ABSTRACT
INTRODUCTION: COVID-19-associated acute respiratory distress syndrome (ARDS) has necessitated the use of extracorporeal membrane oxygenation (ECMO) to support patients with impaired respiratory function. Reports of increased analgosedation requirements in COVID-19 patients receiving ECMO highlight the possible challenges of weaning analgesia and sedation once these patients are decannulated. METHOD(S): This retrospective cohort analysis investigated analgesia and sedation requirements in COVID-19 and non- COVID-19 patients after venovenous (VV) or venopulmonary artery (VPa) ECMO decannulation. The primary outcome was time to weaning of parental analgosedation. Secondary objectives included incidence of enteral analgosedative use to facilitate weaning of parenteral agents, discharge analgesia and sedative prescribing patterns, and incidence of weaning failure. RESULT(S): A total of 58 patients were included;32 COVID-19 ECMO and 26 non-COVID-19 ECMO patients. There was a higher incidence of prolonged weaning postdecannulation in the COVID-19 group compared to the non- COVID-19 group (59.4% vs. 46.2%, P = 0.43). The median (IQR) time to weaning of all parenteral agents was 8 days (4-13) in the COVID-19 group and 6 days (2-10) in the non- COVID-19 group (P = 0.32). Of all agents, median duration to wean dexmedetomidine was longest in both the COVID-19 and non-COVID-19 groups [9.25 days (3.75-13);4.75 days (2-6.75) (P = 0.15)]. COVID-19 patients had a higher incidence of antipsychotic use to facilitate weaning (88% vs. 65%, P = 0.06) and prescription on discharge (47% vs. 27%, P = 0.17). Approximately 19% of patients in each group experienced failure to wean parenteral analgosedation and required re-initiation of parenteral agents during the postdecannulation period. CONCLUSION(S): Weaning of analgosedation was longer in COVID-19 ECMO patients following decannulation. COVID-19 ECMO patients also required greater addition of enteral therapies to manage analgesia and sedation in the post-decannulation period. Future studies are needed to investigate strategies to optimize sedation in these patients.
ABSTRACT
INTRODUCTION: Infection with COVID-19 can lead to acute respiratory distress syndrome requiring intensive care management and extracorporeal membrane oxygenation (ECMO) support. Infection increases the risk of acute deep vein thromboses and/or pulmonary embolisms. Hypercoagulation is enhanced by inflammation and platelet aggregation on the ECMO circuit, and prolonged durations of ECMO increase the risk of bleeding. Minimal evidence regarding optimal anticoagulation practices in COVID-19 patients requiring ECMO support exists. The aim of this study is to evaluate anticoagulation strategies as well as bleeding and thrombotic outcomes in COVID-19 patients requiring ECMO support. METHODS: This single center retrospective observational cohort study evaluated adult ICU patients diagnosed with COVID-19 requiring ECMO support between April 1, 2020 and July 31, 2020. Patients were anticoagulated with unfractionated heparin and anti-Xa goals based on provider preference. The primary safety outcome was incidence of major bleeding defined by Extracorporeal Life Support Organization criteria or thrombotic events. Mortality was included as a secondary outcome. Logistic regression analysis was used to determine predisposing risk factors for major bleeding events. RESULTS: A total of 18 patients were included in the analysis. All patients were cannulated with a ProtekDuo for veno-venous ECMO and CytoSorb cytokine filters were used in 83% of patients. Most common COVID-19 treatments included convalescent plasma (83%) and tocilizumab (72%). Anti-Xa goals ranged from 0.21-0.35 (22%), 0.3-0.5 (61%), 0.3-0.7 (11%), and 0.5-0.7 (6%). There was a higher percentage of females in the major bleed group compared to the non-bleed group (83% vs 25%, p=0.043), and at least one major bleeding event occurred in 6 patients (33%). No thrombotic events were observed. Platelet count, serum creatinine, anti-Xa levels >0.4, and elevated inflammatory markers did not increase risk of bleeding. Mortality was observed in 3 patients (17%). CONCLUSIONS: Major bleeding occurred in 33% of patients. No predisposing risk factors for increased risk of bleeding were identified. Further evaluation of optimal anticoagulation strategies as well as predisposing risk factors associated with bleeding events in COVID-19 patients requiring ECMO support is needed.