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Objectives: In patients with severe respiratory failure, invasive ventilation may deteriorate the pneumomediastinum and hypoxia. This study aimed to compare the mortality and the complications of the patients with coronavirus disease 2019 (COVID-19) related severe ARDS treated with invasive ventilation or veno-venous ECMO (VV-ECMO) to avoid intubation. We hypothesized that VV-ECMO support without prior intubation is a feasible alternative strategy to invasive ventilation. Method(s): This retrospective study evaluated patients with COVID-19 related severe respiratory failure and radiological evidence of pneumomediastinum. The primary outcome was intensive care unit (ICU) survival at 90 days. Result(s): Out of 347 patients with COVID-19 disease treated in our unit, 22 patients developed spontaneous pneumomediastinum associated with deterioration of respiratory function. In 13 patients (59%), invasive ventilation was chosen as initial respiratory support;in 9 patients (41%), VV-ECMO was chosen as initial respiratory support. The median age of the patients in the invasive ventilation group was 62 years (IQR: 49-69) compared to 53 years (IQR: 46-62) in ECMO group (P=0.31). No statistically significant difference in SAPS II score between the groups was observed (39.7 (IQR: 33.2-45.3) vs. 28.9 (IQR:28.4-34.6), P=0.06). No elevated fluid balance within the first 4 days was observed in the ECMO group compared to the invasive ventilation group (162 mL (IQR: -366-2000) vs. 3905 mL (IQR: 2068-6192), P=0.07). VV-ECMO as the initial strategy for supporting patients with severe respiratory failure and pneumomediastinum, was associated with lower 90 days mortality (HR: 0.33 95%-CI: 0.11-0.97, P= 0.04) compared to patients treated with invasive ventilation (Figure). Conclusion(s): VV-ECMO can be an alternative strategy to invasive ventilation for treating patients with severe respiratory failure and spontaneous pneumomediastinum. (Figure Presented).
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Introduction: Central venous-to-arterial carbon dioxide tension ( PvaCO2) can be useful for monitoring adequacy of tissue perfusion in patients with ARDS supported with veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO). However, in theory, the unavoidable mixing of venous blood with blood after the oxygenator can affect PvaCO2 values by increasing central venous oxygen saturation and substantially decreasing CO2 concentration. This study aimed to evaluate acute changes in PvaCO2 after VV-ECMO installation and determine its association with patient outcomes. Method(s): Retrospectively evaluated coronavirus disease 2019 (COVID-19) ARDS patients with at least one concurrent arterial and central venous blood gas analysis before and after VV-ECMO installation as standard care. The primary outcome was intensive care unit (ICU) mortality at 28 days. Result(s): 29 patients were enrolled in the study. All the patients had a 25 F drainage multistage femoral cannula and a 21 F internal jugular infusion cannula. The median distance between the central venous sampling point and the tip of the infusion cannula was 39 [23-73] mm. No statistically significant changes in PvaCO2frelative changes calculated. After were observed 24-48 h after VV-ECMO installation (5 [4-7] mmHg to 6.5 [5-8.2] mmHg, p = 0.12). Hemoglobin concentration decreased 24 to 48 h after VVECMO installation (10.7 [9.5-12.7] g/dl to 9.6 [8.8-11.6] g/dl, p < 0.01) but neither central venous (75 [70-81]% to 73 [67-78]%, p = 0.46) nor arterial oxygen saturation (95 [92-97]% to 95 [93-96]%, p = 0.81) changed significantly. Elevated PvaCO2 after VV-ECMO installation had a good predictive value for 28 day ICU mortality (calculated area under the ROC curve 0.81) (Fig. 1 veno-venous). Conclusion(s): VV-ECMO support appears to have little effect on the PvaCO2 calculation. PvaCO2 can be used to evaluate patients with ARDS supported with VV-ECMO, as persistently elevated values can be associated with poor outcomes.
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Introduction: Invasive ventilation initiation after a prolonged period of non-invasive ventilation (NIV) trial can be associated with poor outcome in coronavirus disease 2019 (COVID-19) ARDS patients. This study aimed to document our center's experience with COVID-19 ARDS patients treated with veno-venous ECMO (VVECMO) after a prolonged NIV trial period to avoid intubation. We speculated that VV-ECMO support is not associated with a worse outcome than invasive ventilation in these patients. Methods: We retrospectively reviewed 6 patients with COVID-19 ARDS who presented severe hypoxemia and pneumomediastinum after NIV (ECMO group). Twenty patients with COVID - 19 and age less than 70 years old were treated in the first wave of the national outbreak and underwent NIV trials for more than 24 h before intubation (Control group). The primary outcome was intensive care unit (ICU) survival and secondary ECMO or mechanical ventilation weaning at 28 days. Results: The age of the patients in the ECMO group was 59 years (IQR: 46 - 65) and SAPS II score 47 (IQR: 46 - 52), compared to 60 years (IQR: 51 - 66) (p = 0.71) and 48 (IQR: 45 - 54) (p = 0.63) in the control group. NIV duration before ECMO or invasive ventilation initiation was 5 days (IQR: 2 - 8) and 3 days (IQR: 1 - 5), respectively (p = 0.13). Drainage multistage femoral cannula 25 F and internal jugular infusion cannula 21 F were placed percutaneously. After cannulation, the patients received light sedation that permitted communication, active physiotherapy and oral feeding. None of the patients in the ECMO group died within 28 days after ECMO initiation (Fig. 1, Panel A) or received invasive ventilation. VV-ECMO was not associated with longer mechanical support than invasive ventilation (HR: 1.26 95%CI: 0.24 - 6.55, p = 0.77) (Fig. 1, Panel B). Conclusions: VV-ECMO can be a not inferior strategy to invasive ventilation for treating patients with COVID-19 ARDS and severe hypoxemia not responding to long trials of NIV. (Table Presented).
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Introduction: Critically ill patients with coronavirus disease 2019 (COVID-19) may present severe tissue perfusion abnormalities. The mixed venous-to-arterial carbon dioxide tension difference ( PvaCO2) is an easily derived parameter identifying insufficient tissue perfusion. The purpose of this study was to evaluate the clinical relevance of high values of PvaCO2 in COVID - 19 patients early after their admission to intensive care unit (ICU). We speculated that high PvaCO2 values might be associated with poor outcome in critically ill COVID-19 patients. Methods: This was a retrospective study conducted in two independent centers of Belgium. We included patients treated in the first wave of the national outbreak with available PvaCO2 within 3 days of admission and without severe hypercapnia ( PCO2 > 75 mmHg). The highest value was registered. Normal values were considered ≤ 6 mmHg, moderate elevations 7 - 9 mmHg, and high elevations > 9 mmHg. The primary outcome was ICU discharge alive and secondary outcome mortality at 28 days. Results: Seventy-three patients were included with median age of 60 years (IQR: 52 to 68), and simplified acute physiology score II (SAPS II) 26.1 (IQR: 19.8 to 29.5). Fifty-three (76%) patients needed invasive ventilation within 24 h after ICU admission (12 h (IQR: 12 to 24). The worst ratio of partial pressure arterial oxygen to the fraction of inspired oxygen ( PaO2/FiO2) within 3 days after admission was 151 (IQR: 86 to 243) and PvaCO2 6 mmHg (IQR: 5 to 9). PvaCO2 > 9 mmHg was associated with longer ICU stay (ICU free days: 0 days (0 - 0) vs 1 day (0 - 18), p = 0.02), independently of PaO2/FiO2 and SAPS II score (HR: 0.21, 95% - CI: 0.05 - 0.92, p = 0.04) (Fig. 1, Panel A), but not to 28 days mortality (HR:1.71, 95% - CI: 0.48 - 5.91, p = 0.41) (Fig. 1, Panel B). Conclusions: In COVID-19 patients, high PvaCO2 values early after ICU admission are associated with prolonged ICU stay independently of hypoxemia and disease severity. (Figure Presented).