A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management
Aakash Shah,
Sagar Dave,
Samuel Galvagno,
Kristen George,
Ashley R. Menne,
Daniel J. Haase,
Brian McCormick,
Raymond Rector,
Siamak Dahi,
Ronson J. Madathil,
Kristopher B. Deatrick,
Mehrdad Ghoreishi,
James S. Gammie,
David J. Kaczorowski,
Thomas M. Scalea,
Jay Menaker,
Daniel Herr,
Ali Tabatabai,
Eric Krause
Affiliations
Aakash Shah
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Sagar Dave
Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Samuel Galvagno
Program in Trauma, Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Kristen George
Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Ashley R. Menne
Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Daniel J. Haase
Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Brian McCormick
Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA
Raymond Rector
Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA
Siamak Dahi
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Ronson J. Madathil
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Kristopher B. Deatrick
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Mehrdad Ghoreishi
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
James S. Gammie
Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
David J. Kaczorowski
Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
Thomas M. Scalea
Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Jay Menaker
Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA 94143, USA
Daniel Herr
Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Ali Tabatabai
Program in Trauma, Department of Medicine, Division of Pulmonary and Critical Care, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Eric Krause
Department of Surgery, Division of Thoracic Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
