The Interplay of Inflammation and Coagulation in COVID-19 Patients Receiving Extracorporeal Membrane Oxygenation Support.

OBJECTIVE: Bleeding and thrombosis are common complications during Extracorporeal Membrane Oxygenation (ECMO) support for COVID-19 patients. We sought to examine the relationship between inflammatory status, coagulation effects, and observed bleeding and thrombosis in patients receiving venovenous (VV) ECMO for COVID-19 respiratory failure. STUDY DESIGN: Cross-sectional cohort study. SETTINGS: Quaternary care institution. PATIENTS: The study period from April 1, 2020, to January 1, 2021, we included all patients with confirmed COVID-19 who received VV ECMO support. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients were supported with VV ECMO during the study period, and 17 patients (53%) survived to hospital discharge. The ECMO nonsurvivors mean lactate dehydrogenase (LDH) levels were markedly elevated in comparison to survivors (1046 u/L [IQR = 509, 1305] vs 489 u/L [385 658], p = 0.003). Platelet/fibrinogen dysfunction, as reflected by the low Maximum Amplitude (MA) on viscoelastic testing, was worse in nonsurvivors (65.25 mm [60.68, 67.67] vs 74.80 mm [73.10, 78.40], p = 0.01). Time-group interaction for the first seven days of ECMO support, showed significantly lower platelet count in the nonsurvivors (140 k/ul [103, 170] vs 189.5 k/ul [ 146, 315], p < 0.001) and higher D-dimer in (21 µg/mL [13, 21] vs 14 µg/mL [3, 21], p < 0.001) in comparison to the survivors. Finally, we found profound statistically significant correlations between the clinical markers of inflammation and markers of coagulation in the nonsurvivors group. The ECMO nonsurvivors experienced higher rate of bleeding (73.3% vs 35.3%, p = 0.03), digital ischemia (46.7% vs 11.8%, p = 0.02), acute renal failure (60% vs 11.8%, p = 0.01) and bloodstream infection (60% vs 23.5%, p = 0.03). CONCLUSION: The correlation between inflammation and coagulation in the nonsurvivors supported with VV ECMO could indicate dysregulated inflammatory response and worse clinical outcomes.

Association Between Patient Race and Ethnicity and Outcomes With COVID-19: A Retrospective Analysis From a Large Mid-Atlantic Health System.

BACKGROUND: Members of racial and ethnic minority groups have been disproportionately impacted by coronavirus-2019 (COVID-19). The objective of the study is to describe associations between race and ethnicity on clinical outcomes such as need for mechanical ventilation and mortality. METHODS: Retrospective cohort study of patients with severe COVID-19 infection admitted within a large, not-for-profit healthcare system in the mid-Atlantic region between March and July, 2020. Patient demographic data and clinical outcomes were abstracted from the electronic health record. Logistic regressions were performed to estimate associations between race and ethnicity and the clinical outcomes. RESULTS: The study population (N = 2931) was stratified into 1 of 3 subgroups: non-Hispanic White (n = 466), non-Hispanic Black (n = 1611), and Hispanic (n = 654). The average age of White, Black, and Hispanic patients was 69 ± 17.06, 64 ± 15.9, and 50 ± 15.53 years old, respectively (P < .001). Compared to White patients, Black and Hispanic patients were at increased odds of needing mechanical ventilation due to COVID-19 pneumonia (odds ratio [OR] Black = 1.35, 95% confidence interval [CI] = 1.04 to 1.75, P < .05; OR Hispanic = 1.43, 95% CI = 1.06 to 1.93, P < .05). When compared to White patients, Hispanic patients were at decreased odds of death (OR = 0.45, 95% CI = 0.32 to 0.63, P < .001). However, when adjusting for age, there were no statistically significant differences in the odds of death between these groups (adjusted OR [aOR] Black = 1.05, 95% CI = 0.80 to 1.38, P = .71; aOR Hispanic = 1.10, 95% CI = 0.76 to 1.60, P = .62). CONCLUSION: Our analysis demonstrated that Hispanic patients were more likely require mechanical ventilation but had lower mortality when compared to White patients, with lower average age likely mediating this association. These findings emphasize the importance of outreach efforts to communities of color to increase prevention measures and vaccination uptake to reduce infection with COVID-19.

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.

Assessing the need for transfer to the intensive care unit for Coronavirus-19 disease: Epidemiology and risk factors.

BACKGROUND: Although many patients with coronavirus disease 2019 (Covid-19) require direct admission to the intensive care unit (ICU), some are sent after admission. Clinicians require an understanding of this phenomenon and various risk stratification approaches for recognizing these subjects. METHODS: We examined all Covid-19 patients sent initially to a ward who subsequently required care in the ICU. We examined the timing transfer and attempted to develop a risk score based on baseline variables to predict progressive disease. We evaluated the utility of the CURB-65 score at identifying the need for ICU transfer. RESULTS: The cohort included 245 subjects (mean age 59.0 ± 14.2 years, 61.2% male) and 20% were eventually sent to the ICU. The median time to transfer was 2.5 days. Approximately 1/3rd of patients were not moved until day 4 or later and the main reason for transfer (79.2%) was worsening respiratory failure. A baseline absolute lymphocyte count (ALC) of ≤0.8 103/ml and a serum ferritin ≥1000 ng/ml were independently associated with ICU transfer. Co-morbid illnesses did not correlate with eventual ICU care. Neither a risk score based on a low ALC and/or high ferritin nor the CURB-65 score performed well at predicting need for transfer. CONCLUSION: Covid-19 patients admitted to general wards face a significant risk for deterioration necessitating ICU admission and respiratory failure can occur late in this disease. Neither baseline clinical factors nor the CURB-65 score perform well as screening tests to categorize these subjects as likely to progress to ICU care.

Extracorporeal membrane oxygenation for COVID-19 induced hypoxia: Single-center study.

INTRODUCTION: The pandemic of the coronavirus disease 2019 (COVID-19) and associated pneumonia represent a clinical and scientific challenge. The role of Extracorporeal Membrane Oxygenation (ECMO) in such a crisis remains unclear. METHODS: We examined COVID-19 patients who were supported for acute respiratory failure by both conventional mechanical ventilation (MV) and ECMO at a tertiary care institution in Washington DC. The study period extended from March 23 to April 29. We identified 59 patients who required invasive mechanical ventilation. Of those, 13 patients required ECMO. RESULTS: Nine out of 13 ECMO (69.2%) patients were decannulated from ECMO. All-cause ICU mortality was comparable between both ECMO and MV groups (6 patients [46.15%] vs. 22 patients [47.82 %], p = 0.92). ECMO non-survivors vs survivors had elevated D-dimer (9.740 mcg/ml [4.84-20.00] vs. 3.800 mcg/ml [2.19-9.11], p = 0.05), LDH (1158 ± 344.5 units/L vs. 575.9 ± 124.0 units/L, p = 0.001), and troponin (0.4315 ± 0.465 ng/ml vs. 0.034 ± 0.043 ng/ml, p = 0.04). Time on MV as expected was significantly longer in ECMO groups (563.3 hours [422.1-613.9] vs. 247.9 hours [101.8-479] in MV group, p = 0.0009) as well as ICU length of stay 576.2 hours [457.5-652.8] in ECMO group vs. 322.2 hours [120.6-569.3] in MV group, p = 0.012). CONCLUSION: ECMO is a supportive intervention for COVID-19 associated pneumonia that could be considered if the optimum mechanical ventilation is deemed ineffective. Biomarkers such as D-dimer, LDH, and troponin could help with discerning the clinical prognosis in patients with COVID-19 pneumonia.