Successful Use of Extracorporeal Life Support in Obesity with COVID-19

Heidi Dalton^1*, Osborn E², Desai M², Lantry J², King C³, Moran P³, Ryan L² and Speir A^2
*Correspondence: Heidi Dalton, Department of Pulmonary/ Lung Transplant, Heart and Vascular Institute, Falls Church, Ethiopia, Email:

Keywords

Extracorporeal • Obesity • COVID-19 • Prognostic indicators • Respiratory failure

Introduction

As the COVID pandemic continues to rise, those most severely stricken develop respiratory failure which is often refractory to conventional mechanical ventilation. The use of extracorporeal life support in such circumstances is controversial as some clinicians perceive this to be an excessive use of limited resources while others do not [1]. As the disease is novel, little data exists on appropriate candidacy and outcome to guide clinical practice. Obesity has been reported by some as an underlying condition with poor prognosis in COVID-19 individuals.

We report our first experience with venovenous ECMO support in a COVID-19 patient with severe respiratory failure and obesity [2].

Case Presentation

A 44-year-old male presented to the emergency department with fever, chills, headache, loose stools, mild dry cough, shortness of breath, fatigue and decreased appetite for 1 week. Past medical history was positive for hypertension and obesity (weight 129.6 kg, BMI 41 kg/m²) [3]. He had recently returned from travel to New York City (1 week prior) without known ill exposures. He was initially prescribed Tamiflu for 2 days by his PCP until influenza testing returned negative. He had no history of lung disease or smoking. Symptoms persisted as above and as he fell within guidelines for testing for COVID-19, he was directed to the emergency department at our center. Initial vital signs revealed fever of 101.5, pulse 81, respiratory rate 31 and oxygen saturation of 92% on room air. Physical exam revealed course breath sounds but was otherwise noncontributory. Chest radiography revealed bilateral infiltrates (Figure 1) [4]. A repeat influenza PCR was negative and blood culture was also negative. He was begun on antibiotics of azithromycin and ceftriaxone. Testing for COVID-19 was performed on admission and positive result was obtained on hospital day 4. He was treated with a 10-day course of remdesivir [5].

Within 24 hours from admission, respiratory status deteriorated despite hi flow nasal cannula of 100% FiO₂ and 60 L and he was intubated. CT angiogram revealed no intrapulmonary thrombus but diffuse bilateral infiltrates (Figure 2) [6]. Echocardiogram was normal for left and right ventricular function. The patient also developed oliguric acute kidney injury with creatinine 3.1, although some urine output was maintained with intravenous diuretics. He was maintained on lung protective ventilation (tidal volume <6 cc/kg, plateau pressure 28-30 cm H₂O, PEEP 14-18, driving pressure 10-13 [7]. Static compliance 31-37 cc/cm H₂O). While initial prone positioning and neuromuscular blockade improved oxygenation, over the ensuing 4 days, no major improvements in ventilator weaning or oxygenation occurred. A trial of inhaled veletri failed to improve oxygenation (Figures 2-4) [8].

Results and Discussion

On day 6 of intubation and after 4 days of proning, oxygenation removed poor with no improvement with prone positioning. Decision for venovenous ECMO cannulation was made by the clinical team in conjunction with family [9]. He was cannulated via the left femoral vein (21 FR) and right femoral vein (25 Fr) and placed on a Cardiohelp system (Maquet), with flows of 3.5 L, 2905 rpm and blender gas flow of FiO₂ 100% 4.5 L. He was also transitioned to a verticalization bed. He was awake and followed commands on ECMO and was able to maintain vertical positioning for several hours each day. Tracheostomy was not performed due to surgical concerns of aerosolization of virus. Anticoagulation was maintained with heparin infusion with goal aPTT of 60-80 sec. Continuous renal replacement therapy was begun in conjunction with ECMO to maintain fluid and acid-base balance. Pseudomonas pneumonia was diagnosed during the ECMO run and he was MRSA positive as well. He received appropriate antibiotics including vancomycin, ceftriaxone and meropenem [10]. Her remained intermittently febrile. Improvement in compliance and gas exchange led to successful decannulation at bedside after 7 days of ECMO support (Figure 3). Respiratory status continued to improve and he was extubated 3 days later, 22 days after initial symptoms began. Renal insufficiency remained but gradual improvement with diuretics negated need for dialysis.

Selected labs over his course are shown in Table 1. While periods of delirium occurred, the patient was often lucid and following commands, talking to family on phone [11].

Table 1. Selected labs.

Conclusion

The use of ECMO in COVID-19+patients is controversial. While some patients may benefit, resource use is high and concern over ECMO support limiting care for other patients is also a concern. Patients with obesity have been noted to have poor prognosis in some anecdotal reports in COVID 19. Our patient, despite his high BMI and concurrent acute kidney injury, responded well to ECMO support. As we learn more about COVID-19 and patient characteristics, further guidance for optimal patient selection and support will occur. In this case, use of VV ECMO was associated with good outcome.

Enclosed find our case report of an obese, COVID-19+patient treated successfully with venovenous extracorporeal life support. There is controversy on use of ECMO in these pandemic times for these critically ill patients, especially those with large BMI. Concerns of heavy resource use is quoted as another reason to not offer ECMO support. Centers with capacity, experience and appropriate patient volume may be able to offer ECMO successfully, however, and information on use of ECMO may help guide the field.

We offer some information on successful use of ECMO in obese patients (this patient is the first of 12 ECMO patients to date receiving ECMO in our center). Of note, although I have no conflicts of interest, I do receive consultant fees for medical director services during transport of ECMO patients for innovative ECMO Concepts, Inc. This has no impact on this report.

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