Pancreatitis in a Patient with Severe Coronavirus Disease Pneumonia Treated with Veno-venous Extracorporeal Membrane Oxygenation

Severe coronavirus disease (COVID-19) can induce serious complications, including acute respiratory distress syndrome, septic shock, and acute kidney injury. However, few reports have associated COVID-19 with pancreatitis. We herein report the case of a 55-year-old patient who developed acute pancreatitis associated with severe COVID-19 pneumonia and was successfully treated with veno-venous extracorporeal membrane oxygenation (ECMO). Elevated pancreatic enzymes levels and computed tomography findings led to the diagnosis of acute pancreatitis due to COVID-19. Although we found that severe COVID-19 pneumonia can lead to pancreatitis, the underlying pathophysiology remains unknown.     

Extracorporeal Membrane Oxygenation Used in Acute Respiratory Distress Syndrome with COVID-19: A Systematic Review and Meta-Analysis

IntroductionProtective pulmonary mechanical ventilation, higher positive end-expiratory pressure, neuromuscular blockade, prone positioning, and pulmonary recruitment procedures are all strategies in severe COVID-19 cases. Extracorporeal Membrane Oxygenation (ECMO) can be seen as an alternative to traditional treatment in certain patients when conventional therapy fails. We present a study that intends to systematically review and meta-analysis ECMO use in COVID-19 patients.MethodsWe search major medical databases (Cochrane Library, PubMed, EMBASE, MedRxiv) for clinical trials that were released between January 2020 until February 2021, had full-text availability, were written in English, and humans studies.We used National Heart, Lung, and Blood Institute (NHLBI) quality evaluation methods for retrospective cohort and cross-sectional studies to evaluate the quality of the articles. In addition, we used the Mantel–Haenszel random-effects meta-analysis of using RevMan 5.4.ResultsA total of 33 studies involving 3090 patients were included in the systematic review and six studies in the meta-analysis. There were 828 patients admitted to the ICU, of which 779 patients had ARDS (94%). Of the total study, 527 patients received ECMO therapy (17%). ARDS incidence was associated with complications during ICU care compared to non-ICU care (OR 107.98; 95% CI 55.51–210.03; p < 0.00001). Indirect comparisons, the incidence of mortality was associated with ECMO compared with non-ECMO (OR 15.79; 95% CI 4.21–59.28; p < 0.0001).ConclusionThe incidence of ARDS was associated with complications during ICU stay, and the incidence of mortality was associated with ECMO. Further study about mechanisms involving illness and death of patients from COVID-19 is needed.     

Drug Fever Due to Favipiravir Administration for the Treatment of a COVID-19 Patient

A 55-year-old Japanese man was hospitalized with the novel coronavirus disease 2019 (COVID-19). On the 14th day after the start of favipiravir administration, the patient developed a fever with a temperature of 38.1℃. His pulse rate also became elevated to 128 bpm, so relative bradycardia was not suspected. Since he was in good overall health and no concomitant symptoms and signs were apparent, we considered it to be drug fever due to favipiravir. After the completion of favipiravir treatment, the patient''s temperature normalized within 24 hours. We herein report this case of drug fever caused by favipiravir.     

Extracorporeal membrane oxygenation in patients with COVID-19: 1-year experience

BackgroundExtracorporeal membrane oxygenation (ECMO) in patients with coronavirus disease 2019 (COVID-19) showed reasonable outcomes. However, recent studies indicated a negative trend and analysis is needed.MethodsBaseline characteristics, laboratory parameters, and outcomes of ECMO-supported patients with COVID-19 were analyzed in a retrospective single-center study. We included hospital admissions until February 28, 2021; patients were followed until discharge/death. Eventually, we compared data between patients hospitalized before and after September 1, 2020.ResultsMedian age of patients treated with ECMO (n=39) was 56 years; most patients were males (n=28, 72%). Median mechanical ventilation time (prior to ECMO) was 6 days, while the median ECMO duration was 19 days. Overall survival rate was 41%. In the sub-analysis, survival until discharge in the first and second epidemic waves was 53% (n=19) and 30% (n=20), respectively (P=0.2). At baseline, compared with patients of the first wave, those of the second wave had higher median body mass index (28.2 vs. 31.1 kg/m², respectively, P=0.02), bicarbonate (27 vs. 31.8 mmol/L, respectively, P=0.033), plasma free hemoglobin (36 vs. 58 mg/L, respectively, P=0.013), alanine aminotransferase (33 vs. 52 U/L, respectively, P=0.018), and pH (7.29 vs. 7.42, respectively, P=0.005), lower rate of pulmonary hypertension (32% vs. 0%, respectively, P=0.008), lower positive end-expiratory pressure (14 vs. 12 cmH₂O, respectively, P=0.04), longer median ECMO duration (16 vs. 24.5 days, respectively, P=0.074), and more frequent major bleeding events (42% vs. 80%, respectively, P=0.022).ConclusionsECMO-supported patients with COVID-19 had an overall survival rate of 41%. Similar to international registries, we observed less favorable outcomes during the second wave. Further research is needed to confirm this signal and find predictors for mortality.     

Venovenous Extracorporeal Membrane Oxygenation to Facilitate Removal of Endobronchial Tumors

Short-term extracorporeal membrane oxygenation is a useful adjunct to thoracic procedures. We report the cases of 2 middle-aged men who were supported with venovenous extracorporeal membrane oxygenation to facilitate tumor debulking and recanalization of the carina and mainstem bronchi. Neither patient had major complications or adverse events. These cases suggest that short-term extracorporeal membrane oxygenation is safe in patients undergoing complex resection or debulking of endobronchial lesions.     

Tracheobronchial Obstruction Due to Blood Clots in Acute Pulmonary Embolism with Cardiac Arrest Managed with Extracorporeal Membrane Oxygenation

A 66-year-old Japanese woman developed pulseless electrical activity following an acute pulmonary embolism and was treated with thrombolytic therapy. She remained hemodynamically unstable and therefore underwent extracorporeal membrane oxygenation (ECMO). While receiving treatment with ECMO, blood clots induced by endobronchial hemorrhage caused tracheobronchial airway obstruction, leading to ventilatory defect. Furthermore, her cardiac function improved, resulting in cerebral hypoxemia progression. Therefore, the blood clots were removed with a Fogarty balloon catheter and endobronchial urokinase administration, resulting in improvement in her respiratory condition. Finally, ECMO was decannulated, and the patient was discharged from our hospital without difficulties in her activities of daily living.     

Successful Use of Veno-Venous Extracorporeal Membrane Oxygenation in an Adult Patient with Sickle Cell Anemia and Severe Acute Chest Syndrome

A 25-year-old female with sickle cell anemia presented with respiratory failure due to acute chest syndrome (ACS). Given her severely compromised cardiopulmonary status, she was started on veno-venous extracorporeal membrane oxygenation (VV-ECMO). After 20 days, the patient’s respiratory status improved and she was successfully decannulated. Veno-venous extracorporeal membrane oxygenation can be utilized for severe ACS in adult patients with sickle cell disease. Prompt initiation of this modality may improve outcomes in adult patients with sickle cell disease complicated by life threatening ACS.     

Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a widely used form of mechanical circulatory support in patients with refractory cardiogenic shock. A common drawback of this modality is a resultant increase in left ventricular afterload.

Anesthetic management of lung transplantation in a patient with end-stage COVID-19 pneumonia: A case report

Rationale:The COVID-19 pandemic is spreading around the world and the leading cause of death is rapidly progressive respiratory failure because of lung damage and consolidation. Lung transplantation is the last line of treatment for chronic end-stage lung diseases. There were several cases of lung transplantation reported in patients with COVID-19 pneumonia. However, anesthetic management of lung transplantation in this subpopulation is rare. We report the anesthetic and perioperative management of lung transplantation in a patient with COVID-19 pneumonia.Patient concerns:A 70-year-old man with a 7-day history of fever was diagnosed with COVID-19 pneumonia. His throat swab was positive for COVID-19, but negative for other common viruses. Chest radiography showed multiple inflammatory foci in both lungs. By day 5, he presented respiratory distress. Computed tomography (CT) scan showed progressive deterioration of both lungs. Starting on day 7, SARS-CoV-2 RNA in bronchoalveolar lavage samples were continuously negative. However, his lung condition deteriorated. By day 17, a veno-venous extracorporeal membrane oxygenation (ECMO) was initiated. After 10 days of ECMO support, the patient''s lung condition did not improve. CT scan revealed bilateral parenchymal consolidation with pulmonary fibrosis and hydrothorax.Diagnosis:Irreversible lung function loss induced by COVID-19 pneumonia.Interventions:Bilateral transplantation was performed because the patient''s lung condition did not improve and CT scan revealed parenchymal consolidation with pulmonary fibrosis after 10 days of ECMO support. Thirty-six hours after the surgery, ECMO was discontinued. A percutaneous transluminal coronary angioplasty and a stent implantation were performed because of acute coronary syndrome and myocardial ischemia 4 days postoperatively.Outcomes:The patient remained hospitalized because of requirements for intermittent assisted ventilation via tracheostomy.Lessons:This case further supports the consideration that lung transplantation can potentially be the successful therapy for these patients who have developed irreversible lung function lose due to COVID-19 pneumonia. However, most critical patients with COVID-19 are older individuals with various comorbidities, which present new anesthetic challenges.     

Timeline of Oxygen Demand in Patients with COVID-19 Pneumonia

Objective In patients with coronavirus disease 2019 (COVID-19), understanding the timeline of oxygen demand and severe respiratory failure, such as intensive care unit (ICU) admission, may clarify the therapeutic window when home-care treatment is possible and help determine the timing of treatment in hospitalized patients to improve the respiratory status. We examined the timeline of respiratory status in hospitalized patients with moderate-to-severe COVID-19 in terms of oxygen demand and ICU admission. Methods We retrospectively assessed all patients with COVID-19 who were admitted to our hospital between February 2020 and February 2021 and required supplemental oxygen. This study included 66 patients who were transferred to the ICU (ICU patients) and 144 patients who were not transferred to the ICU (non-ICU patients). Results In the total cohort, the median duration from symptom onset to the need for supplemental oxygen was 8 [interquartile range (IQR) 6-10] days. This duration was significantly shorter in ICU patients than in non-ICU patients [8 (IQR 6-9) vs. 9 (IQR 6-10) days, p=0.02]. The median duration from symptom onset to ICU admission was 9 (IQR 8-11) days in severely ill patients. The median duration from the initiation of supplemental oxygen to ICU admission was 1.0 (IQR 1-2.75) days. Only 2 of 66 patients (3.0%) were admitted to the ICU six days or later after the initiation of supplemental oxygen. Conclusion Physicians should carefully monitor each patient''s condition after eight days from symptom onset. New therapies and their early administration are needed to reduce the frequency of respiratory failure in COVID-19 patients.     

Successful Rescue of Life-threatening Hemoptysis Caused by Pulmonary Tuberculosis Bridging with Extracorporeal Membrane Oxygenation

Massive hemoptysis is a fatal complication associated with pulmonary tuberculosis (TB). It can lead to severe respiratory failure. Extracorporeal membrane oxygenation (ECMO) is a life-saving technology that is rarely indicated for bleeding disorders. We herein report a 26-year-old man who presented with severe respiratory failure caused by massive hemoptysis with pulmonary TB. Transcatheter artery embolization was successfully performed with venovenous ECMO support. The hemostatic procedure allowed concomitant anticoagulant use, and neither bleeding nor thrombotic complications occurred throughout the clinical course. Administering the appropriate hemostatic procedure with subsequent management, including anticoagulant therapy, supported ECMO application in a case of bleeding.     

静脉-动脉模式体外膜肺氧合机械辅助在心脏外科手术围术期的应用

目的:总结心脏外科手术围术期采用静脉-动脉模式体外膜肺氧合(VA-ECMO)辅助支持治疗患者的救治经验。方法:回顾分析中国医学科学院阜外医院2004年12月至2019年12月307例心脏外科手术围术期使用VAECMO支持治疗患者的临床资料。根据使用VA-ECMO的适应证及不同年龄段应用的患者分析总结,对比使用主动脉内球囊反搏(IABP)联合VA-ECMO辅助患者的临床转归差异。结果:307例患者中,177例(57.7%)为成年患者,男性211例(68.7%),平均VA-ECMO辅助时间为(119.2±72.7)h,209例(68.4%)成功脱机,158例(51.5%)恢复后顺利出院。VA-ECMO机械辅助并发症最为常见的是急性肾功能不全(51.1%)、肺部感染(36.8%)和出血(30.2%)。联合应用IABP者较不用IABP者VA-ECMO辅助时间未能缩短,但呼吸机机械通气时间(131.5 h vs.158.6 h,P=0.013)以及入住重症监护病房(ICU)时间(119.0 h vs.153.2 h,P=0.002)明显缩短,急性肾功能不全(40.0%vs.64.0%,P=0.035)以及胃肠道并发症发生率(7.6%vs.24.0%,P=0.044)明显降低。在术中建立VA-ECMO辅助循环的心脏外科手术患者较ICU床旁建立VA-ECMO者脱机率(77.8%vs.57.9%)和出院后30 d生存率(66.0%vs.35.2%)更高(P均<0.05),急性肾功能不全发生率更低(37.0%vs.66.9%,P<0.05)。结论:VA-ECMO可为心脏外科手术围术期出现循环呼吸功能衰竭的患者提供有效的辅助支持,IABP搏动性血流对于VA-ECMO辅助过程中外周器官灌注有积极作用,早期及时应用VA-ECMO有助于获得更优的短期辅助疗效。     

Venovenous Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis: Starting without Systemic Anticoagulation

Regarding extracorporeal membrane oxygenation (ECMO) support against hemorrhagic conditions, there seems to be a dilemma when deciding between maintaining the circuit patency by systemic anticoagulation and increasing the risk of bleeding. We herein report two cases of diffuse alveolar hemorrhage (DAH) caused by myeloperoxidase (MPO) anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) successfully treated with venovenous (VV)-ECMO support, both initially started without systemic anticoagulation. Under anticoagulation-free ECMO management, we should consider the shortcomings of frequent circuit exchange and hemorrhagic diathesis related to circuit-induced disseminated intravascular coagulation (DIC).     

超声心动图在体外膜肺氧合对心脏支持的应用价值

目的：探讨超声心动图在体外膜肺氧合(ECMO)支持辅助中对心脏的监测作用。方法：2004年12月～2005年8月间连续10例因低心排接受 Veno-Aterial ECMO 支持,其中心脏外科术后8例,心肌病急性心力衰竭拟心脏移植的2例患者,年龄13～60岁,平均(44±12)岁。仪器为 Philips iE33和 sonos 5500彩超仪,均在床旁进行检查,分别在 ECMO 安置前、ECMO 辅助后(撤机前30 min 内流量减至最低)前后观察患者左心室射血分数(INEF)、左心室舒张末前后径(LVEDD)等指标,结合患者临床资料(心率、血压、左心房压及血氧饱和度)对比。并观察并发症情况。结果：10例患者 ECMO 辅助后的 LVEF、LVEDD、心率、血压、左心房压及动脉血氧饱和度均有改善。并发症的检出：机械瓣异常、左心房血栓、心包血凝块、二尖瓣狭窄未纠正各1例。结论：彩色多普勒超声心动图可无创实时评价 ECMO 辅助前后心脏结构及功能变化,及时发现其并发症。     

COVID-19 Pneumonia Resembling an Acute Exacerbation of Interstitial Pneumonia

An 84-year-old man was admitted with hypoxemia and ground-glass opacities with traction bronchiectasis in both lungs and mild fibrosis on computed tomography. We first suspected that he had acute exacerbation of interstitial pneumonia and initiated methylprednisolone pulse therapy. On day 4, he was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia. Although the ground-glass opacities were improved with corticosteroid treatment alone, the hypoxemia persisted, and the plasma D-dimer level increased. Anticoagulant therapy was initiated, and the hypoxemia was improved. COVID-19 pneumonia may result in radiological findings similar to those of acute exacerbation of interstitial pneumonia, and corticosteroids and anticoagulant therapy may lead to favorable outcomes.     

Postpartum extracorporeal membrane oxygenation of a woman with COVID-19-related acute respiratory distress syndrome: A case report

Introduction:Patients with coronavirus disease (COVID-19) may develop acute respiratory distress syndrome (ARDS). There have been few reports of postpartum woman with ARDS secondary to COVID-19 who required respiratory support using veno-venous extracorporeal membrane oxygenation (ECMO). We present the case of a 31-year-old woman who was admitted to hospital at 35 weeks gestation with ARDS secondary to COVID-19 and required ECMO during the postpartum period.Patient concerns:The patient had obvious dyspnea, accompanied by chills and fever. Her dyspnea worsened and her arterial oxygen saturation decreased rapidly.Diagnosis:ARDS secondary to COVID-19.Interventions:Emergency bedside cesarean section. Medications included immunotherapy (thymosin α 1), antivirals (lopinavir/ritonavir and ribavirin), antibiotics (imipenem-cilastatin sodium and vancomycin), and methylprednisolone. Ventilatory support was provided using invasive mechanical ventilation. This was replaced by venous-venous ECMO 5 days postpartum. ECMO management focused on blood volume control, coagulation function adjustment, and airway management.Outcomes:The patient was successfully weaned for ECMO and the ventilator and made a good recovery.Conclusion:Special care, including blood volume control, coagulation function adjustment, and airway management, should be provided to postpartum patients with ARDS secondary to COVID-19 who require ECMO support.