Awake extracorporeal membrane oxygenation support for a critically ill COVID-19 patient: A case report

Extracorporal Membrane Oxygenation in Nonintubated Patients (Awake ECMO) With COVID-19 Adult Respiratory Distress Syndrome: The Israeli Experience

In this retrospective multicenter observational study, we describe the Israeli experience with veno-venous extracorporeal membrane oxygenation (VV ECMO) for the treatment of COVID-19-induced severe adult respiratory distress syndrome (ARDS), in which ECMO cannulation was done while the patients were awake and spontaneously breathing without endotracheal tube, namely "awake ECMO." We enrolled all adult patients with severe ARDS due to COVID-19, treated with VV ECMO between March 1, 2020, and November 30, 2021, in which cannulation was done while the patient was awake and spontaneously breathing. During the study period, 365 COVID-19 ARDS patients were treated with VV ECMO. Of these, 25 (6.8%) were treated as awake ECMO. The patient's mean age was 52 years, and 80% were male. Nine of the 25 patients (36%) remained awake throughout their intensive care unit stay and were not sedated and mechanically ventilated at all. Sixteen (64%) were eventually intubated while being on ECMO. Six months survival was 76%. Median mechanical ventilation-free days on ECMO was 8 (interquartile range 5-12) days. This hypothesis-generating study suggests that treating COVID-19 ARDS patients with VV ECMO without sedation and mechanical ventilation is feasible, yet, additional research will be required in order to determine if this modality offers a survival benefit and to identify who are the patients most likely to benefit from it.

Outcomes of Extracorporeal Membrane Oxygenation (ECMO) for COVID-19 Patients: A Multi-Institutional Analysis

BACKGROUND

In March 2020, COVID-19 was announced as a global pandemic. The first COVID-19 patient was connected to an ECMO device in Israel during that time. Since then, over 200 patients have required ECMO support due to COVID-19 infection. The present study is a multi-institutional analysis of all COVID-19 patients requiring veno-venous (VV) ECMO in Israel. The aim was to characterize and compare the survivors and deceased patients as well as establish risk factors for mortality.

METHODS

This retrospective multi-institutional study was conducted from March 2020 to March 2021 in eleven of twelve ECMO centers operating in Israel. All COVID-19 patients on VV ECMO support were included in the cohort. The patients were analyzed based on their comorbidities, procedural data, adverse event on ECMO, and outcomes. Univariate and multivariate analyses were used to compare the deceased and the surviving patients.

RESULTS

The study included 197 patients, of which 150 (76%) were males, and the mean age was 50.7 ± 12 years. Overall mortality was 106 (54%). Compared with the deceased subjects, survivors were significantly younger (48 ± 11 vs. 53 ± 12 years), suffered less from ischemic heart disease (IHD) (3% vs. 12%), and were ventilated for a significantly shorter period (≤4 days) prior to cannulation (77% vs. 63%). Patients in the deceased group experienced more kidney failure and sepsis. Rates of other complications were comparable between groups.

CONCLUSIONS

Based on this study, we conclude that early cannulation (≤4 days) of younger patients (≤55 years) may improve overall survival and that a history of IHD might indicate a reduced prognosis.

Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Management of acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still a challenge for the staff on intensive-care units (ICU’s) around the world. Many of these patients are treated with invasive ventilation. Sometimes, the occurrence of pneumothorax and/or pneumomediastinum can complicate the course of the disease because initiation of invasive ventilation might be fatal in those patients. Venovenous extracorporal membrane oxygenation (vv-ECMO) is increasingly used to prevent patients with severe ARDS from hypoxia. However, clear recommendations for or against the initiation of vv-ECMO in awake patients are currently lacking. We present the case of a 42-year-old patient with COVID-19-associated severe ARDS, pneumothorax, and pneumomediastinum. To preserve sufficient oxygenation and to avoid invasive ventilation, we implanted a vv-ECMO while the patient was awake. The patient recovered and was discharged home 41 days after transfer to our hospital. We therefore suggest that awake implantation of vv-ECMO might be useful in a subgroup of patients with severe ARDS caused by SARS-CoV-2. However, further evidence is needed to verify our hypothesis.

Rehabilitation for COVID-19 in conjunction with early awake extracorporeal membrane oxygenation support: a case report

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 can lead to acute respiratory distress syndrome. Awake venovenous extracorporeal membrane oxygenation is known to be effective in patients with critical COVID-19 and respiratory failure. This report describes the rehabilitation course and functional progress of a 63-year-old man who contracted severe COVID-19 and underwent awake venovenous extracorporeal membrane oxygenation. He started rehabilitation from the time of isolation while receiving venovenous extracorporeal membrane oxygenation and underwent a 30-day course of inpatient comprehensive rehabilitation. He regained functional independence and cognitive abilities and was able to walk without assistance at hospital discharge without any complications. This study demonstrates the feasibility of starting rehabilitation for COVID-19 early while the patient is on awake venovenous extracorporeal membrane oxygenation and eventually achieving a favorable outcome.