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Use of Extracorporeal Membrane Oxygenation (ECMO) with or without tracheostomy for patients with COVID-19 Respiratory Failure (CARF)
James S. Shahoud, Subbarao Elapavaluru, Michael Collins, Kevin Shahbahrami, Benny Weksler, Hiran Fernando.
Allegheny General Hospital, Pittsburgh, PA, USA.

OBJECTIVE: Previous studies have suggested that only 30-40% of patients requiring ECMO for CARF will eventually be discharged from the hospital. We examined the outcomes of such patients at our institution, with the primary aim to evaluate for factors that predict successful hospital discharge. We also wanted to evaluate the outcomes of tracheostomy when performed on ECMO.
METHODS: Patients requiring ECMO for CARF from 4/1/20-4/1/21 were evaluated. The primary outcome was successful hospital discharge. Baseline characteristics included age, BMI, comorbidities, and risk factor scores such as APACHE, SOFA and RESP. Secondary outcomes included tracheostomy adverse events and sedation requirements pre- and post- tracheostomy.
RESULTS: ECMO was used in 21 patients. Median age was 53(33-68) years, BMI was 35 (22.7-62.2). Median duration of intubation was 23 (2-70) days and ECMO was 12 (1-47) days. ECMO decannulation was achieved in 11(52%) and 8 (38.1%) achieved hospital discharge. None of the baseline characteristics evaluated predicted successful discharge. Tracheostomy was undertaken in 7 patients (4 percutaneous, 3 open). All were performed on ECMO with no tracheostomy-associated complications. Five (62.5%) patients who had tracheostomy were discharged compared to 2/11(15.4%) patients who did not have a tracheostomy (p=0.026). Sedation requirements decreased after tracheostomy (Table 1), facilitating ventilator weaning.
CONCLUSIONS: Similar to other reports, 38% of patients requiring ECMO were discharged from the hospital. Patients undergoing tracheostomy were more likely to be discharged (perhaps related to lower disease severity). Tracheostomy can be safely undertaken while patients are on ECMO, and will help decrease sedation requirements.

Sedative dosing before and after tracheostomy
DrugMean dose 2 days before tracheostomyMean dose 2 days after tracheostomySignificance (p)
Midazolam (mg)115810.186
Hydromorphone (mg)120600.014


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