Long-term extracorporeal membrane oxygenation - from SARS-CoV-2 infection to lung transplantation. / Oxigenação por membrana extracorpórea de longa duração - da infecção por SARS-CoV-2 ao transplante pulmonar.

A healthy 55-year-old woman unvaccinated for SARS-CoV-2 was admitted to the hospital with a SARS-CoV-2 infection with rapid clinical deterioration. On the 17th day of disease, she was intubated, and on the 24th day, the patient was referred and admitted to our extracorporeal membrane oxygenation center. Extracorporeal membrane oxygenation support was initially used to enable lung recovery and allow the patient to rehabilitate and improve her physical condition. Despite an adequate physical condition, the lung function was not adequate to discontinue extracorporeal membrane oxygenation, and the patient was considered for lung transplantation. The intensive rehabilitation program was implemented to improve and maintain the physical status throughout all phases. The extracorporeal membrane oxygenation run had several complications that hindered successful rehabilitation: right ventricular failure that required venoarterial-venous extracorporeal membrane oxygenation for 10 days; six nosocomial infections, four with progression to septic shock; and knee hemarthrosis. To reduce the risk of infection, invasive devices (i.e., invasive mechanical ventilation, central venous catheter, and vesical catheter) were removed whenever possible, keeping only those essential for monitoring and care. After 162 days of extracorporeal membrane oxygenation support without other organ dysfunction, bilateral lobar lung transplantation was performed. Physical and respiratory rehabilitation were continued to promote independence in daily life activities. Four months after surgery, the patient was discharged.

Mulher de 55 anos, saudável e não vacinada para SARS-CoV-2, foi admitida no hospital por infecção SARS-CoV-2 com rápida deterioração clínica. No 17º dia de doença, foi intubada e, no 24º dia, a paciente foi referenciada e admitida no nosso centro de oxigenação por membrana extracorpórea. Inicialmente, o suporte de oxigenação por membrana extracorpórea foi utilizado para possibilitar a recuperação pulmonar e permitir à paciente reabilitar e melhorar sua condição física. Apesar de apresentar uma condição física adequada, a função pulmonar não permitiu suspender a oxigenação por membrana extracorpórea, e a paciente foi aceita para transplante pulmonar. Um programa de reabilitação intensiva foi implementado para melhorar e manter o estado funcional da paciente em todas as fases. O curso de oxigenação por membrana extracorporal apresentou várias complicações que prejudicaram a reabilitação: falência ventricular direita, que exigiu oxigenação por membrana extracorpórea venoarterial-venosa durante 10 dias; seis infecções nosocomiais, sendo quatro com progressão para choque séptico; e hemartrose do joelho. Para reduzir o risco de infecção, sempre que possível removeram-se os dispositivos invasivos (ventilação mecânica invasiva, cateter venoso central e cateter vesical), mantendo-se apenas aqueles estritamente necessários à monitorização e tratamento. Após 162 dias de suporte de oxigenação por membrana extracorpórea sem outra disfunção orgânica, foi realizado o transplante pulmonar lobar bilateral. A reabilitação física e respiratória foi mantida para promover a autonomia nas atividades da vida diária. A paciente recebeu alta hospitalar 4 meses após a cirurgia.

Comparative outcomes of extracorporeal membrane oxygenation for COVID-19 delivered in experienced European centres during successive SARS-CoV-2 variant outbreaks (ECMO-SURGES): an international, multicentre, retrospective cohort study.

BACKGROUND: To inform future research and practice, we aimed to investigate the outcomes of patients who received extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) due to different variants of SARS-CoV-2. METHODS: This retrospective study included consecutive adult patients with laboratory-confirmed SARS-CoV-2 infection who received ECMO for ARDS in 21 experienced ECMO centres in eight European countries (Austria, Belgium, England, France, Germany, Italy, Portugal, and Spain) between Jan 1, 2020, and Sept 30, 2021. We collected data on patient characteristics, clinical status, and management before and after the initiation of ECMO. Participants were grouped according to SARS-CoV-2 variant (wild type, alpha, delta, or other) and period of the pandemic (first [Jan 1-June 30] and second [July 1-Dec 31] semesters of 2020, and first [Jan 1-June 30] and second [July 1-Sept 30] semesters of 2021). Descriptive statistics and Kaplan-Meier survival curves were used to analyse evolving characteristics, management, and patient outcomes over the first 2 years of the pandemic, and independent risk factors of mortality were determined using multivariable Cox regression models. The primary outcome was mortality 90 days after the initiation of ECMO, with follow-up to Dec 30, 2021. FINDINGS: ECMO was initiated in 1345 patients. Patient characteristics and management were similar for the groups of patients infected with different variants, except that those with the delta variant had a younger median age and less hypertension and diabetes. 90-day mortality was 42% (569 of 1345 patients died) overall, and 43% (297/686) in patients infected with wild-type SARS-CoV-2, 39% (152/391) in those with the alpha variant, 40% (78/195) in those with the delta variant, and 58% (42/73) in patients infected with other variants (mainly beta and gamma). Mortality was 10% higher (50%) in the second semester of 2020, when the wild-type variant was still prevailing, than in other semesters (40%). Independent predictors of mortality were age, immunocompromised status, a longer time from intensive care unit admission to intubation, need for renal replacement therapy, and higher Sequential Organ Failure Assessment haemodynamic component score, partial pressure of arterial carbon dioxide, and lactate concentration before ECMO. After adjusting for these variables, mortality was significantly higher with the delta variant than with the other variants, the wild-type strain being the reference. INTERPRETATION: Although crude mortality did not differ between variants, adjusted risk of death was highest for patients treated with ECMO infected with the delta variant of SARS-CoV-2. The higher virulence and poorer outcomes associated with the delta strain might relate to higher viral load and increased inflammatory response syndrome in infected patients, reinforcing the need for a higher rate of vaccination in the population and updated selection criteria for ECMO, should a new and highly virulent strain of SARS-CoV-2 emerge in the future. Mortality was noticeably lower than in other large, multicentre series of patients who received ECMO for COVID-19, highlighting the need to concentrate resources at experienced centres. FUNDING: None.

Cytokine Adsorption Therapy during Extracorporeal Membrane Oxygenation in Adult Patients with COVID-19.

Respiratory failure and systemic inflammation are paramount features of severe SARS-CoV-2 disease (COVID-19). Extracorporeal membrane oxygenation (ECMO) therapy has a potential role in patients with refractory disease. An inflammatory response due to blood contact with hemofilters, functioning as a synergic inflammatory stimulus, can lead to a hyperinflammatory state, relatable to cytokine release syndromes. After the first patient succumbed to a refractory vasodilatory shock believed to be due to hyperinflammatory state, a strategy of blood purification through cytokine adsorption therapy (CAT) with CytoSorb® was designed. In this case series, the authors describe the initial experience with such strategy. CAT was employed with no direct complications and helped controlling the inflammatory state, with all patients halting vasopressor support in 72 h and biomarker levels (C-reactive protein, ferritin, and interleukin-6) showing negative trends in most patients. Analysis of inflammatory biomarkers evolution highlighted 2 biomarker profiles related to the presence or absence of superinfection at the time of CAT implementation. In this case series of severe COVID-19 patients, 3 patients died - irreversible lung fibrosis, complications of critical hypoxemia before ECMO induction and complications of systemic anticoagulation were the causes. This case series aimed to contribute to the body of evidence substantiating CAT utilization in hyperinflammatory patients, namely, COVID-19 patients requiring ECMO rescue.