Critical care & ECMO in the era of COVID-19: why data matters! ELSO webinar, moderated by Dr. Robert Bartlett & Matt Paden, highlighting the current research underway focused on better understanding the impact of COVID-19, and the role of extracorporeal support and ICU care in patients with SARS-CoV-2 Coronavirus infection. Topics & speakers: ELSO Registry and the live dashboard for COVID-19 Cases: Matt Paden & Ryan Barbaro EuroELSO Survey on ECLS in COVID-19, Roberto Lorusso & Jan Bělohlávek COVID-Critical Care Consortium, John Fraser & Heidi Dalton
Here full replay!
… and some slides:
Barbaro R.: We always know data matters! since H1N1 pandemic: now, more than 10 years later, COVID- 19 presented uncertainty & dynamic understanding, but thanks to community data soon start arriving, through: ELSO Registry COVID-19 addendum and live dashboard COVID critical care consortium EuroELSO survey on ECMO in COVID-19
Lorusso R.: with @jan_belohlavek sharing (preliminary) data but really interesting insights from EuroECMO COVID, the scientific “adventure” of EuroELSO survey, amazing collection of data in really short ime, thanks to EuroELSO & collaborative centers.
Fraser J.: presenting COVID critical care consortium, global collaboration of more than 330 hospital across 50 countries, 1021 patients enrolled to date, aimed to characterize COVID-19 ICU pts, & its subgroups: we need data to get whole picture!
And please take the ongoing related surveys, ie neonatal and pediatric ICU & ECMO survey http://bit.ly/3d7MSmR aimed to acquire basic informations on neonates & pediatric SARS-CoV-2 Coronavirus patients requiring ICU admission/ECMO, or the ethics ECMO & pandemis survey.
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.
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/FiO2 < 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
combination of irreversible disease, severe damage of central nervous system or advanced stage of malignant tumor.
Mechanical Ventilation at high settings (FiO2> 0.9, plateau pressure > 30 cmH2O) lasting 7 days or longer;
advanced age in not actually considered a contraindication, it is associated to an increased risk of death;
severe multiple organ failure;
moderate to severe aortic regurgitation and acute aortic dissection could be considered contraindications to VA ECMO support;
no vascular access available for ECMO cannulation due to anatomy alterations or pathological changes involving target vessels.
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-arterial. If differently hypoxemia develops on VA-ECMO, establishing a VAV configuration could be considered.
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.