key: cord-1044704-w733pi67
authors: Hayanga, J. W. Awori; Chatterjee, Subhasis; Kim, Bo Soo; Merritt-Genore, HelenMari; Karianna Milewski, Rita Carrie; Haft, Jonathan W.; Arora, Rakesh C.
title: Venovenous Extracorporeal Membrane Oxygenation in patients with COVID-19 respiratory failure
date: 2021-10-12
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2021.09.059
sha: 1624e472d353970bf3eca572ab7b581154fa065b
doc_id: 1044704
cord_uid: w733pi67

nan

The high level of human-to-human transmissibility of severe acute respiratory syndrome 95 coronavirus 2 (SARS-CoV-2) and the severity of COVID-19 have perpetuated an international 96 public health emergency. Indeed, this pandemic has evolved into the greatest health challenge 97 of the 21st century. Virus entry is mediated by the structural spike membrane protein which 98 plays a significant role in host cell receptor recognition and membrane fusion. Angiotensin 99 converting enzyme 2 (ACE-2) serves as the functional culprit host cell receptor. 16 ECMO thus far, has been framed through the lens of single center, non-randomized reports 105 which vary both in methodology and outcome. 1,2,18,19 Severity of disease may be estimated 106 using the WHO classification, which assigns a grade from 1 to 9 in order of increasing 107 severity. 20 There is, as yet, no designate ECMO-specific scoring system and, to this end, the 108 Murray, (PRedicting dEath for SEvere ARDS on VV-ECMO) (PRESERVE) 18 and (Respiratory 109 ECMO Survival Prediction) Score (RESP) 19 scores each remain applicable in the quantification 110 of severity in this cohort though not necessarily specific to COVID -19 or to its prognosis. In the 111 absence of broad consensus, management strategies have been both dynamic and variable. 3,21 112

With this manuscript, we proffer a distillation of expert opinion in the management of 113 extracorporeal support in COVID patients, drawing upon a collective of high-volume multi-114 institutional experience. 115 116

The high mortality from the virus often prompted the deviation from previously held norms 118 regarding candidacy that had been established in prior landmark trials, such as the 119 "conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult 120 respiratory failure" (CESAR) and "ECMO to rescue acute lung injury in severe ARDS" (EOLIA) 121 trials. 15,22 Based on our collective experience , we observed a shift in three domains. First, 122 candidacy now tends to more greatly favor the younger patient, prioritizing those under 50 years 123 with only single organ dysfunction. Second, there is greater willingness to shorten the interval 124 from intubation to cannulation. A higher chance of success is more likely in those cannulated 125 after less than 3 days of mechanical ventilation while fulfilling EOLIA criteria ( PaO2/FiO2 (PF) 126 ratio <50 mmHg for >3 hours, or <80 mmHg for >6 hours or pH <7.25 with PaCO2 >60 mmHg 127 for >6 hours). 15 Lastly, an array of novel adjunctive pharmacological therapies such as antiviral 128 and monoclonal antibodies and the use of extracorporeal cytoreductive techniques have been 129

introduced as adjuncts to extracorporeal support. The sickest patients typically presented with a 130 median APACHE II "Acute Physiology And Chronic Health Evaluation II" score 1 of score of 131 above 20, Murray score 2 of 3 or greater and Sequential Organ Failure Assessment (SOFA) 132 Score 3 of at least 8. In our collective experience, patients sick enough to require veno-arterial 133 (VA) ECMO from the outset typically developed early multi-system failure and were almost 134 uniformly unsalvageable. .1 We proffer a matrix to provide a rudimentary estimate of survival 135 (Table 1 ) and a list of factors associated with adverse outcome. (Table 2) atelectrauma. Once optimal PEEP is identified, pressure control may be adjusted to maintain 235 peak airway pressures < 30 cm H20. If PEEP determined in this fashion is high enough to 236 precipitate peak pressures > 30 cm H20 in the setting of driving pressure <10 (plateau pressure 237 minus PEEP) and tidal volumes between 2-4 cc/kg of ideal body weight, then the optimal PEEP 238 is titrated down further to achieve a peak airway pressure of <30 cm H20. As the lung function 239 improves, optimal PEEP should continue to be measured and titrated down as tolerated. Once 240 PEEP has been weaned to 10 cm H20 and lungs remain recruited, the ventilator settings can 241 then be weaned with a goal of minimizing driving pressure and liberating the patient from 242 positive pressure. A BMI > 50 also poses a threat to achieving adequate flows on ECMO and 243 may potentially compromise mesenteric and peripheral circulations. Hence, some centers 244 adopted this cut-off as a relative contraindication to conventional mechanical support. The COVID-19 pandemic has created unique healthcare worker staffing shortages and resource 282 challenges. Although the geographic distribution of the pandemic was asymmetric, no large 283 community has been spared. Elective surgical cases had to be postponed to preserve 284 ventilators, ICU beds, and PPE. Many ICUs triaged personnel to newly created COVID-19 units 285 while simultaneously merging other, non-COVID ICUs. 12 COVID-19 placed front-line workers at 286 risk of infection, not just from patients but also from coworkers. As the pandemic progressed, 287 unprecedented nursing shortages forced many ICUs to reallocate personnel, reduce capacity or 288 spend magnitudes higher on salaries for temporary nursing staff. Deficits were further 289 exacerbated by healthcare personnel becoming infected or exposed, necessitating periods of 290 quarantine, school and childcare facility closures that forced working parents to stay home; new 291 opportunities for temporary employment with significantly higher pay and significant emotional 292 burnout from an unprecedented and relentless challenge. 13 293 294 A threshold of volume and utilization has been identified beyond which a nursing-based model 295 become more cost conscious than relying on perfusionists at the bedside. 14 COVID -19 has 296 proved that a pandemic can exert such a strain on staffing ratios that creative solutions, 297 incentivized remuneration models, hazard pay and work-hour flexibility are likely necessary 298 considerations for the future for any high-volume ECMO efforts. The CESAR trial endorsed the 299 transfer of patients to ECMO centers, and many advocate clustering patients within expert 300 ECMO centers for improved outcomes. Others, however, have endorsed grouping ECMO 301 patients within institutions themselves to alleviate staffing shortages and bed capacity within 302 facilities. 303 304 Because ECMO centers typically constitute the "hub" in the hub and spoke model, several 305 patients are often transferred in from lower capacity external critical care settings to the ECMO 306 centers. In these models of care delivery, the early identification and use of transfer protocols 307 allow for safe and expeditious triaging of patients who may benefit from ECMO to the nearest 308 facility with the best capacity to offer support. ECMO transport teams may initiate support at 309 referring institutions and use of transport and safety checklists to facilitate the process. 310

The highest mortality was observed in patients with advanced age or immunosuppression. Most 313 patients who died were ultimately removed from ECMO for futility. The definition of futility varied 314 from weeks to months, depending on prevailing opinion. Many centers developed contingency 315 plans, incorporated ethics members into decision-making and even chose to ration scarce 316 resources such as, ventilators, dialysis circuits, and ECMO circuits. Some centers modified 317 standard ACLS algorithms restricting cardiopulmonary resuscitation in patients with COVID-19, 318

given the near-100% mortality rate. 5 As the pandemic unfolded, resources became limited-first 319 ECMO circuits, then ECMO specialists and nurses. It became necessary to select patients most 320 likely to benefit from support. As overall ECMO capacity diminished, contraindications to ECMO 321 tended to become more stringent, consistent with ELSO guidelines. 21 This is a dynamic process gaps that require scientific inquiry for further elaboration (Table 3) Table 1 Pre-cannulation guide to estimating survival in patients with COVID-19 376 Table 2 Factors associated with adverse outcome 377 Table 3 Areas of Information Deficits 378 

Does obesity portend a poor prognosis?

Can cytoreductive therapies improve survival?

Should the interval between mechanical ventilation and cannulation be limited to 72 hours?

Should we prone patients with COVID-19 while on ECMO?

Should we consider the need for VA -ECMO an absolute contraindication?

Is Right Ventricular dysfunction reversible in COVID-19 ARDS?

Should we limit the duration of support to 50 days?

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Top Row

Rakesh Arora 582 poor prognosis? Can cytoreductive therapies improve survival? Should the interval between mechanical ventilation and cannulation be limited to 72 hours? Should we prone patients with COVID-19 while on ECMO? Should we consider the need for VA -ECMO an absolute contraindication? Is Right Ventricular dysfunction reversible in COVID-19 ARDS?