Posthospitalization outcomes after extracorporeal membrane oxygenation (ECMO) for COVID-19.

BACKGROUND: Critical illness from COVID-19 is associated with prolonged hospitalization and high mortality rates. Extracorporeal membrane oxygenation is used for refractory severe acute respiratory distress syndrome in COVID-19 with outcomes comparable to other indications for extracorporeal membrane oxygenation. However, long-term functional outcomes have yet to be fully elucidated. METHODS: We performed a retrospective chart review of 24 consecutive patients who required extracorporeal membrane oxygenation due to COVID-19 associated severe acute respiratory distress syndrome and survived to hospital discharge. After hospitalization, we contacted patients and administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 tool to assess longer-term outcomes. We abstracted demographics, clinical course, outcomes, and disposition variables from the electronic medical record. Descriptive statistical analysis was used on the retrospective data collection. RESULTS: Inpatient data were analyzed for 24 patients, and 21 of 24 (88%) patients completed the Patient-Reported Outcomes Measurement Information System tool at an average of 8.8 months posthospitalization. At hospital discharge, 62.5% of patients had ongoing oxygen requirements (nasal cannula, trach collar, or mechanical ventilation); 70.8% were discharged to a location other than home. However, at the time of follow-up, only 9.5% of patients required supplemental oxygen, all tracheostomies had been removed, and all patients resided at home. Patients reported relatively high levels of global physical function, and though there was a high reported incidence of fatigue, overall pain scores were low. CONCLUSION: Long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from coronavirus disease 2019 are promising. Extracorporeal membrane oxygenation therapy may confer morbidity benefits in patients with coronavirus disease and remains a valuable modality with excellent functional outcomes and preserved quality of life for survivors.

Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: COVID-19 can cause ARDS that is rapidly progressive, severe, and refractory to conventional therapies. ECMO can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined. SUMMARY BACKGROUND DATA: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best postcannulation management strategy, however, has not yet been defined. METHODS: We conducted a retrospective review from April 1 to July 31, 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality. RESULTS: Forty-four patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs 53.1 years; P < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:-FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs 19.9 days, P = 0.028) and shorter duration of intensive care unit (ICU) length of stay before cannulation (5.6 days vs 11.7 days, P = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%. CONCLUSIONS: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome During Hemorrhagic Shock.

Despite overall improvements in critical care, mortality from acute respiratory distress syndrome (ARDS) remains high. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is used to rescue patients with severe ARDS. Although V-V ECMO can be life-saving, there are significant risks associated with this therapy. Hemorrhage is one of the most common complications. Therefore, some providers are reluctant to use V-V ECMO in patients with severe ARDS who concurrently have a high risk of bleeding or recent active hemorrhage. Several studies have been published detailing the safety of heparin-sparing or completely heparin-free anticoagulation strategies in patients on V-V ECMO. We present the cases of two patients with hemorrhagic shock and ongoing transfusion requirements who developed severe and refractory ARDS while in the operating room for hemorrhage control. After the massive bleeding was stopped, both patients were placed on V-V ECMO and were managed with minimal or no therapeutic anticoagulation for the duration of their course on V-V ECMO. Both patients required multiple operations and procedures while on V-V ECMO and there were no significant hemorrhagic complications. In conclusion, V-V ECMO can be considered for use in select patients with severe ARDS and high risk of hemorrhage, active hemorrhage, or ongoing transfusion requirements.