Overcoming bleeding events related to extracorporeal membrane oxygenation in COVID-19 – Authors' reply

Schmidt, Matthieu; Chommeloux, Juliette; Frère, Corinne; Hékimian, Guillaume

doi:10.1016/s2213-2600(20)30468-9

Cited by 6 publications

(6 citation statements)

References 4 publications

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“…The 60-day mortality rate of 33% that we observed for patients with COVID-19 treated with ECMO is similar to short-term mortality rates observed in ECMO-treated patients during prior pandemics, including mortality rates ranging from 28 to 37% among patients with H1N1 influenza [ 29 , 30 ]. Our observed 60-day mortality rate is also similar to the 60-day mortality rate of 36% reported by a single-center study of 83 ECMO-treated patients with COVID-19 in France, and to the 90-day mortality rate of 37% reported in a large multinational ELSO study of over 1000 ECMO patients [ 18 , 19 ].…”

Section: Discussionsupporting

confidence: 89%

“…Fourth, we did not collect longitudinal data on respiratory mechanics beyond 24 h or prone positioning during ECMO [ 36 , 37 ], which could have been used to further assess lung rest, recovery, and recruitability. It should also be acknowledged that only modest reductions in tidal volumes and driving pressures were observed in the immediate post-ECMO period, somewhat in contrast with other studies demonstrating ultraprotective lung ventilation on ECMO [ 18 , 38 ]. We also did not collect data on lung compliance in patients who did not receive ECMO.…”

Section: Discussionmentioning

confidence: 79%

“…Early reports from China, Europe, and the United States on the use of ECMO in patients with respiratory failure from COVID-19 have been limited by modest sample sizes and short follow-up [ 9 – 17 ]. More recent studies report larger numbers of patients who received ECMO, yet still suffer from lack of a comparative non-ECMO control group [ 18 , 19 ]. Additional data are urgently needed to inform the potential efficacy and safety of ECMO in critically ill adults with severe respiratory failure from COVID-19.…”

Section: Introductionmentioning

confidence: 99%

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Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Brenner²,

et al. 2021

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Purpose Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19). Methods We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO 2 /FiO 2 < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model. Results Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41–58), 137 (72.1%) were men, and the median PaO 2 /FiO 2 prior to ECMO initiation was 72 (IQR 61–90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41–0.74). Results were similar in a secondary analysis limited to patients with PaO 2 /FiO 2 < 80 (HR 0.55; 95% CI 0.40–0.77). Conclusion In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-020-06331-9.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

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Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Brenner²,

et al. 2021

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“…Severe bleeding complications on ECMO are multi factorial (circuit-associated defibrination and throm bocytopenia, dissemi nated intravascular coagulation, acquired von Willebrand syndrome, or COVID-19-associated endotheliitis) and the more intensive anti coagulation regimen in our cohort of patients with COVID-19 receiving ECMO could have contributed to this finding. 26 The appropriate approach regarding anticoagulation during venovenous ECMO in COVID-19 remains undefined and warrants further investigation.…”

Section: Discussionmentioning

confidence: 99%

Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

Lebreton¹,

Schmidt²,

Ponnaiah³

et al. 2021

The Lancet Respiratory Medicine

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171

207

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Background In the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic. Methods In this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO. Findings The 302 patients included who underwent ECMO had a median age of 52 years (IQR 45−58) and Simplified Acute Physiology Score-II of 40 (31−56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H 2 O (14−21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54−70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84−0·99] per day decrease), younger age (2·89 [1·41−5·93] for ≤48 years and 2·01 [1·01−3·99] for 49–56 years vs ≥57 years), higher pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55−0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46–6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation. Interpretation Beyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation...

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“…Pre-COVID evidence-based guidelines for ARDS management include lung-protective ventilation, prone positioning, conservative fluid strategies with the option of open lung strategy and neuromuscular blockade (NMBA) alongside patients with severe hypoxaemia refractory to these interventions having timely access to extracorporeal membrane oxygenation (ECMO) support [ 9 , 11 , 12 ]. Moreover, reports suggest that real-world compliance with evidence-based ARDS management strategies is difficult at a system level [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

Natural history, trajectory, and management of mechanically ventilated COVID-19 patients in the United Kingdom

et al. 2021

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Purpose The trajectory of mechanically ventilated patients with coronavirus disease 2019 (COVID-19) is essential for clinical decisions, yet the focus so far has been on admission characteristics without consideration of the dynamic course of the disease in the context of applied therapeutic interventions. Methods We included adult patients undergoing invasive mechanical ventilation (IMV) within 48 h of intensive care unit (ICU) admission with complete clinical data until ICU death or discharge. We examined the importance of factors associated with disease progression over the first week, implementation and responsiveness to interventions used in acute respiratory distress syndrome (ARDS), and ICU outcome. We used machine learning (ML) and Explainable Artificial Intelligence (XAI) methods to characterise the evolution of clinical parameters and our ICU data visualisation tool is available as a web-based widget ( https://www.CovidUK.ICU ). Results Data for 633 adults with COVID-19 who underwent IMV between 01 March 2020 and 31 August 2020 were analysed. Overall mortality was 43.3% and highest with non-resolution of hypoxaemia [60.4% vs17.6%; P < 0.001; median PaO 2 /FiO 2 on the day of death was 12.3(8.9–18.4) kPa] and non-response to proning (69.5% vs.31.1%; P < 0.001). Two ML models using weeklong data demonstrated an increased predictive accuracy for mortality compared to admission data (74.5% and 76.3% vs 60%, respectively). XAI models highlighted the increasing importance, over the first week, of PaO 2 /FiO 2 in predicting mortality. Prone positioning improved oxygenation only in 45% of patients. A higher peak pressure (OR 1.42[1.06–1.91]; P < 0.05), raised respiratory component (OR 1.71[ 1.17–2.5]; P < 0.01) and cardiovascular component (OR 1.36 [1.04–1.75]; P < 0.05) of the sequential organ failure assessment (SOFA) score and raised lactate (OR 1.33 [0.99–1.79]; P = 0.057) immediately prior to application of prone positioning were associated with lack of oxygenation response. Prone positioning was not applied to 76% of patients with moderate hypoxemia and 45% of those with severe hypoxemia and patients who died without receiving proning interventions had more missed opportunities for prone intervention [7 (3–15.5) versus 2 (0–6); P < 0.001]. Despite the severity of gas exchange deficit, most patients received lung-protective ventilation with tidal volumes less than 8 mL/kg and plateau pressures less than 30cmH 2 O. This was despite systematic errors in measurement of height and derived ideal body weight. Conclusions Refractory hypoxaemia remains a major associ...

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Overcoming bleeding events related to extracorporeal membrane oxygenation in COVID-19 – Authors' reply

Cited by 6 publications

References 4 publications

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

Natural history, trajectory, and management of mechanically ventilated COVID-19 patients in the United Kingdom

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