ABSTRACT
Background: Hemorrhage, coagulopathy and thrombosis (HECTOR) are reported complications of coronavirus disease 2019 (COVID-19) however, more information is needed on the prevalence of these complications and their associated outcomes in intensive care unit (ICU) settings. Aim(s): To determine the prevalence and outcomes of HECTOR complications in ICU patients with COVID-19. Method(s): Observational cohort study spanning 229 ICUs across 32 countries. Patients >=16 years admitted for severe COVID-19 from 1st January 2020, through 31st December 2021 were included. Patient characteristics and clinical data were collected. Survival analysis estimated the instantaneous impact of HECTOR complications on ICU-mortality and discharge. Result(s): HECTOR complications occurred in 1,735 (14%) of 11,972 study-eligible patients. Acute thrombosis occurred in 1,249 (10%) patients, including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial infarction, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic stroke. Hemorrhagic complications were reported in 582 (4.9%) patients, including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, and 77 (13%) with pulmonary hemorrhage. Disseminated intravascular coagulation occurred in 11 (0.09%) patients. Univariate analysis identified diabetes, hypertension, cardiac and kidney disease and ECMO as statistically-significant risk factors for HECTOR complications. Patients with versus without HECTOR complications suffered higher ICU-mortality at 28 days (25%vs.13%, p < 0.001), 90 days (32%vs.15%, p < 0.0001) and overall (44%vs.36%, p < 0.001). Among ICU survivors, the ICU stay was longer (median days 19vs.12, p < 0.001). ICU mortality was similar between patients with and without HECTOR complications (HR = 1.01, 95%CI 0.92-1.12, p = 0.783) where an increased hazard of ICU mortality with hemorrhage (HR = 1.26, 1.09-1.45, p = 0.002) was balanced by a reduced hazard of thrombosis (HR = 0.88, 0.79-0.99, p = 0.03). Kaplan-Meier curves are presented in the Figure. Conclusion(s): HECTOR events are frequent complications of severe COVID-19 in ICU patients. Hemorrhagic, but not thrombotic complications are associated with increased ICU-mortality.
ABSTRACT
Objective: Prone positioning for severe acute respiratory distress syndrome (ARDS) is associated with improved outcome. It is unclear whether prone positioning during Venovenous extracorporeal membrane oxygenation (VV ECMO) has survival benefit. The study investigated the impact of prone positioning on survival during VV ECMO support for COVID-19 acute respiratory failure. Methods: An observational analysis of VV ECMO patients using the COVID-19 Critical Care Consortium (COVID Critical) international registry. We used a multi-state survival model to compare the outcomes of patients treated with or without prone positioning during ECMO. Results: There were 213 COVID-19 patients at 67 participating institutions who were supported with VV ECMO from February 19, 2020, to October 31, 2020. Proning was used in 160 patients (75%) before initiation of ECMO and in 67 patients (31%) during ECMO. Prone positioning during ECMO support was associated with reduced mortality (hazard ratio 0.33, 95% CI, 0.15 to 0.73). Conclusions: Our study highlights that prone-positioning during VV ECMO support for refractory COVID- 19-related ARDS is associated with reduced mortality. Given our observational study design, a randomized controlled trial of prone positioning on VV ECMO is needed to confirm these findings.
ABSTRACT
The COVID-19 Critical Care Consortium is a global project of 360 hospitals from 52 countries sharing emerging insights regarding critically ill patients with COVID-19 (covid-critical.com). Specific data collection forms pertain to ECMO cases. We summarize data of the first 183 ECMO cases, which is 10% of the total. 94% have veno-venous ECMO. The majority are male (69%), the mean age is 50 (standard deviation, 12.3), and the most common ethnicity categories are white (50%), black (13%), and Latin American (12%). The median lengths of ECMO and hospital stay are 14 days and 28 days, respectively. The predominant cannulation drainage site is femoral vein (79%);the predominant return flow sites are the internal jugular vein (55%) and the femoral vein (31%). Platelet counts were significantly lower among ECMO patients compared to non-ECMO patients. The most common anticoagulation strategy is intravenous unfractionated heparin, followed by low molecular weight heparin. Compared to non-ECMO patients, ECMO patients had a hemorrhagic complication more frequently, with the most common sites being gastrointestinal, skin and soft tissue, lungs, and cannulation site. 13 patients (7%) suffered a central nervous system hemorrhagic complication. Conclusion: In this global database, 1 in 10 patients with severe COVID-19 is supported with ECMO. The dedicated ECMO case report form is designed to collect information on treatment details and complications which may aid clinicians using ECMO for COVID-19. Please consider enrolling your patients, which will make analysis of the efficacy and best methods of ECMO possible, in the context of the pandemic.