In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Awake extracorporeal membrane oxygenation in a patient with COVID-19 pneumonia and severe hypoxemic respiratory failure

OBJECTIVE

In the past few years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in patients with severe respiratory insufficiency in whom mechanical ventilation (MV) had failed. MV in severe COVID-19 patients is often accompanied by high respiratory pressures and high oxygen concentrations. Thus, by "placing the lungs at rest" ECMO might spare severe COVID-19 patients from being subjected to aggressive MV. Awake ECMO is another therapeutic alternative for providing extracorporeal oxygenation and ventilation by avoiding the complications of MV.

CASE PRESENTATION

A 65-year-old male diagnosed with COVID-19 pneumonia was admitted to the intensive care unit (ICU) after deteriorating to hypoxemic respiratory failure with acute respiratory distress disorder (ARDS). Awake veno-venous (VV) ECMO was considered after receiving patient consent and was successfully implemented as an attempt to avoid invasive MV. This is one of the first cases described during the COVID-19 pandemic, in which awake VV-ECMO was used in a critically ill COVID-19 patient as a replacement therapy to conventional MV.

CONCLUSIONS

Under the appropriate conditions, awake ECMO might be a suitable alternative approach to avoid complications of aggressive MV in selected critically ill COVID-19 ARDS patients.

Meckel's diverticulum ischemia caused by thromboembolism after coronary artery bypass grafting

A 75-year-old woman underwent emergency coronary artery bypass surgery after acute anterior wall myocardial infarction. Because of the presence of a local peritonitis, an emergency laparotomy was performed in which necrotizing Meckel's diverticulum was found and resected. Microscopically, sections through the diverticulum revealed a fresh thrombus occluded the arterial lumen of diverticulum. The patient had an uneventful postoperative course. We believe that the cause of Meckel's diverticulum ischemia was the development of atrial fibrillation with left atrium thrombus formation followed by embolic obliteration of Meckel's diverticulum feeding artery.

Surgical resection of left atrial myxoma presenting with acute multiple hemorrhagic cerebral infarctions: a case report

Brain ischemia resulting from left atrial myxoma embolization has been well documented. In contrast, the link between the development of intracerebral hemorrhage and myxoma in these patients has little coverage in the literature. The main theory describing this relationship stems from the fact that cardiac myxoma cells metastasize to the brain's vessels, causing destruction of the arterial wall with subsequent formation of fusiform aneurysm and further intracranial bleeding. It is assumed that when a diagnosis of left atrial myxoma with neurologic manifestations is made, surgical resection should be performed without delay to prevent repeated tumor embolization; however, systemic anticoagulation treatment during cardiac surgery with cardiopulmonary bypass is not recommended immediately after intracerebral hemorrhage occurs because of the possibility of extending the infarct's size. We describe a patient with acute hemorrhagic brain infarction and an echocardiographically demonstrated left atrial myxoma that was surgically resected successfully in the acute phase after the onset of the neurologic symptoms.

Ergonomics for children: an educational program for elementary school

Studies indicate that musculoskeletal discomfort and back pain problems are evident not only in adults, but also in children [11,13]. We believe that educating towards a balanced-posture, body-function and movement patterns, as well as their ergonomic implications, can minimize and even prevent these problems. Such an ergonomics awareness educational program has to start at childhood and should be an integral part of the curriculum in the schools. This article presents the educational program "Ergonomics, Movement and Posture" (EMP), which is taught in elementary schools by Physical Education (PE) students of the Kibbutzim College of Education in Israel, as part of their practicum. Although there has been no formal evaluation of the effectiveness of the program, so far, participating children, their parents, the teachers and the principles have offered positive feedback.

Leiomyosarcoma of the superior vena cava: Resection with vascular reconstruction - case report and review of the literature

The present report describes a case of pedunculated intraluminal leiomyosarcoma of the superior vena cava, extending to the right atrium, that was successfully resected surgically. Superior vena cava reconstruction was performed using bovine pericardial graft, saving the sinus node. The pathological variants of this neoplasm according to the anatomical site of the tumour are described.

Impedance cardiography revisited

Previously reported comparisons between cardiac output (CO) results in patients with cardiac conditions measured by thoracic impedance cardiography (TIC) versus thermodilution (TD) reveal upper and lower limits of agreement with two standard deviations (2SD) of approximately +/-2.2 l min(-1), a 44% disparity between the two technologies. We show here that if the electrodes are placed on one wrist and on a contralateral ankle instead of on the chest, a configuration designated as regional impedance cardiography (RIC), the 2SD limit of agreement between RIC and TD is +/-1.0 l min(-1), approximately 20% disparity between the two methods. To compare the performances of the TIC and RIC algorithms, the raw data of peripheral impedance changes yielded by RIC in 43 cardiac patients were used here for software processing and calculating the CO with the TIC algorithm. The 2SD between the TIC and TD was +/-1.7 l min(-1), and after annexing the correcting factors of the RIC formula to the TIC formula, the disparity between TIC and TD further declined to +/-1.25 l min(-1).

CONCLUSIONS

(1) in cardiac conditions, the RIC technology is twice as accurate as TIC; (2) the advantage of RIC is the use of peripheral rather than thoracic impedance signals, supported by correcting factors.

Complication-free duration and the risk of development of retinopathy in elderly diabetic patients

BACKGROUND

Determining which diabetic patients are at risk for complications and targeting these patients for intensive therapy may avoid the unwanted consequences of hypoglycemia in low-risk patients. Since aging is associated with a decrease in the incidence of diabetic retinopathy, we assessed whether long complication-free duration can define elderly patients at lower risk for future development of diabetic retinopathy.

METHODS

In a 10-year clinic-based study, we studied 833 type 2 diabetic patients who were free of diabetic retinopathy and older than 50 years, followed up for more than 4 years. Data included demographic and clinical information on arrival, updated every 3 to 6 months, and yearly direct ophthalmoscopic examination after pupillary dilation by experienced ophthalmologists. All the data were prospectively compiled on relational databases. End points studied were presence of retinopathy, nephropathy, peripheral neuropathy, peripheral vascular disease, hyperlipidemia, and hypertension.

RESULTS

Of the patients without retinopathy at the age of 50 years, 10% developed retinopathy during 4 years of follow-up. These patients had longer duration and younger onset of diabetes than the group without retinopathy at the 4-year follow-up. Clustering of microvascular and macrovascular complications was noted. Discriminant analysis showed the following factors to be significant and independent predictors of the development of retinopathy in the elderly: duration of diabetes, body mass index, age, and glucose control.

CONCLUSIONS

A long complication-free period does not define elderly patients with type 2 diabetes who are at lower risk for future development of retinopathy. On the contrary, the increase in disease duration is significantly associated with the development of retinopathy in this age group, as described in younger patients.