Rachel D. Vanderlaan, MD, PhD
Central Message.
This case highlights a multimodal approach of veno-veno extracorporeal membrane oxygenation and therapeutic plasma exchange in a teenage patient with respiratory failure attributed to COVID-19.
See Article page 265.
COVID-19 infection in pediatric patients is variable, ranging from asymptomatic to a multisystem inflammatory syndrome characterized by elevated cytokines and hyperimmune response. In a small subset of pediatric COVID-19 patients, particularly those with complex medical conditions and important comorbidities, severe respiratory failure can occur with deadly consequences. In the literature, the experience of extracorporeal membrane oxygenation (ECMO) in pediatric patients with severe acute respiratory distress syndrome (ARDS) due to COVID is largely confined to case reports, with some larger US and UK studies capturing outcomes of subsets of pediatric patients with COVID-19 requiring ECMO; however, data surrounding their ECMO course are limited.1, 2, 3, 4 In their case report, Kakuturu and colleagues5 describe the successful use of veno-veno ECMO and therapeutic plasma exchange (TPE) to break the cycle of cytokine storm, coagulopathy, and endothelial dysfunction in a morbidly obese teenager with ARDS attributed to COVID-19. In addition, they highlight a programmatic approach to ECMO recipients involving early extubation and ambulation.
TPE has shown some benefit in adult patients with severe sepsis and multisystem organ failure6 and has been applied to adult patients with fulminant COVID-19 infection as rescue therapy.7,8 TPE is hypothesized to break the cycle of coagulopathy, endothelial dysfunction, and cytokine storm that plays a role in adult COVID-19. Recently published studies show reductions in C-reactive protein, interleukin-6, lactate dehydrogenase, and D-dimer, in addition to improved oxygenation after TPE in critically ill COVID-19 adults.9,10 For patients with fulminant COVID-19 ARDS, TPE is emerging as a potential adjunct to the COVID -19 armamentarium; however, more research is needed to guide its potential use in adult patients.
There are no detailed reports of TPE in pediatric COVID-19 patients and how adult data applies to the pediatric population with severe COVID-19 infection is unclear. TPE has been described as a rescue therapy during the H1N1 pandemic in pediatric patients. Three children with acute lung injury and hemodynamic compromise underwent TPE after failure of conventional therapy and saw improvement in oxygenation and vasopressor support.11 The report by Kakuturu and colleagues highlights the adjunct use of TPE and concomitant reduction in measured inflammatory markers, suggesting a temporal improvement related to TPE use.
This case report describes a 15-year-old patient with many comorbidities found in adult COVID patients (obesity, prediabetes, hypertension), and the generalizability of these results to the broader pediatric population is not clear. However, Kakuturu and colleagues have provided important insights into care for this complex case with their successful use of veno-veno ECMO and TPE in a pediatric patient with severe ARDS attributed to COVID-19. Given the rare occurrence of severe SARS-CoV-2 in pediatric patient, multi-institutional discussions are needed to delineate a role of TPE in critically ill pediatric COVID-19 patients.
Footnotes
Disclosures: The author reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
References
- 1.Di Nardo M., Hoskote A., Thiruchelvam T., Lillie J., Horan M., Belda Hofheinz S. Extracorporeal membrane oxygenation in children with coronavirus disease 2019: preliminary report from the Collaborative European Chapter of the Extracorporeal Life Support Organization Prospective Survey. ASAIO J. 2021;67:121–124. doi: 10.1097/MAT.0000000000001309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Davies P., Evans C., Kanthimathinathan H.K., Lillie J., Brierley J., Waters G. Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. Lancet Child Adolesc Health. 2020;4:669–677. doi: 10.1016/S2352-4642(20)30215-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Dufort E.M., Koumans E.H., Chow E.J., Rosenthal E.M., Muse A., Rowlands J. Multisystem inflammatory syndrome in children in New York State. N Engl J Med. 2020;383:347–358. doi: 10.1056/NEJMoa2021756. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Feldstein L.R., Rose E.B., Horwitz S.M., Collins J.P., Newhams M.M., Son M.B.F. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334–346. doi: 10.1056/NEJMoa2021680. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kakuturu J., McCluskey C., Casey F.L., III, Cicek S., Awori Hayanga J.W. Extracorporeal membrane oxygenation to treat a 15-year-old patient with severe coronavirus disease 2019 (COVID-19) respiratory failure. J Thorac Cardiovasc Surg Tech. 2021;7:265–266. doi: 10.1016/j.xjtc.2021.03.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Busund R., Koukline V., Utrobin U., Nedashkovsky E. Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial. Intensive Care Med. 2002;28:1434–1439. doi: 10.1007/s00134-002-1410-7. [DOI] [PubMed] [Google Scholar]
- 7.Kamran S.M., Mirza Z.E.H., Naseem A., Liaqat J., Fazal I., Alamgir W. Therapeutic plasma exchange for coronavirus disease-2019 triggered cytokine release syndrome; a retrospective propensity-matched control study. PLoS One. 2021;16:e0244853. doi: 10.1371/journal.pone.0244853. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Keith P., Day M., Choe C., Perkins L., Moyer L., Hays E. The successful use of therapeutic plasma exchange for severe COVID-19 acute respiratory distress syndrome with multiple organ failure. SAGE Open Med Case Rep. June 18, 2020 doi: 10.1177/2050313X20933473. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Morath C., Weigand M.A., Zeier M., Speer C., Tiwari-Heckler S., Merle U. Plasma exchange in critically ill COVID-19 patients. Crit Care. 2020;24:481. doi: 10.1186/s13054-020-03171-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gluck W.L., Callahan S.P., Brevetta R.A., Stenbit A.E., Smith W.M., Martin J.C. Efficacy of therapeutic plasma exchange in the treatment of Penn class 3 and 4 cytokine release syndrome complicating COVID-19. Respir Med. 2020;175:106188. doi: 10.1016/j.rmed.2020.106188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Patel P., Nandwani V., Vanchiere J., Conrad S.A., Scott L.K. Use of therapeutic plasma exchange as a rescue therapy in 2009 pH1N1 influenza A—an associated respiratory failure and hemodynamic shock. Pediatr Crit Care Med. 2011;12:e87–e89. doi: 10.1097/PCC.0b013e3181e2a569. [DOI] [PMC free article] [PubMed] [Google Scholar]