Hemoadsorption for management of patients on veno‐venous ECMO support for severe COVID‐19 acute respiratory distress syndrome

Summary Acute respiratory distress syndrome (ARDS) is a rare but life-threatening complication of diabetic ketoacidosis (DKA). We present the case of a young female, with no previous diagnosis of diabetes, presenting in DKA complicated by ARDS requiring extra corporeal membrane oxygenation (ECMO) ventilator support. This case report highlights the importance of early recognition of respiratory complications of severe DKA and their appropriate management. Learning points ARDS is a very rare but life-threatening complication in DKA. The incidence of ARDS remains unknown but less frequent than cerebral oedema in DKA. The mechanism of ARDS in DKA has multifactorial aetiology, including genetic predisposition. Early recognition and consideration of rare pulmonary complication of DKA can increase survival rate and provide very satisfactory outcomes. DKA patients who present with refractory ARDS can be successfully rescued by ECMO support.

Download Full-text

Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation

BMC Pulmonary Medicine ◽

10.1186/s12890-019-1016-2 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Jingen Xia ◽

Sichao Gu ◽

Min Li ◽

Donglin Liu ◽

Xu Huang ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Ecmo Support ◽

Invasive Ventilation ◽

Membrane Oxygenation ◽

Native Lung

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing and non-intubated patients (awake ECMO) may be a novel therapeutic strategy for severe acute respiratory distress syndrome (ARDS) patients. The purpose of this study is to assess the feasibility and safety of awake ECMO in severe ARDS patients receiving prolonged ECMO (> 14 days). Methods We describe our experience with 12 consecutive severe ARDS patients (age, 39.1 ± 16.4 years) supported with awake ECMO to wait for native lung recovery during prolonged ECMO treatment from July 2013 to January 2018. Outcomes are reported including the hospital mortality, ECMO-related complications and physiological data on weaning from invasive ventilation. Results The patients received median 26.0 (15.5, 64.8) days of total ECMO duration in the cohort. The longest ECMO support duration was 121 days. Awake ECMO and extubation was implemented after median 10.2(5.0, 42.9) days of ECMO. Awake ECMO was not associated with increased morbidity. The total invasive ventilation duration, lengths of stay in the ICU and hospital in the cohort were 14.0(12.0, 37.3) days, 33.0(22.3, 56.5) days and 46.5(27.3, 84.8) days, respectively. The hospital mortality rate was 33.3% (4/12) in the cohort. Survivors had more stable respiratory rate and heart rate after extubation when compared to the non-survivors. Conclusions With carefully selected patients, awake ECMO is a feasible and safe strategy for severe pulmonary ARDS patients receiving prolonged ECMO support to wait for native lung recovery.

Download Full-text

ECMO induces early alterations in coagulation and fibrinolysis profiles in COVID-19 patients with acute respiratory distress syndrome.

Thrombosis and Haemostasis ◽

10.1055/a-1529-2257 ◽

2021 ◽

Author(s):

Guillaume Hékimian ◽

Paul Masi ◽

Manon Lejeune ◽

Guillaume Lebreton ◽

Juliette Chommeloux ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Thrombin Generation ◽

Distress Syndrome ◽

Endothelial Activation ◽

Ecmo Support ◽

Bleeding Complications ◽

Pai 1 ◽

Coagulation And Fibrinolysis

Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in COVID-19 patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7 and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m², and a SOFA score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1+2, thrombin-antithrombin, D-Dimers and PAI-1 were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation and fibrinolysis shut-down occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1+2, p<0.01) and fibrin formation markers (fibrin monomers, p<0.001) significantly increased, further resulting in significant decreases in platelet count (p<0.0001) and fibrinogen level (p<0.001). PAI-1 levels significantly decreased from baseline to day 7 (p<0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 non-fatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.

Download Full-text

Extracorporeal membrane oxygenation for acute respiratory distress syndrome in adults: an analysis of differences between survivors and non-survivors

Perfusion ◽

10.1177/0267659117693075 ◽

2017 ◽

Vol 32 (6) ◽

pp. 495-500 ◽

Cited By ~ 7

Author(s):

Bernd Panholzer ◽

Katrin Meckelburg ◽

Katharina Huenges ◽

Grischa Hoffmann ◽

Michael von der Brelie ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Kidney Injury ◽

Study Data ◽

Adverse Outcomes ◽

Ecmo Support ◽

Membrane Oxygenation

Objectives: Over the last decade, extracorporeal membrane oxygenation (ECMO) has become a promising option for patients with severe acute respiratory distress syndrome (ARDS). In this single-center observational cohort study, data from a patient group with severe ARDS treated with ECMO was analyzed. Methods: Data from 46 patients [median age 54 years (18 to 72), male: 65.2%] were evaluated retrospectively between January 2009 and September 2015. Results: Diagnosis leading to ARDS was pneumonia in 63.1% of the patients. The median SOFA Score was 13 (10 to 19) and the median LIS was 3.5 (2.67 to 4). The median duration of ECMO support was 12 days (1 to 86). Twenty-eight patients (60.9%) were successfully weaned from ECMO and 22 patients survived (47.8%). Non-survivors needed significantly more frequent renal replacement therapy (37.5% vs. 18.2%; p<0.01) and transfusion of red blood cell concentrates [0.4 units (0.3 to 1.2) vs. 0.9 units (0.5 to 1.6); p<0.01] during ECMO support compared to patients who survived. Conclusion: This report suggests that ECMO currently allows treatment of severe ARDS with presumed improved survival. The incidence rate of acute kidney injury and transfusion are associated with adverse outcomes.

Download Full-text

Outcomes of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in COVID-19 Patients: A Propensity-Matched Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10122547 ◽

2021 ◽

Vol 10 (12) ◽

pp. 2547

Author(s):

Teresa Autschbach ◽

Nima Hatam ◽

Koray Durak ◽

Oliver Grottke ◽

Michael Dreher ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Ecmo Support ◽

Survival Prediction ◽

Historical Cohort ◽

Membrane Oxygenation ◽

Ecmo Therapy

It remains unclear to what extent the outcomes and complications of extracorporeal membrane oxygenation (ECMO) therapy in COVID-19 patients with acute respiratory distress syndrome (ARDS) differ from non-COVID-19 ARDS patients. In an observational, propensity-matched study, outcomes after ECMO support were compared between 19 COVID-19 patients suffering from ARDS (COVID group) and 34 matched non-COVID-19 ARDS patients (NCOVID group) from our historical cohort. A 1:2 propensity matching was performed based on respiratory ECMO survival prediction (RESP) score, age, gender, bilirubin, and creatinine levels. Patients’ characteristics, laboratory parameters, adverse events, and 90-day survival were analyzed. Patients’ characteristics in COVID and NCOVID groups were similar. Before ECMO initiation, fibrinogen levels were significantly higher in the COVID group (median: 493 vs. 364 mg/dL, p < 0.001). Median ECMO support duration was similar (16 vs. 13 days, p = 0.714, respectively). During ECMO therapy, patients in the COVID group developed significantly more thromboembolic events (TEE) than did those in the NCOVID group (42% vs. 12%, p = 0.031), which were mainly pulmonary artery embolism (PAE) (26% vs. 0%, p = 0.008). The rate of major bleeding events (42% vs. 62%, p = 0.263) was similar. Fibrinogen decreased significantly more in the COVID group than in the NCOVID group (p < 0.001), whereas D-dimer increased in the COVID group (p = 0.011). Additionally, 90-day mortality did not differ (47% vs. 74%; p = 0.064) between COVID and NCOVID groups. Compared with that in non-COVID-19 ARDS patients, ECMO support in COVID-19 patients was associated with comparable in-hospital mortality and similar bleeding rates but a higher incidence of TEE, especially PAE. In contrast, coagulation parameters differed between COVID and NCOVID patients.

Download Full-text

Application of veno-venous extracorporeal membrane oxygenation in lymphoma patients with severe acute respiratory distress syndrome

Medicina Fluminensis ◽

10.21860/medflum2021_365343 ◽

2021 ◽

Vol 57 (1) ◽

pp. 109-113

Author(s):

Dorian Tokmadžić ◽

Kazimir Juričić ◽

Matilda Novosel ◽

Alen Protić

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Hodgkin’S Lymphoma ◽

Distress Syndrome ◽

Ecmo Support ◽

Hodgkin's Lymphoma ◽

Membrane Oxygenation ◽

Vv Ecmo

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.

Download Full-text

Outcomes of Post-Traumatic Acute Respiratory Distress Syndrome (ARDS) in Young Patients with and Without Extracorporeal Membrane Oxygenation (ECMO) at a Level-1 Trauma Center

10.21203/rs.3.rs-1093012/v1 ◽

2021 ◽

Author(s):

Hassan Al-Thani ◽

Ammar Al-Hassani ◽

Ayman El-Menyar ◽

Mohammad Asim ◽

Ibrahim Fawzy

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Odds Ratio ◽

Distress Syndrome ◽

Young Patients ◽

Ecmo Support ◽

Trauma Patients ◽

Post Traumatic

Abstract Background We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. Methods A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. Results We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p=0.43 and Tarone-Ware, p=0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17-53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10-21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p=0.004). Conclusion Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

Download Full-text

Outcomes of Post-traumatic Acute respiratory distress syndrome (ARDS) with and without Extracorporeal membrane oxygenation (ECMO) at A Level-1 Trauma Center

10.21203/rs.3.rs-363195/v1 ◽

2021 ◽

Author(s):

Hassan Al-Thani ◽

Ammar Al-Hassani ◽

Ayman El-Menyar ◽

Mohammad Asim ◽

Ibrahim Fawzy

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Brain Edema ◽

Odds Ratio ◽

Distress Syndrome ◽

Ecmo Support ◽

Trauma Patients ◽

Post Traumatic

Abstract Purpose: We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in patients with and without Extracorporeal membrane oxygenation (ECMO) support.Methods: A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group.Results: We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation. The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p=0.43 and Tarone-Ware, p=0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17-53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10-21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p=0.004).Conclusion: Although ARDS is uncommon in trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

Download Full-text