ABSTRACT
INTRODUCTION: We describe our outcomes in patients with Acute Respiratory Failure (ARF) prior to and during the Coronavirus-19 (COVID-19) pandemic with regards to salvage therapies for ARF METHODS: In our single center retrospective matched cohort study, we collected demographic variables, comorbid conditions, laboratory data, variables on the ventilator, vasopressor use, use of prone ventilation, neuromuscular blockade, and inhaled pulmonary vasodilators. Data was collected from electronic health records for all patients for whom a consultation for Extra Corporeal Membranous Oxygenation (ECMO) for ARF was sought from January 2018 to April 2022. RESULT(S): Two hundred and fifty-three patients (253) received consultation for ECMO for ARF. Of those 189 patients were non COVID-19 related ARF and 141 met the criteria for acute respiratory distress syndrome (ARDS), 64 patients had ARF due to COVID-19, of which 63 patients met criteria for ARDS. Consultation for ECMO was obtained after 3.94 +/- 4.75 days of ARDS and 3.86 +/- 4.91 of Mechanical Ventilation (MV) vs 4.92 +/- 4.67 days of ARDS and 6.11 +/- 4.82 of MV in patients with non-COVID ARF and COVID-19 ARF respectively (p < 0.0001). Patients with non-COVID-19 ARF tended to have higher lactate, more vasopressor needs and were on higher tidal volumes. Prone positioning (67% vs 14.8%;p=0.0001), corticosteroid use (85.9% vs 50.2%, p=0.001) and neuromuscular blockade (87.5% vs 61.3%;p= 0.001) were used more in the COVID-19 ARF group when compared to non-COVID ARF group. There were no statistically significant differences between the two groups in their PRESERVE score, RESP score, Oxygenation Index (OI) or the percentage of patients deemed candidates and initiated on VV-ECMO. In the non- COVID-19 ARF group 30% patients were extubated versus 3.1% patients (p=0.001) in the COVID-19 ARF group, and 32 % patients received tracheostomy versus 47% patients received tracheostomy (p=0.04) in the COVID-19 ARF group. CONCLUSION(S): Patients with ARF and ARDS received ECMO consultation later in the disease course and the use of salvage therapies was more pronounced during the COVID-19 pandemic. There was no difference in risk prognostication scores or use of ECMO in either group. Protocolized ARDS management can help avoid ECMO, subsequent complications and limit resource utilization.
ABSTRACT
INTRODUCTION/HYPOTHESIS: By identifying patients most likely to survive with ventilator support, health systems could improve survival rates among those afflicted and increase ventilator availability for subsequent patients during resource poor pandemic situations. The goal of this study was to prospectively evaluate the utility and discerning power of two different ventilator triage models (Whit & Lo and New York guidelines). METHODS: Prospective observational study of consecutive patients (N=1076) admitted to the Medical Intensive Care Unit during the COVID-19 pandemic from May to August 2020. New York State triage criteria and those proposed by White and Lo were applied. Characteristics and outcomes of those meeting initial criteria for the lowest level of priority for mechanical ventilation (using both criteria) were assessed. Agreement was compared between the 2 sets of triage criteria RESULTS: Among 1076 patients who received mechanical ventilation, the mean (SD) age was 60.5 (15.6) years, 618 (57.4%) were males, 659 (61.5%) were Caucasian, the mean BMI (SD) 30.4 (10.0), 135 (12.5%) had COVID and their SOFA score on admission day was 6.4 (3.0). Comparing the White and Lo triage criteria vs New York guidelines, 159 patients (14.7%) were in the lowest priority category vs 76 patients (7.06%);the mean (SD) age of 63.5 (15.2) years vs 56.2 (15.0) years, 88 (55.3%) vs 42 (55.3%) were males, 104 (65.4%) vs 52 (68.4%) were Caucasian, the mean BMI (SD) 28.8 (7.3) vs30.9 (8.5), 17 (10.7%) vs 4 (5.3%) had COVID, the mean (SD) SOFA score on admission day was 10.2 (2.9) vs 12.9 (1.4), 103 (64.8%) vs 63 (82.9%) patient received MV, the mean (SD) day on MV was 3.7 (5.6) vs 5.5 (6.8), 85 (53.5%) vs 37 (48.7%) survived. Only 63 admissions (5%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.40 (95% CI, 0.36-0.45). CONCLUSIONS: Five percent of admissions were identified as having the lowest priority for ventilator allocation using proposed guidelines with moderate agreement. Approximately a third of these patients (low probability) in both triage criteria survived to discharge. Valid and equitable allocation of limited critical resources should be based on sound scrutiny of proposed triage criteria.