1
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Liu L, Kapralov M, Ashton M. Plant-derived compounds as potential leads for new drug development targeting COVID-19. Phytother Res 2024; 38:1522-1554. [PMID: 38281731 DOI: 10.1002/ptr.8105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024]
Abstract
COVID-19, which was first identified in 2019 in Wuhan, China, is a respiratory illness caused by a virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although some patients infected with COVID-19 can remain asymptomatic, most experience a range of symptoms that can be mild to severe. Common symptoms include fever, cough, shortness of breath, fatigue, loss of taste or smell and muscle aches. In severe cases, complications can arise including pneumonia, acute respiratory distress syndrome, organ failure and even death, particularly in older adults or individuals with underlying health conditions. Treatments for COVID-19 include remdesivir, which has been authorised for emergency use in some countries, and dexamethasone, a corticosteroid used to reduce inflammation in severe cases. Biological drugs including monoclonal antibodies, such as casirivimab and imdevimab, have also been authorised for emergency use in certain situations. While these treatments have improved the outcome for many patients, there is still an urgent need for new treatments. Medicinal plants have long served as a valuable source of new drug leads and may serve as a valuable resource in the development of COVID-19 treatments due to their broad-spectrum antiviral activity. To date, various medicinal plant extracts have been studied for their cellular and molecular interactions, with some demonstrating anti-SARS-CoV-2 activity in vitro. This review explores the evaluation and potential therapeutic applications of these plants against SARS-CoV-2. This review summarises the latest evidence on the activity of different plant extracts and their isolated bioactive compounds against SARS-CoV-2, with a focus on the application of plant-derived compounds in animal models and in human studies.
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Affiliation(s)
- Lingxiu Liu
- Faculty of Medical Sciences, School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, UK
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Maxim Kapralov
- School of Natural and Environmental Sciences, Faculty of Science, Agriculture and Engineering, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Mark Ashton
- Faculty of Medical Sciences, School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, UK
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
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2
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Jacobson JC, Ryan ML, Vogel AM, Mehl SC, Acker SN, Prendergast C, Padilla BE, Lee J, Chao SD, Martin NR, Russell KW, Larsen K, Harting MT, Linden AF, Ignacio RC, Slater BJ, Juang D, Jensen AR, Melhado CG, Pelayo JC, Zhong A, Spencer BL, Gadepalli SK, Maamari M, Jimenez Valencia M, Qureshi FG, Pandya SR. Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections. ASAIO J 2024; 70:146-153. [PMID: 37816012 DOI: 10.1097/mat.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.
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Affiliation(s)
- Jillian C Jacobson
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark L Ryan
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Division of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Connor Prendergast
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Justin Lee
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Stephanie D Chao
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Nolan R Martin
- Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Katie W Russell
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Kezlyn Larsen
- Department of Pediatric Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Allison F Linden
- Section of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Romeo C Ignacio
- Division of Pediatric Surgery/Department of Surgery, University of California School of Medicine, La Jolla, California
| | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Aaron R Jensen
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Caroline G Melhado
- Department of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland, California
| | - Juan Carlos Pelayo
- Division of Pediatric Surgery and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Allen Zhong
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan
- Department of Pediatric Surgery, Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, Ann Arbor, Michigan
| | - Mia Maamari
- Division of Critical Care Medicine, UT Southwestern Medical Center, Children's Medical Center, Dallas, Texas
| | - Maria Jimenez Valencia
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faisal G Qureshi
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir R Pandya
- From the Division of Pediatric Surgery, Children's Medical Center & Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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3
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Stammers AH, Tesdahl EA, Sestokas AK, Mongero LB, Patel K, Barletti S, Firstenberg MS, St. Louis JD, Jain A, Bailey C, Jacobs JP, Weinstein S. Variation in outcomes with extracorporeal membrane oxygenation in the era of coronavirus: A multicenter cohort evaluation. Perfusion 2023; 38:1501-1510. [PMID: 35943298 PMCID: PMC9364073 DOI: 10.1177/02676591221118321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome unresponsive to other interventions. However, a COVID-19 infection may result in a differential tolerance to both medical treatment and ECMO management. The aim of this study was to compare outcomes (mortality, organ failure, circuit complications) in patients on ECMO with and without COVID-19 infection, either by venovenous (VV) or venoarterial (VA) cannulation. This is a multicenter, retrospective analysis of a national database of patients placed on ECMO between May 2020 and January 2022 within the United States. Nine-hundred thirty patients were classified as either Pulmonary (PULM, n = 206), Cardiac (CARD, n = 279) or COVID-19 (COVID, n = 445). Patients were younger in COVID groups: PULM = 48.4 ± 15.8 years versus COVID = 44.9 ± 12.3 years, p = 0.006, and CARD = 57.9 ± 15.4 versus COVID = 46.5 ± 11.8 years, p < 0.001. Total hours on ECMO were greatest for COVID patients with a median support time two-times higher for VV support (365 [101, 657] hours vs 183 [63, 361], p < 0.001), and three times longer for VA support (212 [99, 566] hours vs 70 [17, 159], p < 0.001). Mortality was highest for COVID patients for both cannulation types (VA-70% vs 51% in CARD, p = 0.041, and VV-59% vs PULM-42%, p < 0.001). For VA supported patients hepatic failure was more often seen with COVID patients, while for VV support renal failure was higher. Circuit complications were more frequent in the COVID group as compared to both CARD and PULM with significantly higher circuit change-outs, circuit thromboses and oxygenator failures. Anticoagulation with direct thrombin inhibitors was used more often in COVID compared to both CARD (31% vs 10%, p = 0.002) and PULM (43% vs 15%, p < 0.001) groups. This multicenter observational study has shown that COVID patients on ECMO had higher support times, greater hospital mortality and higher circuit complications, when compared to patients managed for either cardiac or pulmonary lesions.
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Affiliation(s)
| | | | | | | | - Kirti Patel
- Medical Department, SpecialtyCare, Brentwood, TN, USA
| | - Shannon Barletti
- Perfusion Department, Thomas Jefferson University
Hospital, Philadelphia, PA, USA
| | | | | | - Ankit Jain
- Department of Anesthesiology and
Perioperative Medicine, Medical College of
Georgia, Augusta, GA, USA
| | - Caryl Bailey
- Department of Anesthesiology and
Perioperative Medicine, Medical College of
Georgia, Augusta, GA, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division
of Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
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Šoltés J, Skribuckij M, Říha H, Lipš M, Michálek P, Balík M, Pořízka M. Update on Anticoagulation Strategies in Patients with ECMO-A Narrative Review. J Clin Med 2023; 12:6067. [PMID: 37763010 PMCID: PMC10532142 DOI: 10.3390/jcm12186067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient's critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.
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Affiliation(s)
- Ján Šoltés
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Emergency Service of Central Bohemia, Vančurova 1544, 27201 Kladno, Czech Republic
| | - Michal Skribuckij
- Department of Anaesthesia, Golden Jubilee University National Hospital, Clydebank G81 4DY, UK;
| | - Hynek Říha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Michal Lipš
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Pavel Michálek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Martin Balík
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Michal Pořízka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
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5
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Spelde AE, Usman AA, Olia SE, Ibrahim ME, Szeto WY, Cevasco M, Grimm JC, Bermudez CA, Steinberg TB, Vernick WJ, Gutsche JT. Intracannula Thrombus Formation Associated With Dual Lumen ProtekDuo Cannula in Extracorporeal Membrane Oxygenation (ECMO). ASAIO J 2023; 69:e391-e396. [PMID: 36867841 PMCID: PMC10480334 DOI: 10.1097/mat.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in cases of severe respiratory failure refractory to medical management. Use of ECMO is increasing, along with new cannulation strategies including oxygenated right ventricular assist devices (oxy-RVADs). Multiple dual lumen cannulas are now available, which increase the potential for patient mobility and decrease the number of vascular access sites. However, dual lumen, single cannula flow can be limited by adequate inflow, requiring the need for an additional inflow cannula to meet patient demands. This cannula configuration may result in differential flows in the inflow and outflow limbs and altered flow dynamics, increasing the risk of intracannula thrombus. We describe a series of four patients treated with oxy-RVAD for COVID-19-associated respiratory failure complicated by dual lumen ProtekDuo intracannula thrombus.
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Affiliation(s)
- Audrey E. Spelde
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Asad A. Usman
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Salim E. Olia
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael E. Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joshua C. Grimm
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christian A. Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Toby B. Steinberg
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - William J. Vernick
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Jacob T. Gutsche
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
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6
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Fanning JP, Weaver N, Fanning RB, Griffee MJ, Cho SM, Panigada M, Obonyo NG, Zaaqoq AM, Rando H, Chia YW, Fan BE, Sela D, Chiumello D, Coppola S, Labib A, Whitman GJR, Arora RC, Kim BS, Motos A, Torres A, Barbé F, Grasselli G, Zanella A, Etchill E, Usman AA, Feth M, White NM, Suen JY, Li Bassi G, Peek GJ, Fraser JF, Dalton H. Hemorrhage, Disseminated Intravascular Coagulopathy, and Thrombosis Complications Among Critically Ill Patients with COVID-19: An International COVID-19 Critical Care Consortium Study. Crit Care Med 2023; 51:619-631. [PMID: 36867727 PMCID: PMC10089926 DOI: 10.1097/ccm.0000000000005798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To determine the prevalence and outcomes associated with hemorrhage, disseminated intravascular coagulopathy, and thrombosis (HECTOR) complications in ICU patients with COVID-19. DESIGN Prospective, observational study. SETTING Two hundred twenty-nine ICUs across 32 countries. PATIENTS Adult patients (≥ 16 yr) admitted to participating ICUs for severe COVID-19 from January 1, 2020, to December 31, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS HECTOR complications occurred in 1,732 of 11,969 study eligible patients (14%). Acute thrombosis occurred in 1,249 patients (10%), including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial ischemia, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic strokes. Hemorrhagic complications were reported in 579 patients (4.8%), including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, 77 (13%) with pulmonary hemorrhage, and 68 (12%) with hemorrhage associated with extracorporeal membrane oxygenation (ECMO) cannula site. Disseminated intravascular coagulation occurred in 11 patients (0.09%). Univariate analysis showed that diabetes, cardiac and kidney diseases, and ECMO use were risk factors for HECTOR. Among survivors, ICU stay was longer (median days 19 vs 12; p < 0.001) for patients with versus without HECTOR, but the hazard of ICU mortality was similar (hazard ratio [HR] 1.01; 95% CI 0.92-1.12; p = 0.784) overall, although this hazard was identified when non-ECMO patients were considered (HR 1.13; 95% CI 1.02-1.25; p = 0.015). Hemorrhagic complications were associated with an increased hazard of ICU mortality compared to patients without HECTOR complications (HR 1.26; 95% CI 1.09-1.45; p = 0.002), whereas thrombosis complications were associated with reduced hazard (HR 0.88; 95% CI 0.79-0.99, p = 0.03). CONCLUSIONS HECTOR events are frequent complications of severe COVID-19 in ICU patients. Patients receiving ECMO are at particular risk of hemorrhagic complications. Hemorrhagic, but not thrombotic complications, are associated with increased ICU mortality.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Natasha Weaver
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Robert B Fanning
- Northern Hospital, Northern Health, Melbourne, VIC, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Griffee
- Department of Anesthesiology and Perioperative Medicine, Sections of Critical Care and Perioperative Echocardiography, University of Utah, Salt Lake City, UT
- Department of Anesthesiology, Anesthesiology Service, Veteran Affairs Medical Center, Salt Lake City, UT
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Neuroscience Critical Care, Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mauro Panigada
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Initiative to Develop African Research Leaders (IDeAL)/KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
- Department of Medicine, Georgetown University, Washington, DC
| | - Hannah Rando
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Haematology, Tan Tock Seng Hospital, Singapore
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore
| | - Declan Sela
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, Aziende Socio Sanitarie Territoriali (ASST) Santi Paolo e Carlo, San Paolo University Hospital of Milan, Milan, Italy
| | - Ahmed Labib
- Medical Intensive Care Unit, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bo S Kim
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anna Motos
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
| | - Antoni Torres
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Division of Cardiac Surgery, Department of Surgery, Case Western Reserve University, Cleveland, OH
- Centro de Investigación Biomedica En Red - Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Ferran Barbé
- Harrington Heart and Vascular Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, Spain
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Alberto Zanella
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Department of Anesthesia, Intensive Care and Emergency. Milano, Lombardia, Italy
- Institució Catalana de Recerca i Estudis Avançats, Spain
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Asad Ali Usman
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Leida, Spain
| | - Maximilian Feth
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicole M White
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - Giles J Peek
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Heidi Dalton
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
- Congenital Heart Centre, University of Florida, Gainesville, FL
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7
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Zaaqoq A, Sallam T, Merley C, Galloway LA, Desale S, Varghese J, Alnababteh M, Kriner E, Kitahara H, Shupp J, Dalton H, Molina E. The interplay of inflammation and coagulation in COVID-19 Patients receiving extracorporeal membrane oxygenation support. Perfusion 2023; 38:384-392. [PMID: 35000466 PMCID: PMC9931882 DOI: 10.1177/02676591211057506] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Bleeding and thrombosis are common complications during Extracorporeal Membrane Oxygenation (ECMO) support for COVID-19 patients. We sought to examine the relationship between inflammatory status, coagulation effects, and observed bleeding and thrombosis in patients receiving venovenous (VV) ECMO for COVID-19 respiratory failure. STUDY DESIGN Cross-sectional cohort study. SETTINGS Quaternary care institution. PATIENTS The study period from April 1, 2020, to January 1, 2021, we included all patients with confirmed COVID-19 who received VV ECMO support. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Thirty-two patients were supported with VV ECMO during the study period, and 17 patients (53%) survived to hospital discharge. The ECMO nonsurvivors mean lactate dehydrogenase (LDH) levels were markedly elevated in comparison to survivors (1046 u/L [IQR = 509, 1305] vs 489 u/L [385 658], p = 0.003). Platelet/fibrinogen dysfunction, as reflected by the low Maximum Amplitude (MA) on viscoelastic testing, was worse in nonsurvivors (65.25 mm [60.68, 67.67] vs 74.80 mm [73.10, 78.40], p = 0.01). Time-group interaction for the first seven days of ECMO support, showed significantly lower platelet count in the nonsurvivors (140 k/ul [103, 170] vs 189.5 k/ul [ 146, 315], p < 0.001) and higher D-dimer in (21 μg/mL [13, 21] vs 14 μg/mL [3, 21], p < 0.001) in comparison to the survivors. Finally, we found profound statistically significant correlations between the clinical markers of inflammation and markers of coagulation in the nonsurvivors group. The ECMO nonsurvivors experienced higher rate of bleeding (73.3% vs 35.3%, p = 0.03), digital ischemia (46.7% vs 11.8%, p = 0.02), acute renal failure (60% vs 11.8%, p = 0.01) and bloodstream infection (60% vs 23.5%, p = 0.03). CONCLUSION The correlation between inflammation and coagulation in the nonsurvivors supported with VV ECMO could indicate dysregulated inflammatory response and worse clinical outcomes.
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Affiliation(s)
- Akram Zaaqoq
- Department of Critical Care
Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA,Department of Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA,Akram Zaaqoq, MD Department of Critical
Care Medicine Georgetown University 110 Irving St NW, suite 4B65 Washington, DC
20010, USA. E-mail:
| | - Tariq Sallam
- Department of Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
| | - Caitlin Merley
- Department of Medicine, University of
Pennsylvania, Philadelphia, PA, USA
| | - Lan Anh Galloway
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | - Sameer Desale
- MedStar Health Research
Institute, Hyattsville, MD, USA
| | - Jobin Varghese
- Department of Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
| | - Muhtadi Alnababteh
- Department of Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
| | - Eric Kriner
- Department of Critical Care
Medicine, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
| | - Hiroto Kitahara
- Department of Cardiac Surgery, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
| | - Jeffrey Shupp
- Department of Biochemistry and
Molecular & Cellular Biology, MedStar Washington Hospital
Center, Georgetown University Medical Center, Washington, DC,
USA,Department of Surgery, MedStar Washington Hospital Center
and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Heidi Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Virginia, USA, USA
| | - Ezequiel Molina
- Department of Cardiac Surgery, MedStar Washington Hospital
Center, Georgetown University, Washington, DC, USA
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8
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Alessandri F, Di Nardo M, Ramanathan K, Brodie D, MacLaren G. Extracorporeal membrane oxygenation for COVID-19-related acute respiratory distress syndrome: a narrative review. J Intensive Care 2023; 11:5. [PMID: 36755270 PMCID: PMC9907879 DOI: 10.1186/s40560-023-00654-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
A growing body of evidence supports the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) refractory to maximal medical therapy. ARDS may develop in a proportion of patients hospitalized for coronavirus disease 2019 (COVID-19) and ECMO may be used to manage patients refractory to maximal medical therapy to mitigate the risk of ventilator-induced lung injury and provide lung rest while awaiting recovery. The mortality of COVID-19-related ARDS was variously reassessed during the pandemic. Veno-venous (VV) ECMO was the default choice to manage refractory respiratory failure; however, with concomitant severe right ventricular dysfunction, venoarterial (VA) ECMO or mechanical right ventricular assist devices with extracorporeal gas exchange (Oxy-RVAD) were also considered. ECMO has also been used to manage special populations such as pregnant women, pediatric patients affected by severe forms of COVID-19, and, in cases with persistent and seemingly irreversible respiratory failure, as a bridge to successful lung transplantation. In this narrative review, we outline and summarize the most recent evidence that has emerged on ECMO use in different patient populations with COVID-19-related ARDS.
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Affiliation(s)
- Francesco Alessandri
- grid.7841.aDepartment of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | - Matteo Di Nardo
- grid.414125.70000 0001 0727 6809Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Kollengode Ramanathan
- grid.412106.00000 0004 0621 9599Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Daniel Brodie
- grid.21729.3f0000000419368729Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY USA ,grid.239585.00000 0001 2285 2675Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore.
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9
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Fiusco F, Rorro F, Broman LM, Prahl Wittberg L. Numerical and experimental investigation of a lighthouse tip drainage cannula used in extracorporeal membrane oxygenation. Artif Organs 2023; 47:330-341. [PMID: 36227654 PMCID: PMC10092507 DOI: 10.1111/aor.14421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/31/2022] [Accepted: 10/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation is a life-saving therapy used in case of acute respiratory/circulatory failure. Exposure of blood to non-physiological surfaces and high shear stresses is related to hemolytic damage and platelet activation. A detailed knowledge of the fluid dynamics of the components under different scenarios is thus paramount to assess the thrombogenicity of the circuit. METHODS An investigation of the flow structures developing in a conventional lighthouse tip (single-staged) drainage cannula was performed with cross-validated computational fluid dynamics and particle image velocimetry. The aim was to quantify the variation in drainage performance and stress levels induced by different fluid models, hematocrit and vessel-to-cannula flow rate ratios. RESULTS The results showed that the 90° bends of the flow through the side holes created a recirculation zone inside the cannula which increased residence time. Flow structures resembling a jet in a crossflow were also observed. The use of different hematocrits did not significantly affect drainage performances. The most proximal set of holes drained the largest fraction of fluid. However, different flow rate ratios altered the flow rate drained through the tip. The use of 2D data led to a 50% underestimation of shear rate levels. In the drainage zone the non-Newtonian behavior of blood was less relevant. CONCLUSIONS The most proximal holes drained the largest amount of fluid. The flow features and distribution of flow rates among the holes showed little dependence on the hematocrit. The non-Newtonian behavior of blood had a small influence on the dynamics of the flow.
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Affiliation(s)
- Francesco Fiusco
- FLOW, Department of Engineering Mechanics, KTH, Stockholm, Sweden
| | - Federico Rorro
- FLOW, Department of Engineering Mechanics, KTH, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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10
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Varlas VN, Borș RG, Plotogea M, Iordache M, Mehedințu C, Cîrstoiu MM. Thromboprophylaxis in Pregnant Women with COVID-19: An Unsolved Issue. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1949. [PMID: 36767320 PMCID: PMC9915713 DOI: 10.3390/ijerph20031949] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
SARS-CoV-2 infection in pregnant women is of growing interest due to controversy over the use of antiplatelet and/or anticoagulant drugs during pregnancy and postpartum. Pregnant women are susceptible to develop severe forms of viral infections due to pregnancy-related immune alterations, changes in lung functions, and hypercoagulability. The association of pregnancy with SARS-CoV-2 infection can cause an increased incidence of thrombotic complications, especially in the case of patients with some genetic variants that favor inflammation and thrombosis. Compared to the general population, pregnant women may be at increased risk of thrombotic complications related to COVID-19. The lack of extensive clinical trials on thromboprophylaxis and extrapolating data from non-pregnant patients lead to major discrepancies in treating pregnant women with COVID-19. Currently, a multidisciplinary team should determine the dose and duration of prophylactic anticoagulant therapy for these patients, depending on the disease severity, the course of pregnancy, and the estimated due date. This narrative review aims to evaluate the protective effect of thromboprophylaxis in pregnant women with COVID-19. It is unknown at this time whether antiplatelet or anticoagulant therapy initiated at the beginning of pregnancy for various diseases (preeclampsia, intrauterine growth restriction, thrombophilia) offers a degree of protection. The optimal scheme for thromboprophylaxis in pregnant women with COVID-19 must be carefully established through an individualized decision concerning gestational age and the severity of the infection.
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Affiliation(s)
- Valentin Nicolae Varlas
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 050451 Bucharest, Romania
| | - Roxana Georgiana Borș
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
| | - Mihaela Plotogea
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 050451 Bucharest, Romania
- Department of Obstetrics and Gynecology, Nicolae Malaxa Clinical Hospital Bucharest, 022441 Bucharest, Romania
| | - Madalina Iordache
- Doctoral School, “Carol Davila”, University of Medicine and Pharmacy, 4192910 Bucharest, Romania
| | - Claudia Mehedințu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 050451 Bucharest, Romania
| | - Monica Mihaela Cîrstoiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 050451 Bucharest, Romania
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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11
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Guo L, Liu Y, Zhang L, Li Q, Qiu H, Guo Y, Shi Q. Massive Airway Hemorrhage in Severe COVID-19 and the Role of Endotracheal Tube Clamping. Infect Drug Resist 2023; 16:2387-2393. [PMID: 37113528 PMCID: PMC10128077 DOI: 10.2147/idr.s378408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been widely used in treating patients with coronavirus disease 2019 (COVID-19) with severe respiratory failure. However, there are few reports of the successful treatment of patients with massive airway hemorrhage in severe COVID-19 during VV-ECMO treatment. Methods We analyzed the treatment process of a patient with a massive airway hemorrhage in severe COVID-19, who underwent prolonged VV-ECMO treatment. Results A 59-year-old female patient was admitted to the intensive care unit after being confirmed to have severe acute respiratory syndrome coronavirus 2 infection with severe acute respiratory distress syndrome. VV-ECMO, mechanical ventilation, and prone ventilation were administered. Major airway hemorrhage occurred on day 14 of ECMO treatment; conventional management was ineffective. We provided complete VV-ECMO support, discontinued anticoagulation, disconnected the ventilator, clipped the tracheal intubation, and intervened to embolize the descending bronchial arteries. After the airway hemorrhage stopped, we administered cryotherapy under bronchoscopy, low-dose urokinase locally, and bronchoalveolar lavage in the airway to clear the blood clots. The patient's condition gradually improved; she underwent ECMO weaning and decannulation after 88 days of VV-ECMO treatment, and the membrane oxygenator was changed out four times. She was successfully discharged after 182 days in hospital. Conclusion Massive airway hemorrhage in patients with severe COVID-19 and treated with ECMO is catastrophic. It is feasible to clamp the tracheal tube with the full support of ECMO. Notably, bronchoscopy with cryotherapy is effective for removing blood clots.
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Affiliation(s)
- Litao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Lei Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Qing Li
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People’s Republic of China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People’s Republic of China
| | - Yaling Guo
- Department of Infectious Diseases, Xi’an Eighth Hospital, Xi’an, People’s Republic of China
| | - Qindong Shi
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China
- Correspondence: Qindong Shi, Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, No. 277 Road Yanta West, Xi’an, Shaanxi, 710061, People’s Republic of China, Tel +86 029 85323186, Email
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12
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The Use of ECMO for COVID-19: Lessons Learned. Clin Chest Med 2022; 44:335-346. [PMID: 37085223 PMCID: PMC9705197 DOI: 10.1016/j.ccm.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has seen an increase in global cases of severe acute respiratory distress syndrome (ARDS), with a concomitant increased demand for extracorporeal membrane oxygenation (ECMO). Outcomes of patients with severe ARDS due to COVID-19 infection receiving ECMO support are evolving. The need for surge capacity, practical and ethical limitations on implementing ECMO, and the prolonged duration of ECMO support in patients with COVID-19-related ARDS has revealed limitations in organization and resource utilization. Coordination of efforts at multiple levels, from research to implementation, resulted in numerous innovations in the delivery of ECMO.
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13
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Tung A, Dalton A, Hastie J, Jabaley CS, Mittel AM, Nunnally ME, Siddiqui S. The Next Next Wave: How Critical Care Might Learn From COVID in Responding to the Next Pandemic. Anesth Analg 2022; 135:903-910. [PMID: 36269981 DOI: 10.1213/ane.0000000000006204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Avery Tung
- From the Departments of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Allison Dalton
- From the Departments of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Jonathan Hastie
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Craig S Jabaley
- Department of Anesthesiology, Emory University Atlanta, Georgia
| | - Aaron M Mittel
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Health, New York, New York
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Akil A, Napp LC, Rao C, Klaus T, Scheier J, Pappalardo F. Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review. J Clin Med 2022; 11:jcm11205990. [PMID: 36294309 PMCID: PMC9604472 DOI: 10.3390/jcm11205990] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. Adjunct hemoadsorption is increasingly utilized to target underlying hyperinflammation derived from ARDS. This article aims to review available data on the use of CytoSorb© therapy in combination with V-V ECMO in severe ARDS, and to assess the effects on inflammatory, laboratory and clinical parameters, as well as on patient outcomes. A systematic literature review was conducted and reported in compliance with principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. When applicable, a before-and-after analysis for relevant biomarkers and clinical parameters was carried out. CytoSorb© use was associated with significant reductions in circulating levels of C-reactive protein and interleukin-6 (p = 0.039 and p = 0.049, respectively). Increases in PaO2/FiO2 reached significance as well (p = 0.028), while norepinephrine dosage reductions showed a non-significant trend (p = 0.067). Mortality rates in CytoSorb© patients tended to be lower than those of control groups of most included studies, which, however, were characterized by high heterogeneity and low power. In an exploratory analysis on 90-day mortality in COVID-19 patients supported with V-V ECMO, the therapy was associated with a significantly reduced risk of death. Based on the reviewed data, CytoSorb© therapy is able to reduce inflammation and potentially improves survival in ARDS patients treated with V-V ECMO. Early initiation of CytoSorb© in conjunction with ECMO might offer a new approach to enhance lung rest and promote recovery in patients with severe ARDS.
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Affiliation(s)
- Ali Akil
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, 49477 Ibbenbueren, Germany
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | | | | | | | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, 15100 Alessandria, Italy
- Correspondence:
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15
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Méndez Rojano R, Lai A, Zhussupbekov M, Burgreen GW, Cook K, Antaki JF. A fibrin enhanced thrombosis model for medical devices operating at low shear regimes or large surface areas. PLoS Comput Biol 2022; 18:e1010277. [PMID: 36190991 PMCID: PMC9560616 DOI: 10.1371/journal.pcbi.1010277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/13/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
Over the past decade, much of the development of computational models of device-related thrombosis has focused on platelet activity. While those models have been successful in predicting thrombus formation in medical devices operating at high shear rates (> 5000 s−1), they cannot be directly applied to low-shear devices, such as blood oxygenators and catheters, where emerging information suggest that fibrin formation is the predominant mechanism of clotting and platelet activity plays a secondary role. In the current work, we augment an existing platelet-based model of thrombosis with a partial model of the coagulation cascade that includes contact activation of factor XII and fibrin production. To calibrate the model, we simulate a backward-facing-step flow channel that has been extensively characterized in-vitro. Next, we perform blood perfusion experiments through a microfluidic chamber mimicking a hollow fiber membrane oxygenator and validate the model against these observations. The simulation results closely match the time evolution of the thrombus height and length in the backward-facing-step experiment. Application of the model to the microfluidic hollow fiber bundle chamber capture both gross features such as the increasing clotting trend towards the outlet of the chamber, as well as finer local features such as the structure of fibrin around individual hollow fibers. Our results are in line with recent findings that suggest fibrin production, through contact activation of factor XII, drives the thrombus formation in medical devices operating at low shear rates with large surface area to volume ratios. Patients treated with blood-contacting medical devices suffer from clotting complications. Over the past decades, a great effort has been made to develop computational tools to predict and prevent clot formation in these devices. However, most models have focused on platelet activity and neglected other important parts of the problem such as the coagulation cascade reactions that lead to fibrin formation. In the current work, we incorporate this missing element into a well-established and validated model for platelet activity. We then use this novel approach to predict thrombus formation in two experimental configurations. Our results confirm that to accurately predict the clotting process in devices where surface area to volume ratios are large and flow velocity and shear stresses remain low, coagulation reactions and subsequent fibrin formation must be considered. This new model could have great implications for the design and optimization of medical devices such as blood oxygenators. In the long term, the model could evolve into a functional tool to inform anticoagulation therapies for these patients.
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Affiliation(s)
- Rodrigo Méndez Rojano
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
- * E-mail:
| | - Angela Lai
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Mansur Zhussupbekov
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
| | - Greg W. Burgreen
- Center for Advanced Vehicular Systems, Mississippi State University, Starkville, Mississippi, United States of America
| | - Keith Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - James F. Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, United States of America
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16
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Utility of D-dimers in COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:1241-1248. [PMID: 35609187 PMCID: PMC9521394 DOI: 10.1097/mat.0000000000001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A retrospective study was performed examining the trend of inflammatory markers, including D-dimers, in 29 COVID-19 patients requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support. We observed that COVID-19 patients with pre-cannulation D-dimer levels >3,000 ng/mL had a significantly shorter time from admission to cannulation (4.78 vs . 8.44 days, p = 0.049) compared to those with D-dimer <3,000 ng/mL. Furthermore, patients with D-dimer >3,000 ng/mL had a trend of lower pH (7.24 vs . 7.33), higher pCO 2 (61.33 vs . 50.69), and higher vasoactive inotropic score (7.23 vs . 3.97) at time of cannulation, however, these were not statistically significant. This cohort of patients also required a longer duration of ECMO support (51.44 vs . 31.25 days). However, 13 patients required at least one ECMO-circuit exchange and 16 patients did not require any exchanges. There was a consistent drop in D-dimer values after every circuit exchange, which was not observed in any of the other examined inflammatory markers, including ferritin, lactate dehydrogenase, or C-reactive protein. We propose that elevated D-dimer levels (>3,000 ng/mL) reflect increased disease severity in COVID-19, and predict a longer ECMO course. Once on ECMO, however, the D-Dimer level consistently decreased with every circuit exchange, which may reflect thrombus within the oxygenator rather than just disease severity.
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17
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Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM EVIDENCE 2022; 1:EVIDra2200128. [PMID: 38319864 DOI: 10.1056/evidra2200128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Extracorporeal Support for ARDS in AdultsThere is a subset of patients who develop severe ARDS for whom supportive care with mechanical ventilation is insufficient or possibly injurious. The use of ECMO as an adjunct to treat these patients is reviewed.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Toronto General Hospital Research Institute
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18
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Abstract
The activating interplay of thrombosis and inflammation (thromboinflammation) has been established as a major underlying pathway, driving not only cardiovascular disease but also autoimmune disease and most recently, COVID-19. Throughout the years, innate immune cells have emerged as important modulators of this process. As the most abundant white blood cell in humans, neutrophils are well-positioned to propel thromboinflammation. This includes their ability to trigger an organized cell death pathway with the release of decondensed chromatin structures called neutrophil extracellular traps. Decorated with histones and cytoplasmic and granular proteins, neutrophil extracellular traps exert cytotoxic, immunogenic, and prothrombotic effects accelerating disease progression. Distinct steps leading to extracellular DNA release (NETosis) require the activities of PAD4 (protein arginine deiminase 4) catalyzing citrullination of histones and are supported by neutrophil inflammasome. By linking the immunologic function of neutrophils with the procoagulant and proinflammatory activities of monocytes and platelets, PAD4 activity holds important implications for understanding the processes that fuel thromboinflammation. We will also discuss mechanisms whereby vascular occlusion in thromboinflammation depends on the interaction of neutrophil extracellular traps with ultra-large VWF (von Willebrand Factor) and speculate on the importance of PAD4 in neutrophil inflammasome assembly and neutrophil extracellular traps in thromboinflammatory diseases including atherosclerosis and COVID-19.
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Affiliation(s)
- Denisa D Wagner
- Program in Cellular and Molecular Medicine, Division of Hematology and Oncology, Boston Children's Hospital/Harvard Medical School, MA (D.D.W., L.A.H.)
| | - Lukas A Heger
- Program in Cellular and Molecular Medicine, Division of Hematology and Oncology, Boston Children's Hospital/Harvard Medical School, MA (D.D.W., L.A.H.)
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19
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Han D, Leibowitz JL, Han L, Wang S, He G, Griffith BP, Wu ZJ. Computational fluid dynamics analysis and experimental hemolytic performance of three clinical centrifugal blood pumps: Revolution, Rotaflow and CentriMag. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2022; 15. [PMID: 36157896 PMCID: PMC9497451 DOI: 10.1016/j.medntd.2022.100153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Centrifugal blood pumps have become popular for adult extracorporeal membrane oxygenation (ECMO) due to their superior blood handling and reduced thrombosis risk featured by their secondary flow paths that avoid stagnant areas. However, the high rotational speed within a centrifugal blood pump can introduce high shear stress, causing a significant shear-induced hemolysis rate. The Revolution pump, the Rotaflow pump, and the CentriMag pump are three of the leading centrifugal blood pumps on the market. Although many experimental and computational studies have focused on evaluating the hydraulic and hemolytic performances of the Rotaflow and CentriMag pumps, there are few on the Revolution pump. Furthermore, a thorough direct comparison of these three pumps' flow characteristics and hemolysis is not available. In this study, we conducted a computational and experimental analysis to compare the hemolytic performances of the Revolution, Rotaflow, and CentriMag pumps operating under a clinically relevant condition, i.e., the blood flow rate of 5 L/min and pump pressure head of 350 mmHg, for adult ECMO support. In silico simulations were used to characterize the shear stress distributions and predict the hemolysis index, while in vitro blood loop studies experimentally determined hemolysis performance. Comparative simulation results and experimental data demonstrated that the CentriMag pump caused the lowest hemolysis while the Revolution pump generated the highest hemolysis.
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Affiliation(s)
- Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua L. Leibowitz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lu Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shigang Wang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ge He
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P. Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J. Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
- Corresponding author. Department of Surgery, University of Maryland School of Medicine, 10 South Pine Street, MSTF 436, Baltimore, MD, 21201, USA. (Z.J. Wu)
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20
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Aljishi RS, Alkuaibi AH, Al Zayer FA, Al Matouq AH. Extracorporeal Membrane Oxygenation for COVID-19: A Systematic Review. Cureus 2022; 14:e27522. [PMID: 36060406 PMCID: PMC9427068 DOI: 10.7759/cureus.27522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 01/08/2023] Open
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21
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Pratt EH, Stokes JW, Fan E. Bleeding and clotting while supported with ECMO: time to move forward. Intensive Care Med 2022; 48:1059-1061. [PMID: 35829722 DOI: 10.1007/s00134-022-06805-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Elias H Pratt
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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22
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Kumar A, Li GW, Segraves JM, Mattar A, Ramineni M, Loor G, Garcha PS. Pediatric lung transplantation for COVID-19: Unique clinical and psychosocial barriers. Pediatr Transplant 2022; 26:e14351. [PMID: 35799318 PMCID: PMC9350339 DOI: 10.1111/petr.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND SARS-CoV-2 infection in the age group of 0-17 years contributes to approximately 22% of all laboratory-confirmed SARS-CoV-2 infections. Fortunately, this age group has a lower death rate (0.5 per 100 000) that accounts for only 4% of the total deaths due to COVID-19. Despite the low mortality rate in the pediatric population, children of minority groups represented 78% of the deaths highlighting the existing disparities in access to health care. METHODS With the emergence of the more contagious COVID-19 variants and the relatively slow pace of vaccination among the pediatric population, it is possible to see more cases of significant lung injury and potential for transplantation for the younger age group. RESULTS To our knowledge, our patient is the youngest to have undergone lung transplantation for SARS-CoV-2. CONCLUSION The case presented unique challenges, particularly in relation to timing for listing and psychosocial support for parents who were his decision makers.
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Affiliation(s)
- Anupam Kumar
- Division of Pulmonary, Critical Care & Lung TransplantationBaylor College of MedicineHoustonTexasUSA
| | - Gloria W. Li
- Division of Pulmonary, Critical Care & Lung TransplantationBaylor College of MedicineHoustonTexasUSA
| | - Justin M. Segraves
- Division of Pulmonary, Critical Care & Lung TransplantationBaylor College of MedicineHoustonTexasUSA
| | - Aladdein Mattar
- Division of Cardiothoracic SurgeryBaylor College of MedicineHoustonTexasUSA
| | | | - Gabriel Loor
- Division of Cardiothoracic SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Puneet S. Garcha
- Division of Pulmonary, Critical Care & Lung TransplantationBaylor College of MedicineHoustonTexasUSA
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23
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Northam KA, Murray BP, Fischer WA, Charles AG. Major Bleeding and Thrombosis Events in COVID-19 Versus Influenza Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:779-784. [PMID: 35184085 DOI: 10.1097/mat.0000000000001667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Initial reports described a hypercoagulable state and an increased risk of thrombosis in patients who tested positive for SARS-CoV-2. Infected patients with severe acute respiratory distress syndrome in the setting of coronavirus disease 2019 (COVID-19) may require extracorporeal membrane oxygenation (ECMO), leading to coagulopathies and further increasing the risk for bleeding and thrombosis. We conducted a single-center retrospective cohort study to compare the incidence of major bleeding and thrombosis in COVID-19 versus influenza-positive patients requiring ECMO. There was no difference in the incidence of major bleeding (67.7% vs. 85.7%, p = 0.287) or major thrombosis (9.7% vs. 21.4%, p = 0.356) between COVID-19 and influenza patients, respectively. COVID-19 patients experienced significantly fewer major bleeding events per ECMO days compared with influenza (0.1 [interquartile range 0-0.2] vs. 0.2 [interquartile range 0.1-0.5], p = 0.026). Influenza patients may be at higher risk for developing coagulopathies that contribute to bleeding. Larger evaluations are needed to confirm these results and further assess bleeding and thrombosis risk in these populations.
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Affiliation(s)
- Kalynn A Northam
- From the *Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Brian P Murray
- From the *Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - William A Fischer
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Anthony G Charles
- Division of General and Acute Surgery, University of North Carolina Medical Center, Chapel Hill, North Carolina
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24
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Dain AS, Raffini L, Whitworth H. Thrombotic events in critically ill children with coronavirus disease 2019 or multisystem inflammatory syndrome in children. Curr Opin Pediatr 2022; 34:261-267. [PMID: 35634699 PMCID: PMC9197313 DOI: 10.1097/mop.0000000000001130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW To provide an update regarding what is known about thrombotic events and thromboprophylaxis in critically ill children with SARS-CoV-2 infection. RECENT FINDINGS Pediatric patients with SARS-CoV-2 generally have mild illness; however, intensive care is required in about 20-30% of hospitalized children with COVID-19 and an even higher proportion in those with MIS-C. Increased rates of thrombosis have been observed in adults hospitalized with COVID-19, and clinical trials have attempted to optimize thromboprophylaxis. There is significant variability in the estimated incidence of thrombosis in pediatric patients (0-27%) because of variation in patient populations and study design. Multiple studies demonstrate an increased rate of thrombosis compared with baseline in hospitalized pediatric patients. Few studies have evaluated risk factors for thrombosis, but critical illness, older age, and other known thrombosis risk factors appear to increase the risk. Thromboprophylaxis strategies are inconsistent, with little evidence of efficacy but few reports of major bleeding. SUMMARY Critically ill children with SARS-CoV-2-related illnesses are at increased risk of thrombosis. Thromboprophylaxis should be considered in select patients with COVID-19 or MIS-C, though the optimal strategy is not yet known. More data is required to guide practice to prevent thrombosis in this population.
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Affiliation(s)
| | - Leslie Raffini
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hilary Whitworth
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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25
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Toro-Huamanchumo CJ, Castro-Reyes MM, Peralta V, Venancio-Huerta JE, Puescas-Sanchez PR, Peña-Sanchez ER. Efficacy and Safety of Extracorporeal Membrane Oxygenation in Patients under Mechanical Ventilation with COVID-19 and Severe Acute Respiratory Distress Syndrome: A Health Technology Assessment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106080. [PMID: 35627617 PMCID: PMC9140858 DOI: 10.3390/ijerph19106080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023]
Abstract
We aimed to assess the efficacy and safety of extracorporeal membrane oxygenation (ECMO) in patients under mechanical ventilation with COVID-19 and severe acute respiratory distress syndrome (ARDS). A systematic review of the literature published in PubMed, Cochrane Library and LILACS databases, was performed. A manual search was also conducted using the reference lists of the studies included in the full-text assessment, as well as a grey-literature search on Google. Additionally, websites of state institutions and organizations developing clinical practice guidelines and health technology assessments were reviewed. The ClinicalTrials.gov website was screened along with the websites of the International Clinical Trial Registry Platform and the National Registry of Health Research Projects of the Peruvian National Institute of Health. No restrictions were applied in terms of language, time, or country. A total of 13 documents were assessed, which included 7 clinical practice guidelines, 3 health technology assessments, 1 systematic review, 1 randomized clinical trial, and 1 observational study. A critical appraisal was conducted for each document. After this, we considered that the currently available evidence is insufficient for a conclusion supporting the use of ECMO in patients under mechanical ventilation with severe ARDS associated to COVID-19 in terms of mortality, safety, and quality of life.
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Affiliation(s)
- Carlos J. Toro-Huamanchumo
- Health Technology Assessment Unit, Instituto de Evaluación de Tecnologías en Salud e Investigación—IETSI, EsSalud, Lima 15072, Peru; (M.M.C.-R.); (V.P.); (J.E.V.-H.); (E.R.P.-S.)
- Unidad Para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima 15024, Peru
- Correspondence: ; Tel.: +51-944942888
| | - Maribel M. Castro-Reyes
- Health Technology Assessment Unit, Instituto de Evaluación de Tecnologías en Salud e Investigación—IETSI, EsSalud, Lima 15072, Peru; (M.M.C.-R.); (V.P.); (J.E.V.-H.); (E.R.P.-S.)
| | - Verónica Peralta
- Health Technology Assessment Unit, Instituto de Evaluación de Tecnologías en Salud e Investigación—IETSI, EsSalud, Lima 15072, Peru; (M.M.C.-R.); (V.P.); (J.E.V.-H.); (E.R.P.-S.)
| | - Julissa E. Venancio-Huerta
- Health Technology Assessment Unit, Instituto de Evaluación de Tecnologías en Salud e Investigación—IETSI, EsSalud, Lima 15072, Peru; (M.M.C.-R.); (V.P.); (J.E.V.-H.); (E.R.P.-S.)
- Laboratorio de Bioingeniería, Pontificia Universidad Católica del Perú, Lima 15088, Peru
| | | | - Eric R. Peña-Sanchez
- Health Technology Assessment Unit, Instituto de Evaluación de Tecnologías en Salud e Investigación—IETSI, EsSalud, Lima 15072, Peru; (M.M.C.-R.); (V.P.); (J.E.V.-H.); (E.R.P.-S.)
- School of Medicine, Universidad de San Martín de Porres, Chiclayo 14012, Peru
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26
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Injection of Recombinant Tissue Plasminogen Activator into Extracorporeal Membrane Oxygenators Postpones Oxygenator Exchange in COVID-19. ASAIO J 2022; 68:1017-1023. [PMID: 35617687 DOI: 10.1097/mat.0000000000001733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has drastically increased the number of patients requiring extracorporeal life support. We investigate the efficacy and safety of low-dose recombinant tissue-type plasminogen activator (rtPA) injection into exhausted oxygenators to delay exchange in critically ill COVID-19 patients on veno-venous extracorporeal membrane oxygenation (V-V ECMO). Small doses of rtPA were injected directly into the draining section of a V-V ECMO circuit. We compared transmembrane pressure gradient, pump head efficiency, membrane arterial partial oxygen pressure, and membrane arterial partial carbon dioxide pressure before and after the procedure. Bleeding was compared with a matched control group of 20 COVID-19 patients on V-V ECMO receiving standard anticoagulation. Four patients received 16 oxygenator instillations with rtPA at 5, 10, or 20 mg per dose. Administration of rtPA significantly reduced transmembrane pressure gradient (Δpm = 54.8 ± 18.1 mmHg before vs. 38.3 ± 13.3 mmHg after, p < 0.001) in a dose-dependent manner (Pearson's R -0.63, p = 0.023), allowing to delay oxygenator exchange, thus reducing the overall number of consumed oxygenators. rtPA increased blood flow efficiency η (1.20 ± 0.28 ml/revolution before vs. 1.24 ± 0.27 ml/r, p = 0.002). Lysis did not affect membrane blood gases or systemic coagulation. Minor bleeding occurred in 2 of 4 patients (50%) receiving oxygenator lysis as well as 19 of 20 control patients (95%). Lysis of ECMO oxygenators effectively delays oxygenator exchange, if exchange is indicated by an increase in transmembrane pressure gradient. Application of lysis did not result in higher bleeding incidences compared with anticoagulated patients on V-V ECMO for COVID-19.
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27
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Abstract
Purpose of this Review We discuss the role of observational studies and cardiac registries during the COVID-19 pandemic. We focus on published cardiac registries and highlight contributions to the field that have had clinical implications. Recent Findings We included observational studies of COVID-19 patients published in peer-reviewed medical journals with defined inclusion and exclusion criteria, defined study design, and primary outcomes. A PubMed and MEDLINE literature review results in 437 articles, of which 52 include patients with COVID-19 with cardiac endpoints. From July 2020 to December 2021, the average time from last data collected to publication was 8.9 ± 4.1 months, with an increasing trend over time (R = 0.9444, p < 0.0001). Of the 52 articles that met our inclusion criteria, we summarize main findings of 4 manuscripts on stroke, 14 on acute coronary syndrome, 4 on cardiac arrest, 7 on heart failure, 7 on venous thromboembolism, 5 on dysrhythmia, and 11 on different populations at risk for cardiovascular. Summary Registries are cost effective, not disruptive to essential health services, and can be rapidly disseminated with short intervals between last data point collected and publication. In less than 2 years, cardiac registries have filled important gaps in knowledge and informed the care of COVID-19 patients with cardiovascular conditions. Supplementary Information The online version contains supplementary material available at 10.1007/s11886-022-01686-5.
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28
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Bohman JJKK, Seelhammer TG, Mazzeffi M, Gutsche J, Ramakrishna H. The Year in Extracorporeal Membrane Oxygenation: Selected Highlights From 2021. J Cardiothorac Vasc Anesth 2022; 36:1832-1843. [PMID: 35367120 DOI: 10.1053/j.jvca.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022]
Abstract
This review summarizes the extracorporeal membrane oxygenation (ECMO) or extracorporeal life support literature published in 2021. This Selected Highlights article is not intended to be an exhaustive review of the literature, but rather a summarizing of key themes that developed in the ECMO literature during 2021. The primary topics presented include the following: ECMO for coronavirus disease 2019, extracorporeal cardiopulmonary resuscitation, periprocedural cardiopulmonary support with ECMO, and anticoagulation for ECMO.
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Affiliation(s)
- John J Kyle K Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care Medicine, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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29
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Mohanka MR, Joerns J, Lawrence A, Bollineni S, Kaza V, Cheruku S, Leveno M, Chen C, Terada LS, Kershaw CD, Torres F, Peltz M, Wait MA, Hackmann AE, Banga A. ECMO Long Haulers: A Distinct Phenotype of COVID-19-Associated ARDS With Implications for Lung Transplant Candidacy. Transplantation 2022; 106:e202-e211. [PMID: 35135970 PMCID: PMC8942600 DOI: 10.1097/tp.0000000000004052] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/20/2021] [Accepted: 10/14/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Studies indicate that the recovery from coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome may be slower than other viral pneumonia. There are limited data to guide decisions among patients who need extracorporeal membrane oxygenation (ECMO) support, especially the expected time of recovery and considering lung transplantation (LT). METHODS This was a retrospective chart review of patients with COVID-19-associated acute respiratory distress syndrome placed on ECMO between March 1, 2020, and September 15, 2021 (n = 20; median age, 44 y; range, 22-62 y; male:female, 15:5). We contrasted the baseline variables and clinical course of patients with and without the need for ECMO support >30 d (ECMO long haulers, n = 10). RESULTS Ten patients met the criteria for ECMO long haulers (median duration of ECMO, 86 d; range, 42-201 d). The long haulers were healthier at baseline with fewer comorbidities but had worse pulmonary compliance and higher partial pressure of CO2. They had a significantly higher number of membrane oxygenator failures, changes to their cannulation sites, and suffer more complications on ECMO. One of the long hauler was bridged to LT while another 6 patients recovered and were discharged. Overall survival was better among the ECMO long haulers (70% versus 20%; 9.3, 1.2-73; P = 0.03). CONCLUSIONS Despite worse pulmonary physiology, frequent complications, and a tortuous hospital course that may appear to portend a poor prognosis, ECMO long haulers have the potential to recover and be weaned off ECMO without the need for LT. A customized approach comprising a more conservative timeline for the consideration of LT may be prudent among these patients.
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Affiliation(s)
- Manish R Mohanka
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - John Joerns
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Adrian Lawrence
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Srinivas Bollineni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sreekanth Cheruku
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew Leveno
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Catherine Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lance S Terada
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Corey D Kershaw
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael A Wait
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amy E Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amit Banga
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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30
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Abruzzo A, Gorantla V, Thomas SE. Venous thromboembolic events in the setting of extracorporeal membrane oxygenation support in adults: A systematic review. Thromb Res 2022; 212:58-71. [DOI: 10.1016/j.thromres.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 01/04/2023]
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31
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Mercader A, Ye SH, Kim S, Orizondo RA, Cho SK, Wagner WR. PDMS-Zwitterionic Hybrid for Facile, Antifouling Microfluidic Device Fabrication. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2022; 38:3775-3784. [PMID: 35294197 DOI: 10.1021/acs.langmuir.1c03375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Poly(dimethylsiloxane) (PDMS) has been used in a wide range of biomedical devices and medical research due to its biostability, cytocompatibility, gas permeability, and optical properties. Yet, some properties of PDMS create critical limitations, particularly fouling through protein and cell adhesion. In this study, a diallyl-terminated sulfobetaine (SB-diallyl) molecule was synthesized and then directly mixed with a commercial PDMS base (Sylgard 184) and curing agent to produce a zwitterionic group-bearing PDMS (PDMS-SB) hybrid that does not require a complex or an additional surface modification process for the desired end product. In vitro examination of antifouling behavior following exposure to fresh ovine blood showed a significant reduction in platelet deposition for the PDMS-SB hybrid surface compared to that of a PDMS control (p < 0.05, n = 5). The manufacturability via soft lithography using the synthesized polymers was found to be comparable to that for unmodified PDMS. Bonding via O2 plasma treatment was confirmed, and the strength was measured and again found to be comparable to the control. PDMS-SB microfluidic devices were successfully fabricated and showed improved blood compatibility that could reduce channel occlusion due to clot formation relative to PDMS control devices. Further, gas (CO2) transfer through a PDMS-SB hybrid membrane was also tested with a proof-of-concept microchannel device and shown to be comparable to that through the PDMS control.
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Affiliation(s)
- Anthony Mercader
- Department of Mechanical Engineering & Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Sang-Ho Ye
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, United States
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
| | - Seungil Kim
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, United States
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
| | - Ryan A Orizondo
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
| | - Sung Kwon Cho
- Department of Mechanical Engineering & Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - William R Wagner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15219, United States
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
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32
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Zhang Y, Wang L, Fang ZX, Chen J, Zheng JL, Yao M, Chen WY. Mortality in patients with COVID-19 requiring extracorporeal membrane oxygenation: A meta-analysis. World J Clin Cases 2022; 10:2457-2467. [PMID: 35434060 PMCID: PMC8968615 DOI: 10.12998/wjcc.v10.i8.2457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/04/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has become a worldwide pandemic and significant public health issue. The effectiveness of extracorporeal membrane oxygenation (ECMO) in treating COVID-19 patients has been called into question.
AIM To conduct a meta-analysis on the mortality of COVID-19 patients who require ECMO.
METHODS This analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes 2020 (PRISMA) and has been registered at the International Prospective Register of Systematic Reviews (number CRD42020227414). A quality assessment for all the included articles was performed by the Newcastle-Ottawa Scale (NOS). Studies with tenor more COVID-19 patients undergoing ECMO were included. The random-effects model was used to obtain the pooled incidence of mortality in COVID-19 patients receiving ECMO. The source of heterogeneity was investigated using subgroup and sensitivity analyses.
RESULTS We identified 18 articles with 1494 COVID-19 patients who were receiving ECMO. The score of the quality assessment ranged from 5 to 8 on the NOS. The majority of patients received veno-venous ECMO (93.7%). Overall mortality was estimated to be 0.31 [95% confidence interval (CI): 0.24-0.39; I2 = 84.8%] based on random-effect pooled estimates. There were significant differences in mortality between location groups (33.0% vs 55.0% vs 37.0% vs 18.0%, P < 0.001), setting groups (28.0% vs 34.0%, P < 0.001), sample size (37.0% vs 31.0%, P < 0.001), and NOS groups (39.0% vs 19.0%, P < 0.001). However, both subgroup analyses based on location, setting, and sample size, and sensitivity analysis failed to identify the source of heterogeneity. The funnel plot indicated no evident asymmetry, and the Egger's (P = 0.95) and Begg's (P = 0.14) tests also revealed no significant publication bias.
CONCLUSION With more resource assessment and risk-benefit analysis, our data reveal that ECMO might be a feasible and effective treatment for COVID-19 patients.
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Affiliation(s)
- Ye Zhang
- Department of General Practice, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Lei Wang
- Department of General Practice, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Zhi-Xian Fang
- Department of Respiration, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Jing Chen
- Department of Oncology, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Jia-Lian Zheng
- Department of Oncology, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Ming Yao
- Department of Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Wen-Yu Chen
- Department of Respiration, Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
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Lehle K, Philipp A, Foltan M, Schettler F, Ritzka M, Müller T, Lubnow M. Coagulation abnormalities in patients with COVID-19 on venovenous ECLS increased risk for technical complications and support times but had no impact on survival. Artif Organs 2022; 46:1669-1681. [PMID: 35192198 PMCID: PMC9111222 DOI: 10.1111/aor.14218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with severe coronavirus disease-19 (COVID-19)-associated acute respiratory distress on venovenous extracorporeal lung support (V-V ECLS) showed high incidence of vascular as well as ECLS-related thrombotic complications. The latter may influence the outcome of the patients. METHODS This is a retrospective monocentric study on prospectively collected data of technical complications including 69 adult COVID-19 patients on V-V ECLS (ECLS Registry, March 2020 until April 2021) without and with system exchanges. Alterations in ECLS-specific data, hemolysis, coagulation and hemostasis parameters were analyzed. RESULTS Every second COVID-19 patient on V-V ECLS developed technical complications. Optimized ECLS management at our ECLS center reduced cases of acute clot formation (pump head thrombosis, acute oxygenator thrombosis) (17%), and allowed early identification of progressive clotting processes (worsened gas transfer, coagulation disorder) (14%, 54%) with a significant overhang of hyperfibrinolysis (37%). Although COVID-19 disease and technical complications caused prolonged length of stay at the intensive care unit and ECLS support times, the proportion of successful weaning and survival rates were comparable with patients without system exchange. CONCLUSION The survival of ECLS patients with COVID-19 was independent of the requirement for system exchange due to technical-induced coagulation disorders. Close monitoring for circuit clotting is mandatory in COVID-19 patients and is one prerequisite for successful organ support in these difficult patients.
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Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Frank Schettler
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Ritzka
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Short B, Abrams D, Brodie D. Extracorporeal membrane oxygenation for coronavirus disease 2019-related acute respiratory distress syndrome. Curr Opin Crit Care 2022; 28:90-97. [PMID: 34670997 PMCID: PMC8711309 DOI: 10.1097/mcc.0000000000000901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To understand the potential role of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS), highlighting evolving practices and outcomes. RECENT FINDINGS The role for ECMO in COVID-19-related ARDS has evolved throughout the pandemic. Early reports of high mortality led to some to advocate for withholding ECMO in this setting. Subsequent data suggested mortality rates were on par with those from studies conducted prior to the pandemic. However, outcomes are evolving and mortality in these patients may be worsening with time. SUMMARY ECMO has an established role in the treatment of severe forms of ARDS. Current data suggest adherence to the currently accepted algorithm for management of ARDS, including the use of ECMO. However, planning related to resource utilization and strain on healthcare systems are necessary to determine the feasibility of ECMO in specific regions at any given time. Utilization of national and local networks, pooling of resources and ECMO mobilization units are important to optimize access to ECMO as appropriate. Reported complications of ECMO in the setting of COVID-19-related ARDS have been predominantly similar to those reported in studies of non-COVID-19-related ARDS. Further high-quality research is needed.
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Affiliation(s)
- Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
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Wolf J, Alfred A, Gennery AR, New HV, Scarisbrick J, Griffin J. UK national survey of anticoagulation in extra-corporeal photopheresis-Is it time for a UK consensus statement? Transfus Med 2021; 32:77-81. [PMID: 34859511 DOI: 10.1111/tme.12836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/06/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extra-corporeal photopheresis (ECP) requires anticoagulation to prevent circuit clotting. Unfractionated heparin (UFH) is currently the only anticoagulant licensed for the ECP system in use in the United Kingdom (UK). Acid citrate dextrose-A (ACD-A) is the preferred anticoagulant for most other apheresis procedures. Anecdotal evidence suggested variability in ECP practice across the UK with some providers using off-label ACD-A. AIMS We developed a survey together with the UK Photopheresis Society to establish current practice. MATERIALS & METHODS This was distributed to all 17 ECP providers covering 34 UK sites. RESULTS Significant variability in practice was demonstrated with only 36% of responding providers (5/14) using UFH exclusively and 29% (4/14) using ACD-A as standard. CONCLUSION This survey highlights the need for a UK consensus.
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Affiliation(s)
| | - Arun Alfred
- The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Andrew R Gennery
- HSCT Translational and Clinical Research Institute, Newcastle University, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Helen V New
- Imperial College London, London, UK.,NHS Blood and Transplant, Watford, UK
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Chong WH, Saha BK, Medarov BI. A systematic review and meta-analysis comparing the clinical characteristics and outcomes of COVID-19 and influenza patients on ECMO. Respir Investig 2021; 59:748-756. [PMID: 34481816 PMCID: PMC8367736 DOI: 10.1016/j.resinv.2021.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a valuable rescue therapy to treat refractory hypoxemia caused by influenza. The present meta-analysis aimed to compare the clinical characteristics and outcomes of ECMO between COVID-19 and influenza. METHODS We searched the PubMed, Cochrane Library, SCOPUS, and Web of Science databases from inception to May 1, 2021. The included studies compared the clinical characteristics and outcomes of ECMO between adults with COVID-19 and those with influenza. RESULTS The study included four retrospective cohorts involving a total of 129 patients with COVID-19 and 140 with influenza who were treated using ECMO. Clinical characteristics were similar between the COVID-19 and influenza groups, including body mass index (BMI), diabetes mellitus, hypertension, and immunocompromised status. A higher proportion of patients with COVID-19 on ECMO were male (75.9% vs. 62.9%; P = 0.04). There was no difference between the groups in terms of illness severity based on sequential organ failure assessment (SOFA) score or serum pH. Patients with COVID-19 had a longer mean duration of mechanical ventilation before ECMO (6.63 vs. 3.38 days; P < 0.01). The pooled mortality rate was 43.8%. The mean ECMO duration (14.13 vs. 12.55 days; P = 0.25) and mortality rate (42.6% vs. 45.0%; P = 0.99) were comparable between the groups. CONCLUSION Clinical characteristics, ECMO duration, and mortality were comparable between patients with COVID-19 and those with influenza who required ECMO to treat refractory hypoxemia. The duration of mechanical ventilation before ECMO did not influence outcomes. Patients with COVID-19 benefit from ECMO salvage therapy similarly to those with influenza.
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Affiliation(s)
- Woon Hean Chong
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA,Corresponding author. Pulmonary and Critical Care Medicine, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA
| | - Biplab K. Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, 1100 Kentucky Ave. West Plains, Missouri, 65775, USA
| | - Boris I. Medarov
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA
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Jenner WJ, Gorog DA. Incidence of thrombotic complications in COVID-19 : On behalf of ICODE: The International COVID-19 Thrombosis Biomarkers Colloquium. J Thromb Thrombolysis 2021; 52:999-1006. [PMID: 34047938 PMCID: PMC8161345 DOI: 10.1007/s11239-021-02475-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
A high incidence of thrombosis in hospitalised patients with COVID-19 was identified early during the pandemic. Accurately quantifying thrombotic risk may assist prognosis and guide appropriate thromboprophylaxis. Observational studies have estimated the rate of thrombosis in both hospitalised and non-hospitalised patients with COVID-19, and how this corresponds to the severity of illness. In this review, we provide an overview of the incidence and prevalence of arterial and venous thrombotic events in patients with COVID-19 and highlight the limitations in the studies to date. Asymptomatic individuals with COVID-19 and those with mild symptoms are at very low risk of thrombotic complications. However, rates of thrombosis are substantially increased in hospitalised patients, and are strikingly high in those patients who are critically-ill requiring treatment on the intensive care unit and especially those requiring extracorporeal membrane oxygenation. Clinicians managing such patients need to be aware of these risks and take appropriate steps with respect to thromboprophylaxis and heightened clinical vigilance. Large prospective observational studies will more accurately quantify thrombotic rate, and randomized controlled trials are currently investigating optimal thromboprophylactic strategies.
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Affiliation(s)
- William J Jenner
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Diana A Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.
- Faculty of Medicine, Imperial College, National Heart and Lung Institute, London, UK.
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK.
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Argatroban for Anticoagulation in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0530. [PMID: 34514426 DOI: 10.1097/cce.0000000000000530] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population. DESIGN Retrospective cohort. SETTING Single-center tertiary-care facility in Fort Sam Houston, TX, from 2020 to 2021. PATIENTS Twenty-four patients who were cannulated for venovenous extracorporeal membrane oxygenation due to respiratory failure secondary to coronavirus disease 2019. INTERVENTIONS Argatroban, with or without aspirin, was substituted for heparin in coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Eighty percent of our coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation demonstrated heparin resistance, and patients who were initially started on heparin were significantly more likely to require a change to argatroban than vice versa due to difficulty achieving or maintaining therapeutic anticoagulation goals (93.4% vs 11.1%; p < 0.0001). The time to reach the therapeutic anticoagulation goal was significantly longer for patients who were initially started on heparin in comparison with argatroban (24 vs 6 hr; p = 0.0173). Bleeding and thrombotic complications were not significantly different between the two cohorts. CONCLUSIONS Argatroban, with or without aspirin, is an effective anticoagulation strategy for patients who require venovenous extracorporeal membrane oxygenation support secondary to coronavirus disease 2019. In comparison with heparin, this anticoagulation strategy was not associated with a significant difference in bleeding or thrombotic complications, and was associated with a significantly decreased time to therapeutic anticoagulation goal, likely as a result of high rates of heparin resistance observed in this patient population.
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Kalamar Ž, Markota A. Non-SARS-CoV-2 coronavirus severe acute respiratory failure. Minerva Anestesiol 2021; 88:84-85. [PMID: 34337926 DOI: 10.23736/s0375-9393.21.15977-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Žiga Kalamar
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia -
| | - Andrej Markota
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
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Abdeen S, Bdeir K, Abu‐Fanne R, Maraga E, Higazi M, Khurram N, Feldman M, Deshpande C, Litzky LA, Heyman SN, Montone KT, Cines DB, Higazi AA. Alpha-defensins: risk factor for thrombosis in COVID-19 infection. Br J Haematol 2021; 194:44-52. [PMID: 34053084 PMCID: PMC8239944 DOI: 10.1111/bjh.17503] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/13/2022]
Abstract
The inflammatory response to SARS/CoV-2 (COVID-19) infection may contribute to the risk of thromboembolic complications. α-Defensins, antimicrobial peptides released from activated neutrophils, are anti-fibrinolytic and prothrombotic in vitro and in mouse models. In this prospective study of 176 patients with COVID-19 infection, we found that plasma levels of α-defensins were elevated, tracked with disease progression/mortality or resolution and with plasma levels of interleukin-6 (IL-6) and D-dimers. Immunohistochemistry revealed intense deposition of α-defensins in lung vasculature and thrombi. IL-6 stimulated the release of α-defensins from neutrophils, thereby accelerating coagulation and inhibiting fibrinolysis in human blood, imitating the coagulation pattern in COVID-19 patients. The procoagulant effect of IL-6 was inhibited by colchicine, which blocks neutrophil degranulation. These studies describe a link between inflammation and the risk of thromboembolism, and they identify a potential new approach to mitigate this risk in patients with COVID-19 and potentially in other inflammatory prothrombotic conditions.
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Affiliation(s)
- Suhair Abdeen
- Department of Clinical BiochemistryHadassah‐Hebrew UniversityJerusalemIL‐91120Israel
| | - Khalil Bdeir
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Rami Abu‐Fanne
- Heart InstituteHillel Yaffe Medical Center Affiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of TechnologyHaifaIsrael
| | - Emad Maraga
- Heart InstituteHillel Yaffe Medical Center Affiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of TechnologyHaifaIsrael
| | - Mohamed Higazi
- Department of Clinical BiochemistryHadassah‐Hebrew UniversityJerusalemIL‐91120Israel
| | - Nigar Khurram
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Michael Feldman
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Charuhas Deshpande
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Leslie A. Litzky
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Samuel N. Heyman
- Department of MedicineHadassah University HospitalMt. ScopusJerusalemIL‐91240Israel
| | - Kathleen T. Montone
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
| | - Douglas B. Cines
- Departments of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA19104USA
- Department of MedicineUniversity of Pennsylvania‐ Perelman School of MedicinePhiladelphiaPA19104USA
| | - Abd Al‐Roof Higazi
- Department of Clinical BiochemistryHadassah‐Hebrew UniversityJerusalemIL‐91120Israel
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Lang CN, Dettinger JS, Berchtold-Herz M, Utzolino S, Bemtgen X, Zotzmann V, Schmid B, Biever PM, Bode C, Müller-Peltzer K, Duerschmied D, Wengenmayer T, Niesen WD, Staudacher DL. Intracerebral Hemorrhage in COVID-19 Patients with Pulmonary Failure: A Propensity Score-Matched Registry Study. Neurocrit Care 2021; 34:739-747. [PMID: 33619668 PMCID: PMC7899797 DOI: 10.1007/s12028-021-01202-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypercoagulability in Coronavirus Disease 2019 (COVID-19) causes deep vein thrombosis and pulmonary embolism necessitating systemic anticoagulation. Case reports of intracerebral hemorrhages in ventilated COVID-19 patients warrant precaution. It is unclear, however, if COVID-19 patients with acute respiratory distress syndrome (ARDS) with or without veno-venous extracorporeal membrane oxygenation therapy (VV-ECMO) have more intracerebral hemorrhages (ICH) compared to other ARDS patients. METHODS We conducted a retrospective observational single-center study enrolling all patients with ARDS from 01/2018 to 05/2020. PCR-positive SARS-CoV-2 patients with ARDS were allocated to the COVID-19 group. Propensity score matching was performed for age, VV-ECMO, and bleeding risk. RESULTS A total of 163 patients with moderate or severe ARDS were identified, 47 (28.8%) in the COVID-19 group, and 116 (71.2%) in the non-COVID-19 group. In 63/163 cases (38.7%), VV-ECMO therapy was required. The ICU survival was 52.8%. COVID-19 patients were older, more often male, and exhibited a lower SOFA score, but the groups showed similar rates of VV-ECMO therapy. Treatments with antiplatelet agents (p = 0.043) and therapeutic anticoagulation (p = 0.028) were significantly more frequent in the COVID-19 patients. ICH was detected in 22 patients (13.5%) with no statistical difference between the groups (11.2 vs. 19.1% without and with SARS-CoV-2, respectively, p = 0.21). Propensity score matching confirmed similar rates of ICH in both groups (12.8 vs. 19.1% without and with SARS-CoV-2, respectively, p = 0.57), thus leveling out possible confounders. CONCLUSIONS Intracerebral hemorrhage was detected in every tenth patient with ARDS. Despite statistically higher rates of antiplatelet therapy and therapeutic anticoagulation in COVID-19 patients, we found a similar rate of ICH in patients with ARDS due to COVID-19 compared to other causes of ARDS.
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Affiliation(s)
- Corinna N Lang
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johanna S Dettinger
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Stefan Utzolino
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M Biever
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Sakurai H, Fujiwara T, Ohuchi K, Hijikata W, Inoue Y, Seki H, Tahara T, Yokota S, Ogata A, Mizuno T, Arai H. Novel application of indocyanine green fluorescence imaging for real-time detection of thrombus in a membrane oxygenator. Artif Organs 2021; 45:1173-1182. [PMID: 34037247 DOI: 10.1111/aor.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/17/2021] [Accepted: 05/11/2021] [Indexed: 12/31/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) plays an important role in the coronavirus disease 2019 (COVID-19) pandemic. Management of thrombi in ECMO is generally an important issue; especially in ECMO for COVID-19 patients who are prone to thrombus formation, the thrombus formation in oxygenators is an unresolved issue, and it is very difficult to deal with. To prevent thromboembolic complications, it is necessary to develop a method for early thrombus detection. We developed a novel method for detailed real-time observation of thrombi formed in oxygenators using indocyanine green (ICG) fluorescence imaging. The purpose of this study was to verify the efficacy of this novel method through animal experiments. The experiments were performed three times using three pigs equipped with veno-arterial ECMO comprising a centrifugal pump (CAPIOX SL) and an oxygenator (QUADROX). To create thrombogenic conditions, the pump flow rate was set at 1 L/min without anticoagulation. The diluted ICG (0.025 mg/mL) was intravenously administered at a dose of 10 mL once an hour. A single dose of ICG was 0.25mg. The oxygenator was observed with both an optical detector (PDE-neo) and the naked eye every hour after measurement initiation for a total of 8 hours. With this dose of ICG, we could observe it by fluorescence imaging for about 15 minutes. Under ICG imaging, the inside of the oxygenator was observed as a white area. A black dot suspected to be the thrombus appeared 6-8 hours after measurement initiation. The thrombus and the black dot on ICG imaging were finely matched in terms of morphology. Thus, we succeeded in real-time thrombus detection in an oxygenator using ICG imaging. The combined use of ICG imaging and conventional routine screening tests could compensate for each other's weaknesses and significantly improve the safety of ECMO.
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Affiliation(s)
- Hironobu Sakurai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuki Fujiwara
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Katsuhiro Ohuchi
- Department of Advanced Surgical Technology Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataru Hijikata
- School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Yusuke Inoue
- Advanced Medical Engineering Research Center, Asahikawa Medical University, Asahikawa, Japan
| | - Haruna Seki
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoki Tahara
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sachie Yokota
- Faculty of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Asato Ogata
- Faculty of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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44
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Jenner WJ, Kanji R, Mirsadraee S, Gue YX, Price S, Prasad S, Gorog DA. Thrombotic complications in 2928 patients with COVID-19 treated in intensive care: a systematic review. J Thromb Thrombolysis 2021; 51:595-607. [PMID: 33586113 PMCID: PMC7882250 DOI: 10.1007/s11239-021-02394-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
A prothrombotic state is reported with severe COVID-19 infection, which can manifest in venous and arterial thrombotic events. Coagulopathy is reflective of more severe disease and anticoagulant thromboprophylaxis is recommended in hospitalized patients. However, the prevalence of thrombosis on the intensive care unit (ICU) remains unclear, including whether this is sufficiently addressed by conventional anticoagulant thromboprophylaxis. We aimed to identify the rate of thrombotic complications in ICU-treated patients with COVID-19, to inform recommendations for diagnosis and management. A systematic review was conducted to assess the incidence of thrombotic complications in ICU-treated patients with COVID-19. Observational studies and registries reporting thrombotic complications in ICU-treated patients were included. Information extracted included patient demographics, use of thromboprophylaxis or anticoagulation, method of identifying thrombotic complications, and reported patient outcomes. In 28 studies including 2928 patients, thrombotic complications occurred in 34% of ICU-managed patients, with deep venous thrombosis reported in 16.1% and pulmonary embolism in 12.6% of patients, despite anticoagulant thromboprophylaxis, and were associated with high mortality. Studies adopting systematic screening for venous thrombosis with Duplex ultrasound reported a significantly higher incidence of venous thrombosis compared to those relying on clinical suspicion (56.3% vs. 11.0%, p < 0.001). Despite thromboprophylaxis, there is a very high incidence of thrombotic complications in patients with COVID-19 on the ICU. Systematic screening identifies many thrombotic complications that would be missed by relying on clinical suspicion and should be employed, with consideration given to increased dose anticoagulant thromboprophylaxis, whilst awaiting results of prospective trials of anticoagulation in this cohort.
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Affiliation(s)
- William J Jenner
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Saeed Mirsadraee
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ying X Gue
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sanjay Prasad
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
- Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK.
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45
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Mang S, Kalenka A, Broman LM, Supady A, Swol J, Danziger G, Becker A, Hörsch SI, Mertke T, Kaiser R, Bracht H, Zotzmann V, Seiler F, Bals R, Taccone FS, Moerer O, Lorusso R, Bělohlávek J, Muellenbach RM, Lepper PM. Extracorporeal life support in COVID-19-related acute respiratory distress syndrome: A EuroELSO international survey. Artif Organs 2021; 45:495-505. [PMID: 33590542 PMCID: PMC8014805 DOI: 10.1111/aor.13940] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 12/18/2022]
Abstract
Extracorporeal life support (ECLS) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic coronavirus disease 2019 (COVID-19) with ECLS have been restrained. In the meantime, ECLS has been shown to produce similar outcomes in patients with severe COVID-19 compared to existing data on ARDS mortality. We performed an international email survey to assess how ECLS providers worldwide have previously used ECLS during the treatment of critically ill patients with COVID-19. A questionnaire with 45 questions (covering, e.g., indication, technical aspects, benefit, and reasons for treatment discontinuation), mostly multiple choice, was distributed by email to ECLS centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO); 276 ECMO professionals from 98 centers in 30 different countries on four continents reported that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECLS was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECLS varied between less than 2 and more than 4 weeks. The main reason to discontinue ECLS treatment prior to patient's recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators, were responsible for discontinuation of ECLS support. Most ECLS physicians (51%, IQR 30%) agreed that patients with COVID-19-induced ARDS (CARDS) benefitted from ECLS. Overall mortality of COVID-19 patients on ECLS was estimated to be about 55%. ECLS has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECLS. Triage situations were rarely a concern. ECLS providers stated that patients with severe COVID-19 benefitted from ECLS.
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Affiliation(s)
- Sebastian Mang
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Armin Kalenka
- Department of Anaesthesiology and Intensive Care Medicine, District Hospital Bergstrasse, University Hospital Heidelberg, Heppenheim, Germany
| | - Lars Mikael Broman
- ECLS Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Supady
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Justyna Swol
- Department of Pneumology, Allergology and Sleep Medicine, and Intensive Care Medicine, Paracelsus Medical University, General Hospital Nuremberg, Nuremberg, Germany
| | - Guy Danziger
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - André Becker
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Sabrina I Hörsch
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Anaesthesiology, Critical Care Medicine and Pain Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Thilo Mertke
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Anaesthesiology, Critical Care Medicine and Pain Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Ralf Kaiser
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Hendrik Bracht
- Department of Anaesthesiology and Critical Care Medicine, University Hospital of Ulm, Ulm, Germany
| | - Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frederik Seiler
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Robert Bals
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Onnen Moerer
- Department of Anaesthesiology, University Hospital of Göttingen, Göttingen, Germany
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department-Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Bělohlávek
- 2nd Department of Internal Cardiovascular Medicine, General University Hospital, Prague, Czech Republic
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Philipp M Lepper
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, Homburg, Germany.,Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, Homburg, Germany
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46
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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47
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Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. Intensive care management of patients with COVID-19: a practical approach. Ann Intensive Care 2021; 11:36. [PMID: 33604873 PMCID: PMC7891474 DOI: 10.1186/s13613-021-00820-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil.
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Stephanie Itala Rizk
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Bruno Biselli
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Brenno Rizerio Gomes
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Cristina Salvadori Bittar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juliano Pinheiro de Almeida
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | | | - Cibele Garzillo
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Alcino Costa Leme
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Moizo Elena
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fernando Val
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | | | | | - José Antonio Franchini Ramires
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin Bicêtre, France
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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48
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Pellegrini JAS, Rech TH, Schwarz P, de Oliveira ACT, Vieceli T, Moraes RB, Sekine L, Viana MV. Incidence of venous thromboembolism among patients with severe COVID-19 requiring mechanical ventilation compared to other causes of respiratory failure: a prospective cohort study. J Thromb Thrombolysis 2021; 52:482-492. [PMID: 33599858 PMCID: PMC7890785 DOI: 10.1007/s11239-021-02395-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/11/2022]
Abstract
Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, compared to patients with respiratory failure related to other causes. Prospective study that enrolled critically ill adults with suspected COVID-19 pneumonia between June 2, 2020 and August 11, 2020. Critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36.8% vs. 0%, p = 0.023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6.28, 95% confidence interval: 1.19–68.07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1.15, 95% confidence interval: 1.05–1.30). The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes.
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Affiliation(s)
| | - Tatiana Helena Rech
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Patrícia Schwarz
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil
| | | | - Tarsila Vieceli
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Rafael Barberena Moraes
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Pneumology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Leo Sekine
- Transfusion Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,Post-Graduate Program in Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Marina Verçoza Viana
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.
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49
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Tassiopoulos AK, Mofakham S, Rubano JA, Labropoulos N, Bannazadeh M, Drakos P, Volteas P, Cleri NA, Alkadaa LN, Asencio AA, Oganov A, Hou W, Rutigliano DN, Singer AJ, Vosswinkel J, Talamini M, Mikell CB, Kaushansky K. D-Dimer-Driven Anticoagulation Reduces Mortality in Intubated COVID-19 Patients: A Cohort Study With a Propensity-Matched Analysis. Front Med (Lausanne) 2021; 8:631335. [PMID: 33634153 PMCID: PMC7902033 DOI: 10.3389/fmed.2021.631335] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients. Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease. Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively). Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival. What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.
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Affiliation(s)
- Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States.,Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Jerry A Rubano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States.,Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Panagiotis Drakos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Panagiotis Volteas
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Nathaniel A Cleri
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Leor N Alkadaa
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Anthony A Asencio
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Anthony Oganov
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Wei Hou
- Department of Family, Population and Preventive Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Daniel N Rutigliano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Adam J Singer
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
| | - James Vosswinkel
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Mark Talamini
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Charles B Mikell
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, United States
| | - Kenneth Kaushansky
- Department of Medicine, Renaissance School of Medicine, Stony Brook, NY, United States
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Jäckel M, Rilinger J, Lang CN, Zotzmann V, Kaier K, Stachon P, Biever PM, Wengenmayer T, Duerschmied D, Bode C, Staudacher DL, Supady A. Outcome of acute respiratory distress syndrome requiring extracorporeal membrane oxygenation in Covid-19 or influenza: A single-center registry study. Artif Organs 2020; 45:593-601. [PMID: 33188714 PMCID: PMC7753485 DOI: 10.1111/aor.13865] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/18/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
Veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) is used to sustain blood oxygenation and decarboxylation in severe acute respiratory distress syndrome (ARDS). It is under debate if V‐V ECMO is as appropriate for coronavirus disease 2019 (Covid‐19) ARDS as it is for influenza. In this retrospective study, we analyzed all patients with confirmed SARS‐CoV‐2 or influenza A/B infection, ARDS and V‐V ECMO, treated at our medical intensive care unit (ICU) between October 2010 and June 2020. Baseline and procedural characteristics as well as survival 30 days after ECMO cannulation were analyzed. A total of 62 V‐V ECMO patients were included (15 with Covid‐19 and 47 with influenza). Both groups had similar baseline characteristics at cannulation. Thirty days after ECMO cannulation, 13.3% of all patients with Covid‐19 were discharged alive from our ICU compared to 44.7% with influenza (P = .03). Patients with Covid‐19 had fewer ECMO‐free days (0 (0‐9.7) days vs. 13.2 (0‐22.1) days; P = .05). Cumulative incidences of 30‐day‐survival showed no significant differences (48.6% in Covid‐19 patients, 63.7% in influenza patients; P = .23). ICU treatment duration was significantly longer in ARDS patients with V‐V ECMO for Covid‐19 compared to influenza. Thirty‐day mortality was higher in Covid‐19, but not significant.
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Affiliation(s)
- Markus Jäckel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonathan Rilinger
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Corinna Nadine Lang
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Marc Biever
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Leander Staudacher
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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