inside the lungs to keep the airways open. That is a very important parameter that we can adjust with a ventilator. Try to increase PEEP, keep the airways open to deliver more oxygen. Tidal volumes, okay. We try to maintain a low tidal volume in these patients to protect it from trauma or barotrauma, pressure trauma. It's a strong recommendation. Other small technicalities we see within mechanical ventilation is plateau pressures. We want to keep it under 30. If we want higher PEEPs we have to determine based on a severity scale, ARDS severity scale, if it's severe we increase PEEP. Other methods have been tried, have not been proven, such as different ventilator strategies such as APRV, inhaled flowland, but overall it's been generally recommended to avoid steroids in these patients. We prone them and we try all these strategies associated with ARDS to increase oxygenation to the lungs. Most of the time we are successful. Most of the time we face a lot of other secondary issues like super infections of bacteria, renal failure, volume overload. There's different things that are happening. All right once again the basic thing comes down to this. We need to get oxygen into the blood stream. Now we have tried everything from nasal cannula to high flow nasal cannula to mechanical ventilation but we are still at a point where we are not oxygenating these patients. What do we do then? And that's when the pathway to the ECMO comes in and this this decision making is usually determined by the ECMO intensivist, an interventional cardiologist or a referring MD, cardiovascular surgery may be a part of the decision making. This is all institution based but our institution protocol Dr. Chatterjee is going to discuss our experiences here. Okay so I'm going to hand it over to him. Hi my name is Shibashi Chatterjee. I'm a cardiovascular surgeon and critical care intensivist as well as the ECMO program director here at Baylor St. Luke's. Today we'll discuss ECMO for respiratory failure in the COVID-19 pandemic and our experience here at Baylor St. Luke's and the Texas Heart Institute. So the ECMO services that we provide here fall into two broad categories. Cardiogenic and respiratory. The most common indications are post cardiotomy, cardiogenic shock, post myocardial infarction, cardiogenic shock, decompensated heart failure, ECMO in the CPR or salvage settings, and those cases to support our VAD and heart transplant patients. On the respiratory side it's typically for ARDS, for pneumonia to support both lung transplant candidates before and lung transplant recipients after their procedure. And the incidence that we use ECMO for respiratory failure currently is about 20%. Over the course of our Baylor St. Luke's experience we typically do somewhere around 120 cases a year in terms of our overall volume. And this you can see represents about a 25 to 30% increase over the course of the last three to four years. What you'll also notice is that about three or four years ago we had very low survival. Approximately one fourth of our patients both in respiratory and cardiogenic reasons actually survived. And at that point when I became program director one of the things we looked at was what were people dying from. And what we found was that we had a high incidence of neurologic in bleeding and complication. So we set about programmatic initiatives to reorganize the program, focus with other specialists in terms of neurologic outcomes, redo our anticoagulation protocols, and improve our patient selection. And you can see over the course of the last three years that our overall survival has jumped from 26 to 47% and our respiratory failure in particular now is over 60% approaching that of the ELSO database. The way we do ECMO is that we have ECMO conventionally in our 32 bed CV recovery ICU. This is where all the cardiac surgery, liver transplant, and mechanical circulatory support patients go to. All of our ECMO is done in the CV recovery room and that's whether it's for cardiogenic shock or for respiratory failure. We begin with nursing at a two to one ratio and then it's one to one nursing. And then finally we start with four to one ECMO specialist which is a perfusionist. And if we go above four ECMO cases and we bring in a second in-house dedicated perfusionist. And there is always an LVAD ECMO staff intensivist in House 24-7. When as we were getting ready for the COVID search we took a lot of instruction not just from international societies like ELSO but also that of other thought leaders around the world in terms of what they were seeing. And I think at this point our first response to the way ECMO was is that there was a lot of concern because the initial reports that came out of China showed a really prohibitively high mortality rate. This is a series of multiple centers only 17 total ECMO cases but you'll see here that the mortality for ECMO cases was 94% and that's compared to a 70% mortality for conventional management. So these patients were highly sick and the truth was in these patients ECMO didn't really seem to make much of a difference. But at this point talking to colleagues both Asian and European colleagues talking to patients that had experienced a pandemic earlier and at a higher intensity level in Seattle, New York, Baltimore and then talking to local other ECMO centers in our area at Houston Methodist and Memorial Hermann we said about trying to rationally formulate guidelines and organize the program within that. And institutionally we used various intensive care unit services CV surgery as well as colleagues in profusion and nursing and respiratory therapy. A critical thing that had to be decided early on was how were we going to be able to provide PPE and provide and care for our providers to make sure that caregivers were not unnecessarily exposed. And we sort of divided an ICU to as you can see a green yellow red zone with various degrees of PPE required in each zone. And so as a result we converted one we actually had one dedicated COVID ICU that was just for ECMO at a maximum we were up to three ICUs, three 12-bit ICUs that were dedicated to ECMO. But various parts of the ICU would be organized into sort of a green safe zone, a yellow sort of transition zone where more PPE was required and then the red or the patient rooms were full on PPE would be required as can be seen here. We were able to bring out some of the equipment not the ECMO circuits themselves to be able to limit the amount of exposure that different care providers would have going into the rooms. So instead we still during this phase during the ECMO surge we still did most of our ECMO in the CV recovery when it was for cardiogenic shock or for post cardiotomy shock. We did however convert 6-culi A to a dedicated COVID ECMO ICU. The same CV recovery ECMO nurses who were down there were dedicated and then they came up to 6A as a dedicated COVID ECMO nurse. None of the nurses switched during shifts but they were all focused within that. We had a dedicated separate ECMO specialist dedicated to the COVID ECMO cases banishing up to four circuits the most we ever had with six circuits at the same time and we still had our 24-7 in-house ECMO intensivist who would be managing all the ECMO cases not just in CV recovery but also in the COVID ICU on top of working with a dedicated intensivist focusing on just the ECMO cases. So this is what our ICU looked like. We had our monitoring outside the room and just like that. The indications we used for ECMO really didn't differ much from the landmark iolia criteria these were guidance and set from from ELSO itself and basically was characterized by refractory hypoxemia or hypercapnia non-responsive to conventional measures. The guidelines that we used that we developed were sort of multidisciplinary and I think that helped to universalize the adoption. In general we were offered ECMO to patients under the age of 60 I should say 60-ish patients who were mechanically ventilated no more than seven days were denied patients in multi-system organ failure or those with significant comorbidities were cases that we avoided as well as prohibitively high REST scores. So how was this decided? This was decided in the ICU the in-house COVID intensivist called the ECMO intensivist and any consultation also required the ECMO director or the critical care or CVICU service line chiefs so that there was a team and sort of a consensus developed at which point the various cannulation procedure procedure list was consulted and then we had a formal call schedule in terms of delineating who would be cannulating and decannulating and managing complications. So this is a little bit of what our experience looks like so over I think the best sort of metric is taking a look at what the number of mechanically ventilated patients were so we had we've had 50 mechanically ventilation patients as of May 20th subsequently 12 of them actually cleared virus and became COVID negative 14 of these patients are currently inpatient and ventilated right now which represents about 30% of the overall cohort. Nine patients so far went on ECMO for respiratory failure you'll see here that represents 18% of the mechanically ventilated cases overall of all the 50 patients 14 have died which represents just under a 30% mortality and about 19 of them have been discharged alive either to home or to LTCH to date. Now this is data we've done nine ECMO cases this is data for seven the last two just sort of were on just the last few days so it's sort of incomplete but I also use this to benchmark ourselves against the extracorporeal life support or organization or also in their registry dedicated to COVID so the average age of our patients was 45 maybe just a little bit younger than the ELSO registry evenly split between men and women the prevalence you can see here of various comorbidities are listed not as huge and it's impressive these aren't patients with a ton of other medical problems by and large and you can see the rest from there. With respect to disease specific demographics on average from the time patients started symptoms to the time they were hospitalized was about five days and from the time symptom onset to intubation was just about six days so once they arrived in the hospital they tended to deteriorate relatively quickly from the time they were intubated in general do we average about within four and a half days of ECMO initiation and our longest was about eight and a half days after initiation of ECMO you can see here where we are relatively ECMO the ELSO registry you can see this was a sick cohort of patients on average people of over 15 a pdf ratio of about 80 and by and large heart function was preserved you can see here the adjunctive measures that were used just about everyone was prone got prostaglandin E2 were paralyzed not steroids and a number of them got various adjuvant therapies within the that were COVID specific in terms of cannulation configuration most of these patients were femfem cannulated three of the patients were cannulated with a dual lumen Avalon catheter one patient actually started out VAV converted to VV and was our longest case he was on for 41 days before he was successfully decannulated I think I wanted to I want to just take a step back here and just make sure that from an anticoagulation standpoint this is where I think it's really important to have program programmatic infrastructure and understanding so we discussed that one of the things that really improved the protocol was to the program was dedicated heparin monitoring protocol that was understood that was coordinated with the help of our keen path colleagues and so we published this data a few years back and we looked here basically the way we managed anticoagulation is typically we would aim for a PTT at least COVID patients typically somewhere between 65 and 75 we would check it every six hours this is consistent with what we had done previously we managed the thromboelastogram the prolonged art time we were in aiming to be therapeutic there the way we did things is when there was discordance between the two the PTT and the tag we sort of used the anti-10 aid level as sort of a tiebreaker to to make sure we were in the right direction we tried to keep antithrombin three levels greater than 50 percent but definitely between third at least greater than 30 to 50 percent and if we suspected hit then we would switch to bi-valorudin for anticoagulation purposes this shows that in general the hit and the PTT and the tag are rarely discordant probably about 35 to 40 percent of the time where they actually concordant which is where the 10 aid becomes important and it sort of underscores why we can't just rely on the PTT in ECMO cases and this was what we published before in terms of our clinical outcomes you can see significantly improved bleeding complications and most dramatically a pretty significant reduction in mortality most importantly so going back to the COVID cases you can see here this is the international ELSA registry as of last week there were about 935 cases worldwide of which we've contributed nine so far and these are outcomes so eight out of nine patients have survived the average runtime was 16 days which is longer than what the ELSA registry reports like I said our longest case was 41 days we had one patient die of an intracranial hemorrhage at eight days and here you can see the other data with the VVA patient so finally I think one of the other things to emphasize is between myself as the ECMO director at Baylor St. Luke's and at Houston Methodist and Memorial Hermann we sort of formed a consortium to be able to like discuss our joint ECMO experience to be able to discuss things that are working things are not working in real time and here you can see that the collaboration between the three centers we've done a total of 34 cases with very good outcomes about an under nine percent mortality outcome and if you compare that to the ELSA registry that has about an 18 percent mortality outcome we've done pretty well so far in terms of practicing ECMO here so with that I think the important points that I really think I'd like to emphasize is that it was respect to COVID ECMO it's really important to be flexible and I think that along those lines it's recognizing that ECMO is a team sport and what it really requires is excellent profusionists people like Rashid Moody and Adam Harshman and all of our colleagues within profusion have done a great job being flexible and working within that working with our nurses to be able to make sure that we can do this at a dedicated way and to do this as safe as possible and in real time I mean there's no playbook for how to do COVID ECMO we had to sort of discover this on the fly and and everybody wanted to do the best job they could for their patients and as well as working with our intensivist colleagues to be able to to work this right away I think one of the unique challenges about this time was that it's important to set the family expectations normally there's always an opportunity for a face-to-face encounter and I think that was probably of the big challenge I think it was really important to either get on the phone and I tried to make it a point to FaceTime at least once or twice so a couple times a week to be able to see that because I think sometimes your nonverbal communication and just being able to look at another person's eyes really tell something and it's certainly one of the biggest challenges but it's something that if you're focused I think it certainly can be done right and I really think this is underscores to get the process right we discussed anticoagulation and I think that the steps that we had taken over the last couple years to get the anticoagulation right really helped in the COVID situation we didn't have bleeding complications because mainly because we kind of knew how to do this right it's important to be deliberate and thoughtful remember every time you get a lab test you're sending other people into you know to risk and to exposure so I think we were thoughtful and deliberate about that and I think that's important and with that that's essentially it so we'd be happy to entertain any questions


I had a question from one of my mastermind group clients about breathing and talking to new clients. Like do you address breathing? Do you bring up breathing with every new client? And honestly, probably yeah, to some extent. Some people talk about it more than others and some people if I feel like they're just not drinking my Kool-Aid that day, then I'll go do something really generic like squat bench deadlift because arguably that's telling me as much as I need to know for a general fitness client, right? That how coachable are you? How fit are you? How fatigued do you get? How easily does that fatigue come on? All sorts of stuff, right? And I can just jump start into training. I can give you a training stimulus or I can start to teach you the patterns that I want you to know. Now, okay, so let's say they are kind of drinking my Kool-Aid. How do we get to that position? Well, if someone comes in and there are complaining of mobility limitations, then that's when I'm kind of bringing it up a little bit heavier than other people. I'll bring them through just a general movement assessment and general just watch their joints move. How much can you rotate? How well do you do it? What sort of compensations do you do? And then after all that, I have basically the same explanation. I just say, so breathing is really important because without oxygen, you die in like five minutes. And if we, if I took off and I looked into your insides and I took out some of your guts, but I was comparing side to side, you, like we look symmetrical. We've got two hands, two eyes, two nose holes, whatever. But on the inside, we're not really that symmetrical. Like your liver is way bigger than your spleen and your liver's all the way over on the right and your spleen's on the left. So with this and keeping in mind that breathing is really important, it gets easier to breathe in certain positions because you have this big breathing muscle here in the middle of your body that's bigger on one side than it is on the other. And it makes it easier to breathe when you're over here sitting on your right side. So I can predict the way some of your tests will come out and you fit right into that pattern. What I'd like to do now is give you some exercises to see if we can kind of clear some of that up because it'll just let us do cooler stuff over in the gym. Does that sound okay with you?  That's pretty much the depth that'll go into people. I really don't like telling people that they have breathing problems and I'm more cognizant now than I used to be because we've all made mistakes about even not explicitly saying that but implicitly saying that with my behavior. Like, no, no, no, no, no, no, no, you're doing it wrong. I want people to understand when they're doing things wrong and I'll say, okay, that was really good, but try again. I need you to exhale a little bit longer. I want you to sigh out. I want you to pause, FD, exhale, whatever the cue that they may need is I can have that conversation with them. But it's always, well, not always, but it's usually in the context of some other exercise and it's always in the context of some greater goal because ultimately we're in the service industry. I need you to be okay with what I'm doing and I want you to achieve your goal. So I'm just trying to find the best way to do that. That's basically my thoughts on talking about breathing with new clients. Don't force anything if you're not comfortable giving that explanation. If you are comfortable, feel free to steal mine.  If you have any other questions, maybe other suggestions, maybe you want to tell me how you explain breathing to your clients, just leave them in the comments below and as always, don't forget to smash that like button.


Good evening, CUBE fans, and welcome back to the Mile High City. We're here at Supercomputing 2023. My name's Savannah Peterson, joined by CUBE co-founder and co-host John Furrier. John, good evening. This feels like a nightly news broadcast. It's not going to go late, we're going to go late. Whatever it takes, it's just like election coverage. It's like special broadcast. Who's running for office here? And I think Supercomputing's going to win the day. Is it the clouds? Is it the vibrates? I think AI is looking good on the ballot right now. AI is looking- They're certainly the most popular candidate. Definitely could use some intelligence in the office, but definitely, I'm talking about fabrics, not plastics, fabrics. Strong start to this evening segment here at the CUBE after dark. Let's go ahead and welcome our guests before things get too crazy. Summit, thank you so much for being here from Liquid. It's a pleasure to have you. It's a pleasure to be here. Thank you for hosting us. Just in case the audience is not aware of Liquid, though they certainly will be after this show, give us a little bit of background. Sure, Liquid is a composable infrastructure company, and for those that don't know what composable is, I'll take this 30 seconds to explain it. Normally, what we do is we build servers by taking devices and plugging them into the sockets of the motherboard, and what that leads to is static infrastructure. With composability, what we do is we take pools of resources, pools of compute, pools of storage. These days, a lot of pools of GPUs, and we connect them into a switch, a fabric, and then we come in with software and we dynamically build servers at the bare metal. Take this server, take 10 of those storage devices, take 20 of those GPUs, interconnect them at the bare metal, as we say, and build me a dynamic server. The only difference is when that server needs more resources, for example, I need another GPU for my AI workload, we don't send a human with a screwdriver in a cart and try to move things around. What we do is we reprogram that fabric and we add or remove devices from the server depending on what the application layer is required. And the benefit is to do the bare metal work, get that set up and the fabric tends all the management upgrades, configuration, changes. That's right, right? So we dynamically study the workload on the inbound and we spin up our t-shirt size, small, medium, or large, to perfectly match the physical infrastructure to the workload that we're looking to deploy. And the problem that you guys solve is what? So a couple of problems. One problem has to do with performance. So if I need to build a very performant system, I can take a server and attach, for example, 20 GPUs to it and make it go really fast. Another problem we solve is utilization. These devices now are extremely expensive, 20, 30, $40,000 a widget, right? And so the days of putting a GPU in a server at $30,000 a pop and deploying many of them, we don't think that's how GPUs are eventually going to be consumed. We think it's a pool shared resource where we can apply the GPU to any server that needs it whenever it needs it so we can address that utilization problem and change the economics of how we deploy these things. I think you just brought up a really good point. I'm glad that you brought up GPU cost. We're all excited about what's possible. Nobody wants to pay for it and or at least wants the cost to get too high. Our last guest, just Johnny Dallas, has a website he's made called GPUCost.com which is an awesome way to take a glance at just how much that power costs depending on what people are buying and figuring out what GPUs are available. Very interesting tool. You're obviously talking about topics of big hype here, GPUs, AI, but you also have a very important series of announcements. I believe you have three announcements this week. Congratulations. Thank you. Let's hear them. We're hearing them first here on theCUBE. We're getting the scoop before the press release goes out tomorrow. I promise you guys I'd give you guys the early scoop and that's what we're here to do. And so the first announcement will be coming out tomorrow from us. It's a joint announcement between Liquid and Dell and NVIDIA actually. It's around an extremely dense, the most dense NVIDIA Dell GPU server on the market. And so NVIDIA has released a new device called the L40S and we have partnered with NVIDIA and Dell to release a 16-way GPU server where we can apply 16 of these L40Ss to a single Dell server with the power of composability. So we're very excited about that. We expect that to be the highest performance, most dense GPU solution on the market today. That's impressive. Congratulations on that. You have two other big announcements too, correct? We do, we do. And so we're actually at the booth today demonstrating something referred to as CXL. CXL is a new emerging fabric technology and that fabric is being invented for memory desegregation. The ability to desegregate DRAM from the server which is a really important evolution inside the data center. What does that mean just in case folks- Sure, so normally what you do is you take memory and you plug it directly into the motherboard of the server. So what we enable with technologies like CXL is a top-of-rack memory tray where we can dynamically compose memory from that tray to servers depending on what again, what the application workload requires. Flexibility-wise. That's a big deal. It's huge, it's flexibility, it's performance, it's utilization. There's a tremendous amount of benefit being able to desegregate your memory and giving it to applications dynamically on the phone. Hardware's back. Hardware is back, maybe. It never left. This hardware nerd's been waiting for everyone to say this. It's about time everyone remembered what's lovely in powering our entire lives. I'm sorry, I believe you had one more announcement if I'm counting correctly? That is correct. Which is impressive. The third announcement we're actually very excited about, this is again a three-way partnership with Dell and a company called Emulate Hotkey. And on this announcement what we are doing is we're taking our composable technology and we're augmenting Dell's blade servers with GPUs. We are taking blade servers which previously did not have the ability to augment or add GPUs inside of them and through the power of desegregation we're enabling that entire product line with GPU capability. Which blades? It is the MX7000 platform from Dell which is their lead blade platform currently. So they're customers that could have installed servers, could get this and or, right? So both Greenfield and Brownfield, so all of those customers that have invested in blade servers who now want to enable that with AI technology, we're going to partner with Dell to enable that. I was just going to say, what does this mean for AI? I think AI is going to be, it's everywhere, right? So remember GPUs are used for a variety of workloads. AI is obviously the big one that everyone's talking about today, but also virtualization. So we are enabling this blade server with virtualization capability, but it's also important for video rendering in CAD. So regardless of the GPU workload, we are enabling these servers to do more. You know, Savannah brought a good point out and I want to just double down on that second. Everyone loves their NVIDIAs. When they spend a lot of dough on it, they're going to want to use it, get their pound of flesh or get their utilization, whatever they want out of it. So what just pops in my head is the classic TCO, total cost of ownership, because at some level they're kind of ignoring that if they're going to go all in on say millions of GPUs, dollars of GPUs. So how does someone zoom out? Because this to me is the next modern IT architectural question. I got some platform engineering teams out there. We just came back from KubeCon. I got some Kubernetes clusters. I love some bare metal over there. I maybe use some cloud. I got to put it all together. What does the TCO look like?  Is that what you optimize for? You want more GPUs? You want more network? It's very difficult and a lot of our customers tell us they suffer from the 90-10 problem, right? And so when they're deploying things like memory and deploying things like GPU, 90% of the servers have 10% of the resources utilized, 10% of the servers have 90% of the resources utilized. It is almost an impossible thing to balance, right? So this architecture is like composable infrastructure. We allow for the dynamic rebalancing of infrastructure, which again, directly impacts that TCO that we're talking about. She's the most out of your infrastructure. You get your pound of flesh out of your GPUs. You make the compute work. What about the network area? Where's that going to innovation? We're hearing from Broadcom earlier, they're all sighted and jacked up about the Ethernet Alliance 400 gig. 400 going to 800, right? And so those technologies all will enable the ability for us to do things faster, but we'll also enable the ability for us to disaggregate. I think a lot of your viewers need to get this concept of hardware disaggregation, because that is where a lot of the industry is at. Can you explain that please? Because I'd like to get that on the record. What is hardware disaggregation definition mean and why is important? Sure, I think we like to say that the static data center is dead. We think the days of deploying static boxes inside the data center is not the future. We think the future is all about, number one, disaggregating your hardware into individual pools of resources, individual pools of compute, storage, GPU, networking, and then we come in with software-defined methods and we recompose these servers into any shape or form that we need, and that can only be done through the power of disaggregation and fabric technology that ties it all together. Sounds like cloud to me. Sounds like what hyperscalers been doing for years. The hyperscalers have been thinking about the concept of disaggregation for a long time, but we think now it's finally time for enterprises. It looks disaggregated, it's all in their data center. That's right. That's right. We want to bring that power to the enterprise. Yeah, and I think that changes where you can do things, which is very exciting, and it's that could have implications for edge computing and a lot of other things. We talked about composability and the data center. We talked about cost management. I'm curious about sustainability. How does that play into your value proposition? Listen, it's a big important thing related to GPUs, right? The power is a big emerging part of this whole thing and power and utilization go hand in hand, right? The idea here is if I have a rack of infrastructure that's sitting 20% utilized, if I can raise the utilization of that rack to 40, 60, 70%, in theory, I should be able to do with one rack of infrastructure what I previously looked two racks of infrastructure to do, and that's directly how we impact the power, floor space, cooling, TCO argument inside the data center. Utilization and TCO have a one-to-one correlation. Submit and the- That's dramatic. At the HPC community meeting we attended this afternoon that Dell had, there were a couple topics I want to get your reaction to if you don't mind. Density and cooling, I'm sure you'll weigh in on density, we already talked a little bit about that. And then silicon diversity, mainly the CPU and accelerator relationship in the future, CPU and accelerates will be on the same board, more interconnects involved. Take, what's your thoughts on density and cooling and silicon diversity? Sure, density and cooling first. We're starting to approach a point where power is now the limiting factor in how much infrastructure we can deploy inside the data center. When these GPUs begin to run 700 watts per GPU, we quickly get to a point where beyond 32 of them or beyond 16 of them in a rack, we can no longer power and cool that rack. One of the benefits of composability is we can actually have selection, different selection of GPU types. So if we go into an environment where we're limited on power and cooling, we can just switch to a 300 watt GPU, aggregate more of them together and reach higher absolute performance points. I think you have to keep an eye on things like immersion technologies and liquid cooling. I think those are going to become more and more important as we go forward. Silicon diversity is also important for us. One of the hallmarks of our platform is we're heterogeneous GPU types. So we love NVIDIA, we think they make a phenomenal product, that's the majority of our deployments. But our platform is universal. We can support AMD, we can support Intel, we can support other accelerator technologies. And so we think the market is very much focused on a handful of players now, but we think it's a play with strategy in the sense that we want to give a platform where we can give our customers choice. One more question that came up, this is more about AI workloads that introduce new sets of challenges, new workflows, iterations happening, figuring out what happened, how you repeat it and how you measure it. But the issue about AI and ML Perf came up and that is specifically around the data. And you're seeing more and more, let's get together for a week and start testing stuff and you kind of lay it out. How much of that's really going on? ML Perf is important. How do you set up the AI benchmarking? You got to get out there and figure out and scope it. Can you share your thoughts on this new dynamic? Yeah, so benchmarks are important. They give us a standardized way to measure how performance is actually playing out in real world applications. ML Perf is the thing that people are focused on right now. What I'll tell you though for AI in my opinion, it's all about the data, right? And so we make the assertion that if people are serious about AI, more than likely they're going to do it on-prem. And it's a very simple question. If you have petabytes of data, a trillion parameter model, how are you going to train that? You have two options. Option number one is upload all of that data into the cloud and run your AI in the cloud. And a lot of people don't want to move petabytes of data into the cloud. There's tons of concerns about that. Seriously. And if that's not going to happen, the only other option we have is the GPUs come on-prem. And so we think that the ability to do this on-prem and deliver performance is going to be critically important. Things like ML Perf will actually show the world that we can actually be performing. And by the way, that point is also going to lead to, we think, not repatriation, net new opportunities, because if you're running a cloud architecture, I mean, your operating model is cloud, you're on-premises, this one piece of the cloud, you can still go to the public cloud, your workload can move, you move your workload to the edge, far edge, and with satellites coming online, you're going to have a completely connected infrastructure. It doesn't matter what it, I mean... It's a bimodal world, right? And I agree with you, right? There's going to be a certain amount that will live in the cloud and will always be in cloud. And there will be certain net new that we believe will be done on-prem because data's got gravity and they will bring the compute to the data. And by the way, also the movement of the data is one thing. The other thing with the models is intellectual property. Data leakage is a huge factor around training and inferences. And inferences got more traction now because inference is the new real value as you look at the inference, more inferences going on in the way the data sits. That's right, that's right. Agreed, data hygiene. We've been talking about it all week, last week. We were talking about flexibility, we were talking about data hygiene, we were talking about GPUs. I mean, the conversation is only heating up. It's all coming together again, AI, hardware. This is definitely the place to be. What conversations are you most excited to have here on the show floor? Big community and important discussions for you this week, no doubt. Sure, I was asked this question earlier and I think the three hottest things going on in our industry right now is number one, everything AI, right? And so, AI, GPU, that is at the center of what everyone is thinking. This concept of memory disaggregation in CXL for us is critically important and it's getting a tremendous amount of market momentum. We see the hyperscalers jumping into this. And then the last thing I'll tell you guys to keep an eye on is optical interconnects. So, there's optical interconnects. We think that's a new hot emerging space. We will be supporting optical interconnects as part of our disaggregation story. And so, I think that's a threat. And why is that important over, say, for 800 gig ethernet where the bottlenecks might not be the networks? Or is network still the bottleneck? I think what's going to end up happening is the reason why we go to optical number one is power. As you guys mentioned earlier, power, power, power. Optical brings a better power profile. For us, also, a lot of what we do has to do with reach. Being able to go very, very far distances over low latency interconnects. Latency's a critical, critical part of all things AI. That speed of light thing is real. That will help the multi-cloud and super-cloud equations to start getting into more of these pools and composability. We have this grand vision. Eventually, we're going to be composing across data centers, right? Once the latency is acceptable, once we get things fast enough, we're going to be taking a GPU from data center number one and we're going to be composing it, potentially to data center number two. If the latency profile- I think that's a good vision because edge is going to force that because if you're going to have to work at the edge whether it's a far edge or hyper edge, you need to have these data strategies and latency strategies nailed down. There's four kind of markets that we chase with our solution. The first is HPC and research. They consume a lot of AI. The next is enterprise. For the reason that I mentioned is that data is bringing the GPUs to them. Media and entertainment consumes a lot of GPUs and edge. All of the data is created at the edge. And forklifting data and moving it to core to make decisions is not the answer. And so, inevitably, GPUs find their way to the edge. And what is edge limited by? Power, floor space, cooling. Connectivity. Human access, right? And so those are the things we fix, right? With composability. Wow, you have absolutely nailed the definitions. He's going to do wonders for the cube AI. The cube AI just got fed some good content there. Between composable infrastructure, we're talking about the disaggregation of GPUs and the hardware space. That was mind blowing. I saw you fervently taking notes throughout this entire segment. Yeah, I made a couple of notes. What was that again? Tap, tap, tap, tap, tap. I thought that was really awesome. So, but thank you so much for being here. My pleasure. Thank you for having us, guys. We really appreciate the opportunity. And John, thank you for those fantastic questions. And I'm going to close this out here with a first on the cube since I saw something very fun on the show floor. Like we mentioned here, it's super computing 2023. It's a hardware party for all the nerds. There was live bands, there's SkiBall. There's a ton of fun activations all around me. But I saw something I've never seen before on this show floor and it is an entire piece of cheesecake on a stick. So I'm going to take this opportunity and do something that I haven't had the chance to do before. We're here in Denver on the cube live from super computing 2023. And I hope you have some sweet dreams.