Bohman, John K.

OBJECTIVES: Determine the factors associated with mortality in venovenous extracorporeal membrane oxygenation (V-V ECMO) patients with COVID-19 infection and provide an updated report of clinical outcomes for patients treated with V-V ECMO for COVID-19 in Minnesota. DESIGN: Multicenter prospective observational study. SETTING: The four adult Extracorporeal Life Support Organization–certified Centers of Excellence in Minnesota. PATIENTS: A total of 100 patients treated with V-V ECMO for COVID-19–associated acute respiratory distress syndrome (ARDS) from March 2020 to May 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: The primary outcome was 60-day survival for patients treated with V-V ECMO for COVID-19. Outcomes of patients treated from November 2020 to May 2021(cohort 2) were compared with data from a previous cohort of patients, collected from March 2020 to October 2020 (cohort 1). The data from both cohorts were merged into a single dataset (Combined Cohort). Survival on V-V ECMO due to COVID-19–associated ARDS significantly decreased after October 2020 (63% vs 41%; p = 0.026). The median interval from hospital admission to V-V ECMO cannulation was significantly associated with 60-day mortality (10 d [6–14 d] in nonsurvivors vs 7 d [4–9 d] in survivors; p = 0.001) in the Combined Cohort and was also significantly longer in cohort 2 than cohort 1 (10 d [7–14 d] vs 6 d [4–10 d]; p < 0.001). In the Combined Cohort, the 60-day survival for patients who did not receive steroids was 86% (n = 12) versus 45% (n = 39) for patients who received at least one dose of steroids (p = 0.005). CONCLUSIONS: There was a significant increase in mortality for patients treated with V-V ECMO for COVID-19–associated ARDS in cohort 2 compared with cohort 1. Further research is required to determine the cause of the worsening trend in mortality.

BACKGROUND: ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened. METHODS: Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed. RESULTS: Baseline characteristics, tidal volumes, P aO 2 / F IO 2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H 2 O [IQR 6.5–19.4] vs 18 cm H 2 O [IQR 10–22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H 2 O [IQR 13–36.2] vs 12 cm H 2 O [IQR 9–19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83–347.2] vs 16.3 h [IQR 1–99.7], I = .02), and P aO 2 / F IO 2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation. CONCLUSIONS: Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.

We retrospectively reviewed all pertinent extracorporeal membrane oxygenation (ECMO) studies (January 1995 to September 2017) of adults with sepsis as a primary indication for intervention and its association with morbidity and mortality. Collected data included study type, ECMO configuration, outcomes, effect size, and other features. Advanced age was a risk factor for death. Compared with nonsurvivors, survivors had a lower median Sepsis-Related Organ Failure Assessment score on day 3 (15 vs. 18, p = 0.01). Biomarkers in survivors and nonsurvivors, respectively, were peak lactate (from two studies: 4.5 vs. 15.1 mmol/L, p = 0.03; 3.6 ± 3.7 vs. 3.3 ± 2.4 mmol/L, p = 0.850) and procalcitonin levels (41 vs. 164 ng/ml, p = 0.008). Bacteremia was associated with catheter colonization, and 90.5% of a group without bloodstream infections survived to discharge; ECMO weaning was possible for less than half the bloodstream infection group. Myocarditis portended favorable outcomes for patients with sepsis who received ECMO. Extracorporeal membrane oxygenation was used in immunosuppressed patients with refractory cardiopulmonary insufficiency from severe sepsis with successful weaning from ECMO for most patients. Overall survival varied substantially among studies (15.38–71.43%). Existing studies do not present well-defined patterns supporting use of ECMO in sepsis because of sample sizes and disparate study designs.

Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.