乌鸦传媒

Better to start extracorporeal membrane oxygenation (ECMO) sooner rather than later, and hold back on sending older physicians into the wards -- these were among the lessons shared by Chinese doctors treating severe cases of COVID-19 during a sponsored by the American College of Cardiology.

The case of a 31-year-old male Wuhan resident illustrated just how easily COVID-19 can progress to multi-organ dysfunction, according to Chinese doctors who arrived in Wuhan 6 weeks ago to help combat the pandemic.

The patient had complained of 3 weeks of intermittent fever and coughing when he tested positive for the novel coronavirus. Medications he was given in the hospital included treatments for his diabetes and hyperlipidemia, as well as 6 days of , an antiviral not available in the U.S.

Nevertheless, the patient's condition deteriorated as he developed acute heart failure, sepsis, and liver dysfunction. Infection and inflammation biomarkers were very high, the doctors noted.

The staff continued to treat him with everything they had, however, paying attention to him and keeping him hydrated. In the end, he recovered.

Success stories like this one are coming out of China just after the country announced the first day that it found within its borders.

For one, some critically severe patients will still have severe hypoxemia on ventilation and will require ECMO, according to Ning Zhou, MD, PhD, who is currently working in the ICU ward of Tongji Hospital in Wuhan.

The typical ECMO case looks something like this: a man age 50, with 11 days of fever, shortness of breath for 2 days, oxygen saturation of 75%, reduced lymphocyte levels, high NT-proBNP and cardiac troponin I, and ejection fraction 45% on echocardiography. He does not improve on antibacterial, antiviral therapy, but in fact shows hypoxemia getting worse and is sent to the ICU.

Zhou said he has performed five ECMO cases (four recovered, one ongoing) and it's been administered for an average 9.2 days per patient. He recommended that hospital staff employ veno-venous ECMO before trying veno-arterial ECMO.

Importantly, he said, ECMO doesn't help people who are dying, and should be offered earlier, before they get to that point.

"Don't wait. You lose the opportunity, especially for those young patients. ECMO is not for prolonging life for days. It's an opportunity for patients to survive," he emphasized.

People who are less likely to be helped by ECMO include those with irreversible severe brain injury and people over 70 years old, Zhou suggested.

"In China, we don't have so many ECMO systems, resources for all the patients. We have to choose who can probably recover from COVID-19," he said.

Finally, the doctor suggested that it is time to rethink the way patients are intubated before they are given ECMO.

"How about we use ECMO first, or even use ECMO without intubation? This means we can use ECMO to support the lungs without infecting the intubation and ventilation," he said. "We already finished three cases ... We removed the intubation first and continued ECMO for supply of oxygen."

This last suggestion was met with some hesitance from the other doctors. One said he still believed intubation should be performed before ECMO.

Unanimously dismissed by the group, on the other hand, was the idea of bringing in the Impella ventricular assist device to replace some of the heart's function.

This is nearly impossible in the ICU as the device needs to be implanted in the cath lab, the session moderator noted. Furthermore, operators are being told to wear three or four gloves and therefore lose some sense of touch, making this an extremely difficult implant procedure in present circumstances.

Needless to say, hospital staff are advised to wear full personal protective equipment at all times.

Harlan Krumholz, MD, of Yale University and Yale New Haven Hospital in Connecticut, asked during the virtual meeting whether risk factors for poor COVID-19 prognosis might be identified from an international pooling of data.

The Chinese doctors replied that it is very hard to predict individual patients' outcomes. Some patients can appear to be on the recovery but worsen suddenly.

However, men do appear more susceptible to infection, they offered -- Zhou disclosed that of the 30 beds in his ICU ward, more than 20 are filled by men.

The speakers, all men, said that in China, doctors over age 60 are prohibited from going to the front lines. Only junior physicians are allowed to take care of COVID-19 patients.

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