ECMO use in COVID-19: lessons from past respiratory virus outbreaks-a narrative review

Outcomes and Impact of Pre-ECMO Clinical Course in Severe COVID-19-Related ARDS Treated with VV-ECMO: Data from an Italian Referral ECMO Center

Background: The efficacy of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as rescue therapy for refractory COVID-19-related ARDS (C-ARDS) is still debated. We describe the cohort of C-ARDS patients treated with VV-ECMO at our ECMO center, focusing on factors that may affect in-hospital mortality and describing the time course of lung mechanics to assess prognosis. Methods: We performed a prospective observational study in the intensive care unit at the "Città della Salute e della Scienza" University Hospital in Turin, Italy, between March 2020 and December 2021. Indications and management of ECMO followed the Extracorporeal Life Support Organization (ELSO) guidelines. Results: The 60-day in-hospital mortality was particularly high (85.4%). Non-survivor patients were more frequently treated with non-invasive ventilatory support and steroids before ECMO (95.1% vs. 57.1%, p = 0.018 and 73.2% vs. 28.6%, p = 0.033, respectively), while hypertension was the only pre-ECMO factor independently associated with in-hospital mortality (HR: 2.06, 95%CI: 1.06-4.00). High rates of bleeding (85.4%) and superinfections (91.7%) were recorded during ECMO, likely affecting the overall length of ECMO (18 days, IQR: 10-24) and the hospital stay (32 days, IQR: 24-47). Static lung compliance was lower in non-survivors (p = 0.031) and differed over time (p = 0.049), decreasing by 48% compared to initial values in non-survivors. Conclusions: Our data suggest the importance of considering NIS among the common ECMO eligibility criteria and changes in lung compliance during ECMO as a prognostic marker.

Web-based Dashboard on ECMO Utilization in Germany: An Interactive Visualization, Analyses, and Prediction Based on Real-life Data

In Germany, a comprehensive reimbursement policy for extracorporeal membrane oxygenation (ECMO) results in the highest per capita use worldwide, although benefits remain controversial. Public ECMO data is unstructured and poorly accessible to healthcare professionals, researchers, and policymakers. In addition, there are no uniform policies for ECMO allocation which confronts medical personnel with ethical considerations during health crises such as respiratory virus outbreaks.Retrospective information on adult and pediatric ECMO support performed in German hospitals was extracted from publicly available reimbursement data and hospital quality reports and processed to create the web-based ECMO Dashboard built on Open-Source software. Patient-level and hospital-level data were merged resulting in a solid base for ECMO use analysis and ECMO demand forecasting with high spatial granularity at the level of 413 county and city districts in Germany.The ECMO Dashboard ( https://www.ecmo-dash.de/ ), an innovative visual platform, presents the retrospective utilization patterns of ECMO support in Germany. It features interactive maps, comprehensive charts, and tables, providing insights at the hospital, district, and national levels. This tool also highlights the high prevalence of ECMO support in Germany and emphasizes districts with ECMO surplus - where patients from other regions are treated, or deficit - origins from which ECMO patients are transferred to other regions. The dashboard will evolve iteratively to provide stakeholders with vital information for informed and transparent resource allocation and decision-making.Accessible public routine data could support evidence-informed, forward-looking resource management policies, which are urgently needed to increase the quality and prepare the critical care infrastructure for future pandemics.

Visual analysis of the research literature on extracorporeal membrane oxygenation-assisted support for respiratory failure based on CiteSpace and VOSviewer: a 20-year study

Background

This study aims to visually assess the bibliometric status, current hotspots, and development trends in the field of extracorporeal membrane oxygenation (ECMO)-assisted support for respiratory failure through an examination of articles pertaining to ECMO-assisted support for respiratory failure.

Methods

A search was conducted on pertinent literature in the domain of ECMO-assisted support for respiratory failure published from 2003 to 2023, utilizing the Web of Science Core Collection (WOSCC) database. A bibliometric analysis was conducted using CiteSpace and VOSviewer visualization software to identify and assess associations between keywords, countries, institutions, authors, journals, and references.

Results

The present study incorporated a compilation of 1,901 pertinent articles. The United States published the maximum number of research articles in this field, and was closely followed by Germany and China. Furthermore, the University of Michigan was the leading institution in ECMO research. In this context, Daniel Brodie, an American expert, significantly contributed to this field and had published 107 related articles on the subject. Concurrently, active collaboration among ECMO researchers was also observed. Asaio Journal was the most prolific contributor, and Giles J. Peek, 2009, published in Lancet, comprised the most cited article in the field. Additionally, the analysis of keywords could be divided into three categories: (I) neonatal ECMO; (II) complications of ECMO; (III) ECMO application in coronavirus disease 2019 (COVID-19); (IV) application of point-of-care ultra sound in ECMO.

Conclusions

This study employed CiteSpace and VOSviewer to conduct a systematic literature review on ECMO-assisted support for respiratory failure from 2003 to 2023 in the Web of Science core database. The research outcomes in this domain were presented, offering researchers references for them to gain an accurate understanding of the current state of research and emerging trends in this field.

Extracorporeal membrane oxygenation as a bridge to lung transplantation: Practice patterns and patient outcomes

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly relied on to bridge patients with respiratory failure to lung transplantation despite limited evidence for its use in this setting. This study evaluated longitudinal trends in practice patterns, patient characteristics, and outcomes in patients bridged with ECMO to lung transplant.

METHODS

A retrospective review of all adult isolated lung transplant patients in the United Network for Organ Sharing database between 2000 and 2019 was performed. Patients were classified as "ECMO" if supported with ECMO at the time of listing or transplantation and "non-ECMO" otherwise. Linear regression was used to evaluate trends in patient demographics during the study period. Trends in mortality were evaluated using Cox proportional hazards modeling, with time period as the primary covariate (2000-2004, 2005-2009, 2010-2014, or 2015-2019) and age, time on the waitlist, and underlying diagnosis as covariates.

RESULTS

The number of patients included were 40,866, of whom 1,387 (3.4%) were classified as ECMO and 39,479 (96.6%) as no ECMO. Average age and initial Lung Allocation Score increased significantly during the study period in both cohorts, but occurred at a slower rate in the ECMO population. The hazard of death was significantly lower in more recent years (2015-2019) for both the ECMO and non-ECMO cohorts (aHR (adjusted hazards ratio) 0.59, 95% confidence interval (CI) 0.37-0.96 and aHR 0.74, 95% CI 0.70-0.79) when compared to the early years (2000-2004) of the study period.

CONCLUSIONS

Post-transplantation survival for patients bridged to transplantation with ECMO demonstrates ongoing improvement despite cannulation of progressively older and sicker patients.

COVID-19 versus Other Disease Etiologies as the Cause of ARDS in Patients Necessitating Venovenous Extracorporeal Membrane Oxygenation-A Comparison of Patients' Data during the Three Years of the COVID-19 Pandemic

Considering the characteristics of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS), we compared the clinical course and outcomes of patients with ARDS who received venovenous extracorporeal membrane oxygenation (VV ECMO) based on the etiology of ARDS. This retrospective single-center study included adult patients with severe ARDS necessitating VV ECMO during the COVID-19 pandemic. Among 45 patients who received VV ECMO, 21 presented with COVID-19. COVID-19 patients exhibited lower sequential organ failure assessment scores (9 [8-12.75] versus 8 [4-11.5], p = 0.033) but longer duration of VV ECMO support (10.5 days [3.25-29.25] versus 28 days [10.5-70.5] p = 0.018), which was accompanied by an weaning off rate from VV ECMO in 12/24 (50%) versus 12/21 (57.1%) and 28-day mortality in 9/24 [37.5%] versus 2/21 [9.5%] in non-COVID-19 and COVID-19 patients (p = 0.767, p = 0.040), respectively. Finally, in the adjusted Cox regression model for hospital mortality, the hazard ratio of COVID-19 was not significant (hazard ratio 0.350, 95% confidence interval 0.110-1.115, p = 0.076). Although the VV ECMO period was longer, COVID-19 did not significantly impact ECMO weaning off and mortality rates. Nonetheless, judicious patient selections based on risk factors should be followed.

COVID-19 therapeutics: Clinical application of repurposed drugs and futuristic strategies for target-based drug discovery

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes the complicated disease COVID-19. Clinicians are continuously facing huge problems in the treatment of patients, as COVID-19-specific drugs are not available, hence the principle of drug repurposing serves as a one-and-only hope. Globally, the repurposing of many drugs is underway; few of them are already approved by the regulatory bodies for their clinical use and most of them are in different phases of clinical trials. Here in this review, our main aim is to discuss in detail the up-to-date information on the target-based pharmacological classification of repurposed drugs, the potential mechanism of actions, and the current clinical trial status of various drugs which are under repurposing since early 2020. At last, we briefly proposed the probable pharmacological and therapeutic drug targets that may be preferred as a futuristic drug discovery approach in the development of effective medicines.

Extracorporeal Membrane Oxygenation for Severe COVID-19 in Indian Scenario: A Single Center Retrospective Study

Background

Initial reports from Wuhan (China) suggested poor outcomes for severe COVID-19 patients treated with Extracorporeal Membrane Oxygenation (ECMO). Extracorporeal Life Support Organization (ELSO) interim 2019 guidelines also recommended using ECMO only when all conventional therapies are exhausted. However, later studies showed that delayed ECMO initiation may lead to longer ECMO runs, offsetting any benefit from resource conservation by delaying the initiation. Hence, this study was intended to analyze the sociodemographic characteristics, type of ECMO, and complications of its outcome in the Indian scenario.

Materials and methods

Demographic and patient clinical outcome data of all the patients of severe ARDS due to COVID-19 being treated with ECMO from 1st June 2020 to 31st May 2021 at Medica Super-specialty Hospital (Kolkata, India), were retrospectively compiled and analyzed.

Results

Total number of patients treated was 79 with 10% female representation. The mean age was 43 ± 3.2 years and the mean body mass index 37 ± 4.3. Fifty percent of the patient survived. The mean duration of the ECMO run was 17 ± 5.2 days. Sepsis (65%) was the commonest complication observed followed by acute kidney injury (39%).

Conclusion

This study provides significant insight into the outcomes of patients of COVID-19 treated by ECMO in the Indian scenario. Mortality rates of COVID-19 patients on ECMO were comparable to the non-COVID-19 patients, although the ECMO run time was relatively longer. Our study concluded that ECMO should be considered as a treatment option in appropriate COVID-19 cases. However, if the capacity diminishes in a pandemic situation, ECMO consideration should be based on more stringent criteria.

How to cite this article

Sulakshana S, Chatterjee D, Chakraborty A. Extracorporeal Membrane Oxygenation for Severe COVID-19 in Indian Scenario: A Single Center Retrospective Study. Indian J Crit Care Med 2023;27(6):381-385.

Extracorporeal Membrane Oxygenation in Children With COVID-19: A Systematic Review and Meta-Analysis

OBJECTIVES

The indication, complications, and outcomes of extracorporeal membrane oxygenation (ECMO) in children with COVID-19-related illnesses remain unelucidated. Our study aimed to investigate the characteristics and outcomes of ECMO in children with COVID-19-related illnesses.

DATA SOURCES

We searched PubMed and EMBASE databases in March 2022.

STUDY SELECTION

We retrieved all studies involving children (age ≤ 18 yr) with COVID-19-related illnesses who received ECMO.

DATA EXTRACTION

Two authors independently extracted data and assessed the risk of bias. Mortality, successful weaning rate, and complications while on ECMO were synthesized by a one-group meta-analysis using a random-effect model. Meta-regression was performed to explore the risk factors for mortality.

DATA SYNTHESIS

We included 18 observational studies, four case series, and 22 case reports involving 110 children with COVID-19-related illnesses receiving ECMO. The median age was 8 years (range, 10 d to 18 yr), and the median body mass index was 21.4 kg/m 2 (range, 12.3-56.0 kg/m 2 ). The most common comorbidities were obesity (11% [7/63]) and congenital heart disease (11% [7/63]), whereas 48% (30/63) were previously healthy. The most common indications for ECMO were multisystem inflammatory syndrome in children (52% [47/90]) and severe acute respiratory distress syndrome (40% [36/90]). Seventy-one percent (56/79) received venoarterial-ECMO. The median ECMO runtime was 6 days (range, 3-51 d) for venoarterial ECMO and 11 days (range, 3-71 d) for venovenous ECMO. The mortality was 26.6% (95% CI, 15.9-40.9), and the successful weaning rate was 77.0% (95% CI, 55.4-90.1). Complications were seen in 37.0% (95% CI, 23.1-53.5) while on ECMO, including stroke, acute kidney injury, pulmonary edema, and thromboembolism. Corticosteroids and IV immunoglobulin therapies were associated with lower mortality.

CONCLUSIONS

The mortality of children on ECMO for COVID-19 was relatively low. This invasive treatment can be considered as a treatment option for critically ill children with COVID-19.

Right ventricle dysfunction does not predict mortality in patients with SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support

BACKGROUND

The prognostic role of right ventricle dilatation and dysfunction (RVDD) has not been elucidated in patients with coronavirus disease (COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation (ECMO) support.

AIM

To assess whether pre veno-venous (VV) ECMO RVDD were related to in-intensive care unit (ICU) mortality.

METHODS

We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU (an ECMO referral center) from 31^th March 2020 to 31^th August 2021. An echocardiographic exam was performed immediately before VV ECMO implantation.

RESULTS

Males were prevalent (73.8%) and patients with a body mass index > 30 kg/m² were the majority (46/61, 75%). The overall in-ICU mortality rate was 54.1% (33/61). RVDD was detectable in more than half of the population (34/61, 55.7%) and associated with higher simplified organ functional assessment (SOFA) values (P = 0.029) and a longer mechanical ventilation duration prior to ECMO support (P = 0.046). Renal replacement therapy was more frequently needed in RVDD patients (P = 0.002). A higher in-ICU mortality (P = 0.024) was observed in RVDD patients. No echo variables were independent predictors of in-ICU death.

CONCLUSION

In patients with COVID-related respiratory failure on ECMO support, RVDD (dilatation and dysfunction) is a common finding and identifies a subset of patients characterized by a more severe disease (as indicated by higher SOFA values and need of renal replacement therapy) and by a higher in-ICU mortality. RVDD (also when considered separately) did not result independently associated with in-ICU mortality in these patients.

The effects of ECMO on neurological function recovery of critical patients: A double-edged sword

Extracorporeal membrane oxygenation (ECMO) played an important role in the treatment of patients with critical care such as cardiac arrest (CA) and acute respiratory distress syndrome. ECMO is gradually showing its advantages in terms of speed and effectiveness of circulatory support, as it provides adequate cerebral blood flow (CBF) to the patient and ensures the perfusion of organs. ECMO enhances patient survival and improves their neurological prognosis. However, ECMO-related brain complications are also important because of the high risk of death and the associated poor outcomes. We summarized the reported complications related to ECMO for patients with CA, such as north–south syndrome, hypoxic–ischemic brain injury, cerebral ischemia–reperfusion injury, impaired intracranial vascular autoregulation, embolic stroke, intracranial hemorrhage, and brain death. The exact mechanism of ECMO on the role of brain function is unclear. Here we review the pathophysiological mechanisms associated with ECMO in the protection of neurologic function in recent years, as well as the ECMO-related complications in brain and the means to improve it, to provide ideas for the treatment of brain function protection in CA patients.

Otolaryngologic Symptom Severity Post SARS-CoV-2 Infection

Objective(s)

To assess laryngologic symptomatology following SARS-CoV-2 infection and determine whether symptom severity correlates with disease severity.

Methods

Single-institution survey study in participants with documented SARS-CoV-2 infection between March 2020 and February 2021. Data acquired included demographic, infection severity characteristics, comorbidities, and current upper aerodigestive symptoms via validated patient reported outcome measures.  Primary outcomes of interest were scores of symptom severity questionnaires. COVID-19 severity was defined by hospitalization status. Descriptive subgroup analyses were performed to investigate differences in demographics, comorbidities, and symptom severity in hospitalized participants stratified by ICU status. Multivariate logistical regression was used to evaluate significant differences in symptom severity scores by hospitalization status.

Results

Surveys were distributed to 5300 individuals with upper respiratory infections. Ultimately, 470 participants with COVID-19 were included where 352 were hospitalized and 118 were not hospitalized. Those not hospitalized were younger (45.87 vs. 56.28 years), more likely female (74.17 vs. 58.92%), and less likely white (44.17 vs. 52.41%). Severity of dysphonia, dyspnea, cough, and dysphagia was significantly worse in hospitalized patients overall and remained worse at all time points. Cough severity paradoxically worsened in hospitalized respondents over time. Dyspnea scores remained abnormally elevated in respondents even 12 months after resolution of infection.

Conclusion

Results indicate that laryngologic symptoms are expected to be worse in patients hospitalized with COVID-19. Dyspnea and cough symptoms can be expected to persist or even worsen by one-year post infection in those who were hospitalized. Dysphagia and dysphonia symptoms were mild. Non-hospitalized participants tended to have minimal residual symptoms by one year after infection.

ECMO During COVID-19: A Society of Thoracic Surgeons/Extracorporeal Life Support Organization Survey

BACKGROUND

The Society of Thoracic Surgeons Workforce on Critical Care and the Extracorporeal Life Support Organization sought to identify how the coronavirus disease 2019 (COVID-19) pandemic has changed the practice of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) programs across North America.

METHODS

A 26-question survey covering 6 categories (ECMO initiation, cannulation, management, anticoagulation, triage/protocols, and credentialing) was emailed to 276 North American Extracorporeal Life Support Organization centers. ECMO practices before and during the COVID-19 pandemic were compared.

RESULTS

Responses were received from 93 (34%) programs. The percentage of high-volume (>20 cases per year) VV ECMO programs increased during the pandemic from 29% to 41% (P < .001), as did institutions requiring multiple clinicians for determining initiation of ECMO (VV ECMO, 25% to 43% [P = .001]; VA ECMO, 20% to 32% [P = .012]). During the pandemic, more institutions developed their own protocols for resource allocation (23% before to 51%; P < .001), and more programs created sharing arrangements to triage patients and equipment with other centers (31% to 57%; P < .001). Direct thrombin inhibitor use increased for both VA ECMO (13% to 18%; P = .025) and VV ECMO (12% to 24%; P = .005). Although cardiothoracic surgeons remained the primary cannulating proceduralists, VV ECMO cannulations performed by pulmonary and critical care physicians increased (13% to 17%; P = .046).

CONCLUSIONS

The Society of Thoracic Surgeons/Extracorporeal Life Support Organization collaborative survey indicated that the pandemic has affected ECMO practice. Further research on these ECMO strategies and lessons learned during the COVID-19 pandemic may be useful in future global situations.

The Use of Extracorporeal Membrane Oxygenation for Burns: A Systematic Review and Meta-Analysis

Burns are among the leading causes of trauma worldwide, and acute respiratory distress syndrome (ARDS) is a common cause of death in burn patients. Some patients develop hypoxemia refractory to conventional therapies and may be initiated on extracorporeal membrane oxygenation (ECMO) as rescue therapy. We conducted a meta-analysis for studies reporting on survival rates of patients receiving ECMO for burns or inhalation injuries, which was the primary outcome. Secondary outcomes included the hospital and intensive care unit length of stay and duration of ECMO. Random-effects (DerSimonian and Laird) were conducted. The pooled survival from 10 studies was 53.6% (95% confidence interval [CI]: 37.6-69.2%, high certainty). Survival was significantly associated with age (regression coefficient [B]: -0.0088, 95% CI: -0.0155 to -0.0021, p = 0.011) and the proportion of male patients (B: -1.0137 95% CI: -1.9695 to -0.0580, p = 0.038). Patients were cannulated on ECMO for a mean of 8.4 days (95% CI: 6.1-10.7) and remained in the ICU for a mean of 40.4 days (95% CI: 11.4-69.3). Mean hospital length of stay was 45.4 days (95% CI: 31.7-59.0). In conclusion, patients with burn and inhalation injuries who develop ARDS refractory to conservative management have a survival rate of 54% when placed on ECMO.

Diagnosis and treatment of right ventricular dysfunction in patients with COVID-19 on veno-venous extra-corporeal membrane oxygenation

BACKGROUND

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is an effective, but highly resource intensive salvage treatment option in COVID patients with acute respiratory distress syndrome (ARDS). Right ventricular (RV) dysfunction is a known sequelae of COVID-19 induced ARDS, yet there is a paucity of data on the incidence and determinants of RV dysfunction on VV ECMO. We retrospectively examined the determining factors leading to RV failure and means of early identification of this phenomenon in patients on VV ECMO.

METHODS

The data was extracted from March 2020 to March 2021 from the regional University of Washington Extracorporeal Life Support database. The inclusion criteria included patients > 18 years of age with diagnosis of COVID-19. All had already been intubated and mechanically ventilated prior to VV ECMO deployment. Univariate analysis was performed to identify risk factors and surrogate markers for RV dysfunction. In addition, we compared outcomes between those with and without RV dysfunction.

RESULTS

Of the 33 patients that met inclusion criteria, 14 (42%) had echocardiographic evidence of RV dysfunction, 3 of whom were placed on right ventricular assist device support. Chronic lung disease was an independent risk factor for RV dysfunction (p = 0.0002). RV dysfunction was associated with a six-fold increase in troponin I (0.07 ng/ml vs. 0.44 ng/ml, p = 0.039) and four-fold increase in brain natriuretic peptide (BNP) (158 pg/ml vs. 662 pg/ml, p = 0.037). Deep vein thrombosis (DVT, 21% vs. 43%, p = 0.005) and pulmonary embolism (PE, 11% vs. 21%, p = 0.045) were found to be nearly twice as common in the RV dysfunction group. Total survival rate to hospital discharge was 39%. Data trended towards shorter duration of hospital stay (47 vs. 65.6 days, p = 0.15), shorter duration of ECMO support (21 days vs. 36 days, p = 0.06) and improved survival rate to hospital discharge (42.1% vs. 35.7%, p = 0.47) for those with intact RV function compared to the RV dysfunction group.

CONCLUSIONS

RV dysfunction in critically ill patients with COVID-19 pneumonia in common. Trends of troponin I and BNP may be important surrogates for monitoring RV function in patients on VV ECMO. We recommend echocardiographic assessment of the RV on such patients.

Machine learning models for identifying predictors of clinical outcomes with first-line immune checkpoint inhibitor therapy in advanced non-small cell lung cancer

Immune checkpoint inhibitors (ICIs) are standard-of-care as first-line (1L) therapy for advanced non-small cell lung cancer (aNSCLC) without actionable oncogenic driver mutations. While clinical trials demonstrated benefits of ICIs over chemotherapy, variation in outcomes across patients has been observed and trial populations may not be representative of clinical practice. Predictive models can help understand heterogeneity of treatment effects, identify predictors of meaningful clinical outcomes, and may inform treatment decisions. We applied machine learning (ML)-based survival models to a real-world cohort of patients with aNSCLC who received 1L ICI therapy extracted from a US-based electronic health record database. Model performance was evaluated using metrics including concordance index (c-index), and we used explainability techniques to identify significant predictors of overall survival (OS) and progression-free survival (PFS). The ML model achieved c-indices of 0.672 and 0.612 for OS and PFS, respectively, and Kaplan-Meier survival curves showed significant differences between low- and high-risk groups for OS and PFS (both log-rank test p < 0.0001). Identified predictors were mostly consistent with the published literature and/or clinical expectations and largely overlapped for OS and PFS; Eastern Cooperative Oncology Group performance status, programmed cell death-ligand 1 expression levels, and serum albumin were among the top 5 predictors for both outcomes. Prospective and independent data set evaluation is required to confirm these results.

Not just a matter of weight: A case report of ECMO treatment in a severely obese patient

The ELSO Guidelines list a BMI ≥ 40 kg/m² among the relative contraindications to give ECMO treatment in SARS – COV2 patients. We describe a case of a 52-year-old with BMI 50.21 kg/m², admitted to the intensive care unit (ICU) with severe respiratory conditions and successfully treated with extracorporeal membrane oxygenation (ECMO). The application of veno-venous (VV) ECMO will evolve as far as we understand the pathophysiology of the COVID-19 disease and will probably have a determinant role in management of patient with refractory hypoxemia, whose ventilation management is difficult, even in case of severe obesity.

Extracorporeal membrane oxygenation support in children with severe coronavirus disease-2019: A case series

Background

The coronavirus disease-2019 (COVID-19) pandemic has predominantly affected the adult population, but with a significantly lower prevalence in children. Most pediatric patients with COVID-19 have mild course; however, a small number progressed to acute respiratory distress syndrome, hypoxemia, despite optimized conventional therapies. Thus, this study aimed to report a series of six cases of children with severe acute respiratory syndrome coronavirus 2 infection who were supported by extracorporeal membrane oxygenation (ECMO) due to refractory hypoxemic respiratory failure.

Methods

This observational, retrospective, and descriptive study reported a series of cases. Data were retrospectively collected from the medical records of patients who were admitted to the Pediatric Cardiologic Intensive Care of Hospital Dr. Carlos Alberto Studart Gomes and Hospital Regional da Unimed, between March 1, 2020, and June 30, 2021. Sociodemographic, clinical, and laboratory data were analyzed.

Findings

The median age was 1.8 years (range: 0.4-14.5 years), 66.7% were males, and weight varied from 13 to 110 kg. The mean time between the onset of symptoms and cannulation, ECMO duration, and ventilation time were 15 days (range: 6-24 days)], 11 days (range: 6-19 days), and 20.5 days (range: 14-33 days), respectively. Five (83.3%) children were successfully decannulated and four survived with hospital discharge. One child died on ECMO support due to multiple organ dysfunction syndromes after 13 days and another one died 3 days after decannulation due to extensive hemorrhagic stroke. Our case series revealed a 33.3% in-hospital mortality rate. ECMO appears as a viable intervention in selected patients who failed conventional therapies in the pediatric population.

Funding

This observational study received no funding.

A Systematic Review and Meta-Analysis of Extracorporeal Membrane Oxygenation in Patients with Burns

BACKGROUND

Severely burned patients are at high risk for cardiopulmonary failure. Promising studies have stimulated interest in using extracorporeal membrane oxygenation as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. However, the findings from previous studies vary.

METHODS

In this study, the authors conducted a systematic review and meta-analysis using standardized mortality ratios to elucidate the benefits associated with the use of extracorporeal membrane oxygenation in patients with burn and/or inhalation injuries. A literature search was performed, and clinical outcomes in the selected studies were compared.

RESULTS

The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving extracorporeal membrane oxygenation (standardized mortality ratio, 2.07; 95 percent CI, 1.04 to 4.14). However, the subgroup of burn patients with inhalation injuries had lower mortality rates compared to their predicted mortality rates (standardized mortality ratio, 0.95; 95 percent CI, 0.52 to 1.73). Other subgroup analyses reported no benefits from extracorporeal membrane oxygenation; however, these results were not statistically significant. Interestingly, the pooled standardized mortality ratio values decreased as the selected patients' revised Baux scores increased (R = -0.92), indicating that the potential benefits from the treatment increased as the severity of patients with burns increased.

CONCLUSIONS

The authors' meta-analysis revealed that burn patients receiving extracorporeal membrane oxygenation treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with revised Baux scores over 90, would benefit from the treatment. The authors suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for the treatment and early transfer to an extracorporeal membrane oxygenation center.

Chest Pain and Suspected Myocarditis Related to COVID-19 Vaccination in Adolescents-A Case Series

As adolescents started to be vaccinated against coronavirus disease 2019 (COVID-19), suspected myocarditis and pericarditis related to the vaccine were reported in adolescents. According to the Korea Disease Control and Prevention Agency (KDCA), 2,796,270 persons aged 12−18 years were fully vaccinated by December 8. Among these, 9223 adverse events were reported (0.33%). We aimed to elucidate the clinical courses and short-term outcomes for adolescents aged 12−18 with cardiac symptoms and suspected myo- or peri-carditis related to COVID-19 vaccination in South Korea. Methods: We retrospectively collected data on patients ≤ 18 years of age who had suspected myocarditis or pericarditis within 30 days of COVID-19 vaccination, from July 2021 to January 2022. Results: We reported on 40 adolescents in different South Korean provinces at two centers. Twenty-six cases (65%) were male, and the median age was 16 years (range, 13−18; IQR 14.5−17). Twenty-five cases (62.5%) occurred at the first dose, and fifteen (37.5%) occurred after the second dose. Symptoms started at a median of 2 days (range 0−29 days; IQR 1−5 days) after vaccination. The patients were treated with nonsteroidal anti-inflammatory drugs (77.5%), intravenous immunoglobulin (2.5%), glucocorticoids (20%), colchicine (5%), or no therapy (15%). Five patients (12.5%) required intensive care unit admission; one patient needed inotropic/vasoactive support. No patients required extracorporeal membrane oxygenation or died. The median hospital stay was one day (range 0−8 days; IQR 0−2 days). Twenty-one patients (52.5%) had an abnormal electrocardiogram; among these, seven patients had an elevated ST segment, six patients (15%) had decreased ejection fraction (<55%), and LV function was completely recovered in all of them. Conclusions: Most cases of suspected myocarditis after COVID-19 vaccination in adolescents ≤ 18 years had mild symptoms and clinical courses, as well as a complete recovery. Further studies are needed to evaluate long-term outcomes.

The Role of Extracorporeal Membrane Oxygenation in COVID-19

An extracorporeal membrane oxygenation (ECMO) program is an important component in the management of patients with COVID-19, but it is imperative to implement a system that is well-supported by the institution and staffed with well-trained clinicians to both optimize patient outcomes and to keep providers safe. There are many unknowns related to COVID-19, and one of the most challenging aspects for clinicians is the lack of predictive knowledge as to why some patients fail medical therapy and require advanced support such as ECMO. These factors can create challenges during a time of resource scarcity and interruptions in the supply chain. In the current environment, in which resources are limited and an ongoing pandemic, healthcare practitioners need to focus on evidence-based best practice for supportive care of patients with COVID-19 in refractory respiratory or cardiac failure. with As experience is gained, a greater understanding will develop in this cohort of patients regarding need and timing of ECMO. As this pandemic continues, it will be important to compile and analyze multicentered data pertaining to patient-specific outcomes to help guide clinicians caring for patients with COVID-19 undergoing ECMO support. In this paper, the authors demonstrate the strategies utilized by a major quaternary care center in the utilization and management of ECMO for patients with COVID-19.

Outcomes after extracorporeal membrane oxygenation support in COVID-19 and non-COVID-19 patients

BACKGROUND

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) support is increasingly used in the management of COVID-19-related acute respiratory distress syndrome (ARDS). However, the clinical decision-making to initiate V-V ECMO for severe COVID-19 still remains unclear. In order to determine the optimal timing and patient selection, we investigated the outcomes of both COVID-19 and non-COVID-19 patients undergoing V-V ECMO support.

METHODS

Overall, 138 patients were included in this study. Patients were stratified into two cohorts: those with COVID-19 and non-COVID-19 ARDS.

RESULTS

The survival in patients with COVID-19 was statistically similar to non-COVID-19 patients (p = .16). However, the COVID-19 group demonstrated higher rates of bleeding (p = .03) and thrombotic complications (p < .001). The duration of V-V ECMO support was longer in COVID-19 patients compared to non-COVID-19 patients (29.0 ± 27.5 vs 15.9 ± 19.6 days, p < .01). Most notably, in contrast to the non-COVID-19 group, we found that COVID-19 patients who had been on a ventilator for longer than 7 days prior to ECMO had 100% mortality without a lung transplant.

CONCLUSIONS

These findings suggest that COVID-19-associated ARDS was not associated with a higher post-ECMO mortality than non-COVID-19-associated ARDS patients, despite longer duration of extracorporeal support. Early initiation of V-V ECMO is important for improved ECMO outcomes in COVID-19 ARDS patients. Since late initiation of ECMO was associated with extremely high mortality related to lack of pulmonary recovery, it should be used judiciously or as a bridge to lung transplantation.

Effects of Prone Positioning on Respiratory Mechanics and Oxygenation in Critically Ill Patients With COVID-19 Requiring Venovenous Extracorporeal Membrane Oxygenation

Background:

The effect of prone positioning (PP) on respiratory mechanics remains uncertain in patients with severe acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (VV-ECMO).

Methods:

We prospectively analyzed the effects of PP on respiratory mechanics from continuous data with over a thousand time points during 16-h PP sessions in patients with COVID-19 and ARDS under VV-ECMO conditions. The evolution of respiratory mechanical and oxygenation parameters during the PP sessions was evaluated by dividing each PP session into four time quartiles: first quartile: 0–4 h, second quartile: 4–8 h, third quartile: 8–12 h, and fourth quartile: 12–16 h.

Results:

Overall, 38 PP sessions were performed in 10 patients, with 3 [2–5] PP sessions per patient. Seven (70%) patients were responders to at least one PP session. PP significantly increased the PaO₂/FiO₂ ratio by 14 ± 21% and compliance by 8 ± 15%, and significantly decreased the oxygenation index by 13 ± 18% and driving pressure by 8 ± 12%. The effects of PP on respiratory mechanics but not on oxygenation persisted after supine repositioning. PP-induced changes in different respiratory mechanical parameters and oxygenation started as early as the first-time quartile, without any difference in PP-induced changes among the different time quartiles. PP-induced changes in driving pressure (−14 ± 14 vs. −6 ± 10%, p = 0.04) and mechanical power (−11 ± 13 vs. −0.1 ± 12%, p = 0.02) were significantly higher in responders (increase in PaO₂/FiO₂ ratio > 20%) than in non-responder patients.

Conclusions:

In patients with COVID-19 and severe ARDS, PP under VV-ECMO conditions improved the respiratory mechanical and oxygenation parameters, and the effects of PP on respiratory mechanics persisted after supine repositioning.

COVID-19-Associated Spontaneous Pneumomediastinum and Pneumopericardium: Review of Case Series

Coronavirus disease 2019 (COVID-19) and its spectrum of respiratory illnesses ranging from mild to severe and critically ill have been well established. Spontaneous pneumomediastinum and pneumopericardium (PP) appear to be less reported entities and have been found to be reported complications in COVID-19 infection. Pneumomediastinum (PM) and PP are characterized by the presence of air in the mediastinal and pericardial cavity, respectively. Although, generally, secondary to trauma or underlying lung conditions like asthma, bronchiolitis obliterans, and blunt trauma, it can also occur spontaneously without an evident primary cause. PM and PP are increasingly reported complications in COVID-19 patients adversely affecting clinical outcomes. We present a case series of patients with spontaneous pneumomediastinum and pneumopericardium in the presence of underlying COVID-19 infection and their management at our academic medical center.

A Year of Critical Care: The Changing Face of the ICU During COVID-19

During the SARS-CoV-2 pandemic, admissions to hospital intensive care units (ICUs) surged, exerting unprecedented stress on ICU resources and operations. The novelty of the highly infectious coronavirus disease 2019 (COVID-19) required significant changes to the way critically ill patients were managed. Houston Methodist’s incident command center team navigated this health crisis by ramping up its bed capacity, streamlining treatment algorithms, and optimizing ICU staffing while ensuring adequate supplies of personal protective equipment (PPE), ventilators, and other ICU essentials. A tele–critical-care program and its infrastructure were deployed to meet the demands of the pandemic. Community hospitals played a vital role in creating a collaborative ecosystem for the treatment and referral of critically ill patients. Overall, the healthcare industry’s response to COVID-19 forced ICUs to become more efficient and dynamic, with improved patient safety and better resource utilization. This article provides an experiential account of Houston Methodist’s response to the pandemic and discusses the resulting impact on the function of ICUs.

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.

COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning

The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.

Clinical Characteristics Between Survivors and Nonsurvivors of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) Support: A Systematic Review and Meta-Analysis

Background: The use of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19) for refractory respiratory failure, severe cardiac dysfunction, and bridge to lung transplantation has been steadily increasing during the ongoing global pandemic. Objective: Our meta-analysis aims to compare the clinical characteristics between COVID-19 survivors and nonsurvivors requiring ECMO support. Methods: A systematic search of Pubmed, Cochrane, Embase, Scopus, and Web of Science databases was performed between December first, 2019, to June first, 2021. Studies with comparative data of COVID-19 ECMO patients were selected, in which clinical characteristics and complications were assessed. Results: Sixteen cohort studies involving 706 COVID-19 patients requiring ECMO support with pooled mortality rate of 40% were included. Younger age (mean 51 years vs 55 years; P < .001), fewer comorbidities (23% vs 31%; odds ratio [OR] 0.55; P  =  .02), and less renal replacement therapy (RRT) (21% vs 39%; OR 0.41; P  =  .007) and vasopressor (76% vs 92%; OR 0.35; P  =  .008) requirement were demonstrated in COVID-19 survivors requiring ECMO support than nonsurvivors. Survivors also had higher pre-ECMO pH (mean 7.33 vs 7.26; P < .001) than nonsurvivors. No difference was observed in gender, body mass index, duration of mechanical ventilation (MV) before ECMO support initiation, total ECMO support duration, and pre-ECMO parameters of PaO2/FiO2 ratio, tidal volume (mL/kg), positive end-expiratory pressure, and plateau pressure. The rate of bleeding complications was lower in survivors (32% vs 59%; OR 0.36; P  =  .001) than nonsurvivors, but no difference was observed in thromboembolism and secondary infections. Conclusions: We found advanced age, multiple comorbidities, lower pre-ECMO pH, greater RRT, and vasopressor requirements, and bleeding are predictors of death in COVID-19 patients requiring ECMO support. The duration of MV before ECMO support initiation and total ECMO support duration was similar among survivors and nonsurvivors. Our study results have important clinical implications when considering ECMO support in critically ill COVID-19 patients.

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

Ten things you need to know about intensive care unit management of mechanically ventilated patients with COVID-19

Introduction: The ongoing pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has posed important challenges for clinicians and health-care systems worldwide.Areas covered: The aim of this manuscript is to provide brief guidance for intensive care unit management of mechanically ventilated patients with COVID-19 based on the literature and our direct experience with this population. PubMed, EBSCO, and the Cochrane Library were searched up until 15th of January 2021 for relevant literature.Expert opinion: Initially, the respiratory management of COVID-19 relied on the general therapeutic principles for acute respiratory distress syndrome; however, recent findings have suggested that the pathophysiology of hypoxemia in patients with COVID-19 presents specific features and changes over time. Several therapies, including antiviral and anti-inflammatory agents, have been proposed recently. The optimal intensive care unit management of patients with COVID-19 remains unclear; therefore, ongoing and future clinical trials are warranted to clarify the optimal strategies to adopt in this cohort of patients.

Six Month Mortality in Patients with COVID-19 and Non-COVID-19 Viral Pneumonitis Managed with Veno-Venous Extracorporeal Membrane Oxygenation

A significant proportion of patients with COVID-19 develop acute respiratory distress syndrome (ARDS) with high risk of death. The efficacy of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for COVID-19 on longer-term outcomes, unlike in other viral pneumonias, is unknown. In this study, we aimed to compare the 6 month mortality of patients receiving VV-ECMO support for COVID-19 with a historical viral ARDS cohort. Fifty-three consecutive patients with COVID-19 ARDS admitted for VV-ECMO to the Royal Brompton Hospital between March 17, 2020 and May 30, 2020 were identified. Mortality, patient characteristics, complications, and ECMO parameters were then compared to a historical cohort of patients with non-COVID-19 viral pneumonia. At 6 months survival was significantly higher in the COVID-19 than in the non-COVID-19 viral pneumonia cohort (84.9% vs. 66.0%, p = 0.040). Patients with COVID-19 had an increased Murray score (3.50 vs. 3.25, p = 0.005), a decreased burden of organ dysfunction (sequential organ failure score score [8.76 vs. 10.42, p = 0.004]), an increased incidence of pulmonary embolism (69.8% vs. 24.5%, p < 0.001) and in those who survived to decannulation longer ECMO runs (19 vs. 11 days, p = 0.001). Our results suggest that survival in patients supported with EMCO for COVID-19 are at least as good as those treated for non-COVID-19 viral ARDS.

Case Report: Prolonged VV-ECMO (111 Days) Support in a Patient With Severe COVID-19

Venovenous extracorporeal membrane oxygenation (VV-ECMO) may be a lifesaving rescue therapy for patients with severe coronavirus disease 2019 (COVID-19). However, little is known regarding the efficacy of prolonged ECMO (duration longer than 14 days) in patients with COVID-19. In this case report, we report the successful use of prolonged VV-ECMO (111 days) in a 61-year-old man with severe COVID-19. Given the high mortality rate of severe COVID-19, this case provided evidence for use of prolonged VV-ECMO as supportive care in patients with severe COVID-19.

Persistent Right Ventricle Dilatation in SARS-CoV-2-Related Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation Support

Objectives

Venovenous extracorporeal membrane oxygenation (ECMO) support may be considered in experienced centers for patients with acute respiratory distress syndrome (ARDS) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection refractory to conventional treatment. In ECMO patients, echocardiography has emerged as a clinical tool for implantation and clinical management; but to date, little data are available on COVID-related ARDS patients requiring ECMO. The authors assessed the incidence of right ventricular dilatation and dysfunction (RvDys) in patients with COVID-related ARDS requiring ECMO.

Design

Single-center investigation.

Setting

Intensive care unit (ICU).

Participants

A total of 35 patients with COVID-related ARDS requiring ECMO, consecutively admitted to the ICU (March 1, 2020, to February 28, 2021).

Interventions

Serial echocardiographic examinations. RvDys was defined as RV end-diastolic area/LV end-diastolic area >0.6 and tricuspid annular plane excursion <15 mm.

Measurements and Main Results

The incidence of RvDys was 15/35 (42%). RvDys patients underwent ECMO support after a longer period of mechanical ventilation (p = 0.006) and exhibited a higher mortality rate (p = 0.024) than those without RvDys. In nonsurvivors, RvDys was observed in all patients (n = nine) who died with unfavorable progression of COVID-related ARDS. In survivors, weaned from ECMO, a significant reduction in systolic pulmonary arterial pressures was detectable.

Conclusions

According to the authors’ data, in COVID-related ARDS requiring ECMO support, RvDys is common, associated with increased ICU mortality. Overall, the data underscored the clinical role of echocardiography in COVID-related ARDS supported by venovenous ECMO, because serial echocardiographic assessments (especially focused on RV changes) are able to reflect pulmonary COVID disease severity.

Extracorporeal Membrane Oxygenation for COVID-19-associated Severe Acute Respiratory Distress Syndrome in Chile: A Nationwide Incidence and Cohort Study

Rationale: The role of and needs for extracorporeal membrane oxygenation (ECMO) at a population level during the coronavirus disease (COVID-19) pandemic have not been completely established. Objectives: To identify the cumulative incidence of ECMO use in the first pandemic wave and to describe the Nationwide Chilean cohort of ECMO-supported patients with COVID-19. Methods: We conducted a population-based study from March 3 to August 31, 2020, using linked data from national agencies. The cumulative incidence of ECMO use and mortality risk of ECMO-supported patients were calculated and age standardized. In addition, a retrospective cohort analysis was performed. Outcomes were 90-day mortality after ECMO initiation, ECMO-associated complications, and hospital length of stay. Cox regression models were used to explore risk factors for mortality in a time-to-event analysis. Measurements and Main Results: Ninety-four patients with COVID-19 were supported with ECMO (0.42 per population of 100,000, 14.89 per 100,000 positive cases, and 1.2% of intubated patients with COVID-19); 85 were included in the cohort analysis, and the median age was 48 (interquartile range [IQR], 41-55) years, 83.5% were men, and 42.4% had obesity. The median number of pre-ECMO intubation days was 4 (IQR, 2-7), the median Pa_O2/Fi_O2 ratio was 86.8 (IQR, 64-99) mm Hg, 91.8% of patients were prone positioned, and 14 patients had refractory respiratory acidosis. Main complications were infections (70.6%), bleeding (38.8%), and thromboembolism (22.4%); 52 patients were discharged home, and 33 died. The hospital length of stay was a median of 50 (IQR, 24-69) days. Lower respiratory system compliance and higher driving pressure before ECMO initiation were associated with increased mortality. A duration of pre-ECMO intubation ≥10 days was not associated with mortality. Conclusions: Documenting nationwide ECMO needs may help in planning ECMO provision for future COVID-19 pandemic waves. The 90-day mortality of the Chilean cohort of ECMO-supported patients with COVID-19 (38.8%) is comparable to that of previous reports.

Extracorporeal Support Prognostication-Time to Move the Goal Posts?

Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to mostly registry-based data and with mortality as the main outcome of interest. There continues to be a gap in clinically applicable decision support tools to aid in the timing of ECMO cannulation to improve patients' long-term outcomes. We present a brief review of the commonly available adult and pediatric ECMO prognostication tools, their limitations, and future directions.

Palliative Care for Patients on Extracorporeal Membrane Oxygenation for COVID-19 Infection

BACKGROUND

Critically ill patients with COVID-19 infection on extracorporeal membrane oxygenation (ECMO) face high morbidity and mortality. Palliative care consultation may benefit these patients and their families. Prior to the pandemic, our institution implemented a policy of automatic palliative care consultation for all patients on ECMO due to the high mortality, medical complexity, and psychosocial distress associated with these cases.

OBJECTIVES

The main objective was to describe the role of the palliative care team for patients on ECMO for COVID-19 infection. The secondary objective was to describe the clinical outcomes for this cohort.

DESIGN

Case series.

SETTINGS/SUBJECTS

All patients age 18 or older infected by the novel coronavirus who required cannulation on ECMO from March through July of 2020, at an urban, academic medical center in the United States. Inter-disciplinary palliative care consultation occurred for all patients.

RESULTS

Twenty-three patients (median age 43 years [range 28-64], mean body mass index 34.9 kg/m2 [SD 9.2], 65% Hispanic ethnicity) were cannulated on ECMO. Eleven patients died during the hospitalization (48%). Patients older than 50 years of age demonstrated a trend toward increased odds of death compared to those younger than 50 years of age (OR 9.1, P = 0.07). Patients received an average of 6.8 (SD 3.7) palliative clinical encounters across all disciplines. The actions provided by the palliative care team included psychosocial support and counseling, determination of surrogate decision maker (for 100% of patients), pain management (83%), and non-pain symptom management (83%).

CONCLUSIONS

Here, we present one of the first studies describing the patient characteristics, outcomes, and palliative care actions for critically ill patients with COVID-19 on ECMO. Almost half of the patients in this cohort died during their hospitalization. Given the high morbidity and mortality of this condition, we recommend involvement of palliative care for patients/families with COVID-19 infection who are on ECMO. The impact of palliative care on patient and family outcomes, such as symptom control, satisfaction with communication, rates of anxiety, and grief experience merits further investigation.

The Evolution of the Use of Extracorporeal Membrane Oxygenation in Respiratory Failure

Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support patients with acute respiratory failure, most commonly, and severe forms of acute respiratory distress syndrome (ARDS). The marked increase in the global use of ECMO followed the publication of a large randomized trial in 2009 and the experience garnered during the 2009 influenza A (H1N1) pandemic, and has been further supported by the release of a large, randomized clinical trial in 2018, confirming a benefit from using ECMO in patients with severe ARDS. Despite a rapid expansion of ECMO-related publications, optimal management of patients receiving ECMO, in terms of patient selection, ventilator management, anticoagulation, and transfusion strategies, is evolving. Most recently, ECMO is being utilized for an expanding variety of conditions, including for cases of severe pulmonary or cardiac failure from coronavirus disease 2019 (COVID-19). This review evaluates modern evidence for ECMO for respiratory failure and the current challenges in the field.

Extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

BACKGROUND

There are several reports of extracorporeal membrane oxygenation (ECMO) use in patients with coronavirus disease 2019 (COVID-19) who develop severe acute respiratory distress syndrome (ARDS). We conducted a systematic review and meta-analysis to guide clinical decision-making and future research.

METHODS

We searched MEDLINE, Embase, Cochrane and Scopus databases from 1 December 2019 to 10 January 2021 for observational studies or randomised clinical trials examining ECMO in adults with COVID-19 ARDS. We performed random-effects meta-analyses and meta-regression, assessed risk of bias using the Joanna Briggs Institute checklist and rated the certainty of evidence using the GRADE approach. Survival outcomes were presented as pooled proportions while continuous outcomes were presented as pooled means, both with corresponding 95% confidence intervals [CIs]. The primary outcome was in-hospital mortality. Secondary outcomes were duration of ECMO therapy and mechanical ventilation, weaning rate from ECMO and complications during ECMO.

RESULTS

We included twenty-two observational studies with 1896 patients in the meta-analysis. Venovenous ECMO was the predominant mode used (98.6%). The pooled in-hospital mortality in COVID-19 patients (22 studies, 1896 patients) supported with ECMO was 37.1% (95% CI 32.3-42.0%, high certainty). Pooled mortality in the venovenous ECMO group was 35.7% (95% CI 30.7-40.7%, high certainty). Meta-regression found that age and ECMO duration were associated with increased mortality. Duration of ECMO support (18 studies, 1844 patients) was 15.1 days (95% CI 13.4-18.7). Weaning from ECMO (17 studies, 1412 patients) was accomplished in 67.6% (95% CI 50.5-82.7%) of patients. There were a total of 1583 ECMO complications reported (18 studies, 1721 patients) and renal complications were the most common.

CONCLUSION

The majority of patients received venovenous ECMO support for COVID-19-related ARDS. In-hospital mortality in patients receiving ECMO support for COVID-19 was 37.1% during the first year of the pandemic, similar to those with non-COVID-19-related ARDS. Increasing age was a risk factor for death. Venovenous ECMO appears to be an effective intervention in selected patients with COVID-19-related ARDS. PROSPERO CRD42020192627.

Follow-up strategy with long-term veno-venous extracorporeal membrane oxygenation support for complicated severe acute respiratory distress related to COVID-19 and recovery of the lungs

Novel coronavirus-2019 (COVID-19) pandemic has affected all over the world, leading to viral pneumonia-complicating severe acute respiratory distress syndrome and death. Although there is no proven definitive treatment yet, physicians use some assistive methods based on the previous epidemic viral acute respiratory distress syndrome experiences. Extracorporeal membrane oxygenation is one of them. In this report, we present one of the longest survived extracorporeal membrane oxygenation case (71 days) with COVID-19 infection and the pathology of the infected lung, with our veno-venous extracorporeal membrane oxygenation strategy.

Implementation of care for the use of the extracorporeal oxygenation membrane in the COVID-19 pandemic

OBJECTIVE

To report the experience of a quaternary care center on the implementation of a care program for patients with severe hypoxemic respiratory failure due to SARS-CoV-2 requiring an extracorporeal oxygenation membrane.

METHOD

This is an experience report with a descriptive approach, analyzing the use of the extracorporeal oxygenation membrane in a quaternary care center in the city of Rio de Janeiro.

RESULTS

The planning for the use of the extracorporeal oxygenation membrane included training with the professionals and use of the components related to the adaptation of the protocol, equipment, facilities, quality and safety.

FINAL CONSIDERATIONS

Planning, resource allocation and regular training of the team to offer complex interventions, in line with recommendations for good practices in the care for patients with pulmonary complications related to the new coronavirus were essential for the development of the action plan for the use of extracorporeal oxygenation membrane in this pandemic period.

The role of extracorporeal membrane oxygenation in critically ill patients with COVID-19: a narrative review

Extracorporeal life support treatments such as extracorporeal membrane oxygenation (ECMO) have been recommended for the treatment of severe acute respiratory distress syndrome (ARDS) patients with coronavirus disease 2019 (COVID-19). To date, many countries, including China, have adopted ECMO as a treatment for severe COVID-19. However, marked differences in patient survival rates have been reported, and the underlying reasons are unclear. This study aimed to summarize the experience of using ECMO to treat severe COVID-19 and provide suggestions for improving ECMO management. The effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the pathophysiology of COVID-19 and the effects of ECMO on the clinical outcomes in patients with severe cases of COVID-19 were reviewed. Recent data from frontline workers involved in the use of ECMO in Wuhan, China, and those experienced in the implementation of artificial heart and lung support strategies were analysed. There is evidence that ECMO may complicate the pathophysiological state in COVID-19 patients. However, many studies have shown that the appropriate application of ECMO improves the prognosis of such patients. To expand our understanding of the benefits of ECMO for critically ill patients with COVID-19, further prospective, multicentre clinical trials are needed.

Immunoregulatory therapy strategies that target cytokine storms in patients with COVID-19 (Review)

A cytokine storm is an uncontrolled, excessive immune response that contributes to the pathogenesis of coronavirus disease 2019 (COVID-19). Viral infections lead to the loss of negative feedback in immune regulation and an abnormal elevation of the levels of multiple cytokines. In COVID-19, this causes diffuse damage to alveolar functions and may culminate in multiple organ dysfunction. Immunoregulatory therapies target the cytokine storms induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, and include monoclonal antibodies, recombinant granulocyte-macrophage colony stimulating factor, interferon, mesenchymal stem cell-based therapy, thymosin, immunoglobulins and blood purification therapies. These approaches may be effective in the alleviation of COVID-19 symptoms. In this review, cytokine storms caused by SARS-CoV-2 infections are evaluated and discussed, and advances in immunoregulatory therapy strategies for patients with COVID-19 are reviewed.

Respiratory viruses in foods and their potential transmission through the diet: A review of the literature

Respiratory viruses are the main agents causing respiratory tract diseases. Nowadays, coronaviruses - and specifically, SARS-CoV-1, MERS-CoV and SARS-CoV-2 - are the principal responsible for the major epidemic outbreaks of the 21st century. The major routes of transmission for respiratory viruses - including coronaviruses - are via direct and indirect contacts. However, transmission through contaminated foods has not been extensively assessed. The present paper was aimed at reviewing scientific data on the transmission of respiratory viruses through potentially contaminated foods. While the current data seem to suggest that this route of transmission is not likely to occur, in order to increase the knowledge on this issue further investigations are still clearly necessary for a more complete prevention of the risks. Studies should include fresh produce and cooked foods. Anyway, prevention measures and good hygienic practices for both consumers and workers are mandatory when handling and cooking foods.

BD, Salazar Gutierrez G, Gómez González JF, Echeverry Piedrahita DR, Galvis JC, Aguirre-Flórez M. Mechanical ventilation in SARS-CoV-2 patients: state of art

COVID-19-associated infection leads to a pathology of yet unknown clinical behavior, confronting the clinician with various challenges. An extensive search was conducted based on review articles on SARS-CoV-2 infection and studies including mechanical ventilation management strategies in order to complete this narrative review. Evidenced-based treatment for SARS-CoV2 infection is still in the works. We have some tools from our knowledge from past experiences indicating that a step-wise management approach should be used, without neglecting other joint therapeutic measures for improved clinical outcomes of a condition with a high mortality. The current recommendations indicate that patients with severe acute respiratory failure due to SARS-CoV-2 should be managed with protective mechanical ventilation measures. No strong evidence is yet available on the individualization of mechanical ventilation therapy according to phenotypes.

Extracorporeal Membrane Oxygenation and Extracorporeal Cardiopulmonary Resuscitation for a COVID-19 Pediatric Patient: A Successful Outcome

Pediatric population have been affected by the Coronavirus disease 2019 (COVID-19) to a much smaller scale compared with the adult population. The severity of the disease is variable ranging from mild form of pneumonia to severe acute respiratory distress syndrome (ARDS) that necessitates admission to the intensive care unit (ICU) requiring a maximal level of organ support. Failure of the maximum support through mechanical ventilation can lead to the consideration of a higher level of organ support through extracorporeal membrane oxygenation (ECMO). We present a case of an 8 years old girl, who presented with severe ARDS secondary to COVID-19 pneumonia for which a venovenous-ECMO (VV ECMO) was initiated. This was followed by the patient developing cardiac arrest, which was managed with extracorporeal cardiopulmonary resuscitation (ECPR). The patient was also given thrombolytic therapy during the ECPR because of high clinical suspicion for pulmonary embolism. Venovenous-arterial ECMO was then continued and the patient was successfully weaned off both VA and VV ECMO and discharged home with full neurologic recovery. This encouraging result will hopefully lead to more consideration of this lifesaving therapy for severe cardiac and respiratory failure secondary to COVID-19 in pediatric patients.

ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors

BACKGROUND

The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy.

METHODS

A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed.

RESULTS

Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8-32.1) ml/cmH₂O vs 18.7 (17.7-25.0) ml/cmH₂O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16-23) days vs 5 (5-9) days, p = 0.002) and SOFA score was higher (12.0 (10.5-17.0) vs 10.0 (9.0-10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome.

CONCLUSIONS

VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.

ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors

Background:

The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy.

Methods:

A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed.

Results:

Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8–32.1) ml/cmH₂O vs 18.7 (17.7–25.0) ml/cmH₂O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16–23) days vs 5 (5–9) days, p = 0.002) and SOFA score was higher (12.0 (10.5–17.0) vs 10.0 (9.0–10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome.

Conclusions:

VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Expert Recommendations from The Korean Society for Thoracic and Cardiovascular Surgery

Since the first reported case of coronavirus disease 2019 (COVID-19) in December 2019, the numbers of confirmed cases and deaths have continued to increase exponentially despite multi-factorial efforts. Although various attempts have been made to improve the level of evidence for extracorporeal membrane oxygenation (ECMO) treatment over the past 10 years, most experts still hesitate to take an active position on whether to apply ECMO in COVID-19 patients. Several ECMO management guidelines have been published recently, but they reflect some important differences from the Korean medical system and aspects of real-world medical practice in Korea. We aimed to find evidence on the efficacy of ECMO for COVID-19 patients by reviewing the published literature and to propose expert recommendations by analyzing the Korean COVID-19 ECMO registry data.