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Extracorporeal membrane oxygenation (ECMO) for coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) in adults is common, and outcomes are similar to those for non-COVID-19 ARDS on ECMO1. However, children are much less likely to have severe COVID-19 disease, and thus the need for extracorporeal support is rare2,3. Even pediatric solid organ transplant recipients with active COVID-19 infections typically do not require ECMO.4 We present the case of an immunosuppressed pediatric patient with COVID-19-related ARDS who had an excellent outcome on VV-ECMO. An 11-year-old female with a history of polycystic kidney disease status post renal transplant three years earlier was admitted to the pediatric intensive care unit (PICU) with COVID-19 pneumonia. She developed severe ARDS and required intubation on hospital day (HD) 19. The patient's condition deteriorated despite trials of prone positioning, nitric oxide, and neuromuscular blockade. Due to her refractory hypoxemia, she was cannulated to venovenous (VV) ECMO on HD 28 utilizing a 27 french Avalon bi-caval dual lumen cannula. Laboratory testing demonstrated severely impaired immune function due to her baseline immunosuppressive regimen of mycophenolate, prednisone, and tacrolimus. In addition, she had received B cell depleting therapy with Rituximab several months prior to admission for management of transplant rejection. During her ECMO run, she developed pulmonary aspergillus in addition to her COVID-19 infection. Thus, the overall treatment goal was to minimize immunosuppression sufficiently to manage COVID-19 and aspergillus infections while not triggering rejection of her transplanted kidney. On admission, her mycophenolate dose and tacrolimus trough goal were reduced. When her status worsened shortly after intubation, mycophenolate was discontinued, and tacrolimus trough goal was further decreased. For treatment of acute COVID-19 pneumonia she received remdesivir, dexamethasone, tocilizumab, and convalescent plasma. Farther into her course, she was also treated for suspected MIS-C with anakinra, IVIG, and methylprednisolone. COVID-19 polymerase chain reaction (PCR) and cycle threshold times were monitored weekly. Gradually her cycle threshold times increased, and her COVID-19 PCR became negative on HD 61. With this laboratory and clinical improvement, her mycophenolate was restarted at 50% of the previous dose, and the tacrolimus trough goal was increased to its previous level. There were no concerns for graft rejection during her hospitalization. However, continuous renal replacement therapy (CRRT) was required in tandem for the first four days of extracorporeal support. Following this, she maintained good renal function with her transplanted kidney for the remainder of her hospital course. Five days after VV-ECMO cannulation, she was extubated to a high-flow nasal cannula. With weaning of neurosedative infusions, she was able to participate in pulmonary clearance and physical rehabilitation while on ECMO. With aggressive rehab she could sit on the edge of her bed and even transfer to a chair with assistance. After 33 days of ECMO support, she was decannulated on high-flow nasal cannula. She left the PICU on HD 83 and was discharged home without supplemental oxygen on HD 104. Our case experience suggests that extubated VV-ECMO can be a safe and effective rescue therapy for COVID-19-related ARDS in children, even in the setting of immunosuppression. Modification of immunosuppressive regimens in the setting of acute COVID-19 disease is not well described in the pediatric population.3 Our case study demonstrates it is possible to balance the risk of transplant rejection with infection control and ECMO therapy. Immunocompromised pediatric patients with COVID-19 can be considered candidates for ECMO support.
Critical Care | Pediatrics
Orrick, Johanna I.; Holton, Cara; Benton, Tara; and Miller, Jenna, "Extubated VV-ECMO for COVID-19 ARDS in an Immunosuppressed Pediatric Renal Transplant Patient." (2022). Posters. 329.