Introduction In this paper, we describe our experience and early outcomes with critically unwell severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients who required extracorporeal membrane oxygenation (ECMO). We present our standard practices around ECMO decision-making, retrieval, cannulation, ventilation, anticoagulation, tracheostomy, imaging and steroids. Methods A retrospective cohort study using data from the hospital notes on all SARS-CoV-2 patients who required extracorporeal support at St Bartholomew's Hospital between 1 March 2020 and 31 July 2020. In total, this included 18 patients over this time period. Results In total, 18 patients were managed with extracorporeal support and of these 14 survived (78%) with 4 deaths (22%). The mean duration from hospital admission to intubation was 4.1 ± 3.4 days, mean time from intubation to ECMO 2.3 ± 2 days and mean run on ECMO 17.7 ± 9.4 days. Survivor mean days from intubation to extubation was 20.6 ± 9.9 days and survivor mean days from intubation to tracheostomy decannulation 46.6 ± 15.3 days. Time from hospital admission to discharge in survivors was a mean of 57.2 ± 25.8 days. Of the patients requiring extracorporeal support, the initial mode was veno-venous (VV) in 15 (83%), veno-arterial (VA) in 2 (11%) and veno-venous-arterial (VVA) in 1 (6%). On VV extracorporeal support, 2 (11%) required additional VVA. Renal replacement therapy was required in 10 (56%) of the patients. Anticoagulation target anti-Xa of 0.2-0.4 was set, with 10 (56%) patients having a deep vein thrombosis or pulmonary embolism detected and 2 (11%) patients suffering an intracranial haemorrhage. Tracheostomy was performed in 9 (50%) of the patients and high-dose methylprednisolone was given to 7 (39%) of the patients. Conclusion In our cohort of patients with severe SARS-CoV-2 respiratory failure, a long period of invasive ventilation and extracorporeal support was required but achieving good outcomes despite this. There was a significant burden of thromboembolic disease and renal injury. A significant proportion of patients required tracheostomy and steroids to facilitate weaning.
BackgroundCOVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template.MethodsAn 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1–9 (where 1–3 is inappropriate, 4–6 is uncertain and 7–9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again.ResultsDisagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease.ConclusionThe expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.
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