A Total of 207 Days of Veno-Venous Extracorporeal Membrane Oxygenation Support for Severe COVID-19 Prior to Successful Lung Transplantation: A Case Report

Abstract

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a life-saving treatment for respiratory failure that may serve as a bridge to patient recovery or lung transplantation. In COVID-19, recovery is somewhat unpredictable and occasionally occurs after >100 days on VV-ECMO support. Thus, determining therapy cessation may be difficult. We report the case of a 59-year-old male without specific risk factors admitted to a tertiary center for rapidly progressive respiratory failure due to severe COVID-19, despite aggressive mechanical ventilatory support. Immediate insertion of VV-ECMO was associated with prompt resolution of hypoxemia and hypercapnia; however, all therapeutic efforts to wean the patient from VV-ECMO failed. During the prolonged hospitalization on VV-ECMO, sepsis was the most life-threatening complication. The patient overcame roughly 40 superinfections, predominantly affecting the respiratory tract, and spent 183 days on antimicrobial treatment. Although the function of other organ systems was generally stable, gradually progressive right ventricular dysfunction due to precapillary pulmonary hypertension required increasing doses of inotropes. A successful lung transplantation was performed after 207 days of VV-ECMO support. The present case provides evidence for prolonged VV-ECMO therapy as a bridge to lung transplantation in severe COVID-19 despite numerous, predominantly infectious complications.

Outcomes of patients with COVID-19 supported by venovenous extracorporeal membrane oxygenation for greater than 90 days

“…In our institution, once cannulated for ECMO, patients with COVID-19 are managed with an awake ECMO approach emphasizing the avoidance of sedatives, extubation, ambulation, physical therapy, and nutrition. Similar to the reports referenced above, 3 , 4 , 5 , 6 , 7 , 8 , 9 we noted that many patients were requiring prolonged ECMO support, which translated into prolonged intensive care unit (ICU) length of stay (LOS) and prolonged use of ECMO circuits and other resources. Our awake ECMO management strategy is also labor-intensive and requires a dedicated team of physicians, nurses, physician assistants, nurse practitioners, respiratory therapists, perfusionists, ECMO specialists, physical therapists, speech therapists, occupational therapists, pharmacists, and nutritionists.…”

“…Case reports have described ECMO treatment for 42 days, 6 91 days, 7 and 111 days 8 with subsequent recovery and support for 207 days as a bridge to lung transplantation. 9 Several series have chronicled the need for prolonged ECMO support. Dreier and colleagues 4 reported that 7 of 11 COVID-19 ECMO survivors in their series of 16 patients required >28 days of support without identifying any significant predictive factors for the duration of ECMO support.…”

“… 2 There is also emerging evidence that prolonged ECMO support may be required for patients with COVID-19 compared to other indications for ECMO in several patient series 3 , 4 , 5 and case reports. 6 , 7 , 8 , 9 …”