ABSTRACT
Objectives: Implementation of venovenous extracorporeal membrane oxygenation (VVECMO) allowed survival of patients with severe respiratory failure associated with SARS-CoV-2 infection. However, VVECMO treatment is usually associated with long ICU stays, prolonged sedation, and neuromuscular blockage days. Functional disability, due to delirium and acquired muscle weakness, is frequently an inevitable burden causing long term disability. This study aims to analyse main characteristics of patients under ECMO due to COVID-19 pneumonia, their outcomes and functional status six months after ICU discharge. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients receiving VVECMO for SARS-CoV-2 infection were included. Epidemiological and clinical data were reviewed. Functional status at 6 months after ICU discharge was assessed with modified Rankin Scale (mRS). Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9, mean SAPS II was 35.6+/-13.6. Mean time from intubation to cannulation was 5+/-5.6 days in 91 patients;awake-ECMO was performed in 2 patients. Mean ECMO run duration was 33.1+/-30 days (longest ECMO run was 194 days). A period of awake-ECMO was performed on 36.5% of patients, during 16.4+/-21.2 days. ICU-acquired weakness was diagnosed on 64.5% of patients and delirium on 63.4%. Mortality was 24.7% (23 patients) with only 1 patient deceased in hospital after ICU discharge. At 6 months follow-up, all patients were still alive and most of them (65.1%) were independent on all daily activities (mRS <= 2). Conclusion(s): Patients with severe COVID-19 treated with VVECMO support had very good functional outcomes at six-month follow-up. Despite long ICU length-of-stay, high incidence of delirium and acquired muscle weakness, full recovery at six-month post-ICU discharge was achievable in most patients.
ABSTRACT
Objectives: It is well known that severe COVID-19 is associated with complex immunological and inflammatory dysregulation. Both these physiopathological events translate to a high risk of major thrombotic or hemorrhagic events. In patients treated with venovenous extracorporeal membrane oxygenation (VVECMO), membrane dysfunction might affect systemic oxygenation and limit its duration-expectancy. This study aimed to assess the possible causes of extracorporeal membrane failure in COVID-19 patients and its impact on outcome. Method(s): Retrospective, single-center, observational case-control study involving adult COVID-19 patients admitted to an ECMO referral centre in a tertiary university hospital. All patients required VVECMO for acute respiratory failure, including 48 cases who needed one or more extracorporeal membrane exchanges and 45 controls (no membrane exchange). These two groups were compared for demographic characteristics, severity of the disease using validated scores (SAPS II and SOFA), duration of ECMO run, coagulation assessment, cumulative anticoagulation dose, associated complications, and outcomes (ICU and hospital mortality). Result(s): Most patients were males (71.0%) and younger than 50 years (79.5%). Median ECMO run duration was significantly longer in the case group (35.0 vs 14.0 days, p <0.001), as well as ICU length-of-stay (45.5 vs 28 days, p <0.001). Membrane exchange tended to be associated with sepsis (56% vs 33%, p=0.037), major hemorrhage (58% vs 43%, p=0.022), heparin-induced thrombocytopenia (25% vs 9%, p=0.054), higher D-dimer title (17.36 ng/dL vs 7.5 ng/dL, p=0.07) and lower platelet counts (133.000/muL vs 154.000/muL). Median SAPS II (32.0 vs 33.0, p=0.20) and the mortality (27% vs 24%, p >0.99) were similar between these groups. Conclusion(s): In patients with SARS-CoV-2 pneumonia and severe hypoxemia treated with VVECMO support the emergence of infection, coagulopathy and inflammation were associated with high risk of membrane dysfunction. No impact on mortality could be confirmed from these data. Anticoagulation monitoring and dosing strategies should be reinforced to promote membrane protection.
ABSTRACT
Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.
ABSTRACT
Objectives: Airway hemorrhage (AH) frequently complicates extracorporeal membrane oxygenation (ECMO) treatment. Inflammation, coagulopathy and antithrombotic therapy are contributing factors. Patients with COVID-19- associated ARDS (CARDS) supported with ECMO present all these features. We aim to characterize the incidence and the clinical and prognostic impact of AH. Method(s): Review of a cohort of patients with CARDS treated with ECMO support at a single ECMO centre between March 2020-February 2022 (n=92). AH was defined as a clinically significant hemorrhage fit demanded interruption of anticoagulation, transfusional support or bronchoscopy. Univariate analysis was performed using GraphPadPrism. Result(s): One third (n= 31) of patients with CARDS treated with ECMO had clinically significant AH. Patients who developed AH had significantly longer ICU length-of-stay (LoS), ECMO run and invasive mechanical ventilation (IMV) duration. Significant differences in coagulation and inflammatory markers were detected between patients with early (<72h) versus late (>9 days) onset of AH (Table 1). Mortality at day 90, demographics, comorbidities, CT scan pattern and clinical severity indexes were similar between patients with and without AH (NAH). Conclusion(s): In patients with severe CARDS treated with ECMO support, the occurrence of airway hemorrhage leads to clinically important morbidity but does not increase mortality. Distinct pathways may be involved in the development of early v. late AH. (Table Presented).