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      Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

      research-article
      1 , , 2 , 3 , 4 , 1 , 1 , 5 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 4 , 4 , 19 , 20 , 21 , 22 , 23 , 24 , 4 , the STOP-COVID Investigators
      Intensive Care Medicine
      Springer Berlin Heidelberg
      COVID-19, VV-ECMO, Extracorporeal membrane oxygenation, Severe respiratory failure, ARDS, Mortality

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          Abstract

          Purpose

          Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19).

          Methods

          We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO 2/FiO 2 < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model.

          Results

          Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41–58), 137 (72.1%) were men, and the median PaO 2/FiO 2 prior to ECMO initiation was 72 (IQR 61–90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41–0.74). Results were similar in a secondary analysis limited to patients with PaO 2/FiO 2 < 80 (HR 0.55; 95% CI 0.40–0.77).

          Conclusion

          In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality.

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s00134-020-06331-9.

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          Most cited references38

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          The REDCap consortium: Building an international community of software platform partners

          The Research Electronic Data Capture (REDCap) data management platform was developed in 2004 to address an institutional need at Vanderbilt University, then shared with a limited number of adopting sites beginning in 2006. Given bi-directional benefit in early sharing experiments, we created a broader consortium sharing and support model for any academic, non-profit, or government partner wishing to adopt the software. Our sharing framework and consortium-based support model have evolved over time along with the size of the consortium (currently more than 3200 REDCap partners across 128 countries). While the "REDCap Consortium" model represents only one example of how to build and disseminate a software platform, lessons learned from our approach may assist other research institutions seeking to build and disseminate innovative technologies.
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            Acute respiratory distress syndrome: the Berlin Definition.

            The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
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              Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome

              The efficacy of venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) remains controversial.
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                Author and article information

                Contributors
                sshaefi@bidmc.harvard.edu
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0342-4642
                1432-1238
                2 February 2021
                : 1-14
                Affiliations
                [1 ]Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Road, Boston, MA 02215 USA
                [2 ]Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ USA
                [3 ]GRID grid.239835.6, ISNI 0000 0004 0407 6328, Department of Internal Medicine, Heart and Vascular Hospital, , Hackensack Meridian Health Hackensack University Medical Center, ; Hackensack, NJ USA
                [4 ]GRID grid.62560.37, ISNI 0000 0004 0378 8294, Division of Renal Medicine, , Brigham and Women’s Hospital, ; Boston, MA USA
                [5 ]GRID grid.137628.9, ISNI 0000 0004 1936 8753, Division of Nephrology, , New York University Grossman School of Medicine, ; New York, NY USA
                [6 ]GRID grid.240684.c, ISNI 0000 0001 0705 3621, Division of Pulmonary and Critical Care Medicine, , Rush University Medical Center, ; Chicago, IL USA
                [7 ]GRID grid.240684.c, ISNI 0000 0001 0705 3621, Department of Medicine, , Rush University Medical Center, ; Chicago, IL USA
                [8 ]Department of Surgery, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ USA
                [9 ]GRID grid.239835.6, ISNI 0000 0004 0407 6328, Division of Cardiac Surgery, Heart and Vascular Hospital, , Hackensack Meridian Health Hackensack University Medical Center, ; Hackensack, NJ USA
                [10 ]GRID grid.430503.1, ISNI 0000 0001 0703 675X, Division of Renal Diseases and Hypertension, , University of Colorado Anschutz Medical Campus, ; Aurora, CO USA
                [11 ]GRID grid.214458.e, ISNI 0000000086837370, Division of Cardiology, Department of Medicine, , University of Michigan, ; Ann Arbor, MI USA
                [12 ]GRID grid.16753.36, ISNI 0000 0001 2299 3507, Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, , Northwestern University Feinberg School of Medicine, ; Chicago, IL USA
                [13 ]GRID grid.59734.3c, ISNI 0000 0001 0670 2351, Division of Pulmonary, Critical Care, and Sleep Medicine, , Icahn School of Medicine at Mount Sinai, ; New York, NY USA
                [14 ]GRID grid.251993.5, ISNI 0000000121791997, Division of Nephrology, Department of Medicine, , Albert Einstein College of Medicine/Montefiore Medical Center, ; The Bronx, NY USA
                [15 ]GRID grid.25879.31, ISNI 0000 0004 1936 8972, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, , University of Pennsylvania, ; Philadelphia, PA USA
                [16 ]GRID grid.411896.3, ISNI 0000 0004 0384 9827, Division of Critical Care Medicine, , Cooper University Health Care, ; Camden, NJ USA
                [17 ]Department of Internal Medicine, Baylor University Medical Center, Baylor Research Institute, Dallas, TX USA
                [18 ]GRID grid.265892.2, ISNI 0000000106344187, Division of Pulmonary, Allergy, and Critical Care Medicine, , University of Alabama at Birmingham, ; Birmingham, AL USA
                [19 ]GRID grid.214458.e, ISNI 0000000086837370, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, , University of Michigan, ; Ann Arbor, MI USA
                [20 ]GRID grid.412807.8, ISNI 0000 0004 1936 9916, Division of Allergy, Pulmonary, and Critical Care Medicine, , Vanderbilt University Medical Center, ; Nashville, TN USA
                [21 ]GRID grid.38142.3c, ISNI 000000041936754X, Departments of Epidemiology and Biostatistics, , Harvard T.H. Chan School of Public Health, ; Boston, MA USA
                [22 ]GRID grid.413735.7, ISNI 0000 0004 0475 2760, Harvard-MIT Division of Health Sciences and Technology, ; Cambridge, MA USA
                [23 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Department of Anesthesia, Critical Care and Pain Medicine, , Massachusetts General Hospital, ; Boston, MA USA
                [24 ]GRID grid.62560.37, ISNI 0000 0004 0378 8294, Departments of Medicine and Neurology, , Brigham and Women’s Hospital, ; Boston, MA USA
                Author information
                http://orcid.org/0000-0002-6832-3282
                Article
                6331
                10.1007/s00134-020-06331-9
                7851810
                33528595
                333eead5-ac3b-4c82-833b-fad495c9b38b
                © Springer-Verlag GmbH Germany, part of Springer Nature 2021

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                : 12 August 2020
                : 4 December 2020
                Categories
                Original

                Emergency medicine & Trauma
                covid-19,vv-ecmo,extracorporeal membrane oxygenation,severe respiratory failure,ards,mortality

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