Additive treatment considerations in COVID-19-The clinician's perspective on extracorporeal adjunctive purification techniques

Abstract

The aim of this document was to inform the scientific community of sparse preliminary results regarding advanced supportive therapies and technology-driven systems in addition to highlighting the benefits and possibilities of performing concise research during challenging times. Advanced organ support for lung and heart offers the possibility to buy the time needed for recovery. However, remaining a bridging strategy, extracorporeal life support cannot act as the ultimate treatment for the underlying COVID-19 disease. Appropriate patient selection criteria addressed by experts and scientific organizations, such as Extracorporeal Life Support Organization and World Health Organization, may provide significant help in the difficult decision-making and to reduce mortality in patients with profound respiratory and/or cardiac failure due to COVID-19. Severe, systemic cytokine-mediated inflammation associated with the SARS-CoV-2 has also been described. Effects of crosstalk between coagulation and inflammatory pathways appear to significantly affect disease progression and lead to poor outcomes. Multiple therapeutic strategies, including antibody therapies (such as Tocilizumab, Sarilumab, Siltuximab), therapeutic plasma exchange (TPE), and blood purification techniques for direct removal of cytokines, including filtration, dialysis (diffusion), and adsorption are available. Further, we believe, that research should be facilitated and promoted, particularly under the guidance of recognized scientific societies or expert-based multicenter investigation, with rapid communication of critical and relevant information to enhance better appraisal of patient profiles, complications, and treatment modalities.

FIGURE 1

Integration of CytoSorb adsorber bypass in extracorporeal life support (ECLS) circuit. The recommended blood flow rate should be between 150 and 700 mL/min, with a minimum rate of at least 100 mL/min. The blood flow through CytoSorb can be monitored with the aid of an ultrasound Doppler probe (on line A or B) if necessary (courtesy of CytoSorbents Europe GmbH, Berlin Germany). A, bypassing line from ECLS circuit to CytoSorb adsorber; B, bypassing line from CytoSorb adsorber to ECLS circuit; G, connector on CytoSorb bypass to ECLS circuit; 1, connector before ECLS oxygenator membrane; 2, connector upstream of the ECLS pump; H, CytoSorb adsorber [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Clinical application of CytoSorb adsorber and extracorporeal life support (courtesy of CytoSorbents Europe GmbH, Berlin, Germany) [Color figure can be viewed at wileyonlinelibrary.com]