Use of Extracorporeal Membrane Oxygenation for Patients with Coronavirus Disease 2019 Infection.

The coronavirus disease 2019 (COVID-19) pandemic was a cataclysmic event that infected over 772 million and killed over 6.9 million people worldwide. The pandemic pushed hospitals and society to their limits and resulted in incredibly severe respiratory disease in millions of people. This severe respiratory disease often necessitated maximum medical therapy, including the use of extracorporeal membrane oxygenation. While our understanding of COVID-19 and its treatment continue to evolve, we review the current evidence to guide the care of patients with severe COVID-19 infection.

VV-ECMO in critical COVID-19 obese patients: a cohort study.

BACKGROUND: Obesity causes significant difficulties in successful extracorporeal membrane oxygenation (ECMO) support and may interfere with patient outcomes. During the COVID-19 pandemic, we experienced an increased number of obese patients supported with ECMO in our intensive care unit due to severe illness in this population. METHODS: We designed a single-center retrospective study to identify prognostic factors for 180-day survival in obese critical COVID-19 patients receiving venovenous ECMO (VV-ECMO). We included adult critical COVID-19 patients on VV-ECMO, who were obese and overweight (according to the World Health Organization) and admitted to a tertiary hospital's intensive care unit from April 1, 2020, to May 31, 2022. Univariate logistic regression analysis was performed to assess differences in 180-day mortality. RESULTS: Forty-one patients were included. The median age was 55 (IQR 45-60) years, and 70.7% of the patients were male. The median body mass index (BMI) was 36 (IQR 31-42.5) kg/m2; 39% of patients had a BMI ≥ 40 kg/m2. The participants had 3 (IQR 1.5-4) days of mechanical ventilation prior to ECMO, and 63.4% were weaned from VV-ECMO support after a median of 19 (IQR 10-34) days. The median ICU length of stay was 31.9 (IQR 17.5-44.5) days. The duration of mechanical ventilation was 30 (IQR 19-49.5) days. The 180-day mortality rate was 41.5%. Univariate logistic regression analysis revealed that a higher BMI was associated with greater 180-day survival (OR 1.157 [1.038-1.291], p = 0.009). Younger age, female sex, less invasive ventilation time before ECMO, and fewer complications at the time of ECMO cannulation were associated with greater 180-day survival [OR 0.858 (0.774-0.953), p 0.004; OR 0.074 (0.008-0.650), p 0.019; OR 0.612 (0.401-0.933), p 0.022; OR 0.13 (0.03-0.740), p 0.022), respectively]. CONCLUSION: In this retrospective cohort of critical COVID-19 obese adult patients supported by VV-ECMO, a higher BMI, younger age, and female sex were associated with greater 180-day survival. A shorter invasive ventilation time before ECMO and fewer complications at ECMO cannulation were also associated with increased survival.

Duration of Invasive Mechanical Ventilation before Veno-Venous ExtraCorporeal Membrane Oxygenation for Covid-19 related Acute Respiratory Distress Syndrome: The experience of a tertiary care center.

Background: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an efficient ventilatory support in patients with refractory Covid-19-related Acute Respiratory Distress Syndrome (ARDS), however the duration of invasive mechanical ventilation (IMV) before ECMO initiation as a contraindication is still controversial. The aim of this study was to investigate the impact of prolonged IMV prior to VV-ECMO in patients suffering from refractory Covid-19-related ARDS. Methods: This single-center retrospective study included all patients treated with VV-ECMO for refractory Covid-19-related ARDS between January 1, 2020 and May 31, 2022. The impact of IMV duration was investigated by comparing patients on VV-ECMO during the 7 days (and 10 days) following IMV with those assisted after 7 days (and 10 days). The primary endpoint was in-hospital mortality. Results: Sixty-four patients were hospitalized in the ICU for Covid-19-related refractory ARDS requiring VV-ECMO. Global in-hospital mortality was 55 %. Median duration of IMV was 4 [2; 8] days before VV-ECMO initiation. There was no significant difference in in-hospital mortality between patients assisted with IMV pre-VV-ECMO for a duration of ≤7 days (≤10 days) and those assisted after 7 days (and 10 days) ((p = 0.59 and p = 0.45). Conclusion: This study suggests that patients assisted with VV-ECMO after prolonged IMV had the same prognosis than those assisted earlier in refractory Covid-19-related ARDS. Therefore, prolonged mechanical ventilation of more than 7-10 days should not contraindicate VV-ECMO support. An individual approach is necessary to balance the risks and benefits of ECMO in this population.

The use of prone position ventilation in Danish patients with COVID-19-induced severe acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation: A nationwide cohort study with focus on pulmonary effects.

BACKGROUND: Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance. METHODS: This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported. RESULTS: Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course. CONCLUSION: Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.

A Case of COVID-19 Pneumonia Leading to Acute Respiratory Distress Syndrome (ARDS) and Multi-organ Failure Requiring Extracorporeal Membrane Oxygenation (ECMO) for Six Months and an Associated Critical Limb Ischemia.

This article presents the case of a 57-year-old woman with a history of rheumatoid arthritis who developed severe coronavirus disease 2019 (COVID-19) pneumonia that progressed to acute respiratory distress syndrome (ARDS) and multi-system organ failure. Despite initial slow progression and multiple hospital readmissions, her condition rapidly deteriorated, leading to full respiratory failure requiring intubation and ventilation. She was transferred to a specialized center where she underwent extracorporeal membrane oxygenation (ECMO) and hemodialysis for acute renal failure. Unfortunately, she remained dependent on ECMO for an extended period of six months. Although she made a gradual recovery, the prolonged critical care treatment resulted in critical ischemia of multiple extremities, necessitating a below-knee amputation (BKA) of her left lower extremity and transmetatarsal amputations of her right hand. This case reports one of the longest ECMO treatments for COVID-19 and associated comorbidities in the literature. Clinicians could include a longer duration of treatment and potential associated disabilities in the informed consent.

The impact of small movements with dual lumen cannulae during venovenous extracorporeal membrane oxygenation: A computational fluid dynamics analysis.

BACKGROUND AND OBJECTIVES: Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) provides respiratory support to patients with severe lung disease failing conventional medical therapy. An essential component of the ECMO circuit are the cannulas, which drain and return blood into the body. Despite being anchored to the patient to prevent accidental removal, minor cannula movements are common during ECMO. The clinical and haemodynamic consequences of these small movements are currently unclear. This study investigated the risk of thrombosis and recirculation caused by small movements of a dual lumen cannula (DLC) in an adult using computational fluid dynamics. METHODS: The 3D model of an AVALON Elite DLC (27 Fr) and a patient-specific vena cava and right atrium were generated for an adult patient on ECMO. The baseline cannula position was generated where the return jet enters the tricuspid valve. Alternative cannula positions were obtained by shifting the cannula 5 and 15 mm towards inferior (IVC) and superior (SVC) vena cava, respectively. ECMO settings of 4 L/min blood flow and pulsatile flow at SVC and IVC were applied. Recirculation was defined as a scalar value indicating the infused oxygenated blood inside the drainage lumen, while thrombosis risk was evaluated by shear stress, stagnation volume, washout, and turbulent kinetic energy. RESULTS: Recirculation for all models was less than 3.1 %. DLC movements between -5 to 15 mm increased shear stress and turbulence kinetic energy up to 24.7 % and 11.8 %, respectively, compared to the baseline cannula position leading to a higher predicted thrombosis risk. All models obtained a complete washout after nine seconds except for when the cannula migrated 15 mm into the SVC, indicating persisting stasis and circulating zones. CONCLUSION: In conclusion, small DLC movements were not associated with an increased risk of recirculation. However, they may increase the risk of thrombosis due to increased shear rate, turbulence, and slower washout of blood. Developing effective cannula securement devices may reduce this risk.

Late Diagnosis of Langerhans Cell Histiocytosis by Skin Biopsy in a Lung Transplant Candidate Patient.

We present the case of a lung transplant candidate under veno-venous membrane oxygenation assistance (VV ECMO) whose diagnosis of emphysema of undetermined etiology was redefined as Langerhans cell histiocytosis (LCH) due to a scalp skin biopsy performed years after the beginning of his respiratory symptoms. A 20-year-old patient started three years before his admission with progressive dyspnea leading to a diagnosis of bullous emphysema of undetermined cause, which evolved into respiratory failure and evaluation for bilateral lung transplant. Three years later, he developed bilateral pneumonia requiring mechanical ventilation. When refractory hypoxemia ensued, he had to be placed on VV ECMO. Under these conditions, he was transferred to our center and listed for a bilateral pulmonary transplantation. Forty-eight hours after admission, and due to intense polyuria, central diabetes insipidus was diagnosed. In this clinical context, the presence of cutaneous lesions on the scalp was reconsidered and biopsied under the presumption of possible LCH, with pathology analysis confirming the diagnosis. He continued to be assisted with VV ECMO for 66 more days as a bridge to transplantation, developing multi-organ failure and passing away before a donor organ was available. The diagnosis of LCH should be considered in any adult patient with bullous emphysema of undetermined cause. Given the possibility of early therapeutic interventions, the search for its clinical associations (e.g., diabetes insipidus and/or skin lesions) should be a systematic part of the etiologic workup. The availability of skin specimens to reach a diagnosis makes its thorough search an important part of the diagnostic approach.

Association between a low-risk COVID-19 extracorporeal membrane oxygenation criteria and mortality: A retrospective study.

OBJECTIVE: Our study aimed to compare the outcomes of COVID-19 patients who met a low-risk inclusion criteria for veno-venous extra corporeal membrane oxygenation (VV ECMO) with those who did not meet criteria due to higher risk but were subsequently cannulated. METHODS: This was a retrospective observational cohort study that included adult patients who were placed on VV ECMO for COVID-19 related acute respiratory distress syndrome (ARDS) at a tertiary care academic medical center. The primary outcome was the association between the low-risk criteria and mortality. The patients met the criteria if they met EOLIA severe ARDS criteria, no absolute contraindications (age > 60 years, BMI > 55 kg/m2, mechanical ventilation (MV) duration >7 days, irreversible neurologic damage, chronic lung disease, active malignancy, or advanced multiorgan dysfunction), and had three or less relative contraindications (age > 50 years, BMI > 45 kg/m2, comorbidities, MV duration > 4 days, acute kidney injury, receiving vasopressors, hospital LOS > 14 days, or COVID-19 diagnosis > 4 weeks). RESULTS: Sixty-five patients were included from March 2020 through March 2022. Patients were stratified into low-risk or high-risk categories. The median Sequential Organ Failure Assessment score was 7 and the median PaO2/FiO2 ratio was 44 at the time of ECMO cannulation. The in-hospital mortality was 47.8% in the low-risk group and 69.0% in the high-risk group (p = 0.096). CONCLUSION: There was not a statistically significant difference in survival between low-risk patients and high-risk patients; however, there was a trend toward higher survival in the lower-risk group.

Analysis of Patients with Severe ARDS on VV ECMO Treated with Inhaled NO: A Retrospective Observational Study.

(1) Background: This retrospective study focused on severe acute respiratory distress syndrome (ARDS) patients treated with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) and who inhaled nitric oxide (NO) for pulmonary arterial hypertension (PAH) and/or right ventricular failure (RV failure). (2) Methods: Out of 662 ECMO-supported patients, 366 received VV ECMO, including 48 who inhaled NO. We examined the NO's indications, dosing, duration, and the ability to lower PAH. We compared patients with and without inhaled NO in terms of mechanical ventilation duration, ECMO weaning, organ dysfunction, in-hospital mortality, and survival. (3) Results: Patients received 14.5 ± 5.5 ppm NO for 3 days with only one-third experiencing decreased pulmonary arterial pressure. They spent more time on VV ECMO, had a higher ECMO weaning failure frequency, and elevated severity scores (SAPS II and TIPS). A Kaplan-Meier analysis revealed reduced survival in the NO group. Multiple variable logistic regression indicated a twofold increased risk of death for ARDS patients on VV ECMO with NO. We observed no increase in continuous renal replacement therapy. (4) Conclusions: This study suggests that persistent PAH and/or RV failure is associated with poorer outcomes in severe ARDS patients on VV-ECMO, with an inhaled NO responder rate of only 30%, and it does not impact acute kidney failure rates.

Veno-venous extra-corporeal membrane oxygenation in complex tracheobronchial resection.

Background: Elective extra-corporeal membrane oxygenation (ECMO) is rarely used in thoracic surgery, apart from lung transplantation. The purpose of this study was to summarize our institutional experience with the intraoperative use of veno-venous (VV) ECMO in selected cases of main airway surgery. Methods: We retrospectively analyzed the data of 10 patients who underwent main airway surgery with the support of VV-ECMO between June 2013 and August 2022. Results: Surgical procedures included: three carinal resection and reconstruction with complete preservation of the lung parenchyma, one right upper double-sleeve lobectomy and hemi-carinal resection, and one sleeve resection of the left main bronchus after previous right lower bilobectomy, for thoracic malignancies; four tracheal/carinal repair for extensive traumatic laceration; one extended tracheal resection due to post-tracheostomy stenosis in a patient who had previously undergone a left pneumonectomy. The median intraoperative VV-ECMO use was 162.5 minutes. In three cases with complex resection and reconstruction of the carina and in one case of extended post-tracheostomy stenosis and previous pneumonectomy, high-flow VV-ECMO allowed interruption of ventilation for almost 3 hours. In four patients, VV-ECMO was prolonged in the postoperative period to ensure early extubation. There were no perioperative deaths, no complications related to the use of ECMO and no intraoperative change in the planned type of ECMO. Significant complications occurred only in one patient who developed a small anastomotic dehiscence that led to stenosis and required placement of a Montgomery tube. At the median follow-up of 30 months, all 10 patients were still alive. Conclusions: The use of intraoperative VV-ECMO allows safe and precise performance of main airway surgery with minimal postoperative morbidity in patients requiring complex resections and reconstructions and in cases that cannot be managed with conventional ventilation techniques.

Establishment of a Novel Miniature Double-Lumen Catheter Single-Cannulation Venovenous Extracorporeal Membrane Oxygenation Model in the Rat.

In recent years, venovenous extracorporeal membrane oxygenation (VV ECMO) has been used to support patients with severe lung disease. Active use of VV ECMO was also recommended for severe respiratory failure due to COVID-19. However, VV ECMO is also known to cause various complications due to extracorporeal circulation. Although we conducted ECMO research using rats, we have not been able to establish whether double-lumen single-cannulation VV ECMO models in rats have been described previously. The purpose of this study was to establish a simple, stable, and maintainable miniature double-lumen single-canulation VV ECMO model in rats. A double-lumen catheter used as a plain central venous catheter (SMAC plus Seldinger type; Covidien Japan Co., Tokyo, Japan) was passed through the right external jugular vein and advanced into the right atrium as a conduit for venous uptake. The VV ECMO system comprised a roller pump, miniature membrane oxygenator, and polyvinyl chloride tubing line. During VV ECMO, blood pressure and hemodilution rate were maintained at around 80 mmHg and 30%, respectively. Hemoglobin was kept at >9 g/dL, no serious hemolysis was observed, and VV ECMO was maintained without blood transfusion. Oxygenation and removal of carbon dioxide from the blood were confirmed and pH was adequately maintained. This miniature VV ECMO model appears very useful for studying the mechanisms of biological reactions during VV ECMO.

Methicillin-Sensitive Staphylococcus aureus Co-infection in Adolescent Patients With Delta-Variant SARS-CoV-2 Acute Respiratory Failure.

We report a series of five pediatric patients admitted with acute respiratory failure due to delta-variant SARS-CoV-2, found to have a methicillin-sensitive Staphylococcus aureus (MSSA) co-infection. All five patients required escalation of their respiratory support within 24 hours of discovering the MSSA infections. Four out of the five patients received immune-modulating therapies. Four patients required extracorporeal membrane oxygenation support. One patient died, and the other four survived until hospital discharge. Clinicians should consider secondary bacterial infections in patients with COVID-19 treated with immune modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with COVID-19.

Urgent Cesarean Section in a Patient on Venovenous Extracorporeal Membrane Oxygenation.

A G7P6 40-year-old female at 20 weeks gestation, with a history of polysubstance use disorder and hepatitis C, presented to the emergency department with severe shortness of breath and hypoxia requiring intubation. After a thorough workup, she was diagnosed with aspiration pneumonitis and was treated with a course of antibiotics. After progressing well, she was soon extubated and transferred to a subacute rehabilitation facility (SAR). There, she acutely decompensated, requiring readmission, reintubation, and venovenous extracorporeal membrane oxygenation (ECMO) cannulation. After a brief period of improvement, the patient became increasingly unstable with hypotension, anemia, and downtrending fibrinogen. Bedside imaging indicated a possible placental abruption. After extensive discussion among the care teams and patient's healthcare proxy, an urgent cesarean section was performed. Although the fetus was determined to be nonviable, the patient tolerated the procedure well and was eventually decannulated from ECMO and transferred to a SAR.

Racial disparities among patients on venovenous extracorporeal membrane oxygenation in the pre-Coronavirus Disease 2019 and Coronavirus Disease 2019 eras: A retrospective registry review.

Objectives: Although many studies have addressed such disparities caused by COVID-19, to our knowledge, no study has focused on the association of race on outcomes for patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation support. The goal of this study was to assess association of race on death and duration on venovenous extracorporeal membrane oxygenation in both the pre-COVID-19 and COVID-19 eras. Methods: We retrospectively reviewed the Extracorporeal Life Support Organization registry and included adults (≥18 years) who required venovenous extracorporeal membrane oxygenation between January 2019 and April 2021. We performed descriptive statistics and multivariable logistic regression. Our primary outcomes were death and extracorporeal membrane oxygenation duration. Results: A total of 7477 patients were included after excluding 340 patients (4.3%) who were missing race data. In the COVID-19 era, 1474 of 2777 COVID-19-positive patients (53.1%) died. Our regression model suggested somewhat of a protective effect on death for Black and multiple race patients. Additionally, a diagnosis of COVID-19 and patients in the COVID-19 era in general, irrespective of COVID-19 diagnosis, had higher odds of death. Hispanic patients had the longest average venovenous extracorporeal membrane oxygenation run times. Conclusions: Our study using data from the international Extracorporeal Life Support Organization Registry provides updated data on patients supported with venovenous extracorporeal membrane oxygenation in the pre-COVID-19 and COVID-19 eras between 2019 and 2021 with a focus on race. Patients in the COVID-19 era group also had higher mortality compared with those in the pre-COVID-19 era even after being adjusted for COVID-19 diagnosis. Black and multiple races appeared somewhat protective in terms of death. Hispanic race was associated with longer venovenous extracorporeal membrane oxygenation duration.

Trauma pneumonectomy followed by extracorporeal membrane oxygenation cannulation: a case report.

Background: Trauma pneumonectomy remains an incredibly morbid procedure, reserved for the most critical cases where it is the only surgical option to stop massive ongoing hemorrhage. There are only few cases reported in the literature of survivors of trauma pneumonectomy complicated by acute respiratory distress syndrome (ARDS). We present our case of long-term survival in this circumstance. Given the limited published research on survival after prolonged veno-venous extracorporeal membrane oxygenation (VV-ECMO), it is important to share our experiences using VV-ECMO as an adjunct for pulmonary recovery. Case Description: We present a case of a 35-year-old male patient who survived a gunshot wound to the right lung following trauma pneumonectomy with the assistance of VV-ECMO. He developed postoperative hemodynamic instability and required 38 days of VV-ECMO. He ultimately survived discharge from the hospital. One year after his gunshot injury, the patient was living at home with assistance. Urgent VV-ECMO cannulation and a multi-disciplinary approach was lifesaving in the treatment of this patient's post-pneumonectomy ARDS. Conclusions: In review of the literature, ECMO has been used in a few other cases of ARDS following trauma pneumonectomy to allow for full pulmonary recovery. This case highlights the challenges following this morbid procedure, however with a multidisciplinary approach and urgent use of ECMO, a favorable outcome can be achieved.

Veno-venous extracorporeal membrane oxygenation cannulation in prone position.

A 54-year-old woman was referred for veno-venous extracorporeal oxygenation membrane (VV-ECMO) due to refractory hypoxic respiratory failure caused by COVID-19, despite mechanical ventilation and prolonged prone positioning.

Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report.

Background: Massive hemoptysis during pregnancy is very rare. Dieulafoy's disease is one of the causes of massive hemoptysis. There are few reports of ECMO use to treat massive hemoptysis during pregnancy. Findings: We report for the first time a patient with Dieulafoy's disease diagnosed at 29 weeks of pregnancy. The patient's hemoptysis occurred rapidly with large volumes. The bleeding amount reached 500 ml within half an hour, with the development of asphyxia and respiratory and cardiac arrest due to a blood clot blocking the airway. After successful cardiopulmonary resuscitation, the ventilator could not maintain effective ventilation. Emergency establishment of VV-ECMO was performed to maintain oxygen, and hemostasis was successfully achieved by performing bronchial artery embolization twice. We successfully cleaned blood clots in the airway four times by freezing and using a foreign body retrieval basket with an electronic bronchoscope. At the same time, small and smooth nodular lesions were found under bronchoscopy, and blood vessels with a diameter of 1.5 mm were found under Doppler mode with an ultrasonic bronchoscope, which was consistent with a diagnosis of Dieulafoy's disease. VV-ECMO was successfully stopped on the 3rd day of the disease course, tracheal intubation was successfully removed on the 5th day of the disease course, and the patient was discharged with no complications on the 16th day of the disease course.

How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period?

Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.