Introduction: The pandemic of the coronavirus disease 2019 (COVID-19) and associated pneumonia represent a clinical and scientific challenge. The role of Extracorporeal Membrane Oxygenation (ECMO) in such a crisis remains unclear. Methods: We examined COVID-19 patients who were supported for acute respiratory failure by both conventional mechanical ventilation (MV) and ECMO at a tertiary care institution in Washington DC. The study period extended from March 23 to April 29. We identified 59 patients who required invasive mechanical ventilation. Of those, 13 patients required ECMO. Results: Nine out of 13 ECMO (69.2%) patients were decannulated from ECMO. All-cause ICU mortality was comparable between both ECMO and MV groups (6 patients [46.15%] vs. 22 patients [47.82 %], p = 0.92). ECMO non-survivors vs survivors had elevated D-dimer (9.740 mcg/ml [4.84-20.00] vs. 3.800 mcg/ml [2.19-9.11], p = 0.05), LDH (1158 ± 344.5 units/L vs. 575.9 ± 124.0 units/L, p = 0.001), and troponin (0.4315 ± 0.465 ng/ml vs. 0.034 ± 0.043 ng/ml, p = 0.04). Time on MV as expected was significantly longer in ECMO groups (563.3 hours [422.1-613.9] vs. 247.9 hours [101.8-479] in MV group, p = 0.0009) as well as ICU length of stay 576.2 hours [457.5-652.8] in ECMO group vs. 322.2 hours [120.6-569.3] in MV group, p = 0.012). Conclusion: ECMO is a supportive intervention for COVID-19 associated pneumonia that could be considered if the optimum mechanical ventilation is deemed ineffective. Biomarkers such as D-dimer, LDH, and troponin could help with discerning the clinical prognosis in patients with COVID-19 pneumonia.

Background: Although many patients with coronavirus disease 2019 (Covid-19) require direct admission to the intensive care unit (ICU), some are sent after admission. Clinicians require an understanding of this phenomenon and various risk stratification approaches for recognizing these subjects. Methods: We examined all Covid-19 patients sent initially to a ward who subsequently required care in the ICU. We examined the timing transfer and attempted to develop a risk score based on baseline variables to predict progressive disease. We evaluated the utility of the CURB-65 score at identifying the need for ICU transfer. Results: The cohort included 245 subjects (mean age 59.0 ± 14.2 years, 61.2% male) and 20% were eventually sent to the ICU. The median time to transfer was 2.5 days. Approximately 1/3rd of patients were not moved until day 4 or later and the main reason for transfer (79.2%) was worsening respiratory failure. A baseline absolute lymphocyte count (ALC) of ≤0.8 10 3 /ml and a serum ferritin ≥1000 ng/ml were independently associated with ICU transfer. Co-morbid illnesses did not correlate with eventual ICU care. Neither a risk score based on a low ALC and/or high ferritin nor the CURB-65 score performed well at predicting need for transfer. Conclusion: Covid-19 patients admitted to general wards face a significant risk for deterioration necessitating ICU admission and respiratory failure can occur late in this disease. Neither baseline clinical factors nor the CURB-65 score perform well as screening tests to categorize these subjects as likely to progress to ICU care.

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To generate a preliminary version of a novel risk score to predict the need for invasive mechanical ventilation (MV) in patients with COVID-19. METHODS: Retrospective analysis of patients >18 years-of-age with laboratory-confirmed COVID-19 admitted between March 15-April 15, 2020 to a tertiary-care center. Demographic, laboratory, clinical, and outcome information were recorded, using a standard data-collection format. RESULTS: The cohort included 265 subjects (mean age 59.3 AE16.4 years, 55.1% male) and 54 (20.4%) required invasive MV. Significant between-group univariate results, based on the need for invasive MV, were used in multiple-regression analysis. Admission heart rate (HR) (OR 1.032 [CI 1.013-1.015]; p<0.001), SpO2/FIO2 (S/F) ratio (OR .619 [CI .463-.829]; p=0.001), and any positive initial troponin (TnI) (OR 4.18 [CI 1.93-9.036]; p<0.001] independently predicted the need for invasive MV. The best cutoff points for the variables HR and S/F ratio were also determined: HR >101.5 BPM (AUC 0.686, 68.5% sensitivity & 66.4% specificity) and S/F ratio <4.4 (AUC 0.714, 72.2% sensitivity & 61.6% specificity). The overall model showed good calibration (Hosmer-Lemeshow = 6.3; p=0.39) and predictive ability (AUC = .80). Patients with a single, positive variable had an invasive MV risk = 15.4%, but this increased to 29% with 2 variables and 60.5% (p<0.001) with the presence of all 3. CONCLUSIONS: This pilot study provides insight into early factors related to patient acuity and the use of medical resources. Thresholds for 3 common clinical variables-HR, S/F ratio and TnIpredicted the need for invasive MV with good accuracy and provide an easily-applied scoring system to determine risk. CLINICAL IMPLICATIONS: We developed a simple, novel risk score to quantify the need for invasive MV in COVID-19 patients, with preliminary testing showing the 3 components had good predictive ability.