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1.
ASAIO Journal ; 68:63, 2022.
Article in English | EMBASE | ID: covidwho-2032181

ABSTRACT

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).

2.
American Journal of Respiratory and Critical Care Medicine ; 203(9):1, 2021.
Article in English | Web of Science | ID: covidwho-1407322
3.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277249

ABSTRACT

Introduction: Venovenous (VV) Extracorporeal Membrane Oxygenation (ECMO) is an effective rescue therapy for coronavirus disease 2019 (COVID-19)- acute respiratory failure. However, the optimal duration of ECMO support and time to lung recovery remain unknown. Description: A 48-year-old Hispanic male without significant past medical history was transferred to a tertiary care high-volume ECMO center on mechanical ventilation after 11 days of progressive shortness of breath due to COVID-19 pneumonia. He was transferred heavily sedated, paralyzed, in the prone position, and with lung protective mechanical ventilation settings of 6cc/kg of ideal body weight, tidal volume of 350cc, positive end-expiratory pressure of 14 cm H2O, respiratory rate of 30 breaths per minute, and FiO2 of 100%. His driving and plateau pressures were 13 and 27 cm H2O, respectively. Three days after intubation, his PO2/FiO2 ratio repeatedly dropped below 80 and he was placed on Vf -Vj ECMO for severe acute respiratory distress syndrome (ARDS). During his ICU course, the patient received adjunctive therapies, including Remdesivir and Dexamethasone. He was extremely encephalopathic, resulting in a failed trial of extubation and requiring tracheostomy placement 14 days after intubation. His ECMO run was complicated by oxygenator failure and emergent exchange of ECMO circuit despite anticoagulation with bivalirudin. His course was complicated by superimposed Enterobacter pneumonia and he was treated with antibiotics. After 38 days of VV ECMO support, he showed improvement in compliance and gas exchange, indicating lung recovery. The patient was weaned successfully from ECMO and remained on mechanical ventilation for almost 30 days after decannulation. The ICU team carried out aggressive physical therapy, the patient was weaned off mechanical ventilation, his tracheostomy was decannulated, and he was discharged on 2L O2. CT at the time of discharge showed “improved aeration of both lungs” with residual lung fibrosis and bronchiectasis (Figure 1). Discussion: ARDS remains the most common indication for long-term ECMO support, which is frequently complicated by severe deconditioning, secondary infection, and vascular complications. In a stratified analysis of 127 patients who received ECMO support for respiratory failure, patient survival was 52% after being on ECMO for more than 20 days.1 Despite multiple complications, including superimposed infection and oxygenator failure, our patient showed recovery from his ARDS. He was eventually extubated and discharged from the hospital, indicating ECMO as an effective treatment for COVID-19 pneumonia. VV ECMO support for COVID-19 pneumonia should be considered for all eligible patients as infection rates and continue to rise.

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