Extracorporeal life support in pandemics

Pandemic diseases have inflicted significant morbidity and mortality on humankind throughout history, often from acute respiratory failure due to pneumonia and the acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) has been used for the management of patients with ARDS during pandemics of the 21st century, including both the influenza A (H1N1) and coronavirus disease 2019 pandemics. While ECMO has been shown to improve outcomes in ARDS, it is resource intensive. During pandemic conditions, demand for ECMO has often outnumbered access and availability. In light of such limitation, healthcare systems, medical societies, and national governments have, at times, standardized approaches to and coordinated care of patients requiring ECMO in attempts to optimize patient outcomes and access to ECMO. © 2023 Elsevier Inc. All rights reserved.

Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation.

Objective: Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality. Design: Multicenter, retrospective analysis between January 2008 and September 2021. Setting: Three tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich). Patients: Seventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study. Measurements and main results: Fifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28-57) years and SOFA score was 14 (12-17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12-123) at V-VA ECMO upgrade to 9 (3-37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6-22) days and ICU length of stay was 32 (16-46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis. Conclusion: In this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.

Extracorporeal Life Support in Respiratory Failure.

Extracorporeal life support (ECLS) has a role in different types of respiratory failure including acute respiratory distress syndrome (ARDS), decompensated pulmonary hypertension, bridge to lung transplantation, and primary graft dysfunction after lung transplantation. ECLS in ARDS allows for lung-protective ventilation with the goal to reduce the risk of ventilator-induced lung injury. ECLS use in severe ARDS should be considered when conventional management strategies are not sufficient to safely support gas exchange. More research is needed to identify optimal mechanical ventilation during ECLS, weaning ECLS support, strategies for mobilization, sedation and anticoagulation, and long-term outcomes post-ECLS.

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda.

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

Extracorporeal corporeal membrane oxygenation: indications, technical considerations, and future trends

The extracorporeal membrane oxygenation (ECMO) device was initially developed with the goal of providing extended support in patients experiencing cardiac failure. However, ECMO technology has evolved, and now provides a means to successfully manage patients experiencing cardiac and/or pulmonary failure until such time as the patient's body is able to either heal, or undergo transplantation. In addition, it has been used in the management of multisystem organ dysfunction. The life-saving utility of this therapy for critically ill patients has prompted world-wide implementation particularly in resource-rich settings. Innovations in instrumentation, broad clinical implementation, extensive utilization of blood and blood components, and the catastrophic nature of potential complications, have collectively prompted the evolution of a tremendous body of research. In this comprehensive review we briefly describe the early development of the ECMO device and technology, in addition to outlining the function of the device as it now commonly utilized including veno-arterial (VA) vs. veno-venous (VV) and rapid deployment ECMO. This review will also delineate the rationale for ECMO use, common clinical indications, and specialized techniques, in addition to the approaches necessary for their successful implementation. As systemic anticoagulation is frequently utilized to support patients on ECMO, the review also contains an extensive review of anticoagulation management, blood component utilization, and potential hematologic complications of ECMO. The review includes a discussion of more recent trends including the use of ECMO in COVID-19 patients, and the performance of tandem plasma exchange. Finally, areas of current controversy and needed research will be highlighted. © 2022 The authors.

Thrombolysis in Children: A Case Report and Review of the Literature.

Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.

Extracorporeal Membrane Oxygenation for COVID-19: Case Report of Nine Patients.

Covid-19, Coronavirus disease 2019; ARDS, Acute respiratory distress syndrome; ECMO, Extracorporeal Membrane Oxygenation; WHO, World Health Organization; ICUs, Intensive care units. Acute respiratory distress syndrome (ARDS) is a fatal comorbidity of critically ill patients with COVID-19, who often end up on respiratory support. However, the safety and effectiveness of Extracorporeal Membrane Oxygenation (ECMO) in the treatment of COVID-19 remains to be elucidated at present. Here, we report on nine patients who received ECMO due to severe SARS-CoV-2 infection in Wuhan, China. Our initial experiences suggest that carefully selecting patients, as well as management by a well-trained team, are critical to implementing ECMO in patients with COVID-19. More randomized controlled trials with larger sample sizes are needed to evaluate the usefulness of ECMO in patients with COVID-19.

Extracorporeal membrane oxygenation in patients with COVID-19: 1-year experience.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) in patients with coronavirus disease 2019 (COVID-19) showed reasonable outcomes. However, recent studies indicated a negative trend and analysis is needed. METHODS: Baseline characteristics, laboratory parameters, and outcomes of ECMO-supported patients with COVID-19 were analyzed in a retrospective single-center study. We included hospital admissions until February 28, 2021; patients were followed until discharge/death. Eventually, we compared data between patients hospitalized before and after September 1, 2020. RESULTS: Median age of patients treated with ECMO (n=39) was 56 years; most patients were males (n=28, 72%). Median mechanical ventilation time (prior to ECMO) was 6 days, while the median ECMO duration was 19 days. Overall survival rate was 41%. In the sub-analysis, survival until discharge in the first and second epidemic waves was 53% (n=19) and 30% (n=20), respectively (P=0.2). At baseline, compared with patients of the first wave, those of the second wave had higher median body mass index (28.2 vs. 31.1 kg/m2, respectively, P=0.02), bicarbonate (27 vs. 31.8 mmol/L, respectively, P=0.033), plasma free hemoglobin (36 vs. 58 mg/L, respectively, P=0.013), alanine aminotransferase (33 vs. 52 U/L, respectively, P=0.018), and pH (7.29 vs. 7.42, respectively, P=0.005), lower rate of pulmonary hypertension (32% vs. 0%, respectively, P=0.008), lower positive end-expiratory pressure (14 vs. 12 cmH2O, respectively, P=0.04), longer median ECMO duration (16 vs. 24.5 days, respectively, P=0.074), and more frequent major bleeding events (42% vs. 80%, respectively, P=0.022). CONCLUSIONS: ECMO-supported patients with COVID-19 had an overall survival rate of 41%. Similar to international registries, we observed less favorable outcomes during the second wave. Further research is needed to confirm this signal and find predictors for mortality.

Fatal COVID-19 in a Child with Persistence of SARS-CoV-2 Despite Extensive Multidisciplinary Treatment: A Case Report.

Critical Coronavirus disease 2019 (COVID-19) developed in a 7-year-old girl with a history of dystrophy, microcephaly, and central hypothyroidism. Starting with gastrointestinal symptoms, the patient developed severe myocarditis followed by progressive multiple organ failure complicated by Pseudomonas aeruginosa bloodstream infection. Intensive care treatment consisting of invasive ventilation, drainage of pleural effusion, and high catecholamine therapy could not prevent the progression of heart failure, leading to the implantation of venoarterial extracorporeal life support (VA-ECLS) and additional left ventricle support catheter (Impella® pump). Continuous venovenous hemofiltration (CVVH) and extracorporeal hemadsorption therapy (CytoSorb®) were initiated. Whole exome sequencing revealed a mutation of unknown significance in DExH-BOX helicase 30 (DHX30), a gene encoding a RNA helicase. COVID-19 specific antiviral and immunomodulatory treatment did not lead to viral clearance or control of hyperinflammation resulting in the patient's death on extracorporeal life support-(ECLS)-day 20. This fatal case illustrates the potential severity of pediatric COVID-19 and suggests further evaluation of antiviral treatment strategies and vaccination programs for children.