Better to start extracorporeal membrane oxygenation (ECMO) sooner
rather than later, and hold back on sending older physicians into the
wards — these were among the lessons shared by Chinese doctors treating
severe cases of COVID-19 during a Thursday webinar sponsored by the American College of Cardiology.
The case of a 31-year-old male Wuhan resident illustrated just how easily COVID-19
can progress to multi-organ dysfunction, according to Chinese doctors
who arrived in Wuhan 6 weeks ago to help combat the pandemic.
The patient had complained of 3 weeks of intermittent fever and
coughing when he tested positive for the novel coronavirus. Medications
he was given in the hospital included treatments for his diabetes and
hyperlipidemia, as well as 6 days of Arbidol, an antiviral not available in the U.S.
Nevertheless, the patient’s condition deteriorated as he developed
acute heart failure, sepsis, and liver dysfunction. Infection and
inflammation biomarkers were very high, the doctors noted.
The staff continued to treat him with everything they had, however,
paying attention to him and keeping him hydrated. In the end, he
recovered.
Success stories like this one are coming out of China just after the country announced the first day that it found no new COVID-19 cases within its borders.
For one, some critically severe patients will still have severe
hypoxemia on ventilation and will require ECMO, according to Ning Zhou,
MD, PhD, who is currently working in the ICU ward of Tongji Hospital in
Wuhan.
The typical ECMO case looks something like this: a man age 50, with
11 days of fever, shortness of breath for 2 days, oxygen saturation of
75%, reduced lymphocyte levels, high NT-proBNP and cardiac troponin I,
and ejection fraction 45% on echocardiography. He does not improve on
antibacterial, antiviral therapy, but in fact shows hypoxemia getting
worse and is sent to the ICU.
Zhou said he has performed five ECMO cases (four recovered, one
ongoing) and it’s been administered for an average 9.2 days per patient.
He recommended that hospital staff employ veno-venous ECMO before
trying veno-arterial ECMO.
Importantly, he said, ECMO doesn’t help people who are dying, and should be offered earlier, before they get to that point.
“Don’t wait. You lose the opportunity, especially for those young
patients. ECMO is not for prolonging life for days. It’s an opportunity
for patients to survive,” he emphasized.
People who are less likely to be helped by ECMO include those with
irreversible severe brain injury and people over 70 years old, Zhou
suggested.
“In China, we don’t have so many ECMO systems, resources for all the
patients. We have to choose who can probably recover from COVID-19,” he
said.
Finally, the doctor suggested that it is time to rethink the way patients are intubated before they are given ECMO.
“How about we use ECMO first, or even use ECMO without intubation?
This means we can use ECMO to support the lungs without infecting the
intubation and ventilation,” he said. “We already finished three cases …
We removed the intubation first and continued ECMO for supply of
oxygen.”
This last suggestion was met with some hesitance from the other
doctors. One said he still believed intubation should be performed
before ECMO.
Unanimously dismissed by the group, on the other hand, was the idea of bringing in the Impella ventricular assist device to replace some of the heart’s function.
This is nearly impossible in the ICU as the device needs to be
implanted in the cath lab, the session moderator noted. Furthermore,
operators are being told to wear three or four gloves and therefore lose
some sense of touch, making this an extremely difficult implant
procedure in present circumstances.
Needless to say, hospital staff are advised to wear full personal protective equipment at all times.
Harlan Krumholz, MD, of Yale University and Yale New Haven Hospital
in Connecticut, asked during the virtual meeting whether risk factors
for poor COVID-19 prognosis might be identified from an international
pooling of data.
The Chinese doctors replied that it is very hard to predict
individual patients’ outcomes. Some patients can appear to be on the
recovery but worsen suddenly.
However, men do appear more susceptible to infection, they offered —
Zhou disclosed that of the 30 beds in his ICU ward, more than 20 are
filled by men.
The speakers, all men, said that in China, doctors over age 60 are
prohibited from going to the front lines. Only junior physicians are
allowed to take care of COVID-19 patients.
https://www.medpagetoday.com/infectiousdisease/covid19/85520
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