ECMO in COVID-19—prolonged therapy needed? A retrospective analysis of outcome and prognostic factors

Abstract

Background: The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy. Methods: A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed. Results: Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8–32.1) ml/cmH2O vs 18.7 (17.7–25.0) ml/cmH2O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16–23) days vs 5 (5–9) days, p = 0.002) and SOFA score was higher (12.0 (10.5–17.0) vs 10.0 (9.0–10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome. Conclusions: VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…In an early single-center experience, Mols et al reported a shorter ECMO runtime for survivors of ECMO treatment [ 70 ]. However, these findings could not be reproduced in more recent reports [ 121 , 127 , 225 , 226 , 227 , 228 ]. In a very recent analysis of the ELSO database, the authors specifically looked at prolonged ECMO runs >14 days and found survival rates of greater than 50% [ 89 ].…”

“…Our experience as a COVID-19 referral center is consistent with what has been described in the literature. COVID-19 warrants long ECMO runtime and, if necessary, several oxygenator changes or even recannulations, because these factors seem to not be associated with poor survival [ 91 , 184 , 227 , 231 ].…”

Clinical Characteristics Between Survivors and Nonsurvivors of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) Support: A Systematic Review and Meta-Analysis

“…12 cohorts contained comparative body mass index (BMI) data for COVID-19 survivors and nonsurvivors receiving ECMO support (Figure 2). 16,[18][19][20][23][24][25][26][27][28][29] The BMI was comparable among COVID-19 survivors and nonsurvivors requiring ECMO support (mean 30.07kg/m 2 vs 30.86kg/ m 2 , SMD 0.06; 95% CI [ − 0.23, 0.34]; I 2 = 43%; P = .70).…”

“…16,18,20,22,26,27,[29][30][31] Before ECMO support initiation, ten studies demonstrated that PEEP was equal (mean 13.13 vs 13.15 cmH 2 0; SMD 0.07; 95% CI [ − 0.10, 0.23];I 2 = 0%; P = .42) in both COVID-19 survivors and nonsurvivors (Figure 4). 16,[18][19][20]22,[26][27][28]30,31 Among seven studies describing TV before ECMO support initiation, no difference (mean 5.63 vs 5.68 mL/kg; SMD − 0.12; 95% CI [ − 0.33, 0.09];I 2 = 5%; P = .25) in TV was observed between survivors and nonsurvivors (Figure 4). 16,18,19,21,22,27 Lastly, five studies reported comparable plateau pressure (mean 29.82 vs 30.5 cmH 2 0; SMD − 0.18; 95% CI [ − 0.39, 0.03];I 2 = 0%; P = .10) among COVID-19 survivors and nonsurvivors before ECMO support initiation (Figure 4).…”

Transition from Simple V-V to V-A and Hybrid ECMO Configurations in COVID-19 ARDS

“…In this population, circulatory support is required in up to 64% of patients, while the remaining cases might benefit from additional venous cannulations to improve the blood return or perfusion in respiratory support. Contrarily, the available literature reports a much lower percentage of ECMO configuration conversions ranging from 2% to 7% [31][32][33][34][35][36]. This difference might be explained with the different policies applied in ECMO centres all over the world.…”