Tag: Coronavirus

ECMO in COVID-19, message from the ELSO President

Video transcript

The Extracorporeal Life Support Organization, ELSO, is the global nonprofit organization for ExtraCorporeal Membrane Oxygenation (ECMO) and Extracorporeal Life Support (ECLS). We are working with our partners across the globe on the response to COVID-19 as it relates to the use of ECMO for supporting patients infected with the virus.
We are relying on the same sources as others for accurate information related to the rapidly evolving COVID-19 virus epidemiology. Specifically, we will continue to rely on the World Health Organization, the Centers for Disease Control, as well as, local health officials and governments as the situation evolves.  We remain a real-time authoritative resource because of ELSO’s global member centers which provide up-to-date information and data to allow our physicians and scientists to continually edit our recommendations.
COVID-19 can cause respiratory distress in some patients. ECMO has proven to be an effective option to support selective patients with severe respiratory distress, some of which are COVID-19 patients. We are tracking this information globally, including as part of our registry. 
In addition, we are launching new studies and data sharing agreements with our partners across the globe.  As an example, our Asia Pacific ELSO Chapter is coordinating efforts across the Asia Pacific region and globally to study ECMO in the treatment of patients with COVID-19.   The group’s trial, ExtraCorporeal Membrane Oxygenation for Coronavirus 19 Acute Respiratory Distress (ECMOCARD) will study the clinical data of COVID-19 patients where ECMO treatment was provided in more than 50 hospitals across 4 continents and 19 countries. This study has been endorsed by the World Health Organization and the international ECMO research group, ECMONet.
As new studies and results emerge, we will share relevant information on our website.  We will be updating this information with the urgency that this situation requires. We will have a link from our homepage: http://www.elso.org, social media sites on Twitter, Facebook, LinkedIn, and our ELSO ECMOed blog on COVID 19.
Twitter 
Facebook 
Linkedin
ELSO ECMOed blog
We are committed to coordinating with our ECLS centers across the globe and sharing updated information as this situation warrants. 
Thank you, and stay healthy.

Dr. Mark Ogino, ELSO President  

Prof. Bartlett on ECMOCARD

About the ExtraCorporeal Membrane Oxygenation for 2019 novel Coronavirus Acute Respiratory Disease ECMOCARD study, Professor Robert Bartlett, writes:”… our most important weapon in this crisis is data to predict and plan – on a global scale… a global problem needs global collaboration”. Here some words by Professor John Fraser, President of the Asia Pacific ELSO Chapter APELSO, introducing the study.
“Colleagues
As President of the Asia Pacific ELSO, I write to express my gratitude for all the work and collaboration from our brothers and sisters during this time of pandemic.
At times of global crisis, this is where teams show their strength. We have now more than. 50 centres in 20+ countries. over 4 continents that have signed up for the ECMOCARD study. Each night more centres are contacting us to join to work together; innovators and trailblazers that have come before us have given us the skills to hopefully be able to help the most critically unwell. It is in this environment that I am delighted that the father of #ECMO, Prof. Bob Bartlett has written to congratulate the ECMOCARD on the global collaboration we have created. Because a global crisis needs global collaboration for a global solution.
With Best wishes and thanks”
John
Attached, full text of Professor Bartlett letter.

ECMOCARD study

ExtraCorporeal Membrane Oxygenation for 2019 novel Coronavirus Acute Respiratory Disease ECMOCARD study is an multi-centre International study, conducted in all collaborating hospitals/ICU-based research networks in Asia, Australia & New Zealand (APELSO in collaboration with centres within the SPRINT-SARI and ISARIC Networks), and Europe, in COVID-19 patients requiringadmission to to ICU, Mechanical Ventilation &/or ECMO, to characterize:
incidence of ICU admission, need for non-invasive/invasive MV and ECMO 
risk factors, clinical features and severity of respiratory failure 
ECMO technical characteristics & duration of the run 
complications and ICU/Hospital survival 
requirements/time for approvals in participating network regions.

Aim is to recruit all eligible patients at each study location; patients will be studied specifically focusing on collecting data on MV, ECMO, main therapies (includinvasoactives, hypoxaemia rescue therapies, RRT), antibiotics/antivirals, adjunctive therapies, ie immunomodulators, corticosteroids, short-term outcomes.

Inclusion criteria

Laboratory-confirmed COVID-19 infection by real-time PCR and/or next-generation sequencing
Admission to an ICU

Exclusion criteria

MV for other concomitant causes 
ECMO for other concomitant causes 

Coronavirus

Family of RNA viruses which may infect mammals and birds, with 6 species known to cause human disease; 2 strains, the severe acute respiratory syndrome coronavirus SARS-CoV and Middle East respiratory syndrome coronavirus MERS-CoV have caused more serious, sometimes fatal, respiratory illnesses (reported mortality respectively 10% & 37%).

SARS-CoV-2 & COVID-19

In late December, 2019, in Wuhan, Hubei, China, new respiratory syndrome emerged with clinical signs resembling viral pneumonia and person-to-person transmission; analysis from lower respiratory tract samples corroborated emergence of novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 SARSCoV-2, causing  COrona VIrus Disease 2019 (COVID-19).

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.