Bergman Zachary R, Wothe Jillian K, Alwan Fatima S, Lofrano Arianna E, Tointon Kelly M, Doucette Melissa, Bohman John K, Saavedra-Romero Ramiro, Prekker Matthew E, Lusczek Elizabeth R, Beilman Greg, Brunsvold Melissa E
Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA.
Surg Infect (Larchmt). 2021 Dec;22(10):1086-1092. doi: 10.1089/sur.2021.114. Epub 2021 Sep 6.
Venovenous extracorporeal membrane oxygenation (VV-ECMO) for select adults with severe acute respiratory distress syndrome (ARDS) cause by coronavirus disease 2019 (COVID-19) infection is a guideline-supported therapy with associated hospital survival of 62%-74%, similar to expected survival with VV-ECMO for other indications. However, ECMO is a resource-heavy intervention, and these patients often require long ECMO runs and prolonged intensive care unit (ICU) care. Identifying factors associated with mortality in VV-ECMO patients with COVID-19 infection can inform the evaluation of ECMO candidates as well as prognostication for those patients on prolonged VV-ECMO. This was a retrospective cohort study that included all patients who received either VV- or venoarteriovenous (VAV)-ECMO at one of four ECMO Centers of Excellence in the state of Minnesota between March 1, 2020 and November 1, 2020. The primary outcome was 60-day survival. Secondary outcomes were hospital complications, infectious complications, and complications from ECMO. There were 46 patients who met criteria during this study period and 30 survived to 60-day follow-up (65.2%). Prior to cannulation, older patient age (55.5 in non-survivors vs. 49.1 years in survivors; p = 0.03), lower P/F ratio (62.1 vs. 76.2; p = 0.04), and higher sequential organ failure assessment (SOFA) score (8.1 vs. 6.6; p = 0.02) were identified as risk factors for mortality. After ECMO cannulation, increased mortality was associated with increased number of antibiotic days (25.9 vs. 14.5; p = 0.04), increased number of transfusions (23.9 vs. 9.9; p = 0.03), elevated white blood cell (WBC) count at post-ECMO days one through three, elevated D-dimer at post-ECMO day 21-27, and decreased platelet count from post-ECMO days 14 and onward using univariable analysis. Multiple markers of infection including leukocytosis, thrombocytopenia, and increased antibiotic days are associated with increased mortality in patients placed on VV-ECMO for COVID-19 infection and subsequent ARDS. Knowledge of these factors may assist with determining appropriate candidates for this limited resource as well as direct goals of care in prolonged ECMO courses.
对于由2019冠状病毒病（COVID-19）感染引起的严重急性呼吸窘迫综合征（ARDS）的特定成人患者，静脉-静脉体外膜肺氧合（VV-ECMO）是一种有指南支持的治疗方法，其相关的医院生存率为62%-74%，与VV-ECMO用于其他适应症时的预期生存率相似。然而，ECMO是一种资源密集型干预措施，这些患者通常需要长时间使用ECMO以及延长在重症监护病房（ICU）的护理时间。确定COVID-19感染的VV-ECMO患者的死亡相关因素，可以为评估ECMO候选者以及对那些长时间使用VV-ECMO的患者进行预后判断提供依据。这是一项回顾性队列研究，纳入了2020年3月1日至2020年11月1日期间在明尼苏达州四个卓越ECMO中心之一接受VV-或静脉-动脉-静脉（VAV）-ECMO治疗的所有患者。主要结局是60天生存率。次要结局是医院并发症、感染性并发症和ECMO相关并发症。在本研究期间有46名患者符合标准，30名患者存活至60天随访期（65.2%）。在插管前，年龄较大（非存活者为55.5岁，存活者为49.1岁；p = 0.03）、较低的P/F比值（62.1对76.2；p = 0.04）以及较高的序贯器官衰竭评估（SOFA）评分（8.1对6.6；p = 0.02）被确定为死亡的危险因素。在ECMO插管后，通过单变量分析发现，抗生素使用天数增加（25.9天对14.5天；p = 0.04）、输血次数增加（23.9次对9.9次；p = 0.03）、ECMO后第1至3天白细胞（WBC）计数升高、ECMO后第21至27天D-二聚体升高以及ECMO后第14天及以后血小板计数降低与死亡率增加相关。包括白细胞增多、血小板减少和抗生素使用天数增加在内的多种感染标志物与因COVID-19感染及随后的ARDS而接受VV-ECMO治疗的患者死亡率增加相关。了解这些因素可能有助于确定这种有限资源的合适候选者，并指导长时间ECMO治疗过程中的护理目标。
