Delivering extracorporeal membrane oxygenation for patients with COVID-19: what, who, when and how?

Utilisation and outcomes of a mobile (ambulance and air transport) venovenous extracorporeal membrane oxygenation (VV-ECMO) program in Poland during the COVID-19 pandemic - a retrospective, two-centres, case-series study

INTRODUCTION

Many patients required mechanical ventilation support due to severe COVID-19 pneumonia. A significant proportion of mechanically ventilated patients also required venovenous extracorporeal membrane oxygenation (VV-ECMO) due to refractory hypoxemia. A high demand for VV-ECMO support during the pandemic was challenging due to many factors, including limited resources and lack of established transfer protocols. This study aims to present the organisation and outcomes of a mobile VV-ECMO program in two high-volume centres in Poland during the COVID-19 pandemic.

MATERIAL AND METHODS

This retrospective, two-centre case series study, which lasted 36 months, was conducted between March 10, 2020, and January 31, 2023. The data of all patients transferred using venovenous extracorporeal membrane oxygenation (VV-ECMO) were analysed, including five women in the perinatal period with severe respiratory failure attri-buted to the COVID-19 virus. The analysis encompassed baseline patient demographics, Sequential Organ Failure Assessment (SOFA) scores, admission laboratory parameters, ECMO therapy, duration of mechanical ventilation, and patient survival to ICU discharge.

RESULTS

We assessed 86 patients who met the ELSO inclusion criteria and were transported during VV-ECMO support. Mortality in the analysed group was high (80.3%). Despite high mortality, VV-ECMO appeared to be a safe procedure in COVID-19 patients with severe ARDS. No complications were noted in more than half of the analysed procedures. Despite the above, many severe complications were observed, including stroke or cerebral haemorrhage (9.8%) and limb or gut ischemia (1.6%). The most common problems co-existing with VV-ECMO treatment were bleeding complications (34.4%).

CONCLUSIONS

The ICU mortality rate among patients requiring VV-ECMO for COVID-19 in high-volume ECMO centres was high but not associated with the type of transportation.

Multi-horizon predictive models for guiding extracorporeal resource allocation in critically ill COVID-19 patients

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) resource allocation tools are currently lacking. We developed machine learning (ML) models for predicting COVID-19 patients at risk of receiving ECMO to guide patient triage and resource allocation.

MATERIAL AND METHODS

We included COVID-19 patients admitted to intensive care units for >24 h from March 2020 to October 2021, divided into training and testing development and testing-only holdout cohorts. We developed ECMO deployment timely prediction model ForecastECMO using Gradient Boosting Tree (GBT), with pre-ECMO prediction horizons from 0 to 48 h, compared to PaO2/FiO2 ratio, Sequential Organ Failure Assessment score, PREdiction of Survival on ECMO Therapy score, logistic regression, and 30 pre-selected clinical variables GBT Clinical GBT models, with area under the receiver operator curve (AUROC) and precision recall curve (AUPRC) metrics.

RESULTS

ECMO prevalence was 2.89% and 1.73% in development and holdout cohorts. ForecastECMO had the best performance in both cohorts. At the 18-h prediction horizon, a potentially clinically actionable pre-ECMO window, ForecastECMO, had the highest AUROC (0.94 and 0.95) and AUPRC (0.54 and 0.37) in development and holdout cohorts in identifying ECMO patients without data 18 h prior to ECMO.

DISCUSSION AND CONCLUSIONS

We developed a multi-horizon model, ForecastECMO, with high performance in identifying patients receiving ECMO at various prediction horizons. This model has potential to be used as early alert tool to guide ECMO resource allocation for COVID-19 patients. Future prospective multicenter validation would provide evidence for generalizability and real-world application of such models to improve patient outcomes.

Managing Covid-19 in patients with heart failure: current status and future prospects

INTRODUCTION

COVID-19 may contribute to decompensation of previously stable chronic HF or cause a de-novo heart failure, which may come from the hyperinflammatory response and subsequent increase in metabolic demand.

AREAS COVERED

Two independent investigators searched MEDLINE (via PubMed), Europe PMC, and ScienceDirect databases with the following search terms: COVID-19, heart failure, COVID-19 drugs, heart failure drugs, and device therapy. All of the included full-text articles were rigorously evaluated by both authors in case there was disagreement about whether research should be included or not. In total, 157 studies were included and underwent extensive reading by the authors.

EXPERT OPINION

The World Health Organization (WHO) and the National Institute of Health (NIH) have published COVID-19 drug recommendations, although recommendations for HF-specific drug choices in COVID-19 are still lacking. We hope that this review can answer the void of comprehensive research data regarding the management options of HF in the COVID-19 condition so that clinicians can at least choose a more beneficial therapy or avoid combination therapies that have a high burden of side effects on HF; thus, morbidity and mortality in COVID-19 patients with HF may be reduced.

Oxigenación con membrana extracorpórea en el paciente COVID-19: resultados del Registro Español ECMO-COVID de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE)

Introducción y objetivos

La oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes con COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados.

Métodos

En marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes con COVID-19 tratados mediante ECMO veno-arterial (V-A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias preimplante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento tras el alta.

Resultados

Se analizó a un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media de 52,7 y 49,4 años, respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33,3% y el 34,9% de los pacientes con ECMO V-A y V-V, respectivamente, fueron dados de alta del hospital (p = NS) y la mortalidad fue similar, del 56,2% y 50,9% de los casos respectivamente, la inmensa mayoría durante la ECMO y sobre todo por fracaso multiorgánico. El 14,0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196 ± 101,7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0,967; IC 95%: 0,95-0,99; p = 0,004) y la procedencia del propio hospital (OR 0,48; IC 95%: 0,27-0,88; p = 0,018), mientras que la edad (OR 1,063; IC 95%: 1,005-1,12; p = 0,032), la hipertensión arterial (3,593; IC 95%: 1,06-12,19; p = 0,04) y las complicaciones en ECMO globales (2,44; IC 95%: 0,27-0,88; p = 0,019), digestivas (OR 4,23, IC 95%: 1,27-14,07; p = 0,019) y neurológicas (OR 4,66; IC 95%: 1,39-15,62; p = 0,013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente.

Conclusiones

La terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la hipertensión arterial y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional solo se ve influida por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave mejoraría los resultados y la futura investigación clínica.

Duration of invasive mechanical ventilation prior to extracorporeal membrane oxygenation is not associated with survival in acute respiratory distress syndrome caused by coronavirus disease 2019

Background

Duration of invasive mechanical ventilation (IMV) prior to extracorporeal membrane oxygenation (ECMO) affects outcome in acute respiratory distress syndrome (ARDS). In coronavirus disease 2019 (COVID-19) related ARDS, the role of pre-ECMO IMV duration is unclear. This single-centre, retrospective study included critically ill adults treated with ECMO due to severe COVID-19-related ARDS between 01/2020 and 05/2021. The primary objective was to determine whether duration of IMV prior to ECMO cannulation influenced ICU mortality.

Results

During the study period, 101 patients (mean age 56 [SD ± 10] years; 70 [69%] men; median RESP score 2 [IQR 1–4]) were treated with ECMO for COVID-19. Sixty patients (59%) survived to ICU discharge. Median ICU length of stay was 31 [IQR 20.7–51] days, median ECMO duration was 16.4 [IQR 8.7–27.7] days, and median time from intubation to ECMO start was 7.7 [IQR 3.6–12.5] days. Fifty-three (52%) patients had a pre-ECMO IMV duration of > 7 days. Pre-ECMO IMV duration had no effect on survival (p = 0.95). No significant difference in survival was found when patients with a pre-ECMO IMV duration of < 7 days (< 10 days) were compared to ≥ 7 days (≥ 10 days) (p = 0.59 and p = 1.0).

Conclusions

The role of prolonged pre-ECMO IMV duration as a contraindication for ECMO in patients with COVID-19-related ARDS should be scrutinised. Evaluation for ECMO should be assessed on an individual and patient-centred basis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00980-3.

Extracorporeal membrane oxygenation support for SARS-CoV-2: a multi-centered, prospective, observational study in critically ill 92 patients in Saudi Arabia

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been used as a rescue strategy in patients with severe with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2 infection, but there has been little evidence of its efficacy.

OBJECTIVES

To describe the effect of ECMO rescue therapy on patient-important outcomes in patients with severe SARS-CoV-2.

METHODS

A case series study was conducted for the laboratory-confirmed SARS-CoV-2 patients who were admitted to the ICUs of 22 Saudi hospitals, between March 1, 2020, and October 30, 2020, by reviewing patient's medical records prospectively.

RESULTS

ECMO use was associated with higher in-hospital mortality (40.2% vs. 48.9%; p = 0.000); lower COVID-19 virological cure (41.3% vs 14.1%, p = 0.000); and longer hospitalization (20.2 days vs 29.1 days; p = 0.000), ICU stay (12.6 vs 26 days; p = 0.000) and mechanical ventilation use (14.2 days vs 22.4 days; p = 0.000) compared to non-ECMO group. Also, there was a high number of patients with septic shock (19.6%) and multiple organ failure (10.9%); and more complications occurred at any time during hospitalization [pneumothorax (5% vs 29.3%, p = 0.000), bleeding requiring blood transfusion (7.1% vs 38%, p = 0.000), pulmonary embolism (6.4% vs 15.2%, p = 0.016), and gastrointestinal bleeding (3.3% vs 8.7%, p = 0.017)] in the ECMO group. However, PaO2 was significantly higher in the 72-h post-ECMO initiation group and PCO2 was significantly lower in the 72-h post-ECMO start group than those in the 12-h pre-ECMO group (62.9 vs. 70 mmHg, p = 0.002 and 61.8 vs. 51 mmHg, p = 0.042, respectively).

CONCLUSION

Following the use of ECMO, the mortality rate of patients and length of ICU and hospital stay were not improved. However, these findings need to be carefully interpreted, as most of our cohort patients were relatively old and had multiple severe comorbidities. Future randomized trials, although challenging to conduct, are highly needed to confirm or dispute reported observations.

Mortality Risk Assessment in COVID-19 Venovenous Extracorporeal Membrane Oxygenation

BACKGROUND

A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators.

METHODS

A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses.

RESULTS

Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality.

CONCLUSIONS

These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.

Predictive Value of Eosinophil Count on COVID-19 Disease Progression and Outcomes, a Retrospective Study of Leishenshan Hospital in Wuhan, China

BACKGROUND

The potential protective role of eosinophils in the COVID-19 pandemic has aroused great interest, given their potential virus clearance function and the infection resistance of asthma patients to this coronavirus. However, it is unknown whether eosinophil counts could serve as a predictor of the severity of COVID-19.

METHODS

A total of 1004 patients with confirmed COVID-19 who were admitted to Leishenshan Hospital in Wuhan, China, were enrolled in this study, including 905 patients in the general ward and 99 patients in the intensive care unit (ICU). We reviewed their medical data to analyze the association between eosinophils and ICU admission and death.

RESULTS

Of our 1004 patients with COVID-19, low eosinophil counts/ratios were observed in severe cases. After adjusting for confounders that could have affected the outcome, we found that eosinophil counts might not be a predictor of ICU admission. In 99 ICU patients, 58 of whom survived and 41 of whom died, low eosinophil level was an indicator of death in severe COVID-19 patients with a cutoff value of 0.04 × 10⁹/L, which had an area under the curve of 0.665 (95% CI = 1.089-17.839; P = .045) with sensitivity and specificity of 0.569 and 0.7317, respectively.

CONCLUSION

Our research revealed that a low eosinophil level is a predictor of death in ICU patients rather than a cause of ICU admission.

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19

ABSTRACT

Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

COVID-19 and extracorporeal membrane oxygenation: experiences as a patient, general practitioner, wife and mother

I contracted SARS‐CoV‐2 early in the first wave of the COVID‐19 pandemic in the UK and, following nine days of mechanical ventilation, was one of the first few patients to be accepted for venovenous extracorporeal membrane oxygenation. I remained in hospital for 150 days, 34 of which I spent with full extracorporeal respiratory support. I have no recollection of my time on extracorporeal membrane oxygenation, but liberation from it was not the end of my story; I had to overcome numerous physical and mental challenges during recovery and rehabilitation. I hope my story is read by others who are recovering from COVID‐19 or critical illness more generally, and that it provides hope that the challenges of rehabilitation can be overcome. This reflection is a personal view of my illness as a patient. In it, I focus upon the aspects of my care that I can remember, predominantly around the time I became unwell but also during the recovery and rehabilitation period, which remains ongoing despite my discharge from hospital and subsequent return to work as a general practitioner.

Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised many questions about the management of patients with chronic obstructive pulmonary disease (COPD) and whether modifications of their therapy are required. It has raised questions about recognizing and differentiating coronavirus disease (COVID-19) from COPD given the similarity of the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee used established methods for literature review to present an overview of the management of patients with COPD during the COVID-19 pandemic. It is unclear whether patients with COPD are at increased risk of becoming infected with SARS-CoV-2. During periods of high community prevalence of COVID-19, spirometry should only be used when it is essential for COPD diagnosis and/or to assess lung function status for interventional procedures or surgery. Patients with COPD should follow basic infection control measures, including social distancing, hand washing, and wearing a mask or face covering. Patients should remain up to date with appropriate vaccinations, particularly annual influenza vaccination. Although data are limited, inhaled corticosteroids, long-acting bronchodilators, roflumilast, or chronic macrolides should continue to be used as indicated for stable COPD management. Systemic steroids and antibiotics should be used in COPD exacerbations according to the usual indications. Differentiating symptoms of COVID-19 infection from chronic underlying symptoms or those of an acute COPD exacerbation may be challenging. If there is suspicion for COVID-19, testing for SARS-CoV-2 should be considered. Patients who developed moderate-to-severe COVID-19, including hospitalization and pneumonia, should be treated with evolving pharmacotherapeutic approaches as appropriate, including remdesivir, dexamethasone, and anticoagulation. Managing acute respiratory failure should include appropriate oxygen supplementation, prone positioning, noninvasive ventilation, and protective lung strategy in patients with COPD and severe acute respiratory distress syndrome. Patients who developed asymptomatic or mild COVID-19 should be followed with the usual COPD protocols. Patients who developed moderate or worse COVID-19 should be monitored more frequently and accurately than the usual patients with COPD, with particular attention to the need for oxygen therapy.

Role of extracorporeal membrane oxygenation in critically Ill COVID-19 patients and predictors of mortality

The role of extracorporeal membrane oxygenation (ECMO) in the management of critically ill COVID‐19 patients remains unclear. Our study aims to analyze the outcomes and risk factors from patients treated with ECMO. This retrospective, single‐center study includes 17 COVID‐19 patients treated with ECMO. Univariate and multivariate parametric survival regression identified predictors of survival. Nine patients (53%) were successfully weaned from ECMO and discharged. The incidence of in‐hospital mortality was 47%. In a univariate analysis, only four out of 83 pre‐ECMO variables were significantly different; IL‐6, PCT, and NT‐proBNP were significantly higher in non‐survivors than in survivors. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score was significantly higher in survivors. After a multivariate parametric survival regression, IL‐6, NT‐proBNP and RESP scores remained significant independent predictors, with hazard ratios (HR) of 1.069 [95%‐CI: 0.986‐1.160], P = .016 1.001 [95%‐CI: 1.000‐1.001], P = .012; and .843 [95%‐CI: 0.564‐1.260], P = .040, respectively. A prediction model comprising IL‐6, NT‐proBNP, and RESP score showed an area under the curve (AUC) of 0.87, with a sensitivity of 87.5% and 77.8% specificity compared to an AUC of 0.79 for the RESP score alone. The present study suggests that ECMO is a potentially lifesaving treatment for selected critically ill COVID‐19 patients. Considering IL‐6 and NT‐pro‐BNP, in addition to the RESP score, may enhance outcome predictions.

Thromboembolische Erkrankung bei COVID-19-Patienten: Eine kurze narrative Übersichtsarbeit

Die Infektion mit dem Coronavirus 2 (SARS-CoV2, severe acute respiratory syndrome corona virus 2) hat sich zu einer globalen Gesundheitskrise entwickelt. Berichten zufolge ist die Inzidenz von thromboembolischen Erkrankungen bei der SARS-CoV2-Krankheit hoch und betrifft ein breites Spektrum an Organsystemen, von Hautthrombosen bis zu Lungenembolien, Schlaganfall oder Koronarthrombose, bisweilen mit katastrophalen Folgen. Es liegen Hinweise vor, nach denen Thromboembolien, Hyperkoagulabilität und eine Überproduktion proinflammatorischer Zytokine, die einen Zytokinsturm nachahmen, der zu Multiorganversagen führt, eine Schlüsselrolle dabei spielen. Die vorliegende kurze narrative Übersichtsarbeit beleuchtet die Pathophysiologie und die Risikofaktoren der thromboembolischen Erkrankung und liefert einen Rahmen für das Antikoagulationsmanagement auf Grundlage der aktuellen Evidenzlage.

Use of Venovenous Extracorporeal Membrane Oxygenation in Critically-Ill Patients With COVID-19

Acute respiratory distress syndrome (ARDS) related to Coronavirus disease (COVID-19) is associated with high mortality. It has been suggested that venovenous extracorporeal membrane oxygenation (ECMO) was suitable in this indication, albeit the effects of ECMO on the mechanical respiratory parameters have been scarcely described. In this case-series, we prospectively described the use of venovenous ECMO and its effects on mechanical respiratory parameters in eleven COVID-19 patients with severe ARDS. Implantation of ECMO occurred 6 [3–11] days after the onset of mechanical ventilation. At the time of ECMO implantation, all patients received neuromuscular blocking agents, three (27%) received inhaled nitric oxide and prone positioning was performed in all patients with 4 [3−5] sessions of PP per patient. Under ECMO, the tidal volume was significantly decreased from 6.1 [4.0–6.3] to 3.4 [2.5–3.6] mL/kg of predicted body weight and the positive end-expiratory pressure level was increased by 25 ± 27% whereas the driving pressure and the mechanical power decreased by 33 ± 25% and 71 ± 27%, respectively. The PaO₂/FiO₂ ratio significantly increased from 68 [58–89] to 168 [137–218] and the oxygenation index significantly decreased from 28 [26–35] to 13 [10–15]. The duration of ECMO was 12 [8–25] days. Nine (82%) patients experienced ECMO-related complications and the main complication was major bleeding requiring blood transfusions. Intensive care unit mortality rate was 55% but no patient died from ECMO-related complications. In COVID-19 patients with severe ARDS, venovenous ECMO allowed ultra-protective ventilation, improved oxygenation and should be considered in highly selected patients with the most severe ARDS.

Emergency biventricular assist device implantation in a patient with suspected COVID-19 disease

Severe coronavirus disease 2019 (COVID-19) is a multisystem inflammatory disorder and knowledge and experience with severe acute respiratory failure in infected patients has grown considerably since reports of the first few cases. Little is known about the effect of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus on the heart, and it has been suggested that fulminant cardiac failure, with or without respiratory failure, may occur several weeks following infection. A young man presented after a recent viral illness. He was in severe cardiogenic shock and was implanted with an emergency biventricular assist device, which also incorporated an extracorporeal membrane oxygenator. He stabilised soon after and, despite an intracerebral haemorrhage which resolved and bleeding into the trachea following percutaneous tracheostomy, he survived to explant and was successfully stepped down to a rehabilitation unit on postoperative day 50. He tested positive for SARS-CoV-2 antibodies when the test became available on postoperative day 33. We envisage there will be many more such presentations of acute COVID-19-associated cardiogenic shock and we recommend clinicians consider this diagnosis when presented with an acutely unwell patient with an unclear diagnosis following a viral illness. These patients should be discussed as early as possible with a transplant/mechanical circulatory support team.

The challenges of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock

Postcardiotomy cardiogenic shock describes the syndrome of refractory cardiac performance following cardiac surgery. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the management of postcardiotomy cardiogenic shock is controversial, and there are at least three scenarios where it may be necessary: first, pre-emptive postoperative VA-ECMO, where the decision for postoperative mechanical support is made prior to surgery, for example, in the context of poor pre-operative cardiac function; second, early yet unplanned post-cardiopulmonary bypass VA-ECMO following a long duration of cardiopulmonary bypass due to, for example, unexpected surgical complications; third, late rescue VA-ECMO following several attempts at weaning, either immediately following cardiopulmonary bypass or following transfer to the intensive care unit. The use of mechanical circulatory support for postcardiotomy cardiogenic shock is further complicated by the wide range of available devices, the availability of VA-ECMO in different centres, variations in experience and expertise as a function of local VA-ECMO workload, and regional variations in the diagnosis and management of postcardiotomy cardiogenic shock. Furthermore, survival appears to be low for such patients and it is not yet possible to predict who will survive. Many questions remain, however, such as those in relation to practices around patient selection, how best to study long-term outcomes, the ethics and efficacy of ECMO in such patients, and on all aspects of clinical decision-making. This review sets these clinical challenges in the context of the available evidence, including that from our centre.

A Case of Extracorporeal Membrane Oxygenation as a Salvage Therapy for COVID-19-Associated Severe Acute Respiratory Distress Syndrome: Mounting Evidence

Coronavirus disease 2019 (COVID-19) caused by a novel human coronavirus has led to a tsunami of viral illness across the globe, originating from Wuhan, China. Although the value and effectiveness of extracorporeal membrane oxygenation (ECMO) in severe respiratory illness from COVID-19 remains unclear at this time, there is emerging evidence suggesting that it could be utilized as an ultimate treatment in appropriately selected patients not responding to conventional care. We present a case of a 32-year-old COVID-19 positive male with a history of diabetes mellitus who was intubated for severe acute respiratory distress syndrome (ARDS). The patient's hypoxemia failed to improve despite positive pressure ventilation, prone positioning, and use of neuromuscular blockade for ventilator asynchrony. He was evaluated by a multidisciplinary team for considering ECMO for refractory ARDS. He was initiated on venovenous ECMO via dual-site cannulation performed at the bedside. Although his ECMO course was complicated by bleeding, he showed a remarkable improvement in his lung function. ECMO was successfully decannulated after 17 days of initiation. The patient was discharged home after 47 days of hospitalization without any supplemental oxygen and was able to undergo active physical rehabilitation. A multidisciplinary approach is imperative in the initiation and management of ECMO in COVID-19 patients with severe ARDS. While ECMO is labor-intensive, using it in the right phenotype and in specialized centers may lead to positive results. Patients who are young, with fewer comorbidities and single organ dysfunction portray a better prognosis for patients in which ECMO is utilized.

Thromboembolic disease in COVID-19 patients: A brief narrative review

Corona virus 2 (SARS-CoV2/ Severe Acute Respiratory Syndrome Corona Virus 2) infection has emerged as a global health crisis. Incidence of thromboembolic disease is reported to be high in SARS-CoV2 disease and is seen in a multitude of organ systems ranging from cutaneous thrombosis to pulmonary embolism, stroke or coronary thrombosis sometimes with catastrophic outcomes. Evidence points towards a key role of thromboembolism, hypercoagulability and over production of proinflammatory cytokines mimicking a "cytokine storm" which leads to multiorgan failure. This brief narrative review highlights the pathophysiology and risk factors of thromboembolic disease and provides a framework for management of anticoagulation based on the current evidence.

Cardiopulmonary Resuscitation in Intensive Care Unit Patients With Coronavirus Disease 2019

Cardiopulmonary resuscitation (CPR) in patients with severe acute respiratory syndrome coronavirus-2–associated disease (coronavirus disease 2019) poses a unique challenge to health- care providers due to the risk of viral aerosolization and disease transmission. This has caused some centers to modify existing CPR procedures, limit the duration of CPR, or consider avoiding CPR altogether. In this review, the authors propose a procedure for CPR in the intensive care unit that minimizes the number of personnel in the immediate vicinity of the patient and conserves the use of scarce personal protective equipment. Highlighting the low likelihood of successful resuscitation in high-risk patients may prompt patients to decline CPR. The authors recommend the preemptive placement of central venous lines in high-risk patients with intravenous tubing extensions that allow for medication delivery from outside the patients’ rooms. During CPR, this practice can be used to deliver critical medications without delay. The use of a mechanical compression system for CPR further reduces the risk of infectious exposure to health- care providers. Extracorporeal membrane oxygenation should be reserved for patients with few comorbidities and a single failing organ system. Reliable teleconferencing tools are essential to facilitate communication between providers inside and outside the patients' rooms. General principles regarding the ethics and peri-resuscitative management of coronavirus 2019 patients also are discussed.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): a review

In recent years, the prevalence and spread of coronavirus has had a huge impact on global public health. Due to the incomplete understanding of the pathogenic mechanism of the virus, it is difficult for humans to fight against the virus quickly and effectively once the outbreak occurs. In early 2020, a novel coronavirus was discovered in Wuhan, China. Soon after, similar cases were found in other countries around the world, and the number of infected people increased rapidly. So far, the global cumulative number of infected people has exceeded 3 million, and more than 200,000 people have died, which has had a huge impact on global human health and economic development. Every outbreak of disease makes a deep impression on mankind. Herein, we summarize the virology, epidemiology, clinical manifestations, diagnosis, treatment and prevention of SARS-CoV-2, and hope that countries can control the outbreak as soon as possible to minimize the loss.

The role of ECMO in COVID-19: Can it provide rescue therapy in those who are critically ill?

Arising from the city of Wuhan, Hubei province in China, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 has been rapidly spreading since its first presentation in late 2019. The World Health Organization declared a pandemic on the 11th March 2020, and as of 29th of April 2020 more than 3 million cases have been reported worldwide with over 225 000 confirmed deaths. Where mechanical ventilation may not be enough, extracorporeal membrane oxygenation (ECMO) could play a role as a form of rescue therapy and may provide beneficial results in the hands of skilled clinicians in centers with experience of using ECMO appropriately in selected patients. Our understanding of COVID‐19 is ever‐changing and the need for intensive care beds is rising, which means that ECMO will surely play a key role in the near future.