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Predictive factors for membrane oxygenator dysfunction in patients with severe COVID-19 under V-V ECMO
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Introdução: A desregulação imunológica e estado pró-inflamatório da COVID-19 associa-se a maiores taxas de trombose. Em doentes sob ECMO venovenoso (ECMO VV), a COVID-19 atua sinergicamente levando a maior atividade pró-trombótica, com aumento da disfunção do oxigenador de membrana (OM) e necessidade de substituição. Este estudo pretendeu avaliar eventuais preditores de disfunção do OM. Métodos: Estudo retrospetivo, observacional, coorte de doentes adultos com COVID-19 sob ECMO V-V, num centro de referência num hospital universitário terciário, entre março 2020 e fevereiro 2022. Características demográficas, dados sobre suporte de órgão pré-ECMO (dias sob corticoterapia, cânula nasal de alto fluxo, ventilação não invasiva e invasiva), duração total de ECMO, variação da carboxihemoglobina e parâmetros de coagulação nos cinco dias precedentes às trocas de membrana, foram recolhidos de processos eletrónicos. Resultados: A taxa de troca de OM foi 51,61% para pelo menos uma troca. A duração mediana de ECMO foi significativamente superior no grupo de casos (35,0 vs 14,0 dias, p<0,001). Os parâmetros que apresentaram significância estatística, comparando os casos e controlos, foram o total de dias sob corticoterapia pré-ECMO (42 vs 25 dias, p<0,005), sob ventilação mecânica invasiva pré-ECMO (40 vs 19 dias, p<0. 005), necessidade de bloqueadores neuromusculares (13 vs 6 dias, p<0,005); a variação de plaquetas (W=-21, p 0.0312), D-dímeros (W=-21, p 0.0312), aPTT (W=21, p 0.0312), PCR (W=21, p 0.0312), monócitos (W=21, p 0.0312), e carboxihemoglobina (W=21, p 0.0312) 5 dias antes da troca de membrana mostraram significância estatística. Conclusões: A coagulopatia e inflamação induzidas pela COVID-19 podem contribuir para disfunção do OM, levando à sua substituição. Há escassez de estudos que identifiquem preditores de trombose do OM, mas a diminuição absoluta de plaquetas parece ser transversal entre estudos. Estes resultados levantam questões interessantes relativamente à maior necessidade de corticoterapia e alteração nas contagens do leucograma no grupo de casos.
Introduction: COVID-19 immune dysregulation and pro-inflammatory state is associated with higher rates of thrombotic events. In patients under venovenous ECMO (V-V ECMO), COVID-19 acts synergically leading to even higher pro-thrombotic activity, with increased membrane oxygenator (MO) dysfunction and need for replacement. This study aimed to assess possible predictors of MO dysfunction. Methods: This is a retrospective, observational study with a cohort of adult COVID-19 patients requiring V-V ECMO, in an ECMO referral center at a tertiary university hospital, between March 2020 and February 2022. Demographic characteristics, pre-ECMO organ support data (total days under corticotherapy, high-flux nasal cannula, non-invasive and invasive ventilation), total duration of ECMO, carboxy-hemoglobin and coagulation parameters variation during five days prior to each membrane exchange, were collected from electronic files. Results: MO exchange rate was 51.61% for at least one exchange. The median duration of ECMO run was significantly longer in the case group (35,0 vs 14,0 days, p<0.001). Parameters that showed statistical significance, comparing cases and control groups, were total days of corticotherapy pre-ECMO (42 vs 25 days, p<0.005), total days under invasive mechanical ventilation pre-ECMO (40 vs 19 days, p<0.005), need for neuromuscular blocking agents (13 vs 6 days, p<0.005); variation of platelets (W=-21, p 0.0312), D-dimer (W=-21, p 0.0312), aPTT (W=21, p 0.0312), CRP (W=21, p 0.0312), monocytes (W=21, p 0.0312), and carboxyhemoglobin (W=21, p 0.0312), 5 days prior to MO exchange was also significantly different. Conclusions: The coagulopathy and inflammation induced by COVID-19 could contribute to MO dysfunction, requiring exchange. There is a shortage of studies identifying predictors of MO thrombosis and replacement, however, decrease in platelet count seems to be transversal to studies. These results may raise intriguing questions regarding the increased need for corticotherapy and altered leucogram counts in the case group.
Introduction: COVID-19 immune dysregulation and pro-inflammatory state is associated with higher rates of thrombotic events. In patients under venovenous ECMO (V-V ECMO), COVID-19 acts synergically leading to even higher pro-thrombotic activity, with increased membrane oxygenator (MO) dysfunction and need for replacement. This study aimed to assess possible predictors of MO dysfunction. Methods: This is a retrospective, observational study with a cohort of adult COVID-19 patients requiring V-V ECMO, in an ECMO referral center at a tertiary university hospital, between March 2020 and February 2022. Demographic characteristics, pre-ECMO organ support data (total days under corticotherapy, high-flux nasal cannula, non-invasive and invasive ventilation), total duration of ECMO, carboxy-hemoglobin and coagulation parameters variation during five days prior to each membrane exchange, were collected from electronic files. Results: MO exchange rate was 51.61% for at least one exchange. The median duration of ECMO run was significantly longer in the case group (35,0 vs 14,0 days, p<0.001). Parameters that showed statistical significance, comparing cases and control groups, were total days of corticotherapy pre-ECMO (42 vs 25 days, p<0.005), total days under invasive mechanical ventilation pre-ECMO (40 vs 19 days, p<0.005), need for neuromuscular blocking agents (13 vs 6 days, p<0.005); variation of platelets (W=-21, p 0.0312), D-dimer (W=-21, p 0.0312), aPTT (W=21, p 0.0312), CRP (W=21, p 0.0312), monocytes (W=21, p 0.0312), and carboxyhemoglobin (W=21, p 0.0312), 5 days prior to MO exchange was also significantly different. Conclusions: The coagulopathy and inflammation induced by COVID-19 could contribute to MO dysfunction, requiring exchange. There is a shortage of studies identifying predictors of MO thrombosis and replacement, however, decrease in platelet count seems to be transversal to studies. These results may raise intriguing questions regarding the increased need for corticotherapy and altered leucogram counts in the case group.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2024
Palavras-chave
COVID-19 ECMO V-V Disfunção de oxigenador de membrana