key: cord-283968-ege0j4lf
authors: Le Breton, C.; Besset, S.; Freita-Ramos, S.; Amouretti, M.; Billiet, P.A.; Dao, M.; Dumont, L.M.; Federici, L.; Gaborieau, B.; Longrois, D.; Postel-Vinay, P.; Vuillard, C.; Zucman, N.; Lebreton, G.; Combes, A.; Dreyfuss, D.; Ricard, J.D.; Roux, D.
title: Extracorporeal membrane oxygenation for refractory COVID-19 acute respiratory distress syndrome
date: 2020-07-16
journal: J Crit Care
DOI: 10.1016/j.jcrc.2020.07.013
sha: 
doc_id: 283968
cord_uid: ege0j4lf

nan

Recent studies suggest a survival benefit from extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) [1, 2] . However, the role of ECMO remains uncertain for COVID-19-related ARDS [3] .

This stems from the fact that very high mortality rates have been reported in COVID-19 patients treated with ECMO. In a study on 52 critically-ill patients with SARS-CoV-2 pneumonia, six patients received ECMO of whom five died and one was still on ECMO at the time of publication [4] . In another study on 48 patients, ten patients received ECMO. At the time of publication, three patients had died whereas five out of seven were still on ECMO [5].

In another study describing 12 critically-ill COVID-19 patients treated with ECMO, five patients died [6] . Finally, in a report on eight patients treated with ECMO, only three were weaned from the device but were still mechanically ventilated at the time of publication whereas four died and one was still receiving the technique [7].

These results tend to suggest that patients treated with ECMO during severe COVID-19 related ARDS have a poor prognosis. This in turn questions the role of this invasive and expensive treatment.

Our experience markedly differs as we observed a much better prognosis for patients placed Table 1 . Median SAPS2 score on admission was 58 (range 31 to 79). All patients had both bilateral diffuse ground-glass opacities and alveolar confluent opacities on chest Xray. Median duration of mechanical ventilation before ECMO implantation was 6 days.

Median value of PaO 2 /FiO 2 ratio before ECMO initiation was 59. Median tidal volume was 5.25 ml/kg of predicted body weight and median positive end-expiratory pressure 12 cmH 2 O.

Despite the application of a low tidal volume, median plateau pressure was 32 cmH 2 O and median driving pressure 20 cmH 2 0. All patients were hypercapnic (median 65 mmHg, range 59 to 96). Implantation of ECMO allowed for implementation of lung ultraprotective ventilation. Indeed, plateau pressure was set below 25 cmH 2 0, with a positive end-expiratory pressure between 8 to 12 cmH 2 0. This resulted in a median tidal volume of 2.14 ml/kg of predicted body weight. The median output of ECMO was 5 l/min after implantation with a median sweep gas flow rate of 4.0 l/min. Seven major adverse events occurred in four patients ( Table 2) . Three major hemorrhagic events (hemothoraxpatient #13, intra-peritoneal hemorrhage -patient #8, diffuse hemorrhage from cannulas and oropharynx -patient#3) required massive transfusion. Two

Enterococcus faecalis bacteremia (one complicated by mitral endocarditis) resulted from infection at a cannula-insertion site (patients #10 and #13). Two circuit changes were J o u r n a l P r e -p r o o f required: one for device thrombosis and pump dysfunction (patient #8) and one because of severe circuit-related thrombocytopenia (patient #3).

All 13 patients were weaned from ECMO after a median of 13 days (range 3 to 34). Two patients died while still on mechanical ventilation. One was a 41-year-old Jehovah's Witness (patient#1). This fact was unknown at the time of implantation. It was later found that the patient had expressed his refusal of transfusion in a written document. His spouse (trusted person) repeatedly refused that her husband be transfused. Severe bleeding and hemolysis caused by ECMO resulted in a hemoglobin level of less than 5 g/dl. Given the repeated refusal of blood transfusion, decision to withdraw ECMO was done in the hope that the respiratory condition has sufficiently improved to allow for ECMO withdrawal. Catastrophic hypoxemia and lung mechanical properties alteration recurred, and he died three days later.

Improved lung properties and oxygenation allowed for weaning in another patient (patient#8) but he died from cardiogenic shock with massive right ventricular failure seven days later. A diagnosis of pulmonary embolism was suspected but could not be ascertained.

As of June 28 th , 2020 all surviving patients were weaned from the ventilator after a median duration of mechanical ventilation of 29 days (range 20 to 51) and were discharged alive from the ICU (Table 2) 

Specific therapy Other organ support

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Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial

COVID-19, ECMO, and lymphopenia: a word of caution

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered