Title : Early initiation of extracorporeal membrane oxygenation saves live in severe COVID 19 infection: a case report
Abstract:
Background The utilization of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for patients suffering from Covid 19 infection with respiratory failure remains controversial. According to the Extracorporeal life support organization registry, there are 13,126 patients currently on ECMO as of February 25th, 2022. The data reports an in-hospital mortality rate of 47% in patients who were put on ECMO in the last 90 days. We hypothesize that patients may have a higher chance of improvement with early initiation of ECMO treatment for severe Covid 19 disease. Case Presentation A 46-year-old female with a past medical history of morbid obesity, iron deficiency anemia, and asthma was brought to the hospital via paramedics due to altered mental status and shortness of breath. Upon arrival at the Emergency Department (ED), the patient was found to be lethargic, confused, and in severe respiratory distress. Her clinical examination revealed severe hypoxia with SpO2 65%, tachypnea at 55 breaths/min, tachycardia at 154 beats/min, and hypotension with a blood pressure of 96/60 mmHg. On physical exam, the patient was disoriented and the only other pertinent positive finding was diffuse coarse lung sounds bilaterally on auscultation. Her Initial chest radiography showed extensive diffuse bilateral pulmonary infiltrates. Labs reflected leukocytosis with WBC of 13.8 thou/uL, CRP of 29.1 mg/L, Ferritin of 3083 ug/L, and Lactic acid of 3.4 mmol/L. A nasopharyngeal swab was positive by PCR for SARS-CoV-2. While still in the ED, the patient’s respiratory status continued to deteriorate. She didn’t tolerate bilevel positive airway pressure(BiPAP), high flow oxygen, or proning due to continuous hypoxia and agitation. She was ultimately intubated and placed on mechanical ventilation(MV). Multiple MV settings were tried but her respiratory status kept worsening even with high positive end-expiratory pressure (PEEP), deep sedation, and paralysis using neuromuscular blockers. A decision was made to commence veno-venous ECMO on day 1. During her stay at the hospital, she completed a 5-day course of remdesivir, received 2 units of convalescent plasma and 1 dose of sarilumab. She also received intravenous (IV) steroids that were eventually weaned to prednisone with taper. On day 14th of hospitalization, a tracheotomy tube was placed. After a few days, there was a significant improvement in the patient’s condition. She was decannulated from ECMO on day 19th of hospitalization (ECMO day 19). She was weaned from the ventilator gradually as she started to tolerate high flow oxygen via trach mask and was transferred out of the intensive care unit once hemodynamically stable. The patient was eventually discharged to rehabilitation. Conclusion This case report demonstrates a positive outcome in a relatively young patient with acute respiratory failure from COVID-19 due to prompt ECMO initiation on day 1 of the hospitalization. The emphasis here is the usefulness of early ECMO treatment vs late initiation, especially in younger patients without extensive comorbidities. To validate these findings, future prospective multi-center studies are needed in a larger cohort of patients
