Category: 2019nCoV

ELSO Webinar

ECMO in COVID-19

To date, there is limited worldwide experience with using ECMO in COVID-19 patients. The ELSO – Extracorporeal Life Support Organization continues to collect data through our member centers, and will provide recommendations as additional information becomes available. Moreover, to support the ECMO providers community, we are going to host a series of webinars to answer main questions related to Coronavirus outbreak and induced disease COVID-19 & the use of ECMO, involving leaders in the field of intensive care medicine and extracorporeal support ECLS. Any question, doubt or concern? Any particular topic you would like our expert to address?
Send all questions to webinar@elso.org or through DM & stay tuned, info on date/timing coming soon!

COVID-19 infographics

ECMO in COVID-19 related severe cardiopulmonary failure: visual summary of the recently published ELSO – Extracorporeal Life Support Organization Consensus guideline: unique considerations on when & how to provide ECLS in SARS-CoV-2 Coronavirus pandemic, with potential indications/contraindications. Download full document at https://bit.ly/ELSOCOVID19

Surviving Sepsis Campaign COVID-19 guidelines to support management of critically ill ICU patients with SARS-CoV-2 Coronavirus infection: here a graphic summary!
infection control, diagnosis & testing
hemodynamics support monitoring, fluids & vasoactives
non-invasive ventilatory support: SpO2 targets, conventional oxygen therapy, High Flow Nasal Cannula & Non-Invasive Positive Pressure Ventilation
invasive mechanical ventilation: MV settings, recruitment maneuver, prone posi
tioning, fluids, NMBAs & inhaled vasodilators
therapy: steroids antipyretics, antivirals, IVIg, convalescent plasma, rIFNs, chloroquine, tocilizumab & more!
full open access at https://bit.ly/SSCCOVID19

Basic advices & informal decisional algorithm by a study Group on management of critically ills COVID-19 patients based at Niguarda Ca’ Granda Hospital (Director Prof. R. Fumagalli) & Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Director Prof. A. Pesenti) in Milan,  Italy:
hot to set mechanical ventilation (initial acute phase, stabilization, weaning), hot to do recruitment maneuver & notes on porne positioning… to do or (maybe) not?
therapy: antivirals/adjuvants (be careful with lopinavir/ritonavir!) antibiotics, fluids/NE, analgesia & sedation, NMBA
temperature management
monitoring
Aim to stardardize treatments, optimizing outcome & resources consumption, and support physicians, nurses, HCPs dealing with severe respiratory failure related to COVID19, waiting for the response of the immune system, the most effective strategy!
By Thomas Langer & Nicola Bottino
Graphics by @foamecmo available both in English & Italian

Request full document with management advices to the authors
Thomas Langer thomas.langer@unimib.it
& Nicola Bottino bottino.nicola@gmail.com

PS Advices are based on preliminary informations collected during the first experience in China, and during the first week of the emergency in Lombardy, Northern of Italy; additional data ad evidence eventually arising will impose updating the recommendations.

COVID-19 network in Lombardy to early identify, triage & manage SARS-CoV-2 Coronavirus patients: JAMA livestream with Professor Maurizio Cecconi, Here a summary…
Do not underestimate! high percentage of patients will require hospitalization, high percentage will require intensive care: get ready, prepare now, work on protocols and have plans: outbreak could comes near to you! also check related paper by Prof Cecconi, Giacomo Grasselli and Antonio Pesenti just released on JAMA.

COVID19 dedicated GiViTI video conference with intensivists from North of Italy sharing their initial experience with Coronavirus SARSCoV19 epidemics: lung ultrasound LUS, prone positioning, MV, ECMO… it’s like a tsunami, you can’t understand if you are not in.
Recordings of the conference (for the ones speaking in Italian!) available link thanks to Istituto Mario Negri

How to manage critically ills with COVID19? be prepared! be familiar with case definition, ensure strict compliance with IPC, beware of diagnostic testing…
ESICM webinar with Prof Yaseen Arabi moderated by Lennie Derde. Here a graphics, slideset & summary available.

Missed the ESICM COVID-19 webinar with Professor Bin Du from China? here some dedicated notes: data about #Coronavirus pandemic, disease evolution, clinical features, organ failure & need for mechanical ventilation; check ESICM blog at for more data! full open access webinar here. A summary in the graphics.

Update on COVID-19: from epidemiology to clinical characteristics, & some recommendations

Report of the World Health Organization (WHO)-China Joint Mission on Coronavirus Disease 2019:
– major findings about virus, outbreak, transmission dynamics, disease progression/severity, the China response and knowledge gaps;
– recommendations in five major areas to inform the ongoing response in China and globally, for countries with imported cases and/or outbreaks of COVID-19, for uninfected countries, for the public, and for the international community;
– main signs and symptoms, clinical case management and infection prevention and control. There are no specific antiviral or immune modulating agents proven (or recommended) to improve outcomes. All patients are monitored by regular pulse oximetry. The guidelines include supportive care by clinical category (mild, moderate, severe & critical), as well as the role of investigational treatments such as chloroquine phosphate, lopinavir/ritonavir, alpha interferon, ribavirin, arbidol. The application of intubation/invasive mechanical ventilation and ECMO in critically ills can improve survival; clearly, though ECLS is very resource consumptive, any health system would need to carefully weigh the benefits.
Full text open access at http://bit.ly/2uF3L7o

Clinical characteristics of COVID-19 disease in China, data regarding 1099 patients with laboratory-confirmed COrona VIrus Disease 2019 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China on The New England Journal of Medicine: most of patients received diagnosis of pneumonia 91.1%; ARDS diagnosed in 3.4%, and shock in 1.1%; 5.0% of cases were admitted to the ICU, 2.3% underwent invasive mechanical ventilation, ECMO performed in 5 patients (0.5%) with severe disease, 1.4% died. On admission, the degree of severity categorized as nonsevere in 926 patients and severe in 173;.in patients with severe disease presence of any coexisting illness more common, and older age vs nonsevere cases (median of 7 years).
Systemic glucocorticoids given to 18.6% (44.5% if severe disease, 13.7% nonsevere). . Median duration of hospitalization 12 days.
Open access full text on NEJM.

Characteristics of & main lessons from COVID-19 Coronavirus outbreak in China: summary of a report of 72314 cases (data from Chinese CDC), with comparison of COVID-19 with SARS and MERS, and response to the novel Coronavirus epidemic.
Here some of the key findings:
age: 87%: 30-79 years, 1% respectively 10-19 & <10 years
spectrum of disease (confirmed cases): 81% mild, 14% severe, 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
case-fatality rate (confirmed cases): 2.3%, 14.8% in patients aged ≥80 years, 49.0% in critical cases.
Next steps? As global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries, proactive investment in public health infrastructure & capacity crucial to effectively respond to epidemics; persisting in improving international surveillance, cooperation, coordination, & communication, is critical to be better prepared to respond to future new public health threats. Full text open access on JAMA.
Also check the epidemiological characteristics of outbreak COVID-19 on China CDC Weekly.

Characteristics of & main lessons from COVID-19

Characteristics of & main lessons from COVID-19 Coronavirus outbreak in China: summary of a report of 72314 cases (data from Chinese CDC), with comparison of COVID-19 with SARS and MERS, and response to the novel Coronavirus epidemic.
Here some of the key findings:
age: 87%: 30-79 years, 1% respectively 10-19 & <10 years
spectrum of disease (confirmed cases): 81% mild, 14% severe, 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
case-fatality rate (confirmed cases): 2.3%, 14.8% in patients aged ≥80 years, 49.0% in critical cases.
Next steps? As global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries, proactive investment in public health infrastructure & capacity crucial to effectively respond to epidemics; persisting in improving international surveillance, cooperation, coordination, & communication, is critical to be better prepared to respond to future new public health threats. Full text open access on JAMA.
Also check the epidemiological characteristics of outbreak COVID-19 on China CDC Weekly.

CSECLS Recommendations on extracorporeal support for critically ills with COVID-19 pneumonia

Recommendations on Extracorporeal Life Support for critically ill patients with Coronavirus Disease 2019 (COVID-19) pneumonia from the Chinese Society of Extracorporeal Life Support. Along with the sharp increase in confirmed cases of novel Coronavirus infection, some of the most critically ills will require ExtraCorporeal Membrane Oxygenation (ECMO) support. Based on the clinical data related to COVID-19, as well as on the data from previous clinical studies and on the recommendations from the Extracorporeal Life Support Organization (ELSO), the Committee Board of the Chinese Society of Extracorporeal Life Support (CSECLS) drafted a series of recommendations to guide implementation of extracorporeal support in patients with confirmed infection developing refractory respiratory or cardio-respiratory failure: here a summary, attached the full original version.

ECMO Indications

Acute Respiratory Distress Syndrome (ARDS) is one of the most common indications for extracorporeal support in respiratory failure. While providing extracorporeal gas exchange, respiratory ECMO enables lung protective mechanical ventilation settings, allowing the lung to rest, and eventually to recover. In majority of the patients infected with novel Coronavirus, pneumonia were mild and reversible. However, some of these patients became critically ill, with most of them developing dyspnea and/or hypoxemia in 1 week from the onset. Most severe cases rapidly developed ARDS, deteriorating to multiple organ failure. Some patients presented with concurrent cardiac involvement, eventually evolving in circulatory dysfunction in sickest patients. When cardiogenic shock or cardiac arrest occurs, veno-arterial configuration (VA-ECMO) needs to be considered. 

Timing for ECMO support

ECMO could be implemented in patients with ARDS if hypoxemia does not improve despite conventional management strategies, with maximal mechanical ventilation settings (FiO2≥ 0.8, tidal volume 6 ml/kg, PEEP ≥ 10 cmH2O), if no contraindication are present, and when at least one of the following conditions is met:
– PaO2/ FiO2 < 80 mmHg for more than 6 hours
– FiO2 = 1.0,PaO2/FiO< 100 mmHg.
– arterial pH < 7.25, PaCO2 > 60 mmHg for more than 6 hours, and respiratory rate > 35 breaths per minute
– respiratory rate > 35 breaths per minute, and arterial pH < 7.2 with plateau pressure > 30 cmH2O
– coexisting cardiogenic shock or cardiac arrest.

Relative or absolute contraindications for ECMO

  1. combination of irreversible disease, severe damage of central nervous system or advanced stage of malignant tumor.
  2. Mechanical Ventilation at high settings (FiO2> 0.9, plateau pressure > 30 cmH2O) lasting 7 days or longer;
  3. advanced age in not actually considered a contraindication, it is associated to an increased risk of death;
  4. severe multiple organ failure;
  5. moderate to severe aortic regurgitation and acute aortic dissection could be considered contraindications to VA ECMO support;
  6. pharmacologic immunosuppression (absolute neutrophil count < 0.4 × 109/L);
  7. no vascular access available for ECMO cannulation due to anatomy alterations or pathological changes involving target vessels.

ECMO configuration

COVID-19 patients usually present with a normal cardiac function at the early stage, so veno-venous ECMO to support respiratory function has been the preferential configuration; however, right heart function should be closely monitored during the rung. If cardiogenic shock or cardiac arrest occurs, configuration could be shift to veno-arterialIf differently hypoxemia develops on VA-ECMO, establishing a VAV configuration could be considered.

Follow CSECLS on WeChat 中国医师协会体外生命支持专业委员会

Clinical characteristics of Covid-19

Clinical characteristics of patients with 2019nCoV (now properly defined by World Health Organization (WHO) Covid-19) in these 3 papers.

Data extraction on 1,099 patients with laboratory-confirmed #Covid-19 from 552 hospitals in 31 provinces/provincial municipalities through January 29th, 2020. Authors reported 5% of patients admitted to #ICU, 2.18% requiring invasive ventilation, and 1.36% death rate. Extracorporeal membrane oxygenation implemented in 5 severe cases (0.5%). Read additional data (detailed clinical characteristics, radiographic & laboratory findings, complications, treatment & outcome, distribution of patients across China), open access text. Note article is a preprint/not peer-reviewed.

Data from 138 hospitalized patients infected with 2019 novel coronavirus in Wuhan, China also published on JAMA, reporting 26.1% of cases transferred to the intensive care unit, 47.2% received invasive ventilation, 4 patients were switched to #ECMO support; overall mortality 4.3%. Open access text

Clinical characteristics of 137 2019-nCoV-infected patients from tertiary hospitals in Hubei Province, reporting no extracorporeal support (authors relate this finding to the fact that they reported about cases admitted to respiratory departments, with data from ICUs/other departments missing). Open access on Chinese Medical Journal.

WHO Critical Care Training Short Course for SARI

The World Health Organization has launched a free open access course, the WHO Critical Care Training Short Course for Severe Acute Respiratory Infection (SARI), including content on clinical management of patients with a severe acute respiratory infection, intended for clinicians working in ICUs in low and middle-income countries involved in critical care management of adult and pediatric patients with severe forms of SARI, including severe pneumonia, ARDS, sepsis and septic shock, during outbreaks of influenza virus (seasonal) human infection due avian influenza virus (H5N1, H7N9), MERS-CoV, nCoV or other emerging respiratory viral epidemics.
Visit OpenWHO to enrol and take the course. Here a list of the topics covered by the course:
introduction to the 2019nCoV and infection prevention for patients with Severe Acute Respiratory Infections (SARI);
clinical syndromes and pathophysiology of sepsis and ARDS;
triage and early recognition of patients with SARI, with role-playing scenarios;
monitoring patients with SARI;
differential diagnosis, specimen collection and diagnostic tests for SARI;
oxygen Therapy;
antimicrobial therapy and its modification after diagnostic test interpretation;
how to deliver targeted resuscitation for sepsis and septic shock;
mechanical ventilation: how to deliver lung-protective MV in ARDS;
sedation: how to manage pain, agitation and delirium;
best practices to prevent complications;
weaning from mechanical ventilation;
quality in critical care;
pandemic preparedness and ethical considerations.

Additional details and enrolment at OpenWHO

Imaging in 2019nCov infection

Early recognizing imaging features of novel Coronavirus infection: mandatory for promptly implement treatment/support strategies, but also for isolating case and performing an effective public health monitoring/response; some open access paper have been published on Radiology, starting with a series reviewing chest CT scans of symptomatic patients infected with 2019-nCoV, with emphasis on identifying & characterizing the most common findings, including bilateral pulmonary parenchymal ground-glass & consolidative pulmonary opacities, sometimes with rounded morphology and peripheral lung distribution. Notably, cavitation, discrete pulmonary nodules, pleural effusions, lymphadenopathy reported as absent. In seven over eight subjects, follow-up imaging (during study time window) often demonstrated mild or moderate progression of disease as manifested by increasing extent and density of opacities. Open access full text
Key points for radiologists in this related editorial, suggesting to consider in the proper clinical setting, 2019-nCoV as a possible diagnosis as detecting bilateral ground-glass opacities or consolidation at chest imaging (but normal chest CT scan does not exclude the diagnosis!): keep an high level of suspicion and collect detailed potential exposure/travel history. Open access full text

Additional cases, same journal, with interesting CT scans images/movie at
link & link

Novel coronavirus (nCoV) infection

Trending topic

The WHO is distributing an Interim Guidance document for the “Clinical management of severe acute respiratory infection when Novel coronavirus (nCoV) infection is suspected.” The medical community is closely monitoring the outbreak. The WHO guidance document includes a statement to “consider referral patients with refractory hypoxemia despite lung-protective ventilation. . . in settings with access to expertise in ECLS.”
Where ECLS expertise is available, extracorporeal support should be considered according to the standard management algorithm for ARDS in supporting patients with viral lower respiratory tract infection. However, clearly at this time, there is little worldwide experience with using ECMO to support nCOV-infected patients. ELSO will continue to collect data through our member centers and provide recommendations as additional information becomes available.
Dr. Mark Ogino, ELSO – Extracorporeal Life Support Organization President.

The World Health Organization (WHO) Interim Guidance full text open access.

In this first report published on The Lancet, available data (to date) about the recent cluster of pneumonia cases caused by a novel betacoronavirus in Wuhan, China, with the epidemiological, clinical, laboratory, radiological characteristics of these patients, including treatment (n=2, 5% of all reported cases, 15% of the patients requiring ICU care, supported with ECMO) and clinical outcomes. Open access text

A second study on the same journal includes all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data, with outcomes followed up until Jan 25, 2020; 23% admitted to ICU, 17% developed ARDS, 3% treated with extracorporeal support, 11% worsened in a short period of time and died of multiple organ failure. Open access text

On The Lancet also a study reporting epidemiological, clinical, laboratory, radiological, and microbiological findings of 5 patients in a family cluster who presented with unexplained pneumonia after returning to Shenzhen, Guangdong province, China, after a visit to Wuhan, and an additional family member who did not travel to Wuhan, with findings consistent with person-to-person transmission of this novel coronavirus in hospital
and family settings, and the reports of infected travellers in other geographical regions. Open access text
… and some interesting comments:
About novel coronavirus outbreak of global health concern Open access text
on data sharing and outbreaks: best practice exemplified Open access text
… and emerging understandings of 2019-nCoV. Open access text

.

Consider reading this report on The New England Journal of Medicine, about 3 adult patients presented with severe pneumonia admitted to a hospital in Wuhan at the end of December, with details on detection, isolation and characterization of the Novel Coronavirus. Abstract
NEJM has also published an editorial, focusing on this zoonotic coronavirus, which (third time in 3 decades, after evere acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]) has crossed species to infect human populations. Open access text
Moreover, on same journal, a viewpoint on key questions for impact assessment of this new emerging Coronavirus. Open access text

NEJM published data on the first 425 confirmed cases of novel coronavirus infected pneumonia (NCIP) in Wuhan, reporting informations collected on demographic characteristics, exposure history, and illness timelines of laboratory-confirmed cases by January 22, 2020, with estimation of key epidemiologic time-delay distributions. Open access text

The report of a case of importation and human-to-human transmission of nCoV in Vietnam ia also available. Open access link

Moreover, a dedicated page has been created on New England Journal of Medicine, and a special set of practices that will be applied to all submitted manuscripts describing the 2019-nCoV outbreak, has been announced in this editorial, to promote fast publishing.

JAMA published another viewpoint highlighting the perpetual challenge of emerging infectious human diseases caused by pathogens from viral families (formerly thought to be relatively benign) and the importance of sustained preparedness. Open access text
Moreover, another editorial refers about control measures in China, and control measures by governments worldwide, nonpharmaceutical interventions, and role of WHO. Open access text

A dedicated page is available on Centers for Disease Control and Prevention (CDC) website, with outbreak of respiratory illness caused by the novel coronavirus reporting:
– situation news & summary;
– informations/interim guidance for healthcare professionals, including criteria to guide evaluation of patients under investigation (PUI) for 2019-nCoV; recommendations for reporting, testing, and specimen collection; healthcare infection prevention and control recommendations for PUI for 2019-nCoV, and checklists for HCPs/hospitals;
– interim guidance for laboratory professionals working with specimens from PUI for human infections with 2019-nCoV.

An online dashboard for tracking worldwide spread of novel Coronavirus has been built & is regularly updated by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University; the map is freely available! link

But how setting up an ICU to cope with novel Coronavirus infection? read about this experience from Sichuan region, China: ‬
‪equipment preparation ‬
‪education & training of staff‬
‪protection of the staff‬
‪early recognition/classification of disease severity‬
‪restriction of patient contact‬
‪full text open access on ICM

The ELSO – Extracorporeal Life Support Organization will persist in publishing additional evidence and advices, as available, on all our social media channels and on our website, in order to actively contribute to the updating of our community about this topic.