key: cord-0996187-wrkxzp8c
authors: Shih, Emily; DiMaio, J. Michael; Squiers, John J.; Banwait, Jasjit K.; Meyer, Dan M.; George, Timothy J.; Schwartz, Gary S.; Blough, Britton A.; Gottlieb, Robert L.; Gonzalez-Stawinski, Gonzo; Krueger, Anita R.; Monday, Kara; Reddy, Ramachandra C.; Velazco, Jorge F.; Hernandez, Omar; Martin, Chris; Sheasby, Jenelle
title: Venovenous Extracorporeal Membrane Oxygenation for Patients with Refractory Covid-19: Multicenter Experience of Referral Hospitals in a Large Healthcare System
date: 2020-12-01
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.11.073
sha: 4f197486d655ee315a0def944893832ef201905f
doc_id: 996187
cord_uid: wrkxzp8c

Background The benefit of extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress from COVID-19 refractory to medical management and lung-protective mechanical ventilation has not been adequately determined. Methods We reviewed the clinical course of 37 patients with laboratory-confirmed SARS-CoV-2 infection supported by venovenous ECMO at four ECMO referral centers within a large healthcare system. Patient characteristics, progression of hemodynamics and inflammatory markers, and clinical outcomes were evaluated. Results The patients had median age of 51 years (interquartile range [IQR] 40-59), and 73% were male. Peak plateau pressures, vasopressor requirements, and arterial PaCO2 all improved with ECMO support. In our patient population, 24/37 patients (64.8%) survived to decannulation and 21/37 patients (56.8%) survived to discharge. Among patients discharged alive from the ECMO facility, 12 patients were discharged to a long-term acute care or rehabilitation facility, 2 were transferred back to the referring hospital for ventilatory weaning, and 7 were discharged directly home. For patients who were successfully decannulated, median length of time on ECMO was 17 days (IQR 10-33.5). Conclusions Venovenous ECMO represents a useful therapy for patients with refractory severe acute respiratory distress syndrome from COVID-19.

Referral to an ECMO center for consideration of initiation of ECMO was shown to be of benefit 98 in patients with severe ARDS in the CESAR trial, 3 and ECMO was successfully used for severe 99 ARDS patients during the influenza (H1N1) pandemic. 4 Thus, refractory ARDS with refractory 100 severe hypoxemia or hypercarbia in critical COVID-19 cases has prompted ECMO therapy in 101 these patients as well. The benefit of ECMO for COVID-19 has not been adequately determined. 102 Only scarce data are available regarding this population of patients, and rates of survival to 103 discharge have been less than 20% in these reports. 5, 6, 7, 8 In this report, we describe the outcomes 104 of a cohort of patients with severe COVID-19 who were initiated on ECMO the Berlin criteria. 9 Coagulopathy was defined as an international normalized ratio (INR) greater 150 than 3. Liver failure was defined as an alanine transaminase (ALT) greater than five times the 151 normal limit. Cardiogenic shock was defined as sustained systolic blood pressure <90 mmHg, 152 cardiac index (CI) <2.2 L/min/m 2 , or requirement for two or more inotropes 10 strategies before advancing to ECMO, the clinically anticipated survival without ECMO in these 193 patients was anticipated to be extremely low.

All patients underwent initial cannulation at bedside rather than in the operating room. Table 3 . reported survival to discharge rate corresponds well with the rate we report from our healthcare 293 system.

In COVID-19 patients with severe ARDS, respiratory distress seems to have a rapid onset 295 of progression. 14, 15 In our study, the median length of time from admission to intubation was one 296 day. ECMO was typically initiated between 4-7 days after the patients were intubated. All 297 patients were in or near extremis at the time ECMO was initiated. During the study period, an 298 additional two patients, which were excluded from our analysis, were initiated on VA ECMO. 299 We preferred VV ECMO for initial support in most cases because the majority of hemodynamic 300 instability exhibited by these patients was attributed to respiratory acidosis resultant from the 301 ongoing ARDS process, which rapidly resolved on after initiation of VV ECMO. 302 We notably performed ECMO cannulation at bedside in all 37 patients without 303 immediate complications, suggesting that cannulation can be performed safely even during survivors are also essential to ascertain, though no such data is currently available.

This report summarizes novel data from a large healthcare system with multiple centers 324 managing patients with refractory COVID-19 ARDS using ECMO support. Our findings suggest 325 that ECMO use may be a reasonable treatment option in these cases. Further studies addressing 326 ECMO use in COVID-19 are needed to confirm these findings. 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 Influenza A(H1N1)

Extracorporeal membrane oxygenation in the treatment of severe pulmonary and cardiac compromise in Coronavirus Disease 2019: Experience with 32 patients

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Veno-venous extracorporeal membrane oxygenation for respiratory failure in COVID-19 patients: early experience from a major academic medical center in North America

Extracorporeal membrane oxygenation support in severe COVID-19

Acute respiratory distress syndrome: the Berlin definition

Should we emergently revascularize Occluded Coronaries for cardiogenic shocK: an international randomized trial of emergency PTCA/CABG-trial design. The SHOCK Trial Study Group

Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Covid-19 in critically ill patients in the seattle region -case series

Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry

Rapid progression to acute respiratory distress syndrome: review of current understanding of critical illness from COVID-19 infection

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

CPR cardiopulmonary resuscitation, CRRT continuous renal replacement therapy. VV venovenous, VAV veno-arterio-venous, VVA veno-veno-arterial

Clinical outcomes of patients with severe acute respiratory distress syndrome associated with refractory COVID-19 who were initiated on venovenous ECMO including use of concurrent therapies and complications related to ECMO. The total cohort comprised of 37 patients; the numerator and denominator (number of eligible patients) for relevant outcomes are

ECMO extracorporeal membrane oxygenation, ICU intensive care unit, LOS length of stay, INR international normalized ratio, ALT alanine transaminase. In hospital mortality is calculated from patients who were discharged or expired in the hospital. Duration of continuous ventilation, ICU LOS, and hospital LOS calculated from the 21 patients who survived to discharge