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Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-Venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

Authors:
Lauren A Raff Jared R Gallaher Daniel Johnson Evan J Raff Anthony G Charles Trista S Reid

Ann Surg 2020 Dec 22. Epub 2020 Dec 22.

*University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of Surgery, Chapel Hill, NC †University of North Carolina at Chapel Hill School of Medicine ‡University of North Carolina at Chapel Hill, Division of Hospital Medicine, Department of Medicine, Chapel Hill, NC §University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of General Surgery, Chapel Hill, NC.

Objective: COVID-19 can cause acute respiratory distress syndrome (ARDS) that is rapidly progressive, severe, and refractory to conventional therapies. Extracorporeal membrane oxygenation (ECMO) can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined.

Summary Background Data: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best post-cannulation management strategy, however, has not yet been defined.

Methods: We conducted a retrospective review from April 1 to July 31 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality.

Results: 44% of patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs. 53.1 years; p < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs. 19.9 days, p = 0.028) and shorter duration of intensive care unit (ICU) length of stay (LOS) prior to cannulation (5.6 days vs. 11.7 days, p = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%.

Conclusions: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

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http://dx.doi.org/10.1097/SLA.0000000000004683DOI Listing
December 2020

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