COVID-19 Respiratory Failure: Targeting Inflammation on VV-ECMO Support

Abstract

The outbreak of novel coronavirus (SARS-CoV-2) that causes the respiratory illness COVID-19 has led to unprecedented efforts at containment due to its rapid community spread, associated mortality, and lack of immunization and treatment. We herein detail a case of a young patient who suffered life-threatening disease and multiorgan failure. His clinical course involved rapid and profound respiratory decompensation such that he required support with venovenous extracorporeal membrane oxygenation (VV-ECMO). He also demonstrated hyperinflammation (C-reactive protein peak 444.6 mg/L) with severe cytokine elevation (Interleukin-6 peak > 3000 pg/ml). Through treatment targeting hyperinflammation, he recovered from critical COVID-19 respiratory failure and required only 160 hours of VV-ECMO support. He was extubated 4 days after decannulation, had progressive renal recovery, and was discharged to home on hospital day 24. Of note, repeat SARS-CoV-2 test was negative 21 days after his first positive test. We present one of the first successful cases of VV-ECMO support to recovery of COVID-19 respiratory failure in North America.

Figure 1.

Temporal relationship of tocilizumab and high-dose vitamin C therapy during VV-ECMO therapy with selected clinical laboratory results. The first dose of tocilizumab is denoted with a single dashed line and vitamin C with an alternating dashed line. A: C-reactive protein. B: Absolute lymphocyte count. C: Ferritin. VV-ECMO, venovenous extracorporeal membrane oxygenation.

Figure 2.

Temporal relationship of tocilizumab and high-dose vitamin C therapy during VV-ECMO therapy with oxygenation, mechanical ventilation, and ECMO parameters. The first dose of tocilizumab is denoted with a single dashed line and vitamin C with an alternating dashed line. A: Partial pressure of arterial oxygen to fraction of inhaled oxygen ratio (PaO₂:FiO₂). B: Fraction of inhaled oxygen (FiO₂) on the ventilator and ECMO circuit. C: Positive end-expiratory pressure (PEEP, cm H₂O) and tidal volume indexed to ideal body weight (ml/kg). D: ECMO flow rate and sweep speed. VV-ECMO, venovenous extracorporeal membrane oxygenation.