Extracorporeal membrane oxygenation (ECMO) in patients with severe COVID-19 adult respiratory distress syndrome: a systematic review and meta-analysis

Relationship between the Pre-ECMO and ECMO Time and Survival of Severe COVID-19 Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) is the etiology of acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used to support gas exchange in patients who have failed conventional mechanical ventilation. However, there is no clear consensus on the timing of ECMO use in severe COVID-19 patients.

OBJECTIVE

The aim of this study is to compare the differences in pre-ECMO time and ECMO duration between COVID-19 survivors and non-survivors and to explore the association between them.

METHODS

PubMed, the Cochrane Library, Embase, and other sources were searched until 21 October 2022. Studies reporting the relationship between ECMO-related time and COVID-19 survival were included. All available data were pooled using random-effects methods. Linear regression analysis was used to determine the correlation between pre-ECMO time and ECMO duration. The meta-analysis was registered with PROSPERO under registration number CRD42023403236.

RESULTS

Out of the initial 2473 citations, we analyzed 318 full-text articles, and 54 studies were included, involving 13,691 patients. There were significant differences between survivors and non-survivors in the time from COVID-19 diagnosis (standardized mean difference (SMD) = -0.41, 95% confidence interval (CI): [-0.53, -0.29], p < 0.00001), hospital (SMD = -0.53, 95% CI: [-0.97, -0.09], p = 0.02) and intensive care unit (ICU) admission (SMD = -0.28, 95% CI: [-0.49, -0.08], p = 0.007), intubation or mechanical ventilation to ECMO (SMD = -0.21, 95% CI: [-0.32, -0.09], p = 0.0003) and ECMO duration (SMD = -0.18, 95% CI: [-0.30, -0.06], p = 0.003). There was no statistical association between a longer time from symptom onset to ECMO (hazard ratio (HR) = 1.05, 95% CI: [0.99, 1.12], p = 0.11) or time from intubation or mechanical ventilation (MV) and the risk of mortality (highest vs. lowest time groups odds ratio (OR) = 1.18, 95% CI: [0.78, 1.78], p = 0.42; per one-day increase OR = 1.14, 95% CI: [0.86, 1.52], p = 0.36; HR = 0.99, 95% CI: [0.95, 1.02], p = 0.39). There was no linear relationship between pre-ECMO time and ECMO duration.

CONCLUSION

There are differences in pre-ECMO time between COVID-19 survivors and non-survivors, and there is insufficient evidence to conclude that longer pre-ECMO time is responsible for reduced survival in COVID-19 patients. ECMO duration differed between survivors and non-survivors, and the timing of pre-ECMO does not have an impact on ECMO duration. Further studies are needed to explore the association between pre-ECMO and ECMO time in the survival of COVID-19 patients.

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

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.

De-escalation of Anti-tumor Necrosis Factor Alpha Agents and Reduction in Adverse Effects: A Systematic Review

Background: The long-term use of anti-TNF-α agents can lead to adverse effects, such as infections and immune-mediated cutaneous reactions. Whether de-escalation by dose reduction or interval lengthening reduces these adverse effects is uncertain. This systematic review aims to compare the incidence of infections and skin manifestations after anti-TNF-α dose de-escalation with standard dosing. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception to 14 January 2022. Randomized controlled trials (RCTs) and observational studies comparing anti-TNF-α de-escalation strategies with standard dosing among patients with inflammatory conditions, that report on infections, skin manifestations, or both, were included. The risk of bias was assessed with the revised Cochrane risk-of bias tool (RCTs) or the Newcastle–Ottawa scale (non-RCTs). Results: Fourteen RCTs and six observational studies (or 2706 patients) were included. Eight RCTs had low risk of bias or some concerns. Four non-RCTs were of good methodological quality. The studies described patients with axial spondyloarthritis (8 studies, 780 patients), rheumatoid arthritis (7 studies, 1458 patients), psoriasis (3 studies, 332 patients), or inflammatory bowel disease (2 studies, 136 patients). De-escalation strategies included interval lengthening (12 studies, 1317 patients), dose reduction (6 studies, 1130 patients), or both (2 studies, 259 patients). Overall, the occurrence of infections and skin manifestations did not differ between standard treatment and de-escalation. The disappearance of infections or skin manifestations after de-escalation was only reported in two studies. The majority of studies focused on etanercept and adalimumab. Heterogeneity in reporting of infections and skin manifestations precluded meta-analysis. Conclusion: We found that anti-TNF-α de-escalation does not reduce infections or skin reactions. A de-escalation strategy should not be recommended for the sole purpose of reducing drug-related adverse effects. The meticulous documentation of adverse effects is recommended to further address this question. Registration: PROSPERO CRD42021252977.

The Year in Extracorporeal Membrane Oxygenation: Selected Highlights From 2021

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.

Thoracic surgery in Egypt

General thoracic surgery operations in Egypt are performed mainly by cardiothoracic surgeons and less oftenly by dedicated thoracic surgeons and general surgeons. This is mainly due to the relatively small number of thoracic surgeons in relation to population as only 210 cardiothoracic surgery specialists and 458 consultants are registered with the Egyptian Medical Syndicate (EMS) in a country with a population of more than 100 million people. Thoracic surgeons in Egypt are faced with a number of burdens, including the need to propagate the service to advanced technology infront of the obstacle of limited resources. Other burdens include higher incidence of TB, trauma and foreign body inhalation related to cultural backgrounds. More centres now are major video-assisted thoracic surgery (VATS) providing centres and others are specialized in more complex surgeries like complicated airway procedures and radical surgery for mesothelioma. As part of the international community, the COVID-19 pandemic has put more burdens on the thoracic surgery service as most centres have reduced their elective surgery workload to less than half of usual. Interestingly, the pandemic has allowed a self-referral screening programme with widespread Computed Tomography (CT) chest being performed among the population allowing thoracic surgeons to operate more on early stage lung cancer. The academic challenges for thoracic surgeons are even more with need for developing national databases. Nevertheless, thoracic surgeons in Egypt are optimistic regarding the future. The rising interest among the younger population will push training programs to meet the interests of enthusiastic junior surgeons. While the ancient history of thoracic surgery in Egypt seems to be extraordinary, the future perspectives promise to be more rewarding.