Clinical Characteristics Between Survivors and Nonsurvivors of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) Support: A Systematic Review and Meta-Analysis

Risk Factors for the Mortality of Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation in a Non-Centralized Setting: A Nationwide Study

BACKGROUND

Limited data are available on the mortality rates of patients receiving extracorporeal membrane oxygenation (ECMO) support for coronavirus disease 2019 (COVID-19). We aimed to analyze the relationship between COVID-19 and clinical outcomes for patients receiving ECMO.

METHODS

We retrospectively investigated patients with COVID-19 pneumonia requiring ECMO in 19 hospitals across Korea from January 1, 2020 to August 31, 2021. The primary outcome was the 90-day mortality after ECMO initiation. We performed multivariate analysis using a logistic regression model to estimate the odds ratio (OR) of 90-day mortality. Survival differences were analyzed using the Kaplan-Meier (KM) method.

RESULTS

Of 127 patients with COVID-19 pneumonia who received ECMO, 70 patients (55.1%) died within 90 days of ECMO initiation. The median age was 64 years, and 63% of patients were male. The incidence of ECMO was increased with age but was decreased after 70 years of age. However, the survival rate was decreased linearly with age. In multivariate analysis, age (OR, 1.048; 95% confidence interval [CI], 1.010-1.089; P = 0.014) and receipt of continuous renal replacement therapy (CRRT) (OR, 3.069; 95% CI, 1.312-7.180; P = 0.010) were significantly associated with an increased risk of 90-day mortality. KM curves showed significant differences in survival between groups according to age (65 years) (log-rank P = 0.021) and receipt of CRRT (log-rank P = 0.004).

CONCLUSION

Older age and receipt of CRRT were associated with higher mortality rates among patients with COVID-19 who received ECMO.

Outcomes of COVID-19 patients undergoing extracorporeal membrane oxygenation: A systematic review and meta-Analysis

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has been ongoing for over 3 years, during which numerous clinical and experimental studies have been conducted. The objective of this systematic review and meta-analysis was to assess the survival probability and complications of COVID-19 patients receiving extracorporeal membrane oxygenation (ECMO).

METHODS

We searched the databases by using Population-Intervention-Comparison-Outcome-Study Design (PICOS). We conducted a search of the PubMed, Web of Science, and EMBASE databases to retrieve studies published until December 10, 2022. A random-effects meta-analysis, subgroup analysis, and assessed the studies using the Newcastle-Ottawa Scale score. The results were presented as pooled morbidity with 95% confidence intervals.

RESULTS

The study was conducted on 19 studies that enrolled a total of 1494 patients, and the results showed a pooled survival probability of 66.0%. The pooled morbidity for intracranial hemorrhage was 8.7%, intracranial thrombosis 7.0%, pneumothorax 9.0%, pulmonary embolism 11.0%, pulmonary hemorrhage 9.0%, heart failure 14.0%, liver failure 13.0%, renal injury 44.0%, gastrointestinal hemorrhage 6.0%, gastrointestinal ischemia 6.0% and venous thrombosis 31.0%.

CONCLUSION

This systematic review and meta-analysis of observational studies focused on the survival probability and complications of COVID-19 patients undergoing ECMO, which are significant in evaluating the use of ECMO in COVID-19 patients and provide a basis for further research.

TRIAL REGISTRATION

Our study was registered on PROSPERO with registration number CRD42022382555.

Factors associated with bleeding complications in patients with coronavirus disease 2019 admitted to intensive care units: A multicenter retrospective cohort study

AIMS/INTRODUCTION

Diabetes is a major risk factor for coronavirus disease 2019 (COVID-19) severity. We aimed to retrospectively investigate the rates of patients with no diabetes, untreated diabetes, treated diabetes, COVID-19-related diabetes and the factors associated with bleeding complications in a cohort of patients with severe COVID-19.

MATERIALS AND METHODS

This was a multicenter, retrospective, observational study. Participants were COVID-19 patients enrolled in the Cross-sectional ICU Information Search System (CRISIS) from February 2020 to March 2022. Patients were classified into four groups according to diabetes status and treatment status. Hemorrhagic complications were defined as bleeding requiring transfusion of four or more red blood cell units, a drop of hemoglobin of ≥2 g in 24 h and retroperitoneal, airway or intracranial bleeding. Logistic regression analysis was carried out to examine factors associated with bleeding complications.

RESULTS

A total of 1,076 patients were included in the analysis. The rates of patients in the no diabetes, untreated diabetes, treated diabetes and COVID-19-related diabetes groups were 17.4, 23.0, 23.9 and 35.7%, respectively. Bleeding complications were observed in 7.5% of all patients. Glycated hemoglobin level and renal failure were significantly correlated with bleeding complications (odds ratio 1.16, 95% confidence interval 1.02-1.33 and 2.77, 95% confidence interval 1.16-6.63, respectively). Patients with diabetes, including those with COVID-19-related diabetes, accounted for approximately 83% of all cases.

CONCLUSIONS

In patients with severe COVID-19 with high glycated hemoglobin and renal failure, we recommend additional attention to the course of COVID-19, given the risk of bleeding complications.

Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series

OBJECTIVE

The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil.

METHODS

We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021.

RESULTS

Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10).

CONCLUSIONS

Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

Extracorporeal membrane oxygenation for COVID-19 and influenza associated acute respiratory distress syndrome: a systematic review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been used extensively for H1N1 influenza and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) to improve gas exchange and quickly correct hypoxemia and hypercapnia. This systematic review summarized the evidence on ECMO for the treatment of COVID-19 and influenza-associated ARDS.

RESEARCH DESIGN AND METHODS

This is a systematic review and meta-analysis of studies to compare the efficacy and safety of ECMO with conventional mechanical ventilation in adults with COVID-19 and influenza-associated ARDS. The study performed a structured search on PubMed, Embase, Web of Science, Scopus and The Cochrane Library. The primary outcome was hospital mortality.

RESULTS

The study included 15 observational studies with 5239 patients with COVID-19 and influenza-associated ARDS. The use of ECMO significantly reduced in-hospital mortality in COVID-19-associated ARDS (OR = 0.40; 95% CI = 0.27-0.58; P < 0.00001) but did not reduce influenza-related mortality (OR = 1.08; 95% CI = 0.41-2.87; P = 0.87). Moreover, ECMO treatment meaningfully increased the incidence of bleeding complications (OR = 7.66; 95% CI = 2.47-23.72; P = 0.0004).

CONCLUSION

The use of ECMO significantly reduced in-hospital mortality in COVID-19- associated ARDS, which may be related to the advances in ECMO-related techniques and the increased experience of clinicians. However, the incidence of bleeding complications remains high. [Figure: see text].

Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.

COVID-19-Related ARDS: Key Mechanistic Features and Treatments

Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome historically characterized by the presence of severe hypoxemia, high-permeability pulmonary edema manifesting as diffuse alveolar infiltrate on chest radiograph, and reduced compliance of the integrated respiratory system as a result of widespread compressive atelectasis and fluid-filled alveoli. Coronavirus disease 19 (COVID-19)-associated ARDS (C-ARDS) is a novel etiology caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that may present with distinct clinical features as a result of the viral pathobiology unique to SARS-CoV-2. In particular, severe injury to the pulmonary vascular endothelium, accompanied by the presence of diffuse microthrombi in the pulmonary microcirculation, can lead to a clinical presentation in which the severity of impaired gas exchange becomes uncoupled from lung capacity and respiratory mechanics. The purpose of this review is to highlight the key mechanistic features of C-ARDS and to discuss the implications these features have on its treatment. In some patients with C-ARDS, rigid adherence to guidelines derived from clinical trials in the pre-COVID era may not be appropriate.

Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis

BACKGROUND

A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated.

OBJECTIVES

To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients.

METHODS

Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021.

RESULTS

Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups.

CONCLUSIONS

Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.