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In Reply We are writing in reference to the Letters to the Editors on our recently published article, “Extracorporeal Membrane Oxygenation for Patients With COVID-19 in Severe Respiratory Failure.”1 We appreciate the comments from the authors. We would like to take this opportunity to not only respond to their queries, but also provide updates on the final outcomes of the patients presented in the article.
All 40 patients have now completed their hospital course. Thirty-three patients (82.5%) have been weaned off extracorporeal membrane oxygenation (ECMO). Twenty patients (50.0%) were discharged home, and 13 patients (32.5%) discharged to a short-term rehabilitation center are now home. The mean (SE) time from ECMO initiation to extubation was 11.1 (1.9) days. The mean (SE) time from extubation to ECMO decannulation was 22.2 (3.3) days. The total mean (SE) time receiving mechanical ventilation was 15.0 (2.2) days, time receiving ECMO was 33.3 (4.5) days, and hospitalization was 55.2 (5.7) days.
Five patients (12.5%) had significant bleeding requiring more than 5 units of blood transfusion within a 12-hour period. Four patients (10%) developed septic shock requiring 2 or more vasopressors. Three patients (7.5%) developed kidney failure requiring kidney replacement therapy while receiving ECMO. One patient (2.5%) required revision of the ECMO cannula, and 1 patient (2.5%) had a tracheostomy. One patient (2.5%) experienced a stroke. Overall, 7 patients (17.5%) did not survive, with 6 developing overwhelming sepsis.
The low mortality and morbidity in this cohort may be associated with our approach to ECMO support. Multiple studies have now indicated that patients with coronavirus disease 2019 (COVID-19) have a higher propensity of developing right ventricular failure,2,3 as Kopanczyk et al highlight in their Letter. Although we did not measure right ventricular function in this group of patients, it is possible that our cannulation technique with the single-access, dual-stage right atrium–to–pulmonary artery cannula might have provided additional right-sided heart support. Other potential advantages of this cannula included single-site access to facilitate patient mobility and less mixing of deoxygenated blood. There were minimal cannula-associated complications or revisions. Extubating patients while receiving ECMO provided several benefits including weaning of sedatives, improving patient mobilization, and avoiding ventilator-associated trauma. Our ECMO teams, which included nurses, physician assistants, physical/respiratory therapists, and perfusionists among others, allowed for expert care to obtain our observed outcomes.
With regards to the details on ventilator and steroid management requested by Venkata et al, we feel that an in-depth description is beyond the scope of this Letter. We are currently putting together a thorough analysis and comparison of our ventilator management and sedation wean parameters, as well as our steroid and anticoagulation use protocols with those of other academic centers. We hope to summarize the findings in a separate article.
In conclusion, single-access, dual-stage venovenous ECMO with early extubation appears to be safe and effective in patients with COVID-19 respiratory failure. The low mortality and complication rates are likely the result of several aspects of our treatment protocol including cannulation technique, early extubation, and regular patient mobilization while receiving ECMO.
Corresponding Author: Antone J. Tatooles, MD, Advocate Christ Medical Center, 4400 W 95th St, Ste 308, Oak Lawn, IL 60453 (email@example.com).
Published Online: January 27, 2021. doi:10.1001/jamasurg.2020.6640
Conflict of Interest Disclosures: Dr Tatooles reported personal fees from Abbott outside the submitted work. No other disclosures were reported.
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Mustafa AK, Tatooles AJ. Extracorporeal Membrane Oxygenation and Coronavirus Disease 2019—Reply. JAMA Surg. 2021;156(4):403. doi:10.1001/jamasurg.2020.6640
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