Potential for recovery after extremely prolonged VV-ECMO support in well-selected severe COVID-19 patients: a retrospective cohort study.

BACKGROUND: VenoVenous ExtraCorporeal Membrane Oxygenation (VV-ECMO) has been widely used as supportive therapy for severe respiratory failure related to Acute Respiratory Distress Syndrome (ARDS) due to coronavirus 2019 (COVID-19). Only a few data describe the maximum time under VV-ECMO during which pulmonary recovery remains possible. The main objective of this study is to describe the outcomes of prolonged VV-ECMO in patients with COVID-19-related ARDS. METHODS: This retrospective study was conducted at a tertiary ECMO center in Brussels, Belgium, between March 2020 and April 2022. All adult patients with ARDS due to COVID-19 who were managed with ECMO therapy for more than 50 days as a bridge to recovery were included. RESULTS: Fourteen patients met the inclusion criteria. The mean duration of VV-ECMO was 87 ± 29 days. Ten (71%) patients were discharged alive from the hospital. The 90-day survival was 86%, and the one-year survival was 71%. The evolution of the patients was characterized by very impaired pulmonary compliance that started to improve slowly and progressively on day 53 (± 25) after the start of ECMO. Of note, four patients improved substantially after a second course of steroids. CONCLUSIONS: There is potential for recovery in patients with very severe ARDS due to COVID-19 supported by VV-ECMO for up to 151 days.

Prolonged extracorporeal membrane oxygenation in pediatrics: How long did we wait?

BACKGROUND: In this study, we aimed to evaluate the duration of extracorporeal membrane oxygenation (ECMO) and its effect on outcomes. Also, we sought to identify hospital mortality predictors and determine when ECMO support began to be ineffective. METHODS: This was a single-center, retrospective cohort study conducted between January 2014 and January 2022. The prolonged ECMO (pECMO) cut-off point was accepted as 14 days. RESULTS: Thirty-one (29.2%) of 106 patients followed up with ECMO had pECMO. The mean follow-up period of the patients who underwent pECMO was 22 (range, 15-72) days, and the mean age was 75 ± 72 months. According to the results of our heterogeneous study population, life expectancy decreased dramatically towards the 21st day. Hospital mortality predictors were determined in the logistic regression analysis in all ECMO groups in our study as high Pediatric Logistic Organ Dysfunction (PELOD) two score, continuous renal replacement therapy (CRRT) use, and sepsis. The pECMO mortality was 61.2% and the overall mortality was 53.0%, with the highest mortality rate in the bridge-to-transplant group (90.9%) because of lack of organ donation in our country. CONCLUSIONS: In our study, the PELOD two score, presence of sepsis, and use of CRRT were found to be in the predictors of in-hospital ECMO mortality model. Considering the complications, in the COX regression model analysis, the factors affecting the probability of dying in patients followed under ECMO were found to be bleeding, thrombosis, and thrombocytopenia.

Severe Lung Dysfunction and Pulmonary Blood Flow during Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is indicated for patients with severe respiratory and/or circulatory failure. The standard technique to visualize the extent of pulmonary damage during ECMO is computed tomography (CT). PURPOSE: This single-center, retrospective study investigated whether pulmonary blood flow (PBF) measured with echocardiography can assist in assessing the extent of pulmonary damage and whether echocardiography and CT findings are associated with patient outcomes. METHODS: All patients (>15 years) commenced on ECMO between 2011 and 2017 with septic shock of pulmonary origin and a treatment time >28 days were screened. Of 277 eligible patients, 9 were identified where both CT and echocardiography had been consecutively performed. RESULTS: CT failed to indicate any differences in viable lung parenchyma within or between survivors and non-survivors at any time during ECMO treatment. Upon initiation of ECMO, the survivors (n = 5) and non-survivors (n = 4) had similar PBF. During a full course of ECMO support, survivors showed no change in PBF (3.8 ± 2.1 at ECMO start vs. 7.9 ± 4.3 L/min, p = 0.12), whereas non-survivors significantly deteriorated in PBF from 3.5 ± 1.0 to 1.0 ± 1.1 L/min (p = 0.029). Tidal volumes were significantly lower over time among the non-survivors, p = 0.047. CONCLUSIONS: In prolonged ECMO for pulmonary septic shock, CT was not found to be effective for the evaluation of pulmonary viability or recovery. This hypothesis-generating investigation supports echocardiography as a tool to predict pulmonary recovery via the assessment of PBF at the early to later stages of ECMO support.

Outcomes of patients with COVID-19 supported by venovenous extracorporeal membrane oxygenation for greater than 90 days.

Objective: To determine the characteristics and outcomes of patients requiring prolonged (>90 days) venovenous extracorporeal membrane oxygenation (VV ECMO) support for refractory Coronavirus disease 2019 (COVID-19)-associated respiratory failure. Methods: A retrospective, observational analysis of consecutive patients requiring VV ECMO for COVID-19-associated respiratory failure was performed at a single institution between March 2020 and January 2022. Data were collected from the medical records. Patients were predominantly cannulated and supported long-term with a single, dual-lumen cannula in the internal jugular vein with the tip positioned in the pulmonary artery. All patients were managed with an awake VV ECMO approach, emphasizing avoidance of sedatives, extubation, ambulation, physical therapy, and nutrition. Patients requiring >90 days of ECMO were identified, analyzed, and compared to those needing a shorter duration of support. Results: A total of 44 patients were supported on VV ECMO during the study period, of whom 36 (82%) survived to discharge. Thirty-one patients were supported for <90 days, of whom 28 (90%) were discharged alive. Thirteen patients required >90 days of ECMO. All patients were extubated. Eight patients (62%) survived to discharge, with 1 patient requiring lung transplantation prior to decannulation. All survivors were free from mechanical ventilation and alive at a 6-month follow-up. Of the 4 patients who died on prolonged ECMO, 2 developed hemothorax necessitating surgery and 2 succumbed to fatal intracranial hemorrhage. Conclusions: Patients treated with VV ECMO for COVID-19-associated respiratory failure may require prolonged support to recover. Extubation, ambulation, aggressive rehabilitation, and nutritional support while on ECMO can yield favorable outcomes.