Covid 19 care, ECMO usage and outcomes in a time of crisis at a major medical center

ABSTRACT

Objective: Outline the impact of COVID 19 and use of ECMO at INOVA Fairfax Medical Center, a full service, 1000 bed facility. Methods: Review of the EMR and use of descriptive statistics. Results: Between March 2020-February 13, 2021, 3220 COVID admissions occurred, of which 23% required ICU care and 10% mechanical ventilation (MV). Average hospital stay was 8 days and ICU 13 days. 51% of ICU patients (pts) received MV and 13% of vented pts (7% of ICU admissions) received ECMO. Data on 48 ECMO pts in 2020 is presented. Eligibility for ECMO included Age < 60 yrs, failed lung protective ventilation (TV< 6cc/kg, Pplat < 30 cm H2O) or acidosis (pH< 7.20, pCO2>65), trial of neuromuscular blockade and prone positioning, p/f< 100 torr. Up to 12 ECMO patients supported simultaneously (prior ECMO census cap of 4-7).Age range 15-68yrs. By quarters of 2020 ECMO Q1, 7 pts, duration 6-27 days, 100% survival;Q2, 30 patients, duration 3-95 days, 60% survival. 95 d pt decannulated but expired later;Q3 6 pts, duration 5-66 d, 50% survival, no survivor past 26 d;Q4 9 pts, 67% surv, duration 2-27d, survivor at 27d. Overall ECMO survival (n=48) 67% to discharge. Conclusions: 1. Initially, elective admissions were cancelled to allow care for over 200-300 COVID pts per day. Critical illness required expansion of ECMO services outside the usual site (CVICU), requiring emergent training of nursing and medical staff by core ECMO physicians and ECMO specialist staff. 2. Prone positioning helpful (before or during ECMO);3. higher levels of anticoagulation (heparin or bivalirudin) required due to acute/persistent thrombus;4. Bronchoscopy/tracheostomy performed without complications;5. Resumption of elective and non- COVID critically ill admissions in Q3 and Q4 resulted in inability to accept ECMO referrals in the second wave of pandemic, highlighting need for more experienced ECMO beds.