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Objective: Outline the impact of COVID 19 and use of ECMO at INOVA Fairfax Medical Center, a full service, 1000 bed facility. Methods: Review of the EMR and use of descriptive statistics. Results: Between March 2020-February 13, 2021, 3220 COVID admissions occurred, of which 23% required ICU care and 10% mechanical ventilation (MV). Average hospital stay was 8 days and ICU 13 days. 51% of ICU patients (pts) received MV and 13% of vented pts (7% of ICU admissions) received ECMO. Data on 48 ECMO pts in 2020 is presented. Eligibility for ECMO included: Age < 60 yrs, failed lung protective ventilation (TV< 6cc/kg, Pplat < 30 cm H2O) or acidosis (pH< 7.20, pCO2>65), trial of neuromuscular blockade and prone positioning, p/f< 100 torr. Up to 12 ECMO patients supported simultaneously (prior ECMO census cap of 4-7).Age range 15-68yrs. By quarters of 2020 ECMO: Q1, 7 pts, duration 6-27 days, 100% survival;Q2, 30 patients, duration 3-95 days, 60% survival. 95 d pt decannulated but expired later;Q3 6 pts, duration 5-66 d, 50% survival, no survivor past 26 d;Q4 9 pts, 67% surv, duration 2-27d, survivor at 27d. Overall ECMO survival (n=48): 67% to discharge. Conclusions: 1. Initially, elective admissions were cancelled to allow care for over 200-300 COVID pts per day. Critical illness required expansion of ECMO services outside the usual site (CVICU), requiring emergent training of nursing and medical staff by core ECMO physicians and ECMO specialist staff. 2. Prone positioning helpful (before or during ECMO);3. higher levels of anticoagulation (heparin or bivalirudin) required due to acute/persistent thrombus;4. Bronchoscopy/tracheostomy performed without complications;5. Resumption of elective and non- COVID critically ill admissions in Q3 and Q4 resulted in inability to accept ECMO referrals in the second wave of pandemic, highlighting need for more experienced ECMO beds.
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Objective: To compare usage and outcomes of COVID and non-COVID venovenous ECMO patients. Methods: Database review and descriptive statistics Results: In 2019, a total of 29 patients received VV ECMO for respiratory failure not related to COVID 19. Age ranged from 6 months to 70 years. Overall survival was 62%. In 2020, 48 patients received VV ECMO for COVID respiratory failure, with overall survival of 67%. Despite the sudden increase in VV ECMO volume for an entity with no prior ECMO experience at our site, survival was similar to other ECMO patients. Conclusions: Experienced ECMO centers may achieve good survival with ECMO support of new patient diseases, even during stressful pandemic situations. Lessons learned during ECMO care of new illnesses such as COVID in large centers may provide data to improve care in smaller and less experienced sites. Collaborations such as the international COVID Consortium/ECMO Card group can assist with data sharing and development of best practice between a wide range of centers.
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Objective: The successful use of ECMO in adult patients with severe respiratory failure from COVID-19 has been reported, but there is little data in children or adolescents except those with cardiac manifestations. Thus, the utility of ECMO in pediatric patients with severe respiratory failure is not well established. Describe the clinical course and outcome of three pediatric patients with COVID-19 who progressed to Acute Respiratory Distress Syndrome (ARDS) requiring ECMO. Methods: Data related to demographics, clinical course, ECMO course and outcome from three consecutive pediatric patients who received venovenous (VV) ECMO due to COVID-19-associated respiratory failure were analyzed from electronic health records. IRB approval was given. Results: We describe three patients (see Figure 1) aged 14 to 16 who all had acute COVID-19 leading to the acute respiratory distress syndrome - one patient whose father died from COVID following ECMO and two brothers. The patients presented between days 4 and 10 of symptoms and rapidly required escalation of care including intubation, nitric oxide and VV ECMO. All three patients were treated with methylprednisolone, though with differing regimens;two received remdesivir through a clinical trial;and two required tracheostomy placement for respiratory support, with one having the tracheostomy tube removed prior to discharge. ECMO was continued for 9 to 24 days, with no episodes of recannulation, major bleeding events or other complications from the ECMO therapy. All three patients were eventually discharged;two were discharged home and one transferred to acute rehabilitation. Conclusions: These cases show the safe and effective use of VV ECMO in COVID-19-associated ARDS. Pediatric critical care physicians should be aware of the ability to use VV ECMO for pulmonary support in patients with COVID-19 illness and should consider early transfer to ECMO capable units to improve survival from ARDS related mortality.
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INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a high rate of thrombotic complications related to an acute inflammatory state. D-dimer has been established as a marker of disease severity in COVID-19. Despite a paucity of data, D-dimer concentration has been used by institutions to identify candidates for intensified anticoagulant treatment for prevention and mitigation of the thrombotic complications associated with COVID-19. Thromboelastography (TEG) maximum amplitude (MA) has been validated as a marker of hypercoagulability with previous research defining hypercoagulability by a TEG MA ≥ 68 mm. We examined the relationship between common clinical laboratory parameters and hypercoagulability as represented by TEG MA. METHODS: We performed a single center retrospective analysis of consecutive patients who received ECMO for the treatment of COVID-19 with simultaneous TEG, coagulation, and inflammatory markers (D-dimer, fibrinogen, ferritin, and C-reactive protein) drawn during hospitalization. TEG MA values and inflammatory markers were compared in patients with and without a thrombotic complication during admission. Correlation tests were performed to identify the coagulation and inflammatory markers that may predict hypercoagulability as defined by elevated TEG MA. RESULTS: 168 TEGs were available in 24 patients. C-reactive protein and fibrinogen were significantly higher in patients that developed a thrombotic event versus those that did not (p=0.038 and p=0.043 respectively). There was no difference in D-dimer between groups (p=0.312). D-dimer was negatively correlated with TEG MA (p<0.001) and explained little of the variance in this variable (adjusted R2=0.162). Fibrinogen was significantly positively correlated (p<0.001) with MA and explained over 50% of the variance. A fibrinogen > 441 mg/dL had high diagnostic accuracy (sensitivity of 91.2%, specificity of 85.7%) for the detection of MA ≥ 68 mm. CONCLUSIONS: In critically ill patients with COVID-19, D-dimer had an inverse relationship with hypercoagulability as measured by TEG MA. D-dimer elevation may reflect severity of COVID-19 related sepsis rather than designate patients likely to benefit from anticoagulation. Fibrinogen concentration may represent a more useful marker of hypercoagulability in this population.
ABSTRACT
Background: D dimer is suggested as a marker of hypercoagulability in COVID patients and identify those for anticoagulation therapy. Methods: A single center analysis of 24 consecutive COVID ECMO patients who had simultaneous coagulation, inflammatory markers, and TEG 5000™ drawn.Values were compared in patients with and without a thrombotic complication during admission. Results: Pt characteristics: All Subjects Macrothrombosis No thrombosis P Value n=24 n=12 n=12 MA (mm) 72.8 (71.2,78.4) 74.9 (72.3, 79.9) 72.1 (70.6, 77.9) 0.225 R time (min) 10.4 (8.5,12.8) 11.6 (8.6, 12.5) 10.3 (8.4, 13.1) 0.864 D-dimer (ug/mL) 3.5 (2.4,7.9) 3.1 (2.4, 4.6) 3.9 (2.5, 9.0) 0.312 Fibrinogen (mg/dL) 543.5 (476.5, 674.6) 582.5 (538.4, 758.4) 501.5 (447.5, 575.9) 0.043 CRP (mg/dL) 11.1 (4.8, 17.8) 15.3 (8.4, 26.9) 7.55 (3.2, 12.3) 0.038 Ferritin (ng/mL) 985.2 (631.0, 2047.9) 1004.6 (577.8, 2258.3) 965.8 (730.7, 1785.0) 0.922 Bleeding complication 2 (8.3%) 2 (8.3%) 0 (0.0%) 0.478 TEG MA level >68 has been associated with hypercoagulable state. Of168 TEGs (46 heparin, 122 bivalirudin) analyzed, D-dimer was negatively correlated with TEG MA and explained little of the variance in this variable (adjusted R =0.162). Fibrinogen was significantly positively correlated (p<0.001) with MA and explained over 50% of variance. Fibrinogen >441 mg/dL had high diagnostic accuracy (sensitivity 91.2%, specificity 85.7%) for the detection of MA ≥ 68 mm. Conclusion: D dimer may not be adequate to identify hypercoagulable patients for anticoagulation therapy. Fibrinogen and/or viscoelastic testing may prove more accurate. Further work is required in this unique patient population.