COVID-19 and ECMO: An Unhappy Marriage of Endothelial Dysfunction and Hemostatic Derangements

Seelhammer, Troy G.; Plack, Daniel L; Lal, Amos; Nabzdyk, Christoph S.

doi:10.1053/j.jvca.2020.09.132

Cited by 8 publications

(8 citation statements)

References 25 publications

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“…29 However, the rate of severe bleeding, including intracranial hemorrhage, and fatal bleeding on ECMO was particularly high in these studies. The hemostatic changes induced by ECMO support in COVID-19 patients have been yet poorly documented [15][16][17][18][19]30,31 and the optimal anticoagulation scheme remains unknown. The present study aimed to fill this knowledge gap by comprehensively describing the kinetics of coagulation and fibrinolysis markers during vv-ECMO support and their potential contribution to outcomes.…”

Section: Discussionmentioning

confidence: 99%

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Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

et al. 2021

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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.

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Section: Discussionmentioning

confidence: 99%

“…Positive end-expiratory pressure, cm of water Plateau pressure, cm of water Compliance, ml/cm of water 12 [10][11][12][13][14][15] 30 [28][29][30][31][32][33][34] 20.3 [15.3-30.3] 12 [7][8][9][10][11][12] 29 [19][20][21][22][23][24][25][26][27][28][29][30] 22.5 [21.2-32.9] 14 [10][11][12][13][14][15] 30 [28][29][30][31][32][33][34]…”

Section: Tidal Volume Ml/kgmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

et al. 2021

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“… 11 The multi-system involvement can be explained by binding of a surface glycoprotein on SARS COV2 (commonly referred to as the “spike protein”) to angiotensin converting enzyme 2(ACE 2) receptors expressed not only by vascular endothelial cells but also by epithelial cells in the lungs, heart, kidney and intestine. 12 …”

Section: Pathophysiology Of Rv Dysfunction In Covid-19mentioning

confidence: 99%

“…protein") to angiotensin converting enzyme 2(ACE 2) receptors expressed not only by vascular endothelial cells but also by epithelial cells in the lungs, heart, kidney and intestine. 12 The entry of the virus contributes to inflammation and damage of the endothelial cells causing release of plasminogen activator which explains the high D-dimer concentration in severe cases, and prothrombotic mediators primarily factor VIIIc and von Willebrand factor multimers. The latter mediates the consequent deposit of microvascular thrombi, especially in affected pulmonary vessels.…”

mentioning

confidence: 99%

The Right Ventricle in COVID-19 Lung Injury: Proposed Mechanisms, Management, and Research Gaps

Isgrò

Yusuff

Zochios

2021

Journal of Cardiothoracic and Vascular Anesthesia

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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“…ECMO can be lifesaving for patients with profound and refractory hypoxemia in COVID-19 ARDS. Due to extensive hospital resource utilization, availability of equipment and invasive nature of ECMO; it remains to be used as a salvage therapy for patients in which despite optimal mechanical ventilation strategies, adequate oxygenation or ventilation cannot be achieved [38][39][40]. As per the recent ELSO (extracorporeal life-support organization) guidance paper; PaO2:FiO2 less than 80 mm Hg for more than 6 hours or PaO2:FiO2 less than 50 mm Hg for less than 3 hours should prompt an early ECMO consult [41].…”

Section: Discussionmentioning

confidence: 99%

Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome

Lal

Mishra

Akhtar

et al. 2021

Monaldi Arch Chest Dis

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COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.

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COVID-19 and ECMO: An Unhappy Marriage of Endothelial Dysfunction and Hemostatic Derangements

Cited by 8 publications

References 25 publications

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome

The Right Ventricle in COVID-19 Lung Injury: Proposed Mechanisms, Management, and Research Gaps

Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome

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