ABSTRACT
INTRODUCTION: Similar to use during the H1N1 pandemic as a means of improved survival in patients with severe acute respiratory distress syndrome (ARDS), there may be a role for extracorporeal membrane oxygenation (ECMO) in patients with severe ARDS secondary to the novel coronavirus (SARS-CoV2 causing COVID). Limited data, however, exists for the use of ECMO in this population. The purpose of this study was to evaluate outcomes between COVID and non- COVID patients receiving venovenous (VV) ECMO. METHODS: This was a retrospective review of 15 COVID and 15 non-COVID patients receiving VV ECMO at Rush University Medical Center. Patients were excluded if they were receiving ECMO at the time of data analysis. The primary outcome was days requiring mechanical ventilation (MV) and ECMO. Secondary outcomes included: discharge disposition, hospital length of stay (LOS) and survival. Data collected included: demographics, co-morbidities, ECMO characteristics, MV and ECMO days, hospital LOS, discharge disposition, and survival. RESULTS: In our cohort, the median age was 45.0 [36.0-51.0] versus 47.0 [36.0-52.0] in the COVID versus non-COVID groups, respectively. Similarly, BMI and comorbidities were not different between groups. A majority of patients in the COVID group were Hispanic (46.7%) versus the non-COVID group (33.3%). Inhaled epoprostenol was delivered prior to ECMO in 73.3% of COVID patients versus 20.0% of non-COVID patients. A 31 French Protek was placed in all COVID ECMO patients versus 46.7% of non-COVID ECMO patients. Days receiving MV were 12.0 [6.0-24.0] and 18.0 [12.0-35.0] and receiving ECMO were 30.0 [23.0-50.0] versus 27.0 days [19.0-56.0] in the COVID and non-COVID groups, respectively. Hospital LOS was 37.0 [29.5-52.5] in the COVID group versus 46.0 [29.0-60.0] days in the non-COVID group. Of note, two patients in the COVID group were hospitalized at the time of data analysis. Survival was 93.3% in both ECMO groups and a majority of patients were discharged to a rehabilitation facility (53.3%). CONCLUSIONS: These data suggest that ECMO may be a useful means of supporting patients with refractory hypoxic respiratory failure secondary to COVID. Future studies are needed to thoroughly evaluate the role of ECMO in this patient population.
ABSTRACT
Background: Severe coronavirus disease 2019 (COVID-19) not only causes acute pulmonary pathology leading to acute respiratory distress syndrome needing intubation, but also leads to acute kidney injury (AKI) requiring renal replacement therapy (RRT). Due to hemodynamic instability, these patients (pts) often need either continuous RRT (CRRT) or prolonged intermittent RRT (PIRRT). Accelerated Veno-Venous Hemodialysis (AVVHD), a form of PIRRT with typically 40-50 liter of dialysate used over 8-10 hours has been successfully used to treat hemodynamically unstable pts. In the past, we have published extracorporeal circuit clotting (ECC) to be low (5%) even without anticoagulation. However as hypercoagulability is extreme with COVID-19, we noticed a marked increase in ECC. Unfractionated heparin (UFH) was the initial anticoagulation of choice during the early phase of the pandemic but was ineffective in preventing ECC, prompting a trial of low molecular weight heparin (LMWH). Methods: We conducted a single-center retrospective study to evaluate the efficacy and safety of LMWH vs UFH in preventing ECC in pts with AKI due to COVID-19 who received AVVHD from 3/25/20 through 4/30/20 at a large academic medical center. Data collected included pt demographics, type of anticoagulation and thrombolytic use, treatment characteristics including clotting frequency as well as bleeding complications. ECC was defined as any event that required an unexpected interruption in treatment or the use of thrombolytics. Results: A total of 58 pts received 408 AVVHD treatments. The average pt age was 58 years, 65% were male, 66% were black and 69% were obese with body mass index >;30 kg/m2. 188/408 (46%) of AVVHD treatments received anticoagulation with UFH while 165/408 (40%) of treatments received LMWH. ECC occurred in 30% of AVVHD treatments who received UFH vs 15% in the LMWH group, a relative risk reduction of 50% (P = 0.001). 47.1% pts who were on UFH had ECC on the first RRT treatment compared to 13.6% on LMWH (P = 0.01). Only 1 pt experienced a major bleeding event in the UFH group and none with LMWH. Conclusions: Anticoagulation with LMWH is superior to UFH in reducing ECC in pts receiving AVVHD for AKI due to COVID-19 without an increased risk of bleeding.