Extracorporeal membrane oxygenation with right ventricular support in COVID-19 patients with severe acute respiratory distress syndrome
Year: 2021
Type: editorial
Abstract: Central MessageSingle access, dual-stage veno-venous ECMO with right ventricular support is safe and effective in COVID-19 patients with severe acute respiratory distress syndrome in whom mechanical ventilatory support is failing. Single access, dual-stage veno-venous ECMO with right ventricular support is safe and effective in COVID-19 patients with severe acute respiratory distress syndrome in whom mechanical ventilatory support is failing. Rare cases of COVID-19 infection can lead to life-threatening respiratory failure.1Richardson S. Hirsch J.S. Narasimhan M. Crawford J.M. McGinn T. Davidson K.W. et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6528) Google Scholar Despite attempts to control the disease with social distancing and mass vaccination, 2% of patients continue to succumb to lung injury related to infection with this virus.2The Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Coronavirus COVID-19 global cases.https://coronavirus.jhu.edu/map.htmlGoogle Scholar Mechanical ventilatory support is the primary intervention for patients with worsening respiratory failure progressing to acute respiratory distress syndrome.3Fan E. Beitler J.R. Brochard L. Calfee C.S. Ferguson N.D. Slutsky A.S. et al.COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted?.Lancet Respir Med. 2020; 8: 816-821Abstract Full Text Full Text PDF PubMed Scopus (338) Google Scholar,4Bhatraju P.K. Ghassemieh B.J. Nichols M. Kim R. Jerome K.R. Nalla A.K. et al.COVID-19 in critically ill patients in the Seattle region - case series.N Engl J Med. 2020; 382: 2012-2022Crossref PubMed Scopus (1833) Google Scholar Barotrauma, prolonged sedation, and nosocomial pneumonia in patients who require mechanical support further lead to secondary complications and potentially limit recovery.5Hill A.D. Fowler R.A. Burns K.E. Rose L. Pinto R.L. Scales D.C. Long-term outcomes and health care utilization after prolonged mechanical ventilation.Ann Am Thorac Soc. 2017; 14: 355-362Crossref PubMed Scopus (81) Google Scholar Veno-venous extracorporeal membrane oxygenation (ECMO) has been used in severe cases of respiratory failure.6Brodie D. Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults.N Engl J Med. 2011; 365: 1905-1914Crossref PubMed Scopus (632) Google Scholar, 7Combes A. Hajage D. Capellier G. Demoule A. Lavoué S. Guervilly C. et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.N Engl J Med. 2018; 378: 1965-1975Crossref PubMed Scopus (1460) Google Scholar, 8Alshahrani M.S. Sindi A. Alshamsi F. Al-Omari A. El Tahan M. Alahmadi B. et al.Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus.Ann Intensive Care. 2018; 8: 3Crossref PubMed Scopus (148) Google Scholar The international Extracorporeal Life Support Organization reported a 51% survival in patients with COVID-19 respiratory failure who were supported with ECMO.9Extracorporeal Life Support Organization (ELSO)ECMO in COVID-19.https://www.elso.org/Registry/FullCOVID19RegistryDashboard.aspxGoogle Scholar The largest US multicenter study reported a survival of 42%.10Saeed O, Tatooles AJ, Farooq M, Schwartz G, Pham DT, Mustafa AK, et al. Characteristics and outcomes of patients with COVID-19 supported by extracorporeal membrane oxygenation: a retrospective multicenter study. J Thorac Cardiovasc Surg. Published online May 18, 2021. https://doi.org/10.1016/j.jtcvs.2021.04.089Google Scholar Several cannulation strategies can be applied, and no randomized clinical trial has evaluated the superiority of one technique over another. Throughout the pandemic our practice has applied veno-venous ECMO with right ventricular support using a dual-stage right atrium to pulmonary artery cannula, the Protek-Duo (CardiacAssist, Inc), for COVID-19 infected patients with respiratory failure in whom conventional mechanical ventilatory support has failed. The rationale for adopting this system was on the basis of inadequate support observed in patients supported with 2 venous cannulas. Recirculation using 2 venous cannulas for support and difficulty mobilizing the patient provided the impetus for change. Conversion to a single access site with right atrial to pulmonary artery catheter provided several advantages: stable platform with rare catheter malposition, adequate flows, and decreased recirculation of drainage blood. Ambulation with this system was simplified. Even with limited patient access with patients in quarantine and during subsequent prolonged support with ambulation catheter malposition was uncommon. Moreover, pulmonary artery pressure measurements were conducted during catheter implantation, and showed severe pulmonary hypertension in all patients. Acute cor pulmonale in COVID-19 patients carries significantly higher mortality,11Creel-Bulos C. Hockstein M. Amin N. Melhem S. Truong A. Sharifpour M. Acute cor pulmonale in critically ill patients with COVID-19.N Engl J Med. 2020; 382: e70Crossref PubMed Scopus (110) Google Scholar,12Li Y. Li H. Zhu S. Xie Y. Wang B. He L. et al.Prognostic value of right ventricular longitudinal strain in patients with COVID-19.JACC Cardiovasc Imaging. 2020; 13: 2287-2299Crossref PubMed Scopus (324) Google Scholar and obesity and acute respiratory distress syndrome are independent risk factors for right ventricular failure.13Chahal H. McClelland R.L. Tandri H. Jain A. Turkbey E.B. Hundley W.G. et al.Obesity and right ventricular structure and function: the MESA-right ventricle study.Chest. 2012; 141: 388-395Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar,14Zochios V. Parhar K. Tunnicliffe W. Roscoe A. Gao F. The right ventricle in ARDS.Chest. 2017; 152: 181-193Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar As such, the Protek-Duo was chosen over other single access dual lumen catheters because of the additional potential for right ventricular support, with flow directly into the pulmonary circulation. Although the limitation of this cannula has not been evaluated, the durability of this system has been observed in a patient maintained on support for 10 months using a single cannula. Over the past year and a half, 150 patients were supported with ECMO using the single access, dual-stage right atrium to pulmonary artery cannula. Early results of our first 40 patients were published in JAMA Surgery.15Mustafa A.K. Alexander P.J. Joshi D.J. Tabachnick D.R. Cross C.A. Pappas P.S. et al.Extracorporeal membrane oxygenation for patients with COVID-19 in severe respiratory failure.JAMA Surg. 2020; 155: 990-992Crossref PubMed Scopus (142) Google Scholar,16Mustafa A.K. Tatooles A.J. Extracorporeal membrane oxygenation and coronavirus disease 2019-reply.JAMA Surg. 2021; 156: 403Crossref Scopus (7) Google Scholar Survival to discharge was 82.5%.16Mustafa A.K. Tatooles A.J. Extracorporeal membrane oxygenation and coronavirus disease 2019-reply.JAMA Surg. 2021; 156: 403Crossref Scopus (7) Google Scholar As the care of patients with COVID-19 infection requiring ECMO has evolved, we describe our approach, patient selection, institutional requirements, cannulation strategy, management, and the results of our experience. All patients were treated and studied at Advocate Christ Medical Center (AHC-7426-C5000376) and Rush University Medical Center (ORA-20040401) from March 17, 2020, and onward. Waiver of the need for consent was obtained. The data were deidentified during analysis and publication to protect patient privacy. Of the 136 patients who have completed their hospital course, 75% were extubated from the ventilator, and 67% decannulated from ECMO and discharged alive. Only 3% required long-term rehabilitation, and 24% needed supplemental oxygen at discharge. The average time for mechanical ventilation was 23.5 ± 5.4 days, and ECMO was 48.4 ± 4.9 days. The average age was 46.9 (SEM, ± 1.1) years; 71% were men and 52% were Hispanic. The average body mass index (BMI) was 34.3 ± 0.6, with obesity noted in 68% of the patients. More than 80% were prone, chemically paralyzed, and receiving vasopressors before ECMO initiation. Major complications such as stroke, as well as acute kidney or liver injuries, were limited. Tracheostomy was performed in 13% of patients. Mortality was 95% in this subgroup. Criteria for ECMO were based on Extracorporeal Life Support Organization principles. Patients supported were younger than 70 years old with single organ dysfunction and suffering from severe hypoxia or hypercarbia despite maximum ventilatory support similar to the stringent criteria described by the ECMO to rescue acute lung injury in severe ARDS trial group.7Combes A. Hajage D. Capellier G. Demoule A. Lavoué S. Guervilly C. et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.N Engl J Med. 2018; 378: 1965-1975Crossref PubMed Scopus (1460) Google Scholar Although most patients supported were obese, absolute BMI weighed into the decision to offer ECMO support. BMI <50 was preferred. Extreme obesity provides additional challenges, and these include difficulty ambulating patients and assuring adequate ECMO flows. The limitations of institutional resources such as critical care hospital beds and nursing staff were additional factors in our decision-making. Some of the absolute contraindications to ECMO placement were outlined in our previous publication.15Mustafa A.K. Alexander P.J. Joshi D.J. Tabachnick D.R. Cross C.A. Pappas P.S. et al.Extracorporeal membrane oxygenation for patients with COVID-19 in severe respiratory failure.JAMA Surg. 2020; 155: 990-992Crossref PubMed Scopus (142) Google Scholar Briefly, they include patients who have suffered a cardiac arrest without return of spontaneous circulation, those with severe acidosis or significantly elevated lactate levels, patients with multi-system organ failure, those with projected life expectancy <5 years before COVID-19 infection, as well as patients with known severe preexisting chronic, life-threatening conditions. Patients on the mechanical ventilator for >2 weeks were not considered for support. Successful application of ECMO requires a dedicated, experienced team with coordinated care of physicians, allied health professionals, perfusionists, respiratory, physical, occupational, and speech therapists, pharmacists, and nutritionists. Critical care nursing is paramount. Cardiothoracic surgeons are core team members whose expertise provides leadership and guidance in the management of these patients. Institutional limitations due to physical space and staffed beds dictate capacity. Focused units provide consistent adherence to principles of ECMO support.17Bartlett R.H. Physiology of gas exchange during ECMO for respiratory failure.J Intensive Care Med. 2017; 32: 243-248Crossref PubMed Scopus (49) Google Scholar Adequate supplies of pumps, oxygenators, and cannulas are required. A variety of support systems are now available for which no direct comparisons have been published. Centrifugal pumps, including Abbott Centrimag and LivaNova Revolution with Maquet Quadrox or occasionally Medtronic MC3 Nautilus oxygenators, have been used in all of our patients. Recovery is slow, often requiring months of in-hospital care. Veno-venous ECMO works parallel to the native circulation, so there will always be a mixing of oxygenated ECMO blood with desaturated native venous blood. Therefore, no veno-venous support system will thoroughly oxygenate all blood entering the arterial system. If desaturated native venous flow (ie, the cardiac output) increases while the ECMO flow is constant, the arterial saturation will decrease.17Bartlett R.H. Physiology of gas exchange during ECMO for respiratory failure.J Intensive Care Med. 2017; 32: 243-248Crossref PubMed Scopus (49) Google Scholar Extreme oxygen extraction also leads to a reduction in native venous saturation, which decreases arterial saturation at constant ECMO flow. As such, optimizing oxygen delivery and evaluating oxygen consumption are important principles of ECMO management. The goal is to maintain oxygen delivery at least 3 times oxygen consumption.17Bartlett R.H. Physiology of gas exchange during ECMO for respiratory failure.J Intensive Care Med. 2017; 32: 243-248Crossref PubMed Scopus (49) Google Scholar This requires a calculation of the arterial blood oxygen content, which on the basis of the partial pressure of oxygen, oxygen saturation, and hemoglobin levels. Despite single access, veno-venous ECMO, patients with extreme BMI, high cardiac output, and significant oxygen extraction might still be hypoxemic. Assessment of arterial lactate in these patients is also critical to the determination of adequate support. As long as oxygen delivery is >3 times oxygen consumption, aerobic metabolism is assured, and lactate will typically be within normal limits. Although a variety of cannulation strategies are feasible, a single access, dual-stage right atrium to pulmonary artery cannula with access through the internal jugular vein was primarily used in most of our patients. Properly secured cannula placement is critical (Figure 1). Placement requires fluoroscopy, and is best performed in an operative or hybrid suite where imaging is optimal; however, bedside insertion with portable imaging has been required for patients unable to tolerate any movement. Access most commonly is performed through the right internal jugular vein, although left internal jugular or subclavian vein approaches are equally successful. A balloon-tipped catheter is floated into the pulmonary artery and exchanged over a stiff wire. The access site is dilated, and the catheter is advanced to the main pulmonary artery. Not uncommonly, the distal tip of the catheter extends to the left or right main pulmonary artery because the length of the catheter as the inflow is best positioned to the right atrium. Small patients are not appropriate for cannulation with the Protek-Duo because of the length of the catheter. Patients with estimated distance from the right atrium to pulmonary artery of <17 centimeters or restricted vascular access unable to accommodate a 29-French cannula are supported with alternative strategies. Two venous cannulas without right ventricular support are the initial strategy in pediatric patients who have required ECMO support. Alternative approaches are applied for rare patients who require greater flow or pediatric patients who require ventricular support. Direct cannulation of the pulmonary artery or aorta is performed through a sternotomy. An 8- or 10-mm vascular graft is sewn to the main pulmonary artery or ascending aorta. These grafts are tunneled subcutaneously and connected to the outflow circuit. Percutaneous cannulation of the right atrium provides inflow with conversion to veno-arterial or veno-venous ECMO. Decannulation is performed with ligation of the graft and by burying of the residual stump subcutaneously without reoperative sternotomy. Rapidly declining patients who are intolerant of transfer to the operating room are initially supported with femoral-femoral or internal jugular-femoral cannulation. With ongoing support, most of these patients are converted to the Protek-Duo. The rationale for conversion is primarily to simplify access, avoid recirculation, maintain efficient gas exchange, and provide long-term catheter stability without malposition. Right ventricular failure is a devastating consequence in many patients with severe COVID-19 respiratory failure.11Creel-Bulos C. Hockstein M. Amin N. Melhem S. Truong A. Sharifpour M. Acute cor pulmonale in critically ill patients with COVID-19.N Engl J Med. 2020; 382: e70Crossref PubMed Scopus (110) Google Scholar,12Li Y. Li H. Zhu S. Xie Y. Wang B. He L. et al.Prognostic value of right ventricular longitudinal strain in patients with COVID-19.JACC Cardiovasc Imaging. 2020; 13: 2287-2299Crossref PubMed Scopus (324) Google Scholar Elevated central venous and right ventricular pressures as well as significant pulmonary hypertension at the time of ECMO initiation were routinely noted. As such, supporting the right heart under these circumstances has potential benefits. We also routinely use pulmonary vasodilators such as inhaled nitric oxide. Initial management involves discontinuation of paralytics and minimizing ventilatory barotrauma by reducing the plateau pressures to <20 mm Hg. The goal is to extubate all patients after cannulation. Extubating patients during ECMO avoids barotrauma related to mechanical ventilation and avoids nosocomial pneumonia. Discontinuing paralytics and weaning sedatives facilitate mobilization and are associated with improved outcomes. Significant challenges are encountered when attempting to wean sedation. Agitation and increased work of breathing increase oxygen consumption and CO2 production. Therefore, ECMO blood flow and sweep gas flow should be increased during weaning from sedation. The rapidly rising partial pressure of CO2 is the primary cause of agitation and dyspnea. Assessment of metabolism by measuring lactic acid is an important determinant of adequate support. Not uncommonly, patients will have transient periods of relative hypoxemia with decreased oxygen saturations during weaning trials. Getting to an awake status, and treating hypoxemia and hypercarbia cannot be managed by inexperienced caregivers by increasing ventilatory support. Relative hypoxemia must be tolerated when there is no evidence of end-organ malperfusion. Blood transfusion is required to increase oxygen content and improve delivery. Experience has shown that titrating sweep with increased CO2 removal during episodes of symptomatic increased work of breathing has decreased the air hunger patients manifest and facilitated the ability to get patients off the ventilator. Most patients will require polypharmacy while weaning, including narcotics, anxiolytics, and antipsychotics. No single combination of drugs can be applied to all patients because clinical response varies and individual tailoring of sedation is required. Patients with prolonged pre-ECMO mechanical ventilatory support with high-dose sedatives require longer weaning periods; several weeks might be required. Anticoagulation with direct thrombin inhibitors was initiated with titration of prothrombin time between 50 and 70 seconds. Hypercoagulability is also detrimental to the ECMO circuit because clots can hamper flow and damage the oxygenator.18Lubnow M. Philipp A. Foltan M. Bull Enger T. Lunz D. Bein T. et al.Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange–retrospective analysis of 265 cases.PLoS One. 2014; 9: e112316Crossref PubMed Scopus (131) Google Scholar Choice of anticoagulation was initiated because of early heparin resistance and avoidance of heparin-associated requires an patient to with stable without flow or saturation with normal lactic acid was might be required to maintain normal oxygen content and the of lactic Tracheostomy is not in this of patients. goal is to the limit and provide lung over time with and physical With patients off ventilator support, sedatives are physical is and most patients will on ECMO. is initiated on ECMO. physical, occupational, and speech with are the of (Figure Ambulation on ECMO is critical for clinical 1). Not uncommonly, patients have of lung that not improve they patients increased and subsequent ECMO support is With patients ambulating on ECMO, long-term care is after lung and discontinuation of ECMO support. and complications are observed in this of patients. Patients with COVID-19 are to vein pulmonary and B. D. T. E. et al.COVID-19 and or for and Am 2020; PubMed Scopus Google Scholar, S. H. et as a of COVID-19 in the Engl J Med. 2020; 382: PubMed Scopus Google Scholar, F. T. R. G. Y. et and risk factors for of with COVID-19 in a retrospective 2020; Full Text Full Text PDF PubMed Scopus Google Scholar is often associated with a that might with ECMO circuit exchange and often requires transfusion complications and require of requires and to The outflow of the Protek-Duo in the cannula because of and length with to flow has been associated with Rare cases of cannula over time have also been observed with subsequent failure is and requires ongoing An increase in lactate levels, worsening blood increasing and pressure and flow limitations are of Despite within days. also have for months in the of from or with failure is associated with a As such, the and of is critically ECMO in COVID-19 patients has to outcomes. single access, dual-stage veno-venous cannula with right ventricular support provides a stable support platform to facilitate ECMO. Alternative cannulation strategies might be required to outcomes. the patient from sedation and mechanical early and on physical and respiratory on ECMO are critical of our With this approach, patients with the most with on their were to a (Figure with most discharged and a requiring long-term of a return to a of Recovery requires with prolonged is significant with and We in the of the of with ECMO is best
Source: JTCVS Open
Language: English
Subfield: Biomedical Engineering
Field: Engineering
Domain: Physical Sciences
Open Access status: gold
Estimated APC paid: $2,100
OpenAlex ID: W3210455513