Racial disparities among patients on venovenous extracorporeal membrane oxygenation in the pre-Coronavirus Disease 2019 and Coronavirus Disease 2019 eras: A retrospective registry review

Objectives

Although many studies have addressed such disparities caused by COVID-19, to our knowledge, no study has focused on the association of race on outcomes for patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation support. The goal of this study was to assess association of race on death and duration on venovenous extracorporeal membrane oxygenation in both the pre-COVID-19 and COVID-19 eras.

Methods

We retrospectively reviewed the Extracorporeal Life Support Organization registry and included adults (≥18 years) who required venovenous extracorporeal membrane oxygenation between January 2019 and April 2021. We performed descriptive statistics and multivariable logistic regression. Our primary outcomes were death and extracorporeal membrane oxygenation duration.

Results

A total of 7477 patients were included after excluding 340 patients (4.3%) who were missing race data. In the COVID-19 era, 1474 of 2777 COVID-19-positive patients (53.1%) died. Our regression model suggested somewhat of a protective effect on death for Black and multiple race patients. Additionally, a diagnosis of COVID-19 and patients in the COVID-19 era in general, irrespective of COVID-19 diagnosis, had higher odds of death. Hispanic patients had the longest average venovenous extracorporeal membrane oxygenation run times.

Conclusions

Our study using data from the international Extracorporeal Life Support Organization Registry provides updated data on patients supported with venovenous extracorporeal membrane oxygenation in the pre-COVID-19 and COVID-19 eras between 2019 and 2021 with a focus on race. Patients in the COVID-19 era group also had higher mortality compared with those in the pre-COVID-19 era even after being adjusted for COVID-19 diagnosis. Black and multiple races appeared somewhat protective in terms of death. Hispanic race was associated with longer venovenous extracorporeal membrane oxygenation duration.

Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report

Background

Massive hemoptysis during pregnancy is very rare. Dieulafoy's disease is one of the causes of massive hemoptysis. There are few reports of ECMO use to treat massive hemoptysis during pregnancy.

Findings

We report for the first time a patient with Dieulafoy's disease diagnosed at 29 weeks of pregnancy. The patient's hemoptysis occurred rapidly with large volumes. The bleeding amount reached 500 ml within half an hour, with the development of asphyxia and respiratory and cardiac arrest due to a blood clot blocking the airway. After successful cardiopulmonary resuscitation, the ventilator could not maintain effective ventilation. Emergency establishment of VV-ECMO was performed to maintain oxygen, and hemostasis was successfully achieved by performing bronchial artery embolization twice. We successfully cleaned blood clots in the airway four times by freezing and using a foreign body retrieval basket with an electronic bronchoscope. At the same time, small and smooth nodular lesions were found under bronchoscopy, and blood vessels with a diameter of 1.5 mm were found under Doppler mode with an ultrasonic bronchoscope, which was consistent with a diagnosis of Dieulafoy's disease. VV-ECMO was successfully stopped on the 3rd day of the disease course, tracheal intubation was successfully removed on the 5th day of the disease course, and the patient was discharged with no complications on the 16th day of the disease course.

An atypical airway cast

A 60-year-old man intubated for airway protection after smoke inhalation was found to have decompensated hypercapnic respiratory failure. Fiberoptic bronchoscopy revealed obstructive airway slough and pseudomembrane, a manifestation of severe inhalation injury. Veno-venous extracorporeal membrane oxygenation was established for stabilization. The airway casts were removed successfully with periprocedural veno-venous extracorporeal membrane oxygenation support.

A Novel Percutaneous Snare-Assisted Manipulation and Repositioning of a ProtekDuo Cannula in a COVID-19 Acute Respiratory Distress Syndrome

Venovenous extracorporeal membrane oxygenation [VV-ECMO] has gained increasing notoriety during the COVID-19 pandemic as a salvation therapy for fulminant respiratory failure. Various configurations can present unique challenges in management. For instance, the ProtekDuo cannula is a 29Fr to 31Fr dual-lumen cannula inserted by way of the right internal jugular vein that allows for right atrium to pulmonary artery bypass with an attached oxygenator, essentially resulting in VV-ECMO. Understanding that these different configurations inevitably dictate the types of complications that can arise during the circuit implantation and management is imperative. However, in a hemodynamically unstable patient, time or resources may not permit standard maneuvers for management. In conclusion, we present an innovative, percutaneous approach which allowed the restoration of flow and oxygenation in a decompensating ProtekDuo patient without having to explant/disconnect the circuit or implant a new VV-ECMO circuit.

Veno-venous extracorporeal membrane oxygenation cannulation in prone position

A 54-year-old woman was referred for veno-venous extracorporeal oxygenation membrane (VV-ECMO) due to refractory hypoxic respiratory failure caused by COVID-19, despite mechanical ventilation and prolonged prone positioning.

Cannula-Associated Deep Vein Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Patients with and Without Systemic Anticoagulation

OBJECTIVE

To identify and compare the rates of cannula-associated deep vein thrombosis (CaDVT) in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) who receive systemic anticoagulation (AC) and those who do not receive AC.

DESIGN

Retrospective observational study.

SETTING

Tertiary academic medical center.

PARTICIPANTS

Consecutive patients who successfully have been decannulated from VV-ECMO for treatment of refractory acute respiratory distress syndrome between 2017 and 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After decannulation of ECMO, a duplex sonograph was performed on the cannulation sites to determine the incidence and characteristics of cannula-related thrombosis. Thrombosis was classified as occlusive or nearly occlusive. Ninety-four of 161 patients were weaned from VV-ECMO. Nineteen patients who were placed on VV-ECMO due to COVID-19 were excluded. Twenty-seven of 52 patients (52%) who did not receive AC were identified to have thrombus. Twelve of 23 patients (52%) who received AC were identified to have thrombus. Patients who received AC required more blood products during the ECMO run and required longer support on VV-ECMO.

CONCLUSION

This study showed a high incidence of cannula-related venous thrombosis after VV-ECMO decannulation. Surprisingly, the incidence of CaDVT in anticoagulation-free patients was the same as in patients requiring anticoagulation. Anticoagulated patients required longer support on VV-ECMO and required more transfusions. Routine post-decannulation screening for DVT is recommended due to the high incidence of CaDVT.

Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO

BACKGROUND

Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure.

OBJECTIVE

To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support.

METHODS

We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation.

RESULTS

We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs 13.4 mcg/kg/day, P = 0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs 53.5 mg/kg/day, P < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01).

CONCLUSION AND RELEVANCE

Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.

Early Tracheostomy May Be Performed Safely in Obese COVID-19 Patients Supported on VV-ECMO

OBJECTIVE

Obese patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory failure (ARDS) often require prolonged intubation. However, data are sparse regarding optimal tracheostomy timing in obese adults with COVID-19 requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). This study retrospectively describes the course of obese patients with COVID-19 who underwent tracheostomy on VV-ECMO between March 2020 and December 2022.

METHODS

There were 62 participants with a median age of 43 (interquartile range [IQR] 33 to 53) years and a median body mass index of 42 (IQR 34 to 50) kg/m2 who received VV-ECMO for COVID-19-associated ARDS. Of those, 42 underwent tracheostomy on VV-ECMO, and 50% (n = 21) of the 42 patients underwent early (within 14 days of initiated ventilatory support) tracheostomy.

RESULTS

Among patients who received tracheostomies, the combined respiratory tract and lung parenchymal bleeding rate was 29% (n = 12), but only 7% required surgical intervention for bleeding from the tracheostomy site (n = 3). The hospital length of stay (LOS) was 42 (IQR 36 to 57) days, and mortality rate was 38% (n = 16). Tracheostomy timing was not associated with differences in respiratory tract bleeding, mechanical ventilatory support duration, VV-ECMO support duration, intensive care unit LOS, hospital LOS, mortality, or survival probability.

CONCLUSIONS

Although an individualized and holistic approach to clinical decision making continues to be necessary, the findings of this study suggest that early tracheostomy may be performed safely in obese patients with COVID-19 on VV-ECMO.

Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice

Context

After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO).

Purpose

In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline.

Methods

We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation.

Results

Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval.

Conclusions

The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.

Delayed tracheoesophageal fistula and refractory respiratory failure caused by inhalation burns and emergency venovenous ECMO to facilitate its management: a case report

Acquired tracheoesophageal fistulae are uncommon in burn patients but can occur as a complication of inhalation injury. We report a case of a 30-year-old male patient presenting after suffering from inhalation and 25% total body surface area burns. On post burns day 14 he developed a massive tracheoesophageal fistula causing refractory acute respiratory failure. Veno-venous extracorporeal membrane (VV ECMO) oxygenation was initiated without systemic anticoagulation via bi-femoral cannulation under transthoracic echocardiography guidance. He underwent successful 5-hour apnoeic ventilation-assisted surgical repair of the fistula via a right posterolateral thoracotomy. ECMO was discontinued after 36 hours, and he was discharged to the ward after 33 days in the intensive care unit. Inhalation burn injury can cause a delayed life-threatening tracheoesophageal fistula. Surgical repair can be successfully performed for this condition. VV- ECMO can be used to facilitate prolonged apnoeic surgery and to manage refractory respiratory failure due to this condition.

Management of two circulations in a COVID-19 patient with secondary superinfection

Optimal oxygenation in the intensive care unit requires adequate pulmonary gas exchange, oxygen-carrying capacity in the form of hemoglobin, sufficient delivery of oxygenated hemoglobin to the tissue, and an appropriate tissue oxygen demand. In this Case Study in Physiology, we describe a patient with COVID-19 whose pulmonary gas exchange and oxygen delivery were severely compromised by COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. His clinical course was complicated by a secondary superinfection with staphylococcus aureus and sepsis. This case study is provided with two goals in mind (1) We outline how basic physiology was used to address life-threatening consequences of a novel infection-COVID-19. (2) We describe a strategy of whole-body cooling to lower the cardiac output and oxygen consumption, use of the shunt equation to optimize flow to the ECMO circuit, and transfusion to improve oxygen-carrying capacity when ECMO alone failed to provide sufficient oxygenation.

Veno-venous extracorporeal membrane oxygenation for the treatment of respiratory compromise

Extracorporeal membrane oxygenation for the purpose of intervening upon profound cardiovascular or pulmonary compromise has proven to be a worthy intervention. Technological advancements have allowed this mode of therapy to become more effective and widespread. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a commonly used strategy to help manage patients with pulmonary dysfunction refractory to traditional management methods. This review intends to focus upon common indications and the clinical considerations for the institution of VV-ECMO as well as some of its known complications.

Chronic pain treatment with pregabalin in end stage respiratory failure patients awaiting lung transplantation on ambulatory veno-venous extra corporeal membrane oxygenator support; a series of nine cases

Background

End-stage respiratory failure is non-treatable with mechanical ventilation and can be treated with veno-venous extracorporeal membrane oxygenators (VV-ECMO). It can also be used as a bridge to lung transplantation or recovery of lung function. This patient group can suffer from chronic pain, which is further exacerbated by painful procedures required as part of treatment. Pregabalin is licensed for chronic neuropathic pain and generalized anxiety disorder. Thus far, it has not been tried in routine analgesia protocols for pain relief of patients on VV-ECMO.

Case Series

We included nine patients aged 17-54 years on VV-ECMO awaiting lung transplantation. Exclusion criteria were acute kidney injury and chronic kidney disease. All patients had morphine patient-control analgesia. In addition, pregabalin 50 mg twice daily was initiated in all patients with dose escalation as required. Pain scores and quality of sleep were evaluated daily. All patients experienced significant pain relief, demonstrated by reduced pain scores after treatment commencement. The mean visual analogue scale score was reduced significantly from 6 ± 2 to 3 ± 1. A significant increase in good-quality sleep duration was recorded from 5 ± 1.7 hours per day before to 8 ± 2.1 hours per day after pregabalin treatment. All patients except for two reported reduced anxiety levels of at least 2 ± 1 scale improvement (p <0.05).

Conclusions

Pregabalin is an efficient analgesic with accompanying anxiolytic effects in this group of patients with unique characteristics such as high analgesia requirements and exacerbated psychological and emotional stress. HIPPOKRATIA 2023, 27 (1):22-24.

A Dedicated Expert ECMO-Team and Strict Patient Selection Improve Survival of Patients with Severe SARS-CoV-2 ARDS Supported by VV-ECMO

The SARS-CoV-2 pandemic has overwhelmed health care systems worldwide since its first wave. Intensive care units have been under a significant amount of pressure as patients with the most severe form of the disease presented with acute respiratory distress syndrome (ARDS). A proportion of them experienced refractory acute respiratory failure and had to be supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO). The present retrospective study reports the experiences of our ECMO center in the management of COVID-19 patients with refractory ARDS. Patient characteristics and outcomes are presented through the different waves of the pandemic. A cohort study was conducted on patients with refractory ARDS due to COVID-19 infection who were admitted to the intensive care unit (ICU) at the Geneva University Hospital and supported with VV-ECMO between 14 March 2020 and January 2022. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit of the hospital and the Swiss Society of Intensive Care Medicine. Among the 500 ARDS patients admitted to our ICU, 41 patients with a median age of 57 (52−63) years, a body mass index (BMI) of 28 (26−32) kg/m2, and a SAPS II score of 57 (47−67), and 27 (66%) of whom were men required VV-ECMO. None of the patients were vaccinated. The time of ventilation, including noninvasive ventilation (NIV) and mechanical ventilation (MV), and the time of MV before ECMO were 7 (4−11) days and 4 (1−7) days, respectively. The time under ECMO was 20 (10−27) days. The ICU and hospital lengths of stay were 36 (21−45) days and 45 (33−69) days, respectively. The survival rate for patients on ECMO was 59%. Comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter ventilation duration before ECMO (NIV + MV: 5.5 (1.3−9) vs. 9 (6.5−13.5) days, p = 0.0026 and MV alone: 1.6 (0.4−5.5) vs. 5.8 (5−8) days, p < 0.0001). The management of patients on ECMO by an experienced ECMO team dedicated to this activity was associated with improved survival (78% vs. 28%, p = 0.0012). Between the first wave and the following waves, patients presented with a higher incidence of ventilator-associated pneumonia (100% vs. 82%, p = 0.0325) but had better survival rates (74% vs. 35%, p = 0.024). The present study suggests that both the prompt insertion of VV-ECMO to control refractory hypoxemia and the involvement of an ECMO team improve the survival of COVID-19 patients.

Venovenous extracorporeal membrane oxygenation support in patients with COVID-19 respiratory failure: A multicenter study

Objective

The COVID-19 pandemic presents a high mortality rate amongst patients who develop severe acute respiratory distress syndrome (ARDS). The purpose of this study was to evaluate the outcomes of venovenous extracorporeal membrane oxygenation (VV-ECMO) in COVID-19-related ARDS and identify the patients who benefit the most from this procedure.

Methods

Adult patients with COVID-19 and severe ARDS requiring VV-ECMO support at 4 academic institutions between March and October 2020 were included. Data were collected through retrospective chart reviews. Bivariate and multivariable analyses were performed with the primary outcome of in-hospital mortality.

Results

Fifty-one consecutive patients underwent VV-ECMO with a mean age of 50.4 years; 64.7% were men. Survival to hospital discharge was 62.8%. Median intensive care unit and hospitalization duration were 27.4 days (interquartile range [IQR], 17-37 days) and 34.5 days (IQR, 23-43 days), respectively. Survivors and nonsurvivors had a median ECMO cannulation time of 11 days (IQR, 8-18) and 17 days (IQR, 12-25 days). The average postdecannulation length of stay was 17.5 days (IQR, 12.4-25 days) for survivors and 0 days for nonsurvivors (IQR, 0-6 days). Only 1 nonsurvivor was able to be decannulated. Clinical characteristics associated with mortality between nonsurviors and survivors included increasing age (P = .0048), hemorrhagic stroke (P = .0014), and postoperative dialysis (P = .0013) were associated with mortality in a bivariate model and retained statistical significance in a multivariable model.

Conclusions

This multicenter study confirms the effectiveness of VV-ECMO in selected critically ill patients with COVID-19-related severe ARDS. The survival of these patients is comparable to non-COVID-19-related ARDS.

Echocardiography for extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.

Improvement in activities of daily living and exercise tolerance in a patient with severe COVID-19 and femoral nerve palsy after Kaifukuki rehabilitation: a case report

Yashiro T, Wada Y, Sugiyama M, Tateno H, Kasai F, Kawate N. Improvement in activities of daily living and exercise tolerance in a patient with severe COVID-19 and femoral nerve palsy after Kaifukuki rehabilitation: a case report. Jpn J Compr Rehabil Sci 2021; 12: 53-57.

Introduction

There have been many reports on rehabilitation techniques for patients with coronavirus disease 2019 (COVID-19). However, few have reported on the use of Kaifukuki rehabilitation for severe COVID-19 cases with complications of femoral nerve palsy after veno-venous extracorporeal membrane oxygenation (VV-ECMO) management.

Case

A male in his 50s who underwent VV-ECMO management during the course of his treatment for COVID-19 developed femoral nerve palsy due to iliopsoas hematoma. From day 120 after admission, he underwent Kaifukuki rehabilitation focusing on exercise therapy, activities of daily living (ADL) training, and respiratory rehabilitation to improve ADL and exercise tolerance. His respiratory function, functional independence measure scores, and 6-min walk test results improved. The patient was discharged on day 196. His recovery progressed without any further deterioration.

Discussion

Kaifukuki rehabilitation, focusing on respiratory rehabilitation, contributed to the improvement of ADL and exercise tolerance in a patient with severe COVID-19. In addition, attention should be paid to femoral nerve palsy after VV-ECMO.

Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population

PURPOSE

Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population.

METHODS

A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement.

RESULTS

During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33).

CONCLUSIONS

There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.

Emergency lower gastrointestinal endoscopy performed safely in a COVID-19 patient on extracorporeal membrane oxygenation (ECMO) with hemorrhagic shock

Emergency endoscopy in coronavirus disease 2019 (COVID-19) patients should be avoided whenever possible to ensure the safety of medical staff; however, it may be unavoidable in some cases. We report a case of emergency lower gastrointestinal endoscopy performed with full personal protective equipment in a patient on extracorporeal membrane oxygenation with severe COVID-19 pneumonia admitted in a restricted area under negative pressure in the intensive care unit. To avoid the risk of fecal-oral transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the procedure, the patient's lower body was covered with a 2 m² vinyl sheet with an aperture (diameter, approximately 2 cm). None of the medical staff involved exhibited any signs of SARS-CoV-2 infection after the procedure. Although patients with severe COVID-19 pneumonia on extracorporeal membrane oxygenation have a high risk of bleeding, we believe that emergency lower endoscopy can be safely performed in such patients by reducing exposure to dispersed feces and using full personal protective equipment.

Timing of VV-ECMO therapy implementation influences prognosis of COVID-19 patients

Introduction

Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID‐19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID‐19 patients.

Methods

A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID‐19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV‐ECMO from March 14 to May 31. The VV‐ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine.

Results

Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m², and SAPS II score 56 ± 3) were put on VV‐ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non‐survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died.

Conclusion

The present results suggest that VV‐ECMO can be safely utilized in appropriately selected COVID‐19 patients with refractory hypoxemia. The main information for clinicians is that late VV‐ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile.

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

PURPOSE

Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19).

METHODS

We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO₂/FiO₂ < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model.

RESULTS

Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41-58), 137 (72.1%) were men, and the median PaO₂/FiO₂ prior to ECMO initiation was 72 (IQR 61-90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41-0.74). Results were similar in a secondary analysis limited to patients with PaO₂/FiO₂ < 80 (HR 0.55; 95% CI 0.40-0.77).

CONCLUSION

In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality.

Clinical course of a critically ill patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Although several studies have reported on the clinical and epidemiological characteristics of the patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), clinical course of the most severe cases requiring treatment in ICU have been insufficiently reported. A 73-year-old man traveling on a cruise ship with history of hypertension and dyslipidemia developed high fever, dyspnea and cough after 7 days of steroid treatment for sudden sensorineural hearing loss, and tested positive for SARS-CoV-2 in sputa polymerase chain reaction (PCR) examination. His respiratory function deteriorated despite treatments with lopinavir/ritonavir, oseltamivir, azithromycin and meropenem at a regional hospital. He was intubated and transferred to the ICU in the tertiary university hospital on day 10 (ICU day 1). Interferon beta-1b subcutaneous injection was initiated immediately to enhance anti-viral therapy, and favipiravir on ICU day 10 upon availability. Progression of organ dysfunctions necessitated inhalation of nitrogen oxide for respiratory dysfunction, noradrenaline for cardiovascular dysfunction and continuous renal replacement therapy for renal dysfunction. His blood samples PCR also tested positive for SARS-CoV-2, indicating viremia, concomitantly with elevated IL-6 levels. VV-ECMO was initiated after sudden exacerbation of respiratory dysfunction on ICU day 7 to maintain oxygenation. The sustained excessive inflammatory cytokines in the present case might have led to the exacerbation of the disease, requiring vigorous organ support therapies to allow for survival and recovery from the rapid progression of multiple organ dysfunctions and severe respiratory failure.

Venovenous Extracorporeal Membrane Oxygenation Combined with Fiberoptic Bronchoscopy-Assisted CO2 Cryotherapy in the Treatment of Massive Hemoptysis in Pregnancy: A Case Report

Background

Massive hemoptysis in pregnancy is very rare but can be life-threatening for both the pregnant woman and fetus. Extracorporeal membrane oxygenation (ECMO) is extremely rare in the treatment of severe hemoptysis in pregnancy. Here we describe the case of massive hemoptysis in the second trimester of pregnancy successfully treated with a combination of venovenous (VV)-ECMO, and bronchial artery embolization combined with fiberoptic bronchoscopy–assisted CO₂ cryotherapy.

Case Presentation

A 34-year-old patient at 28 2/7 weeks gestation with a history of hemoptysis for 3 days was transferred to our care. Massive hemoptysis completely blocked the trachea and main bronchus, and a ventilator could not carry out ventilation. ECMO was performed immediately when oxygenation was not maintained. A right lower bronchial artery hemorrhage was found by bronchial arteriography under ECMO, and embolization with microcoils and gelatin sponge particles was then performed. An emergency bedside carbon dioxide cryo-thrombectomy was performed under fiberoptic bronchoscopy because of obstruction of the trachea and main bronchus. Endotracheal cryotherapy was repeated (for a total three times) until bronchoscopic evaluation confirmed no obstruction of the trachea and no active bleeding in the airway. On day 7, ECMO was successfully evacuated. On day 15, the patient was extubated. On day 17, the tracheotomy was closed and replaced by nasal oxygen inhalation. On day 20, the patient was discharged from hospital. The patient has had no recurrence of hemoptysis in 3-month follow-up.

Conclusion

VV-ECMO combined with carbon dioxide cryotherapy in the treatment of pregnancy complicated with massive hemoptysis is an effective treatment, when massive hemoptysis completely blocked the trachea.

Use of venovenous extracorporeal membrane oxygenation for resection of a large paratracheal mass causing critical tracheal stenosis: A case report

Critical airway stenosis is challenging for surgeons and anesthesiologists to secure a reliable airway for ventilation. The use of venovenous (VV)-extracorporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea; a planned intraoperative VV-ECMO was instituted to allow safe orotracheal intubation of a double-lumen endotracheal tube for lung isolation and tumor resection.

COVID19 Acute respiratory distress syndrome and extra-corporeal membrane oxygenation; A mere option or ultimate necessity

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia (hypoxemia persisting despite lung-protective ventilation). One aspect of ECMO is whether there would be an application of the technology related to the Coronavirus pandemic. The number of people diagnosed with Coronavirus disease (COVID19) has crossed the five million mark on 9 August 2020, with a case fatality rate of 5.2%. Due to this exponential increase in the number of coronavirus disease (COVID19) cases particularly the ones associated with ARDS, experts are evaluating the need for ECMO in intensive care units. Herein, we chronicle a review encompassing the available evidence on ECMO and its potential role in COVID19 ARDS, as we aim for optimal patient care with appropriate resource utilization and conservation.

Nebulized in-line endotracheal dornase alfa and albuterol administered to mechanically ventilated COVID-19 patients: a case series

Background

Mechanically ventilated patients with COVID-19 have a mortality of 24–53%, in part due to distal mucopurulent secretions interfering with ventilation. DNA from neutrophil extracellular traps (NETs) contribute to the viscosity of mucopurulent secretions and NETs are found in the serum of COVID-19 patients. Dornase alfa is recombinant human DNase 1 and is used to digest DNA in mucoid sputum. Here, we report a single-center case series where dornase alfa was co-administered with albuterol through an in-line nebulizer system.

Methods

Demographic and clinical data were collected from the electronic medical records of five mechanically ventilated patients with COVID-19—including three requiring veno-venous extracorporeal membrane oxygenation—treated with nebulized in-line endotracheal dornase alfa and albuterol, between March 31 and April 24, 2020. Data on tolerability and response were analyzed.

Results

The fraction of inspired oxygen requirements was reduced for all five patients after initiating dornase alfa administration. All patients were successfully extubated, discharged from hospital and remain alive. No drug-associated toxicities were identified.

Conclusions

Results suggest that dornase alfa will be well-tolerated by patients with severe COVID-19. Clinical trials are required to formally test the dosing, safety, and efficacy of dornase alfa in COVID-19, and several have been recently registered.

Vascular access in ECMO

In critically ill patients, deserving extracorporeal membrane oxygenation (ECMO), choosing the right pattern of cannulation such as veno-venous (VV), veno-arterial (VA), veno-veno-arterial (VVA), and central; selecting the appropriate size cannulae; and good cannulation techniques are all pre-requisites for the successful outcome of ECMO. We are describing the selection criteria for choosing appropriate size cannulae, cannulation configurations, available cannulae, and possible complications. A brief note on anticoagulation was added.

COVID-19 Assessment with Bedside Lung Ultrasound in a Population of Intensive Care Patients Treated with Mechanical Ventilation and ECMO

The COVID-19 pandemic has increased the need for an accessible, point-of-care and accurate imaging modality for pulmonary assessment. COVID-19 pneumonia is mainly monitored with chest X-ray, however, lung ultrasound (LUS) is an emerging tool for pulmonary evaluation. In this study, patients with verified COVID-19 disease hospitalized at the intensive care unit and treated with ventilator and extracorporal membrane oxygenation (ECMO) were evaluated with LUS for pulmonary changes. LUS findings were compared to C-reactive protein (CRP) and ventilator settings. Ten patients were included and scanned the day after initiation of ECMO and thereafter every second day until, if possible, weaned from ECMO. In total 38 scans adding up to 228 cineloops were recorded and analyzed off-line with the use of a constructed LUS score. The study indicated that patients with a trend of lower LUS scores over time were capable of being weaned from ECMO. LUS score was associated to CRP (R = 0.34; p < 0.03) and compliance (R = 0.60; p < 0.0001), with the strongest correlation to compliance. LUS may be used as a primary imaging modality for pulmonary assessment reducing the use of chest X-ray in COVID-19 patients treated with ventilator and ECMO.

Acquired factor XIII deficiency in two patients with bleeding events during veno-venous extracorporeal membrane oxygenation treatment

We report two cases of acquired factor XIII deficiency with bleeding events during veno-venous extracorporeal membrane oxygenation (ECMO). Case 1: A 76-year-old man diagnosed with aspiration pneumonia after near-drowning was started on ECMO. Later, the patient presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 29%. Although the patient recovered after receiving 1200 International Units of factor XIII concentrate, the patient had another episode of decreased factor XIII activity and bloody stool and was treated again with factor XIII concentrate. Case 2: A 48-year-old female diagnosed with pneumonia was started on ECMO. Soon after, she presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 39%. The patient was treated with 720 IU of factor XIII concentrate with good recovery. Acquired factor XIII deficiency cannot be detected by routine coagulation tests, therefore it may be under-diagnosed in the ICU. Detection of acquired factor XIII deficiency is essential when treating a bleeding ECMO patient.

Venovenous extracorporeal membrane oxygenation for the management of critical airway stenosis

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used not only support gas transfer of patients suffering from respiratory failure, but also to manage hypoxic patients with critical airway obstruction during various procedures. We present a case in which we electively used VV-ECMO to facilitate tube placement and tracheal biopsy in a 67-year-old female with critical tracheal stenosis. The patient was transferred to our hospital for a surgical treatment after emergent tracheostomy for postoperative management of cerebral hemorrhage in right putamen. Her trachea was severely stenotic and just enough for a 5.5 mm tracheostomy tube. Removal of tracheostomy tube, tracheal wall biopsy and intra-tracheal tube placement were successfully performed under VV-ECMO support, drainage from inferior vena cava returned into the right ventricle (RV). RV perfusion was a very useful and effective method in VV-ECMO system, although some careful wire management was needed under fluoroscopic guidance.

Pregnancy complicated by influenza A ARDS requiring consecutive VV-ECMO treatment with successful vaginal delivery

A 29-year-old woman presented with influenza A ARDS at 23⁺⁰ weeks of gestation. Mechanical ventilation failed and VV-ECMO was started in a non-ECMO hospital. Transportation was performed on ECMO. Within 5 days ECMO weaning was successful. Fetal condition was stable, and decision to continue pregnancy was taken. However, second VV-ECMO was needed due to ventilator-associated pneumonia. At 25⁺⁶ weeks, the patient spontaneously delivered a neonate vaginally. Patient's condition improved, and ECMO could be removed 10 days postpartum. 2-year follow-up showed no severe consequences in the mother and the child.

The use of VV-ECMO in patients with drug dependencies

The purpose of this study is to determine the effect of illicit drug and alcohol dependencies on mortality, length of stay, and complications in patients who have been supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) following respiratory failure not responsive to conventional methods of ventilation. 584 VV-ECMO referrals received at Wythenshawe Hospital were reviewed for evidence of drug dependency. 13 patients were identified as being drug-dependent and having undergone treatment with VV-ECMO. A matched cohort of 13 non-drug-dependent patients was identified using date of birth, pre-ECMO Murray Score, and primary diagnosis. The outcomes were compared. 19 more complications were found amongst the drug-dependent patients compared with the non-drug-dependent cohort (39 vs 20). A mean difference of 1.46 complications per patient was calculated (p = 0.005). Mortality after 180 days was reported in 4 of the drug-dependent patients, compared with one in the matched cohort. Length of stay on ECMO was increased on average by 1.93 days amongst the drug-dependent patients (p = 0.557); however, the sample size was not great enough to achieve statistical significance. Patients with drug dependencies undergoing VV-ECMO have more complications when compared with a cohort of patients with no proven or suspected drug dependencies. Differences in morbidity and mortality were not statistically significant.

Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support

BACKGROUND

Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients.

METHODS

We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS.

RESULTS

The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024).

CONCLUSIONS

In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).