Giraud Raphaël, Wozniak Hannah, Donner Viviane, Looyens Carole, Assouline Benjamin, Bendjelid Karim
Intensive Care Unit, Geneva University Hospitals, CH-1205 Geneva, Switzerland.
Geneva Hemodynamic Research Group, Faculty of Medicine, University of Geneva, CH-1211 Geneva, Switzerland.
J Clin Med. 2022 Dec 28;12(1):230. doi: 10.3390/jcm12010230.
The SARS-CoV-2 pandemic has overwhelmed health care systems worldwide since its first wave. Intensive care units have been under a significant amount of pressure as patients with the most severe form of the disease presented with acute respiratory distress syndrome (ARDS). A proportion of them experienced refractory acute respiratory failure and had to be supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO). The present retrospective study reports the experiences of our ECMO center in the management of COVID-19 patients with refractory ARDS. Patient characteristics and outcomes are presented through the different waves of the pandemic. A cohort study was conducted on patients with refractory ARDS due to COVID-19 infection who were admitted to the intensive care unit (ICU) at the Geneva University Hospital and supported with VV-ECMO between 14 March 2020 and January 2022. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit of the hospital and the Swiss Society of Intensive Care Medicine. Among the 500 ARDS patients admitted to our ICU, 41 patients with a median age of 57 (52−63) years, a body mass index (BMI) of 28 (26−32) kg/m2, and a SAPS II score of 57 (47−67), and 27 (66%) of whom were men required VV-ECMO. None of the patients were vaccinated. The time of ventilation, including noninvasive ventilation (NIV) and mechanical ventilation (MV), and the time of MV before ECMO were 7 (4−11) days and 4 (1−7) days, respectively. The time under ECMO was 20 (10−27) days. The ICU and hospital lengths of stay were 36 (21−45) days and 45 (33−69) days, respectively. The survival rate for patients on ECMO was 59%. Comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter ventilation duration before ECMO (NIV + MV: 5.5 (1.3−9) vs. 9 (6.5−13.5) days, p = 0.0026 and MV alone: 1.6 (0.4−5.5) vs. 5.8 (5−8) days, p < 0.0001). The management of patients on ECMO by an experienced ECMO team dedicated to this activity was associated with improved survival (78% vs. 28%, p = 0.0012). Between the first wave and the following waves, patients presented with a higher incidence of ventilator-associated pneumonia (100% vs. 82%, p = 0.0325) but had better survival rates (74% vs. 35%, p = 0.024). The present study suggests that both the prompt insertion of VV-ECMO to control refractory hypoxemia and the involvement of an ECMO team improve the survival of COVID-19 patients.
自第一波疫情以来，新型冠状病毒肺炎（SARS-CoV-2）大流行已使全球医疗系统不堪重负。由于最严重形式的疾病患者出现急性呼吸窘迫综合征（ARDS），重症监护病房承受着巨大压力。其中一部分患者经历了难治性急性呼吸衰竭，不得不接受静脉-静脉体外膜肺氧合（VV-ECMO）支持。本回顾性研究报告了我们的ECMO中心在管理COVID-19合并难治性ARDS患者方面的经验。通过疫情的不同阶段展示患者特征和结局。对2020年3月14日至2022年1月期间因COVID-19感染入住日内瓦大学医院重症监护病房（ICU）并接受VV-ECMO支持的难治性ARDS患者进行了队列研究。VV-ECMO实施标准根据医院当地危机处理小组和瑞士重症医学学会验证的机构算法确定。在我们ICU收治的500例ARDS患者中，41例患者接受了VV-ECMO，中位年龄为57（52 - 63）岁，体重指数（BMI）为28（26 - 32）kg/m²，简化急性生理学评分（SAPS）II评分为57（47 - 67），其中27例（66%）为男性。所有患者均未接种疫苗。通气时间，包括无创通气（NIV）和有创机械通气（MV），以及ECMO前的MV时间分别为7（4 - 11）天和4（1 - 7）天。ECMO支持时间为20（10 - 27）天。ICU住院时间和医院住院时间分别为36（21 - 45）天和45（33 - 69）天。接受ECMO治疗患者的生存率为59%。幸存者与非幸存者的对比分析表明，幸存者在ECMO前的通气时间明显更短（NIV + MV：5.5（1.3 - 9）天 vs. 9（6.5 - 13.5）天，p = 0.0026；单独MV：1.6（0.4 - 5.5）天 vs. 5.8（5 - 8）天，p < 0.0001）。由专门从事此项工作的经验丰富的ECMO团队管理接受ECMO治疗的患者与生存率提高相关（78% vs. 28%，p = 0.0012）。在第一波疫情和后续波次之间，患者呼吸机相关性肺炎的发生率更高（100% vs. 82%，p = 0.0325），但生存率更高（74% vs. 35%，p = 0.024）。本研究表明，及时插入VV-ECMO以控制难治性低氧血症以及ECMO团队的参与可提高COVID-19患者的生存率。
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