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Analysis of COVID-19 associated respiratory failure : clinical characterization and comparison of outcomes in conventional and awake ECMO protocols
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Introdução: A circulação extracorporal venovenosa com oxigenação de membrana (VV-ECMO) tem sido frequentemente utilizada no suporte de doentes COVID-19 que desenvolvem insuficiência respiratória refratária, apesar da otimização da ventilação mecânica invasiva (IMV). A estratégia de Awake ECMO pode limitar a lesão pulmonar induzida pelo ventilador, o desenvolvimento de fraqueza muscular adquirida na unidade de cuidados intensivos (ICUAW) e o delirium, permitindo uma reabilitação precoce.
Objetivos: Caracterizar e comparar os resultados de dois subgrupos de doentes com pneumonia grave a SARS-CoV-2 tratados com VV-ECMO: Awake vs. Convencional.
Métodos: Foi realizada uma revisão retrospetiva dos registos médicos de 92 doentes com COVID-19, tratados num centro de referência ECMO, entre março de 2020 e abril de 2022. Analisámos as características basais, resultados e resposta ao tratamento pré-ECMO/ECMO. A população foi dividida em dois grupos: Awake (em respiração espontânea no momento da descanulação) e Convencional (descanulados antes do desmame da IMV).
Resultados: Foram incluídos 92 doentes com idade média de 49.8 ± 12.1 anos, dos quais 65 (70.7%) eram do sexo masculino; o índice de massa corporal médio foi de 31.5 ± 7.5 kg/m2. As características basais, comorbilidades e complicações foram semelhantes entre os grupos Awake (n=34) e Convencional (n=58). Um doente Awake morreu (2.9%) vs. 21 doentes (36.2%) no grupo Convencional (p<0.001). No geral, os não sobreviventes eram mais velhos (p=0.014), tinham mais dias de doença pré-ECMO (p=0.027) e mais complicações hemorrágicas (p=0.027). Os doentes Awake tiveram mais dias de suporte ventilatório não invasivo pré-ECMO (p=0.040), SOFA mais baixo na canulação (p=0.007), cursos de ECMO mais longos (p=0.021) e menor necessidade de curarização (p=0.006). Estudando apenas os sobreviventes, o grupo Awake teve uma incidência mais baixa de delirium (p=0.035) e uma menor tendência para desenvolver ICUAW (p=0.124).Conclusão: Os nossos resultados sugerem que a Awake ECMO é uma estratégia viável em doentes selecionados com COVID-19, e que pode ser utilizada com baixa mortalidade e incidência de complicações. Estes doentes teriam uma maior reserva funcional e menos disfunção orgânica na altura da canulação. São necessários mais estudos para confirmar estes dados e aplicá-los a doentes em cursos de Awake ECMO completos.
Introduction: Venovenous extracorporeal membrane oxygenation (VV-ECMO) was largely used to support COVID-19 patients that developed refractory respiratory failure, despite optimized invasive mechanical ventilation (IMV). An Awake ECMO strategy may limit ventilator induced lung injury, the development of intensive care unit acquired weakness (ICUAW) and delirium, while allowing early rehabilitation. Objectives: Characterize and compare the outcomes of two subgroups of VV-ECMO treated patients with severe COVID-19 pneumonia: Awake vs. Conventional. Methods: A retrospective medical record data review was performed, including 92 COVID-19 patients treated with VV-ECMO at an ECMO referral center, between March 2020 and April 2022. We analyzed baseline characteristics, outcomes and pre-ECMO/ECMO treatment progression. Patients were divided in two groups: Awake (breathing spontaneously at the moment of decannulation) and Conventional (decannulated before IMV weaning). Results: 92 patients were included, with mean age 49.8 ± 12.1 years; 65 patients (70.7%) were male and mean body-mass index was 31.5 ± 7.5 kg/m2. Demographics, comorbidities and complications were similar between the Awake (n=34) and Conventional (n=58) groups. One Awake patient died (2.9%) vs. 21 patients (36.2%) in the Conventional group (p-value=<0.001). Overall, non-survivors were older (p-value=0.014), had more sick days before ECMO initiation (p-value=0.027) and more hemorrhagic complications (p-value=0.027). Awake patients had more non-invasive ventilatory support days pre-ECMO (p-value=0.040), lower SOFA score at cannulation (p-value=0.007), longer ECMO runs (p-value=0.021), and less use of neuromuscular blocking agents (p-value=0.006). In survivors, the Awake group had reduced incidence of delirium (p-value=0.035) and less tendency to develop ICUAW (p-value=0.124). Conclusion: Our results show that awake ECMO is feasible with very low mortality and complications in well-selected COVID-19 patients. These patients were probably more fit and had less organ dysfunction at the time of cannulation than patients in the Conventional group. More studies are needed to confirm this data and apply it to complete Awake ECMO patients.
Introduction: Venovenous extracorporeal membrane oxygenation (VV-ECMO) was largely used to support COVID-19 patients that developed refractory respiratory failure, despite optimized invasive mechanical ventilation (IMV). An Awake ECMO strategy may limit ventilator induced lung injury, the development of intensive care unit acquired weakness (ICUAW) and delirium, while allowing early rehabilitation. Objectives: Characterize and compare the outcomes of two subgroups of VV-ECMO treated patients with severe COVID-19 pneumonia: Awake vs. Conventional. Methods: A retrospective medical record data review was performed, including 92 COVID-19 patients treated with VV-ECMO at an ECMO referral center, between March 2020 and April 2022. We analyzed baseline characteristics, outcomes and pre-ECMO/ECMO treatment progression. Patients were divided in two groups: Awake (breathing spontaneously at the moment of decannulation) and Conventional (decannulated before IMV weaning). Results: 92 patients were included, with mean age 49.8 ± 12.1 years; 65 patients (70.7%) were male and mean body-mass index was 31.5 ± 7.5 kg/m2. Demographics, comorbidities and complications were similar between the Awake (n=34) and Conventional (n=58) groups. One Awake patient died (2.9%) vs. 21 patients (36.2%) in the Conventional group (p-value=<0.001). Overall, non-survivors were older (p-value=0.014), had more sick days before ECMO initiation (p-value=0.027) and more hemorrhagic complications (p-value=0.027). Awake patients had more non-invasive ventilatory support days pre-ECMO (p-value=0.040), lower SOFA score at cannulation (p-value=0.007), longer ECMO runs (p-value=0.021), and less use of neuromuscular blocking agents (p-value=0.006). In survivors, the Awake group had reduced incidence of delirium (p-value=0.035) and less tendency to develop ICUAW (p-value=0.124). Conclusion: Our results show that awake ECMO is feasible with very low mortality and complications in well-selected COVID-19 patients. These patients were probably more fit and had less organ dysfunction at the time of cannulation than patients in the Conventional group. More studies are needed to confirm this data and apply it to complete Awake ECMO patients.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022
Palavras-chave
COVID-19 Awake ECMO Circulação extracorporal venovenosa com oxigenação de membrana (VV-ECMO) Delirium Fraqueza muscular adquirida na unidade de cuidados intensivos (ICUAW)