Non-invasive oxygenation support in acutely hypoxemic COVID-19 patients admitted to the ICU: a multicenter observational retrospective study.

BACKGROUND: Non-invasive oxygenation strategies have a prominent role in the treatment of acute hypoxemic respiratory failure during the coronavirus disease 2019 (COVID-19). While the efficacy of these therapies has been studied in hospitalized patients with COVID-19, the clinical outcomes associated with oxygen masks, high-flow oxygen therapy by nasal cannula and non-invasive mechanical ventilation in critically ill intensive care unit (ICU) patients remain unclear. METHODS: In this retrospective study, we used the best of nine covariate balancing algorithms on all baseline covariates in critically ill COVID-19 patients supported with > 10 L of supplemental oxygen at one of the 26 participating ICUs in Catalonia, Spain, between March 14 and April 15, 2020. RESULTS: Of the 1093 non-invasively oxygenated patients at ICU admission treated with one of the three stand-alone non-invasive oxygenation strategies, 897 (82%) required endotracheal intubation and 310 (28%) died during the ICU stay. High-flow oxygen therapy by nasal cannula (n = 439) and non-invasive mechanical ventilation (n = 101) were associated with a lower rate of endotracheal intubation (70% and 88%, respectively) than oxygen masks (n = 553 and 91% intubated), p < 0.001. Compared to oxygen masks, high-flow oxygen therapy by nasal cannula was associated with lower ICU mortality (hazard ratio 0.75 [95% CI 0.58-0.98), and the hazard ratio for ICU mortality was 1.21 [95% CI 0.80-1.83] for non-invasive mechanical ventilation. CONCLUSION: In critically ill COVID-19 ICU patients and, in the absence of conclusive data, high-flow oxygen therapy by nasal cannula may be the approach of choice as the primary non-invasive oxygenation support strategy.

Oxigenación con membrana extracorpórea en el paciente COVID-19: resultados del Registro Español ECMO-COVID de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) Extracorporeal Membrane Oxigenation in COVID-19 patients: results of the ECMO-COVID Registry of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE)

Introducción y objetivos: la oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria y/o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: en marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes COVID-19 tratados mediante ECMO veno-arterial (V- A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias pre-implante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento post-alta. Resultados: se analizaron un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media 52.7 y 49.4 años respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33.3% y 34.9% de los pacientes con ECMO V-A y V-V respectivamente fueron dados de alta del hospital (p=NS) y la mortalidad fue similar, del 56.2% y 50.9% de los casos respectivamente, la inmensa mayoría durante la ECMO y predominantemente por fracaso multiorgánico. El 14.0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196+/-101.7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0.967, IC 95% 0.95-0.99, p=0.004) y la procedencia del propio hospital (OR 0.48, IC 95% 0.27-0.88, p=0.018), mientras que la edad (OR 1.063, IC 95% 1.005-1.12, p=0.032), la hipertensión arterial (3.593, IC 95% 1.06-12.19, p=0.04) y las complicaciones en ECMO globales (2.44, IC 95% 0.27-0.88, p=0.019), digestivas (OR 4,23, IC 95% 1.27-14.07, p=0.019) y neurológicas (OR 4.66, IC 95% 1.39-15.62, p=0.013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: la terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la HTA y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional sólo se ve influenciada por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave, mejoraría los resultados y la futura investigación clínica

Oxigenación con membrana extracorpórea en el paciente COVID-19: resultados del Registro Español ECMO-COVID de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE)

RESUMEN Introducción y objetivos: la oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria y/o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: en marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes COVID-19 tratados mediante ECMO veno-arterial (V- A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias pre-implante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento post-alta. Resultados: se analizaron un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media 52.7 y 49.4 años respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33.3% y 34.9% de los pacientes con ECMO V-A y V-V respectivamente fueron dados de alta del hospital (p=NS) y la mortalidad fue similar, del 56.2% y 50.9% de los casos respectivamente, la inmensa mayoría durante la ECMO y predominantemente por fracaso multiorgánico. El 14.0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196+/-101.7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0.967, IC 95% 0.95-0.99, p=0.004) y la procedencia del propio hospital (OR 0.48, IC 95% 0.27-0.88, p=0.018), mientras que la edad (OR 1.063, IC 95% 1.005-1.12, p=0.032), la hipertensión arterial (3.593, IC 95% 1.06-12.19, p=0.04) y las complicaciones en ECMO globales (2.44, IC 95% 0.27-0.88, p=0.019), digestivas (OR 4,23, IC 95% 1.27-14.07, p=0.019) y neurológicas (OR 4.66, IC 95% 1.39-15.62, p=0.013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: la terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la HTA y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional sólo se ve influenciada por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave, mejoraría los resultados y la futura investigación clínica Background and aim: COVID-19 patients with severe heart or respiratory failure are potential candidates for extracorporeal membrane oxygenation (ECMO). Indications and management of these patients are unclear. Our aim is to describe the results of a prospective registry of COVID-19 patients treated with ECMO. Methods: an anonymous prospective registry of COVID-19 patients treated with veno-arterial (V-A) or veno-venous (V-V) ECMO was created on march 2020. Clinical, analytical and respiratory pre-implantation variables, implantation data and post-implantation course data were recorded. The primary endpoint was all cause in-hospital mortality. Secondary events were functional recovery and the combined endpoint of mortality and functional recovery in patients followed at least 3 months after discharge. Results: Three hundred and sixty-six patients from 25 hospitals were analyzed, 347 V-V ECMO and 18 V-A ECMO patients (mean age 52.7 and 49.5 years respectively). Patients with V-V ECMO were more obese, had less frequently organ damage other than respiratory failure and needed less inotropic support. Thirty three percent of V-A ECMO and 34.9% of V-A ECMO were discharged (p=NS). Hospital mortality was non-significantly different, 56.2% versus 50.9% respectively, mainly during ECMO therapy and mostly due to multiorgan failure. Other 51 patients (14%) remained admitted. Mean follow-up was 196+/-101.7 days (95% IC 95170.8-221.6). After logistic regression, body weight (OR 0.967, IC 95% 0.95-0.99, p=0.004) and ECMO implantation in the own centre (OR 0.48, IC 95% 0.27-0.88, p=0.018) were protective for hospital mortality. Age (OR 1.063, IC 95% 1.005-1.12, p=0.032), arterial hypertension (3.593, IC 95% 1.06-12.19, p=0.04) and global (2.44, IC 95% 0.27-0.88, p=0.019), digestive (OR 4,23, IC 95% 1.27-14.07, p=0.019) and neurological (OR 4.66, IC 95% 1.39-15.62, p=0.013) complications during ECMO therapy were independent predictors of primary endpoint occurrence. Only the post-discharge day at follow-up was independent predictor of both secondary endpoints occurrence. Conclusions: hospital survival of severely ill COVID-19 patients treated with ECMO is near 50%. Age, arterial hypertension and ECMO complications are predictors of hospital mortality, and body weight and implantation in the own centre are protective. Functional recovery is only predicted by the follow-up time after discharge. A more homogeneous management of these patients is warranted for clinical results and future research optimization.

Severe acute kidney injury in critically ill COVID-19 patients.

BACKGROUND: Acute kidney injury (AKI) is frequent in Coronavirus Infection Disease 2019 (COVID-19) patients. Factors associated with AKI in COVID-19 intensive care unit (ICU) patients and their outcomes have not been previously explored. METHODS: Prospective observational study of COVID-19 patients admitted to the ICUs of the Hospital Clínic of Barcelona (Spain), from March 25th to April 21st, 2020, who developed AKI stage 2 or higher (AKIN classification). The primary goal was to describe the characteristics of moderate-severe AKI of COVID-19 patients in an ICU context. As a secondary goal, we aimed to find independent predictors of AKI progression, Renal Replacement Therapy (RRT) requirement and mortality among these patients. RESULTS: During the study period, 52 out of 237 ICU patients, developed AKIN stage 2 or higher and were included in the study. A Sequential Organ Failure Assessment (SOFA) score at AKI diagnosis of 8 or higher was associated with RRT, OR 5.2, p 0.032. At the time of AKI diagnosis, patients had a worse liver profile and higher inflammation markers than at admission. Fifty per cent of the patients presented AKI progression from AKIN 2 to 3 and 28.85% required RRT. The use of corticosteroids in 69.2% of patients was associated with a reduced requirement of RRT, OR 0.13 (CI 95% 0.02-0.89), p 0.037. AKI was associated with high mortality (50%) and a longer hospital stay, median 35 vs 18 days (p 0.024). CONCLUSIONS: The prevalence of moderate/severe AKI in COVID-19 patients admitted to the ICU is high and has a strong correlation with mortality and length of hospital stay.

COVID-19 Pulmonary Failure and Extracorporeal Membrane Oxygenation: First Experience from Three European Extracorporeal Membrane Oxygenation Centers.

On April 17, 2020, a coronavirus disease 2019 (COVID-19) webinar was held by selected international experts in the field of intensive care and specialized respiratory ECMO centers from Germany, Italy, Spain, and the United Kingdom, which was hosted by the German Heart Centre Berlin/Charité. The experts shared their experience about the treatment of 42 patients with severe acute respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). Patients were predominantly male (male-to-female ratio: 3:1), with a mean age of 51 years (range: 25-73 years). VV-ECMO support was indicated in 30% of the ventilated COVID-19 patients. The mean time requiring mechanical ventilation was 16.5 days, with a mean duration of ECMO support of 10.6 days. At the time of the webinar, a total of 17 patients had already been decannulated from ECMO, whereas six died with multiorgan failure. 18 patients remained on ECMO, with their final outcomes unknown at the time of the webinar. Hospital mortality was 25.6% (as of April 17, 2020). In this respect, VV-ECMO, provided by expert centers, is a recognized and validated mode of advanced life-support during the recent COVID-19 pandemic with good outcomes.