A CASE OF NINE WEEKS ON VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION FOR COVID-19

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 was declared a public health emergency by the World Health Organization in January 2020. The development of acute respiratory distress syndrome (ARDS) due to COVID-19 has high mortality. We present a case of 9 weeks of veno-venous extracorporeal membrane oxygenation (VV ECMO) for COVID-19 ARDS. CASE PRESENTATION: A 47-year-old male with a positive COVID-19 test 5 days prior to admission presented to the emergency department with dyspnea. He was severely hypoxemic prompting admission to the intensive care unit and treatment with high flow nasal canula, glucocorticoids, inhaled nitric oxide and remdesivir. He remained hypoxemic requiring intubation. His hypoxemia worsened despite maximal ventilatory support, proning and paralysis. He was evaluated and considered a candidate for VV ECMO. His cannulation strategy included right femoral vein drainage and right internal jugular (IJ) return cannulas. Anticoagulation for the ECMO circuit was held at 5 days due to bloody secretions and hematochezia. He was started on early nutritional supplementation with high protein tube feeds. Physical therapy included tilting to an upright position with a special bed and passive range of motion exercises. His course was complicated by prolonged respiratory failure requiring tracheostomy, nosocomial pneumonias, bilateral pneumothoraces, right IJ line associated venous thrombosis and bacteremia with native mitral valve endocarditis. At 60 days, his lung compliance began to improve. His ECMO gas sweep and delivered fractional oxygen percentage were incrementally decreased as his native lung gas exchange improved. He was decannulated after 65 days on ECMO. He had continued improvement in physical and respiratory function, including tracheostomy decannulation. He was discharged home after 12 weeks on 1-liter nasal cannula and currently uses oxygen with exertion with minimal dyspnea. DISCUSSION: VV ECMO in traditional ARDS has shown to improve mortality in patients with respiratory failure. Respiratory failure in patients with COVID-19 ARDS tends to be more protracted than traditional ARDS. COVID-19 ARDS patients have higher lung compliance, ventilatory ratio and lung recruitment early in the course. They can have persistent lung diffusion and radiologic abnormalities at 3 months with lingering pulmonary effects post-infection. COVID-19 ARDS patients who require ECMO eventually lose lung compliance. Improvement in tidal volume is the first sign of lung recovery in traditional and COVID-19 ARDS. CONCLUSIONS: VV ECMO is a viable option for the management of COVID-19 ARDS. Longer ECMO support in COVID-19 patients is expected given the difference in lung physiology compared to traditional ARDS and further research into VV ECMO and COVID-19 ARDS is needed. REFERENCE #1: Combes, Alain et al. "ECMO for severe ARDS: systematic review and individual patient data meta-analysis." Intensive care medicine vol. 46,11 (2020): 2048-2057. REFERENCE #2: Haudebourg, Anne-Fleur et al. "Respiratory Mechanics of COVID-19- versus Non-COVID-19-associated Acute Respiratory Distress Syndrome." American journal of respiratory and critical care medicine vol. 202,2 (2020): 287-290. REFERENCE #3: Combes, Alain et al. "Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome." The New England journal of medicine vol. 378,21 (2018): 1965-1975. DISCLOSURES: No relevant relationships by Kathy Chan, source=Web Response No relevant relationships by Hekmat Nasiri, source=Web Response No relevant relationships by Sudhir Rajan, source=Web Response