Prolonged unconsciousness in severe COVID-19 infection with veno-venous ECMO support

Objectives: Patients with severe COVID-19 infections have been shown to have prolonged periods of coma followed by meaningful neurological recovery. Therefore, neurological prognostication is challenging, particularly in those who require veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We hoped to evaluate which variables can be considered when trying to predict neurological recovery. Method(s): We conducted a case-control retrospective chart review of patients on VV-ECMO from March 2020 to January 2022. This time-frame was selected to limit the effect of post-pandemic changes in sedation practices. Our outcome was duration of unconsciousness, defined as days with GCS motor score <6. We first conducted a matched cohort analysis, comparing COVID and non-COVID patients. We then performed a Classification and Regression Tree (CART) analysis to determine the Relative Variable Importance (RVI) of clinical variables associated with duration of unconsciousness. Result(s): Our matched analysis included 52 patients, 27 (52%) of whom had COVID-19. There were no significant differences in the baseline characteristics of the groups (Table 1). Patients with COVID-19 had a significantly longer median duration on ECMO (p<0.001) and hospital length of stay (p=0.003). The median duration of unconsciousness was similar between COVID-19 and non-COVID patients (p=0.58). The CART analysis results (Figure 1) showed that the most important variables to predict duration of unconsciousness were successive variations in GCS (RVI 100%) and GCS standard deviation (RVI 99%). COVID positivity only had a weak predictability (RVI 4%). Conclusion(s): Our analysis has shown that in patients on VV-ECMO, those with COVID-19 spent a longer time on ECMO and in the hospital. While there was no significant difference in the duration of unconsciousness, we found that patients who had high fluctuations of GCS during ECMO had a shorter duration of coma. (Figure Presented).

Prolonged Unconsciousness in Severe Covid-19 Pneumonia with Venovenous Ecmo Support

INTRODUCTION: Neurological prognostication is an important part of caring for critically ill patients and can help guide goals of care. This has become a challenge when caring for patients with severe COVID-19 pneumonia, as they have been shown to often have prolonged periods of coma followed by meaningful neurological recovery. However, this has not been studied in patients who require venovenous extracorporeal membrane oxygenation (VV-ECMO) support. We hypothesize that patients with COVID-19 pneumonia on VV-ECMO will have a more prolonged period of unconsciousness when compared to their COVID-negative counterparts. METHOD(S): We conducted a retrospective chart review of all patients who received VV-ECMO support at our institution from March 2020 to January 2022. This timeframe was selected to limit the effect of any changes in sedation practices that were brought about by the COVID-19 pandemic. We compared the daily Glascow Coma Scale (GCS) of patients with COVID-19 pneumonia to those who were cannulated for other etiologies. Our outcomes were duration of unconsciousness, which was defined as time from intubation to GCS motor score=6 for 48 hours, as well as changes in GCS over time. RESULT(S): Our preliminary analysis included 84 patients, 57 (68%) of whom were COVID-19 positive. There were no significant differences in the baseline characteristics of the groups, including initial Sequential Organ Failure Assessment score and need for renal replacement therapy. Patients with COVID-19 pneumonia had a significantly longer duration on ECMO in hours (952 vs 312, p< 0.001) and hospital length of stay in days (42 vs 30, p=0.01). There was no significant difference in the duration of unconsciousness (days) between the two groups (11 vs 9, p=0.21). However, the trend in GCS over time was notable as we found that patients with COVID-19 spent more days unresponsive, defined as a GCS=3 (8 vs 5, p=0.04). CONCLUSION(S): Our preliminary analysis found that in patients on VV-ECMO, those with COVID-19 pneumonia spent a longer time on ECMO and in the hospital. While there was no difference in the duration of unconsciousness, patients with COVID-19 spent more of that period unresponsive prior to recovery. While additional analysis is needed, this finding may assist providers when prognosticating neurological recovery.

Cannula-Associated Deep Vein Thromboses are Prevalent in COVID-19 Veno-venous Extracorporeal Membrane Oxygenation Patients

Background: Patients with severe COVID-19 related respiratory failure may require veno-venous extracorporeal membrane oxygenation (VV ECMO). After decannulation, patients on VV ECMO have historically had high percentages of cannula-associated deep vein thrombosis (CaDVT). Due to their hypercoagulable state and prolonged course on VV ECMO, we hypothesized that patients with COVID-19 would experience a higher rate of CaDVT when compared to their non-COVID-19 counterparts. We also described the association between location and size of cannula in the development of CaDVTs. Methods: This was a single center retrospective review of patients ≥ 18 years old who were treated with VV ECMO and decannulated from January 1, 2014, to January 10, 2022. Patients who were placed on VV ECMO due to trauma and patients who were cannulated for veno-arterial ECMO were excluded. Patients were managed in a dedicated Lung Rescue Unit and anticoagulated with a heparin infusion at a goal partial thromboplastin time (aPTT) of 45-55 or 60-80 depending on the presence of clotting complications. Post-decannulation venous duplexes were performed 24 hours after decannulation and if positive for DVT, performed again in 2 weeks. Univariate and multivariate analyses were conducted to analyze our primary outcome of the development of CaDVT. Results: A total of 291 patients met our inclusion criteria: 76 COVID-19 VV ECMO patients and 215 non-COVID-19 VV ECMO patients. Decannulated COVID-19 VV ECMO patients had a significantly higher body mass index (BMI) (35.8, 32.9, p= 0.03) and length of ECMO run (hours) (660, 312, p< 0.001) than their non-COVID-19 counterparts. Most decannulated patients in both groups received post-decannulation duplexes (96%, 99%, p= 0.45). COVID-19 and non-COVID-19 patients decannulated from VV ECMO both experienced high incidences of CaDVT on initial post-decannulation ultrasound (95%, 88%, p= 0.13). COVID-19 patients were more likely to have multiple CaDVTs (32%, 11%, p< 0.001). Patients with COVID- 19 experienced a higher rate of right common femoral CaDVT (47%, 17%, p< 0.001) and a higher percentage of 25 French drainage cannula CaDVT (48%, 18%, p< 0.001). COVID-19 VV ECMO patients had a significantly higher incidence of persistent CaDVT on repeat ultrasound (78%, 56%, p= 0.03). A logistic regression was performed with all decannulated patients. Age, BMI, hours on ECMO, COVID-19 status, and size and location of ECMO cannulas did not predict the presence of DVT. Conclusion: Both COVID-19 and non-COVID-19 VV ECMO patients had high rates of CaDVTs. The utilization of VV ECMO in COVID-19 respiratory failure was associated with a higher incidence of CaDVTs on repeat ultrasound as compared to patients with non-COVID-19 related respiratory failure. Regular post-decannulation screening, treatment, and follow up imaging should be performed. Further investigation into the effect of anticoagulation strategy is needed. (Table Presented).

Early guided palliative communication intervention to optimize family support and manage expectations for patients receiving extracorporeal membrane oxygenation (Ecmo)

Introduction: Extracorporeal membrane oxygenation (ECMO) is increasingly instituted for patients with severe circulatory or respiratory failure and as bridge to recovery or destination therapies (device implantation or organ transplantation). Morbidity and mortality for those patients is high. Hypothesis: ECMO combined with COVID isolation presents an additional set of challenges for patients, families. Objective: To test feasibility of an early, concurrent, and semi-structured palliative care intervention in improving communication, clarifying goals of care, and highlighting the experience of patients' families. Methods: IRB Approved Qualitative study using content analysis of guided, in-depth discussions with families of COVID-19 patients within 48-72 hours of being cannulated for ECMO between March-October 2020. Scripted template was developed to guide and facilitate goals of care conversations and to ensure consistent communication with family members throughout patients' disease trajectory. Patient demographics, comorbidities, clinical course, length of stay, and discharge disposition was obtained from the institution's COVID-19 Data Warehouse and analyzed using descriptive statistics Setting: Large urban academic medical center. Results: Patients were 44 ± 10 years, Hispanic or Latino 27/43 (63%), white 3 (7%), Black 8 (19%). Palliative care documentation for ECMO acknowledgement meeting was 36/43 (84%). Timely and guided communication demonstrated themes expressed by families including 1) social isolation and related grief of not being at patient's bedside;2) helping children of patients adjust to a new normal;3) coping with multiple family members suffering from COVID-19;4) importance of faith and spirituality;5) need for hope and gratitude 6) futility of prolonged ECMO stay. Survival to discharge 24/43 (56%). There was no statistical difference in hospital survival or length of stay between patients with and without documented palliative care. Conclusions: Early and ongoing palliative care intervention is feasible to support families' acknowledgment of complexity, benefits and limitations of ECMO, and it is useful in highlighting families' experiences, managing expectations and alleviating suffering.

Outcomes of Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Failure in Viral infections

Introduction: We evaluated the outcomes of Venovenous-extracorporeal membrane oxygenation (VV-ECMO) in patients with COVID-19 compared to patients with non-COVID viral infections. Methods: We retrospectively reviewed all adult VV-ECMO patients admitted from 8/2014-8/2020 for viral etiology. Data were analyzed with parametric and non-parametric statistics as indicated to compare COVID and non-COVID patients Results: 89 patients were included (35 COVID-19 vs. 54 non-COVID). 40 (74%) of the non-COVID patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs. 1 days, p=0.003), higher PaCO2 (64 vs 53 mmHg, p=0.012), and white blood cell count (14 vs. 9 x103/uL, p=0.004). There was no difference in pre-cannulation pH, P/F ratio, lactate, ventilator parameters, and RESP score between the two groups. Overall in-hospital mortality was 33.3% (n=30). COVID-19 patients had a higher mortality (49% vs. 24%, p=0.017) when compared to non-COVID patients. COVID-19 patients also had a longer median ECMO duration (654 [514, 1092] vs. 394 [280, 713] hours, p=0.002) and a similar median hospital length of stay (HLOS) (48 [30, 59] days vs. 41 [22, 57], p=0.334). COVID-19 survivors had longer median time on ECMO than non-COVID survivors (585 vs 395 hours p=0.03) but had a similar HLOS. Conclusion: Overall, VV-ECMO supported COVID-19 patients had a higher mortality. While COVID-19 survivors had significantly longer VV-ECMO runs than non-COVID survivors, both had similar HLOS. A potentially modifiable clinical factor that may improve outcomes is earlier cannulation, as COVID-19 patients had a significantly longer duration of pre-cannulation ventilator support.