Bleeding and Thrombotic complications in COVID-19-associated ARDS requiring ECMO

Abstract

Background: Coronavirus disease 2019 (COVID-19) is a hypercoagulable state with increased thrombotic and bleeding risk. In this study we analyzed bleeding and thrombotic complications in severe COVID-19-associated acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO). Methods: Single-center observational study of adult non-trauma patients undergoing ECMO for COVID-19 (n=67) or all other cause of ARDS (n=60). Results: In COVID-19 group duration of invasive mechanical ventilation prior to ECMO was lower (2.0 (0-4.0) vs. 3.0 (1.0-6.0); days) and ECMO retrieval less frequent (71 vs. 87; %). No significant differences were found in SAPS II, APACHE II or in the in-hospital survival predicted by the RESP score. Baseline ventilatory and gas exchange parameters did not differ. During the first 7 days of ECMO support COVID-19 group presented higher platelets and fibrinogen, lower aPTT, but no differences in D-dimer. Thrombotic complications were similar between groups, including pulmonary embolism (which was a rare event). A significantly higher rate of severe bleeding, namely hemothorax (13.4 vs. 3.3; %), was found in COVID-19 group, with lower hemoglobin and higher red blood cell transfusions. This associated with longer ECMO duration (47 (17-80) vs. 19 (12-30); days) and hospital length of stay (54 (23-96) vs. 31 (18-48); days) in COVID-19 group, with a non-significant trend towards higher hospital mortality. Conclusions: In our single-center experience, severe COVID-19-associated ARDS requiring ECMO presented high rates of severe bleeding complications and a protracted course. Further studies are needed to clarify the risks and benefits of ECMO in severe COVID-19-associated ARDS.