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ASAIO Journal ; 68:63, 2022.
Article in English | EMBASE | ID: covidwho-2032181


Background: In patients with COVID-19 and respiratory failure, class 3 obesity (body mass index > 40 kg/m2) has been associated with worse survival. Obese patients on mechanical ventilation with progressively more severe acute respiratory syndrome (ARDS) may be offered venovenous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The impact of morbid obesity on the outcome of COVID-19 patients supported with VV ECMO has been underexplored. Methods: This is a multicenter, retrospective observational cohort analysis of critically ill adults with COVID-19 ARDS requiring advanced mechanical ventilation with or without VV ECMO. Data was collected from 236 international institutions forming the COVID-19 Critical Care Consortium international registry. Patients were admitted between January 2020 to December 2021. Included patients were stratified by ECMO status and a BMI threshold at 40 kg/m2. Median values with interquartile range (IQR) were used to summarize continuous variables and multi-state analysis was used to explore the effect of Class 3 obesity on the study endpoints of patient survival to discharge or death. Results: Complete data was available on 8851 of 9059 patients on mechanical ventilation, of which 767 patients required VV ECMO. For the entire study group, older age and male gender were associated with an increased risk of death. The demographics and comorbidities of the higher BMI (H >40 kg/m2) and lower BMI (L ≤40 kg/m2) cohorts were similar with the exception of age and weight. Patients with a higher BMI were younger. The median age of the H, non-ECMO cohort was 56 years (46-64), and the H, ECMO cohort was 41 years (35-51) versus the L, non-ECMO cohort of 64 years(55-71), and the L, ECMO cohort of 53years (45-60). Patients requiring VV ECMO had higher SOFA scores, experienced longer ICU and hospital lengths of stay, and a longer duration of total mechanical ventilation. Table The median time to intubation was longer in the mechanical ventilation only group (2 versus 0 days). Predictors for requiring ECMO included younger age, higher BMI and male gender. Risk factors for death included advancing age (every 10 years), male gender and increasing BMI (every 5kg/m2). The association between BMI and a higher rate of death was reduced in the mechanical ventilation only group (HR 0.92, 95% confidence interval 0.85 to 0.99). Conclusion: In patients with severe ARDS due to COVID-19 requiring mechanical ventilation, the likelihood of progressing to VV ECMO therapy or experiencing death is impacted by age, gender and higher BMI. The cohort of COVID-19 patients that ultimately required ECMO appear to be sicker at time hospital admission owing to the shorter time until mechanical ventilation. It appears the association between increasing BMI and death differs among the ECMO and mechanical ventilation alone cohorts. We would advocate for a prospective study to determine the benefit of VVECMO for the obese patient requiring VV-ECMO for COVID-19 ARDS. (Figure Presented).

ASAIO Journal ; 68(SUPPL 1):5, 2022.
Article in English | EMBASE | ID: covidwho-1912945


Purpose of study: Due to the high incidence of ARDS in those with COVID-19, ECMO centers began utilizing this therapy in early phases of the pandemic. Although receiving care at a high volume ECMO center has been associated with improved mortality amongst this patient population, there are significant obstacles associated with providing this service to those residing far from such centers. Amidst a pandemic, these challenges are compounded. Our urban, academic medical center serves as one of the highest volume ECMO referral centers in the Southeastern United States;amidst the pandemic we expanded our geographical boundaries to provide aid to those in need. Authors sought to describe characteristics of patients transported, evaluate for potential predictors of treatment success and to review our remote cannulation training and process. Additionally to identify transport associated challenges and lessons learned. Methods: Retrospective case series of critically ill, adult patients (≥18 years of age) with laboratory-confirmed COVID-19 transported to our medical center by our ECMO transport team from March 24, 2020 through June 8, 2021. Our team examined: age, gender, body mass index, ratio of arterial partial pressure to fractional inspired oxygen (P/F ratio);duration of mechanical ventilation, ECMO support and ICU admission. Descriptive statistics including mean, standard deviation, ranges, median, percentages and associated interquartile ranges (IQR) were used. Summary of results: 63 adult patients admitted to the Intensive Care Unit (ICU) with COVID associated ARDS requiring ECMO support were admitted to our ECMO center. The mean age of those transferred was 44 years old [SD 12;IQR 36-56] (Table 1). Fifty nine percent [n=37] of patients were male, fifty two percent [n=33] were African American, and the average body mass index (BMI) of our cohort was 39.7 [SD 11.3;IQR 31-48.5]. Medical history of hypertension and diabetes were commonly noted in forty six and twenty four percent of patients respectively (Table 1). All but one patient [n=62] required mechanical ventilation during their hospitalization. The majority of patients [77.8%;n=35] had severe ARDS -defined as P/F ratio less than 100-on transfer. Median days of admission and mechanical ventilation at the time of ECMO initiation were 8 days [IQR 5-12] and 4 days [IQR 2-6] respectively. Majority of patients [92% n=58] were transferred from facilities outside of our healthcare system and via ambulance [98.3% n=57]. Amidst those, eighty seven percent [n=55] were remotely cannulated (Table 2). Transport distances ranged from 2.2 to 236 miles [median 22.5 miles;IQR 8.3-79] and round trip transport times-not including time for pre cannulation preparation, cannulation, initiation of ECMO support and preparing patients for transport-ranged from 18 to 476 minutes [median 83 min;IQR 44-194]. Median duration of ECMO support was 17 days [IQR 9.5-34.5]. Duration of mechanical ventilator support was a median of 24 days [IQR 14-34]. Length of stay in the intensive care unit (ICU) [median 36 days;IQR 17-49] and hospital [median 39 days;IQR 25-57] varied. Amongst those discharged thus far, sixty percent survived [n=31]. Twenty nine percent percent [n=10] were discharged to their homes, fifty three percent [n=18] to rehabilitation facilities and nine percent [n=3] were back to the referral medical centers for continuation of care once they were determined to no longer have need for ECMO or transplantation. The majority of factors evaluated were not found to be statistically significant predictors of treatment success. Although ICU and hospital duration were noted to have p-values of significance, the associated odds ratios and small sample size make true clinical significance difficult to interpret.

ASAIO Journal ; 67(SUPPL 3):17, 2021.
Article in English | EMBASE | ID: covidwho-1481524


Introduction: Coagulopathy associated with COVID-19 presents a unique challenge when balancing the risk of thromboembolism versus bleeding complications in critically ill patients. This is particularly important in patients receiving extracorporeal membrane oxygenation (ECMO), as anticoagulation is used to offset increased thromboembolic risk, which may put patients at increased risk of periprocedural bleeding. The aim of this study is to evaluate risk of periprocedural bleeding in patients with COVID-19 on ECMO who undergo operative or percutaneous tracheostomy placement. Methods: This is an IRB approved retrospective chart review of the incidence of periprocedural bleeding in morbidly obese patients on ECMO. Participants included adults ≥18 years of age with laboratory-confirmed COVID-19 who were underwent either remote ECMO cannulation and transfer or where cannulated at an ECMO center. All participants were admitted to an ECMO ICU for daily management and subsequently underwent tracheostomy while on ECMO. Results: A total of 36 participants were included, of whom 61% were male. Participants had a median age of 47.5 (IQR 37.5-58) years and a median BMI of 38.5 (IQR 29-49) kg/m2, and 15/36 (42%) of patients had a BMI <35 kg/m2. Tracheostomy-associated bleeding occurred in 9/36 (25.0%) of patients. Subgroup analysis showed that in patients with a BMI <35 kg/m2, only 2/15 (13.3%) had periprocedural bleeding. In patients with BMI ≥35 kg/m2, 7/21 (33.3%) had periprocedural bleeding. All patients who had periprocedural bleeding required transfusion with blood products. Conclusion: Increased BMI is associated with an increased risk of bleeding complications following tracheostomy in patients on ECMO.

ASAIO Journal ; 66(SUPPL 3):66, 2020.
Article in English | EMBASE | ID: covidwho-984410


Transporting patients on ECMO is a proven safe and effective mode of transferring critically ill patients requiring maximum mechanical ventilator support to a regional quaternary care center. Prior to the COVID-19 pandemic, mobile ECMO teams were able to be transported without suffering adverse events. With the COVID-19, the safety of the staff and transport team adds a new layer of challenges. We conducted a retrospective study of 79 patients (median age 36 years old, 41% male) who were cannulated at an outside hospital and transported on Venovenous or Venoarterial ECMO to one of five quaternary care centers. The average distance travelled was 27 miles (SD 23 miles) and the duration of the transport was 56 minutes (SD 36 minutes) from ambulance bay to ambulance bay. The teams consisted of 1-2 physicians for cannulation and patient management, 2 critical care transport nurses and a driver or pilot. Mobile ECMO team members practiced strict ACE precautions while caring for the patient and were in standard PPE at other times. The primary mode of transportation was ground. Six patients were transported by air. There were no instances of transport related adverse events including pump failures, cannulation complications at the OSH or decannulations in transit. There were no instances of the transport team members contracting COVID-19 at 30 days after transport. By adhering to best practices and ACE precautions, patients with COVID-19 can be safely cannulated at an outside hospital and transported to a quaternary care center without increased risk to the transport team.