Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19

Modifying Candidacy and Management to Improve Extracorporeal Support During Supply-Demand Mismatch

Background

Candidacy for venovenous extracorporeal membrane oxygenation is dictated by ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) criteria. We evaluated the effect of modifying candidacy on the basis of escalating demand and limited resources.

Methods

We retrospectively reviewed adult patients diagnosed with COVID-19-related severe acute respiratory distress syndrome who failed to respond to conventional ventilation and required extracorporeal support at our institution. Candidacy was restricted with a published probability model because of supply-demand mismatch and high mortality observed after the first surge. Age <55 years, mechanical ventilation days <3, and minimal comorbidities were prioritized. Primary outcomes included time to decannulation, extubation, tracheostomy, discharge, and death. Hospital and intensive care unit length of stay and hospitalization costs were evaluated. Predictors included cannulation strategy, before and after criteria implementation, use of cytoreductive techniques, timing of tracheostomy, and body mass index. Propensity score matching, multistate Cox proportional hazards models, and generalized linear models were used.

Results

Our sample comprised 105 patients, 26 from before criteria implementation ("before" phase) and 79 after ("after" phase). Propensity score results indicated no significant differences in death (P = .152) and costs (P = .063) between the groups. Patients who received cytoreductive therapy had lower total costs (P = .033). Those who underwent single-site cannulation had higher probability of decannulation (P = .009), discharge (P < .001), tracheostomy (P < .001), and extubation alive (P < .001) and lower risk of death (P = .017).

Conclusions

Modifying candidacy by objective criteria with the use of adjunctive therapies may improve outcomes and lower costs during periods of supply-demand mismatch.

Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review

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.