Extracorporeal membrane oxygenation support for SARS-CoV-2: a multi-centered, prospective, observational study in critically ill 92 patients in Saudi Arabia

Abstract

Background Extracorporeal membrane oxygenation (ECMO) has been used as a rescue strategy in patients with severe with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2 infection, but there has been little evidence of its efficacy. Objectives To describe the effect of ECMO rescue therapy on patient-important outcomes in patients with severe SARS-CoV-2. Methods A case series study was conducted for the laboratory-confirmed SARS-CoV-2 patients who were admitted to the ICUs of 22 Saudi hospitals, between March 1, 2020, and October 30, 2020, by reviewing patient’s medical records prospectively. Results ECMO use was associated with higher in-hospital mortality (40.2% vs. 48.9%; p = 0.000); lower COVID-19 virological cure (41.3% vs 14.1%, p = 0.000); and longer hospitalization (20.2 days vs 29.1 days; p = 0.000), ICU stay (12.6 vs 26 days; p = 0.000) and mechanical ventilation use (14.2 days vs 22.4 days; p = 0.000) compared to non-ECMO group. Also, there was a high number of patients with septic shock (19.6%) and multiple organ failure (10.9%); and more complications occurred at any time during hospitalization [pneumothorax (5% vs 29.3%, p = 0.000), bleeding requiring blood transfusion (7.1% vs 38%, p = 0.000), pulmonary embolism (6.4% vs 15.2%, p = 0.016), and gastrointestinal bleeding (3.3% vs 8.7%, p = 0.017)] in the ECMO group. However, PaO2 was significantly higher in the 72-h post-ECMO initiation group and PCO2 was significantly lower in the 72-h post-ECMO start group than those in the 12-h pre-ECMO group (62.9 vs. 70 mmHg, p = 0.002 and 61.8 vs. 51 mmHg, p = 0.042, respectively). Conclusion Following the use of ECMO, the mortality rate of patients and length of ICU and hospital stay were not improved. However, these findings need to be carefully interpreted, as most of our cohort patients were relatively old and had multiple severe comorbidities. Future randomized trials, although challenging to conduct, are highly needed to confirm or dispute reported observations.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature*

“…Two congenital diaphragmatic studies found contrasting results (153, 154) and two obstetric studies showed higher ECMO use in patients from diverse backgrounds (155, 156). None examined language and only one Saudi Arabian study examined immigration status with greater ECMO utilization with legal (vs illegal) entry but higher use in non-nationals (vs Saudi Arabians) (157).…”

“…Individual-level primary themes were: 1) differential access to care (28, 30, 33, 106, 114, 122, 168, 170), 2) varying clinical presentations (26, 27, 30, 31, 80, 92, 128, 161, 168), 3) different religious/cultural preferences (26, 27, 80, 89, 93, 168), or other unmeasured individual SDoH as confounders (30, 84, 96). Hospital-level mechanisms included: 1) provider-level treatment variation (26, 31, 80, 93, 167, 169) and 2) between-hospital variability in offering ECMO, timing of initiation, organizational structure, experience, and standardized care practices/processes (27, 30, 31, 80, 90, 106, 122, 123, 129–131, 154, 157, 161, 168–173). Specific systemic/structural factors such as legal frameworks, economic systems, and social policies included: 1) healthcare system adequacy (pay-for-performance measures [31, 122], disparate insurance access and quality [28, 32, 106, 128, 167] and, in countries with universal healthcare, need for enhanced systems to serve marginalized communities [30, 110, 114, 117]) and 2) geographic centralization, balancing consolidated expertise, and quality with accessibility of time-critical technology (106, 171–174).…”

Fungal Infections in the ICU during the COVID-19 Era: Descriptive and Comparative Analysis of 178 Patients

“…Barotrauma has been shown to be quite prevalent in COVID-19 patients. Pneumothorax has been identified in up to 20% of mechanically ventilated patients and to almost 30% of patients on ECMO [ 30 , 31 , 32 ]. It is noteworthy that our patients with fungal infections more frequently had barotrauma (68.4% vs. 18.9%), which included pneumothorax, pneumomediastinum, and subcutaneous emphysema.…”

Risk Factors for Bleeding in Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation and Effects of Transcatheter Arterial Embolization for Hemostasis

“…The clinical characteristics of the groups with and without bleeding events are shown in Table 1. In this study, body mass index (BMI) of 30 kg/m 2 or greater was used as a cutoff value for high vs. normal weight because moderate or severe obesity (BMI greater than or equal to 30 kg/m 2 ) has been reported as a risk factor for severe COVID-19 infection [14,15]. Hypertension, diabetes mellitus, cardiovascular disease, chronic obstructive pulmonary disease, and chronic kidney disease were evaluated as comorbidities because they are also known as risk factors [14,16].…”

“…In this study, body mass index (BMI) of 30 kg/m 2 or greater was used as a cutoff value for high vs. normal weight because moderate or severe obesity (BMI greater than or equal to 30 kg/m 2 ) has been reported as a risk factor for severe COVID-19 infection [14,15]. Hypertension, diabetes mellitus, cardiovascular disease, chronic obstructive pulmonary disease, and chronic kidney disease were evaluated as comorbidities because they are also known as risk factors [14,16]. The hospitalization period was defined as the duration from the date of admission to that of discharge, but all enrolled patients were transferred to other hospitals to continue their treatment after completing ECMO therapy because our hospital is a tertiary referral center.…”