The Feasibility of Ecmo before Mechanical Ventilation for Severe Respiratory Failure Due to Covid-19

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is typically used to support severe ARDS after the failure of invasive mechanical ventilation (IMV). IMV may cause harm in patients with preexisting barotrauma, shock, or immune compromise. METHOD(S): Single center case-control study of VV-ECMO before IMV (awake ECMO;n=24) compared to conventional ECMO (n=76) after IMV in COVID-19 patients. Groups were compared at baseline before cannulation (awake ECMO) or intubation (conventional ECMO). Propensity matching was performed based on body mass index and injury severity (Simplified Acute Physiology Score II [SAPS II], PaO2:FiO2 ratio). The primary outcome was survival to discharge. Secondary measures of duration of IMV and adverse events were examined. Multivariable adjustments were performed. RESULT(S): Awake ECMO compared to conventional ECMO patients at baseline were more tachypneic (mean +/- standard deviation: 36.3 +/- 9.6 vs 27.4 +/- 7.3;p< 0.0001) with lower SpO2 (median [interquartile range]: 87% [81-92.5] vs 93% [87-96];p=0.01) but similar SAPS II. Fifteen (68%) of awake ECMO patients eventually required IMV. Survival to discharge in awake ECMO trended towards improvement compared to conventional ECMO (70.8% vs. 52.6%;p=0.12). After propensity matching, awake ECMO was associated with increased survival (adjusted odds ratio 6.84 [95% confidence interval 1.08 - 43.38]). Awake ECMO was associated with less duration of IMV before and after propensity matching. Adverse events were similar between groups. CONCLUSION(S): Awake ECMO before IMV is associated with acceptable survival, similar adverse events, and shorter duration of IMV compared to conventional ECMO. This strategy may be preferable in carefully selected patients.

Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists

Objective: In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults. Design(s): Narrative review/perspective. Setting(s): Not applicable. Patient(s): Not applicable. Intervention(s): None. Measurements and Main Results: The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU. Conclusion(s): This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise. Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.