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Background: Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Method(s): Patients with severe COVID-19 and who were >=70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Result(s): The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77+/-5 versus 76+/-5, p<0.001) and more frail (Clinical Frailty Scale 4+/-2 versus 3+/-2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3-8) versus 7 days (4-10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1-5) versus 2 (1-5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7+/-3 versus 5+/-3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017;and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72-336) hours versus 260 hours (120-528), p<0.001). CHF patients had significantly higher ICU-(52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001;OR 1.87, 95% CI 1.5- 2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5-2.3;p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5-1.5;p=0.137). Conclusion(s): In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short-and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders.
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Background: Since March 2020, COVID-19 pandemic has tremendously challenged the global health care system. In patients with severe therapy-refractory acute respiratory distress syndrome (ARDS), veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains the ultimo ratio therapy;however, the outcome is still not satisfying. Prolonged mechanically ventilation of ARDS patients, especially with high driving pressure, may further damage the lung and contributes to impaired outcome. Method(s): Between 2020 and 2022, a total of 82 patients were treated with vv-ECMO for severe COVID-19-related ARDS in our department. The patients were prospectively enrolled into an institutional database and subsequent retrospectively reviewed. Patients were divided Patients were divided in regard to the duration of pre-ECMO mechanically ventilation (Group 1 [<=2 days]: n = 40;Group 2 [>2 days]: n = 36). The remaining n = 6 patients were excluded due to awake ECMO implantation. Result(s): Except gender (Group 1: 22.5% female, Group 2: 58.3% female, p < 0.01), baseline characteristics such as demographic data and concomitant diseases were comparable between the two groups. The mean duration between the onset of the first COVID-19 related symptoms and ECMO implantation was 14 +/- 7 days and between intubation and ECMO implantation 0.8 +/- 0.8 days for Group 1 compared with 18 +/- 7 days (p = 0.04), respectively, 7.6 +/- 4.3 days (p < 0.001) for Group 2. We did not observed differences regarding the incidence of severe ECMO-related adverse events in regard to the pre-ECMO mechanical ventilation time. However, successful ECMO weaning rate was numerically increased in Group 1 (42.5%) compared with Group 2 (25.0%, p = 0.15) with shorter support time until weaning (Group 1: 16 +/- 13 days, Group 2: 44 +/- 44 days, p = 0.08). A similar trend was also found for in-hospital death (Group 1: 60.0%, Group 2: 77.8%, p = 0.08). Conclusion(s): Early ECMO implantation after orotracheal intubation for severe COVID-19-related ARDS did not affect the peri-interventional morbidity. However, we observed a numerically increased weaning rate as well as increased survival in patients with early ECMO implantation after intubation. As lung-protective ventilation can be achieved by early ECMO implantation in COVID-19 patients, it potentially decreases the ventilator-associated lung damage.
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Background: Since late 2019, infections with novel coronavirus SARS-CoV-2 have caused a global pandemic. By now, limited adequate pharmacological therapy exists for severe COVID-19 related acute respiratory distress syndrome (ARDS). Therefore, treatment with veno-venous extracorporeal membrane oxygenation (vv-ECMO) still is considered as an ultimate rescue option. However, especially in obese patients, implantation of vv-EMCO cannulas is challenging and results in these patients are often considered as inferior to normal weight control patients. Method(s): Between 2020 and 2022, a total of 82 patients were treated with vv-ECMO for severe COVID-19-related ARDS in our department. All patients were prospectively enrolled into an institutional database and retrospectively reviewed for the purpose of this study. Patients were divided concerning their body mass index (BMI) (BMI <= 30.0 kg/m2 : control, n = 41;BMI > 30.0 kg/m2 : obesity, n = 41). Result(s): Mean BMI of the control group was 27.0 +/- 2.1 kg/m2 compared with 33.5 +/- 5.3 kg/m2 in obesity group (p < 0.01). Minimum BMI of the whole cohort was 23.0 kg/m2 and maximum BMI 50.0 kg/m2. There were no relevant differences regarding age, gender and the incidence of concomitant diseases, except for diabetes (control: 17.1%, obesity: 41.5%, p = 0.03) and renal insufficiency (control: 22.0%, obesity: 4.9%, p = 0.05) between the two study groups. Peri-interventional incidence of severe device-related adverse events such as bleeding (control: 17.1%, obesity: 25.0%, p = 0.42), ischemic stroke (control: 9.8%, obesity: 10.0%, p > 0.99), intracranial bleeding (control: 22.0%, obesity: 27.5%, p = 0.61), and visceral ischemia (control: 4.9%, obesity: 12.2%, p = 0.43) did not differ with regard to the BMI. Weaning from vv-ECMO was achieved in 39.0% of the obese patients and in 34.0% of the controls (p = 0.82). In-hospital death was observed for 75.6% of the control patients compared with 61.0% for the obesity group (p = 0.24). Conclusion(s): vv-ECMO as ultimate rescue therapy for serve COVID-19-related ARDS is also feasible in obese patients. Although implantation of the cannulas may be more difficult in obese patients, the results regarding weaning rate and survival are encouraging and not inferior to non-obese patients. However, an increased rate of kidney injury in the control group during vv-ECMO support may represent a relevant confounder, which should be investigated in larger study cohorts.
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Background: With progression of the COVID-19 pandemic the veno-venous ECMO therapy as an ultima ratio is gaining a new value by the increasing number of patients with therapy refractive ARDS. This study aims to observe the prognoses and the long-term complications following ECMO to improve therapy options and patient satisfaction. Method(s): In the period between March 2020 and February 2022, a total of 98 patients were treated with vv-ECMO in case of a COVID-19-related ARDS in our center. Demographic and health-specific parameters of all patients were recorded in a database. In addition, the patients were followed up via a telephonic consultation 6 months after discharge from the hospital. Data were retrospectively analyzed. Result(s): Of all treated patients, 29 survived the hospital stay. After a period of 6 months following discharge, 28 (97%) of these patients were still alive. The results showed that almost all of them (n = 27) still did not completely recover by the time of follow-up. Eighteen (64%) of the patients were still suffering from persistent dyspnea and 13 (46%) were still under ongoing respiratory rehabilitation. However, none of the patients was still in stationary hospital treatment or under mechanical ventilation therapy, but 6 (21%) patients still required O2 therapy at their home and 12 (43%) still suffered from cognitive problems. Because of the mentioned long-term effects, among other things, at that point only 6 patients were possible to return to their working life. With regard to patients' gender, we found persistent dyspnea in 83% of female and only in 50% of male patients. Cognitive problems were obvious in 58% of the women and in 31% of men. Conclusion(s): The majority of patients surviving ECMO therapy based on a COVID-19 infection suffered from long-term limitations. In our follow-up, female patients showed a higher incidence of long-term consequences than male patients. Since we are still in an early stage of research about the virus, it remains important to determine short-term as well as long-term effects of therapy options to optimize the outcome.
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Purpose Since the beginning of the current pandemic in late 2019, three accumulations of severe COVID-19 infections (so-called infective waves) caused a fulminant increase in hospitalization. In therapy-refractory patients, veno-venous extracorporeal membrane oxygenation (vv-ECMO) was used since the early beginning. However, potential developments in vv-EMCO therapy still need to be proven. Methods Between 2020 and 2021 a total of n=60 patients were treated with vv-ECMO for severe COVID-19 related acute respiratory distress syndrome in our department. The patients were prospectively enrolled into an institutional database, followed-up and subsequent retrospectively reviewed. Patients were divided concerning the date of vv-ECMO onset into three groups (03/2020-09/2020: 1. wave, n=11;10/2020-02/2021: 2. wave, n=23;03/2021-08/2021: 3. wave, n=26). Results From the first to the third wave, patients seemed to be younger, more likely to be female as well as more likely obese. While patients of the first wave regularly developed acute kidney failure (81.3 %), these adverse event was seldom in the second (21.7) and third wave (15.4 5)(p=0.01). In contrast to that, other device-related complications such as stroke, bleeding or visceral ischemia did not differ between the three waves. Most apparent changes during the pandemic were prolonged ECMO support duration (1. wave: 8.5 ± 2.1, 2. wave: 54.0 ± 122.7, 3. wave: 28.0 ± 18.6), ECMO weaning rate (1. wave: 18.2 %, 2. wave: 39.1, 3. wave: 44.0 %) and in-hospital mortality (1. wave: 81.8 %, 2. wave: 69.6, 3. wave: 56.0 %), although none of these effects reached statistical significance. Conclusion Although our data cover only a small study population, we observed clear trends towards younger and heavier patients during the pandemic. Most likely, due to a learning effect, support duration of ECMO patients distinctly increased during the pandemic. Subsequently, weaning and survival also increased. However, differences in patient selection could act as a major confounder for these results.
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Background:Since late 2019, three accumulations of severe COVID-19 infections (the so-called infective waves) led to a fulminant increase in hospitalized patients,Therapy with veno-venous extracorporeal membrane oxygenation (vv-ECMO) was used since the early beginning of the pandemic in therapy-refractory cases,However, potential developments in vv-EMCO therapy still need to be proven,Method:Between 2020 and 2021 a total of 60 patients were treated with vv-ECMO for severe COVID-19-related acute respiratory distress syndrome in our department,The patients were prospectively enrolled into a database and subsequent retrospectively reviewed,Patients were divided concerning the date of vv-ECMO onset into three groups (03/2020-09/2020: 1,wave,n=11;10/2020-02/2021: 2,wave,n=23;03/2021-08/2021: 3,wave,n=26),Results:Table 1shows the detailed pre-A nd peri-interventional data of the three study groups,From the first to the third wave, patients seemed to be younger, more likely to be female as well as more likely obese,While patients of the first wave regularly developed acute kidney failure, these adverse event was seldom in the second and third wave (p=0.01),In contrast to that, other device-related complications such as stroke, bleeding or visceral ischemia did not differ between the three waves,Most apparent changes during the pandemic were prolonged ECMO support duration (1,wave: 8.5±2.1, 2,wave: 54.0±122.7, 3,wave: 28.0±18.6), ECMO weaning rate (1,wave: 18.2%, 2,wave: 39.1, 3,wave: 44.0%) and in-hospital mortality (1,wave: 81.8%, 2,wave: 69.6, 3,wave: 56.0%), although none of these effects reached statistical significance,Conclusion:Although our data cover only a small study population, we observed clear trends toward younger and heavier patients during the pandemic,Most likely, due to a learning effect, support duration of ECMO patients distinctly increased during the pandemic,Subsequently, weaning and survival also increased.
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The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a “should be considered” recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.