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. 2022 Jun 28;26(1):190.
doi: 10.1186/s13054-022-04053-6.

Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation

Johannes Herrmann  1 , Christopher Lotz  1 , Christian Karagiannidis  2 , Steffen Weber-Carstens  3 , Stefan Kluge  4 , Christian Putensen  5 , Andreas Wehrfritz  6 , Karsten Schmidt  7 , Richard K Ellerkmann  8 , Daniel Oswald  9 , Gösta Lotz  10 , Viviane Zotzmann  11   12 , Onnen Moerer  13 , Christian Kühn  14 , Matthias Kochanek  15 , Ralf Muellenbach  16 , Matthias Gaertner  17 , Falk Fichtner  18 , Florian Brettner  19 , Michael Findeisen  20 , Markus Heim  21 , Tobias Lahmer  22 , Felix Rosenow  23 , Nils Haake  24 , Philipp M Lepper  25 , Peter Rosenberger  26 , Stephan Braune  27 , Mirjam Kohls  28 , Peter Heuschmann  28   29 , Patrick Meybohm  30 ; German ECMO COVID Study Group
Collaborators, Affiliations

Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation

Johannes Herrmann et al. Crit Care. .

Abstract

Background: Severe COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients.

Methods: 673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival.

Results: Most patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58-99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41-0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28-1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events.

Conclusions: Structural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival.

Trial registration: Registered in the German Clinical Trials Register (study ID: DRKS00022964, retrospectively registered, September 7th 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022964 .

Keywords: Acute respiratory distress syndrome (ARDS); COVID-19; Case-volume relationship; Extracorporeal life support; Intensive care.

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Conflict of interest statement

Christian Karagiannidis reports support for the present manuscript by Xenios (advisory board member), Getinge (personal fees); personal fees by Bayer, Xenios, Pfizer, Getinge; President of the German Society of internal Intensive Care Medicine; Lead of the German ICU Registry. Stefan Kluge reports consulting fees by Baxter, Fresenius Medical Care; payment by Baxter, Fresenius Medical Care. Karsten Schmidt reports research grants from Stiftung Universitätsmedizin Essen (Microcirculation/Sepsis/Covid-19), Heidelberger Stiftung Chirurgie (Microcirculation/Sepsis); payment for lectures (Buthylcholinesterase and Inflammation) by Dr. Franz Köhler Chemie GmbH. Onnen Moerer reports research grants from CSL Behring: Unrestricted Grant from CS Behring (research related to extracorporeal membrane oxygenation); Member of the national CEOsys network Germany (Covid ecosystem), which is funded by the Federal Ministry of Education and Research (BMBF). [FKZ 01KX2021]; Participation as speaker in workshops on haemodynamic monitoring at the European Medical School in Oldenburg, Germany; Expert testimonies for legal proceedings related to Critical Care or Anesthesiology cases on malpractice accusation by district courts and conciliation committees. Matthias Kochanek reports payment for lectures for Astellas, MSD, Gilead, Pfizer; stock or stock options by Biontech, Moderna; member of DGIIN, DGIM, DIVI. Tobias Lahmer reports payment for lectures and presentations by Gilead, MSD, Pfizer, ADVITOS GmbH. Peter Heuschmann reports research grants from German Ministry of Research and Education, European Union, Charité – Universitätsmedizin Berlin, Berlin Chamber of Physicians, German Parkinson Society, University Hospital Würzburg, Robert Koch Institute, German Heart Foundation, Federal Joint Committee (G-BA) within the Innovationfond, German Research Foundation, Bavarian State (ministry for science and the arts), German Cancer Aid, Charité – Universitätsmedizin Berlin (within Mondafis; supported by an unrestricted research grant to the Charité from Bayer), University Göttingen (within FIND-AF randomized; supported by an unrestricted research grant to the University Göttingen from Boehringer-Ingelheim), University Hospital Heidelberg (within RASUNOA-prime; supported by an unrestricted research grant to the University Hospital Heidelberg from Bayer, BMS, Boehringer-Ingelheim, Daiichi Sankyo), outside the submitted work. Peter Kranke reports research grants for CEOsys projects in the Network University Medicine (NUM) (institutional grants); chairman of the ESAIC guideline committee. Thorsten Brenner reports research grants from Deutsche Forschungsgemeinschaft (DFG), Dietmar Hopp Stiftung, Innovationsfonds/Gemeinsamer Bundesauschuss (G-BA), Stiftung Universitäts-medizin Essen; payments by CSL Behring GmbH, Schöchl medical education GmbH, Boehringer Ingelheim Pharma GmbH, Biotest AG, Baxter Deutschland GmbH, Astellas Pharma GmbH, B. Braun Melsungen AG, MSD Sharp & Dohme GmbH, Lücke Kongresse GmbH, Akademie für Infektionsmedizin e.V.; 2 patents on biomarkers in sepsis/septic shock with BRAHMS GmbH. Frank Herbstreit reports speaker honoria by Biotest; paid expert witness at several courts; International Anesthesia Research Society: Support for Attendance of Annual Meeting; Senior Editor: Anesthesia & Analgesia. All other authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Flowchart patient recruitment
Fig. 2
Fig. 2
Volume-outcome relationship of COVID-19 ECMO. Case volume. Case volume vs. survival in low (n = 96, survival 20%), intermediate (n = 329, survival 30%) and high volume (n = 248, survival 38%) ECMO centers. Annual case volumes prior to the pandemic were defined as low (< 20/year), intermediate (20–49/year) and high (> 50/year). Lower lines (ECMO ICU discharged alive) depict the percentage of patents discharged alive from the ECMO providing ICU. ICU discharge destinations were mainly other ICUs (40%), rehabilitation facilities (33%), or general wards (23%) (data not shown)
Fig. 3
Fig. 3
Risk factors for mortality. Adjusted odds ratios (OR) and 95% confidence intervals (CI) of risk factors for mortality according to the final model of block wise logistic regression (Table 3, Block 1–4). References for each variable are indicated (ref)
See this image and copyright information in PMC

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