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INTRODUCTION: Patients supported on extracorporeal membrane oxygenation (ECMO) due to COVID-19 are at an increased risk of both thromboembolic complications and thrombocytopenia. Bivalirudin, a direct thrombin inhibitor, is increasingly being utilized for anticoagulation in the ECMO patient though there is largely a lack of literature within the COVID-19 population. The objective of our study was to evaluate the safety and efficacy of alternative anticoagulation with bivalirudin in patients on ECMO with COVID-19 respiratory failure. METHOD(S): This was a non-interventional retrospective chart review conducted at a single center large community hospital between January 2020 - November 2021. We included both venovenous (VV) and venoarterial (VA) adult ECMO patients anticoagulated with bivalirudin that tested positive for COVID-19. Patients were excluded if their duration of ECMO cannulation was less than 48 hours. Descriptive statistical analyses were performed utilizing median with interquartile range and frequency with percent as appropriate. RESULT(S): Overall, 180 ECMO patients were included in the study. The duration of ECMO cannulation was 29 (9-54) days and our cohort experienced a 42% mortality rate. The rate of thrombotic events including in-circuit thrombosis, arterial and venous thrombotic events was 22%. The median initial platelet count on ECMO was 206 (157-274) and the median nadir was 85 (48-121). ELSO defined major bleeding occurred at a rate of 53% within this cohort. CONCLUSION(S): To our knowledge, this study describes the largest number of patients anticoagulated with bivalirudin for ECMO secondary to COVID-19. Our results suggest similar rates of thrombotic events compared to ELSO registry data. While the half-life of bivalirudin is short, clinicians should still be cautious of bleeding due to lack of a specific reversal agent. Retrospective studies with a comparator cohort, as well as randomized trials are warranted to further evaluate the selection of intravenous anticoagulants in the ECMO population with and without COVID-19.
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INTRODUCTION: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used successfully to treat COVID-19 patients in severe respiratory failure. The objective of our multi-center study is to evaluate mortality, time of ECMO initiation, and demographics in COVID-19 patients treated with VV-ECMO. METHOD(S): Electronic medical records from March 2020 to October 2021 were studied in 49 sites across the United States. Patients treated with ECMO who tested positive for COVID-19 were included in this retrospective data analysis (N=363, age interquartile range: 37-55 years). Odds of inhospital mortality were compared using logistic regression models. At thresholds 1-7 days, patients classified as 'early ECMO' were matched to 'delayed ECMO' patients using coarsened exact matching, resulting in 7 independent analyses for early/delayed ECMO cannulation relative to the number of days of pre-ECMO mechanical ventilation (MV). RESULT(S): There were no significant differences in mortality in patients who received early or delayed ECMO. There were also no significant differences in mortality between races, body mass index (BMI), smoking status, hypertension, chronic kidney disease, coronary artery disease, steroid use, or diabetes pre-cannulation. Lastly, pre-cannulation factors associated with mortality in COVID-19 patients treated with ECMO include the use of vasopressors, which was associated with an 87% increase in mortality (p=0.017, confidence interval [CI] 1.12, 3.15);proning, which was associated with a 85% increase in mortality (p=0.015, CI 1.13, 3.06);and the use of baricitinib, which was associated with a four-fold increase in mortality (p=0.041, CI 1.11, 17.6). CONCLUSION(S): We found no evidence that particular demographic characteristics (including race, BMI, or smoking status) contribute to mortality, nor did we find evidence that the length of time on MV prior to ECMO influences mortality. The analysis of large datasets in the ECMO population may better inform clinical decision making.
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SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Extracorporeal membrane oxygenation (ECMO), typically veno-venous, is used to treat COVID19 patients with severe acute respiratory distress syndrome (ARDS) and is associated with decreased mortality in some reports. This study sought to determine the effect of ECMO versus conventional invasive mechanical ventilation (IMV) on hospital mortality for ARDS due to COVID19, and to compare functional status at discharge. METHODS: This was a retrospective, multicenter cohort study of adult patients admitted for COVID19 within a large US hospital network between March 1, 2020 and October 31, 2021. Patients were included if they required IMV with a fraction of inspired oxygen (FiO2) of at least 80% or VV ECMO. Patients were excluded if they were not independent, had a history of severe neurologic impairment, chronic obstructive pulmonary disease, chronic systolic heart failure, end stage renal disease, cirrhosis, metastatic malignancy, or a length of stay <24 hours. ECMO criteria and management were at the discretion of the treating center. Conventional IMV patients were assigned a randomized pseudo-baseline, and coarsened exact matching was used to match ECMO to conventional IMV patients based on age, sex, body mass index, pre-baseline severity of hypoxemia, prone positioning, receipt of corticosteroids, Tocilizumab, Baricitinib, acute renal replacement therapy, and vasopressors. Differences in hospital mortality and discharge destination were assessed through weighted logistic regression and weighted multinomial logit regression, respectively. RESULTS: We identified 207,965 patients across 168 hospitals for review, and 10,571 patients met study criteria. After matching, 275 ECMO patients and 5,808 conventional IMV patients were available for comparison. ECMO was associated with a significant mortality reduction, 36% versus 61% (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.34-0.57). Compared to conventional IMV survivors, ECMO survivors were significantly more likely to be discharged to acute rehabilitation than long term acute care (relative risk ratio (RRR) 2.23, 95% CI 1.16-4.32). ECMO survivors were also significantly more likely to be discharged to another acute care hospital for further management (RRR 3.21, 95% CI 1.75-5.92). CONCLUSIONS: This study demonstrates that ECMO support is significantly associated with reduced mortality in patients with severe ARDS due to COVID19 compared to conventional invasive mechanical ventilation. Further studies are needed to aid in prognostication, patient selection, and timing of intervention to maximize the benefit of this limited resource. CLINICAL IMPLICATIONS: These findings illustrate the importance of timely referral to an ECMO center for severely ill COVID19 patients, and may influence ECMO-capable centers to expand the use of ECMO in appropriate patients for this indication. DISCLOSURES: No relevant relationships by Elliott Cohen No relevant relationships by Katherine Cyr No relevant relationships by Jeffrey DellaVolpe No relevant relationships by Jamie Jarzembowski No relevant relationships by Chandra Kunavarapu no disclosure on file for Thomas Mcrae;Employee relationship with HCA Healthcare Please note: 6/1/2017 to current Added 04/04/2022 by Daniel Schlauch, value=Salary No relevant relationships by Owen Stell No relevant relationships by sage whitmore
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Background: The Seraph® 100 Microbind ® Affinity Blood Filter (Seraph ®100) is an extracorporeal broad-spectrum sorbent hemoperfusion filter that removes pathogens and cytokines from the blood and has Emergency Use Authorization (EUA) for the treatment of severe COVID-19. Seraph® 100 can be adapted and primed to a NxStage continuous renal replacement therapy (CRRT) machine and connected to the patient's ECMO circuit. This form of hemofiltration provided a safe and effective approach to decreasing pathogen response within the blood and was tested in our center. Case Review: A 42-year-old male with a past medical history of obesity, hypertension and hypothyroidism was admitted for acute hypoxemic respiratory failure secondary to COVID-19. His 65 day ECMO course was complicated by encephalopathy, right heart dysfunction, severe epistaxis, esophageal ulcers and enterococcus faecalis bacteremia. On ECMO day 16, the patient became febrile, C-reactive protein increased to 215 mg/L and he became hypotensive. In addition to appropriate antibiotics, the multidisciplinary team decided to initiate Seraph® 100 for the E.faecalis bacteremia. The filter was adapted and primed into the NxStage machine by the nurse caring for the patient. The NxStage lines were then connected to the ECMO circuit via pigtail connections. The blood was cycled from the post-oxygenator pigtail to the NxStage and returned to the pre-oxygenator pigtail on the ECMO circuit. The target time for continuous Seraph® 100 therapy is between 24-48 hours. Cultures were collected from the NxStage line pre-filter and again, six hours later, from a port post-filter. The pre-filter cultures came back positive for E.faecalis and the post-filter cultures were negative. Additional blood cultures collected the following day remained negative. The patient's condition improved rapidly and allowed him to begin physical therapy and reduce ventilator support over the next 48 days on ECMO. He was discharged from the hospital to rehab for two weeks before going home. Discussion: Introduction of hemofiltration by Exthera provided an additional therapy that has proven to be effective in the reduction of sepsis causing pathogens when used in conjunction with conventional care for patients with COVID-19 suffering from bacteremia. In this case, incorporating hemofiltration via the ECMO circuit showed no increase in undue risk to the patient with an efficacy in decreasing bacteremia, contributing to the survival of the patient.