In December 2019 in the city of Wuhan in China, a series of patients with unclear pneumonia was noticed, some of whom have died of it. In virological analyses of samples from the patients' deep respiratory tract, a novel coronavirus was isolated (SARS-CoV-2). The disease spread rapidly in the city of Wuhan at the beginning of 2020 and soon beyond in China and, in the coming weeks, around the world. Initial studies described numerous severe courses, particularly those associated with increased patient age and previous cardiovascular, metabolic and respiratory diseases. A small number of the particularly severely ill patients required not only highly invasive ventilation therapy but also extracorporeal membrane oxygenation (vv-ECMO) to supply the patient's blood with sufficient oxygen. Even under maximum intensive care treatment, a very high mortality rate of approximately 80-100% was observed in this patient group. In addition, high levels of interleukin-6 (IL-6) could be detected in the blood of these severely ill patients, which in turn were associated with poor outcome. From experience in the therapy of severely ill patients with severe infections and respiratory failure, we know that treatment with a CytoSorb® adsorber can lead to a reduction of the circulating pro- and anti-inflammatory cytokines and thus improve the course of the disease and the outcome of the patients. The aim of the study is to investigate the influence of extracorporeal cytokine adsorption on interleukin-6-levels and time to successful ECMO explantation under controlled conditions in patients with particularly severe COVID-19 disease requiring extracorporeal membrane oxygenation.
In December 2019, a series of unexplained cases of pneumonia in the city of Wuhan in China
has come to light. In virologic analyses of samples from the patients' deep respiratory
tract, a novel coronavirus was isolated (first named 2019-nCoV, then SARS-CoV-2). The disease
spread rapidly in the city of Wuhan in early 2020 and soon beyond. On 30 January 2020, the
Director-General of the World Health Organization (WHO) declared the outbreak a public health
emergency of international concern, and on 11 March 2020, the World Health Organization
declared the virus a pandemic.
In humans, an infection with the virus can cause respiratory tract infections or even very
severe pneumonia - these often end fatally, especially in old and pre-diseased patients. Due
to the novelty of the virus, the data basis for therapy is very limited. To date, there are
no clinical data for an effective specific therapy, nor is there a vaccination against the
virus available, so that therapy, especially intensive care treatment for very severe
courses, must concentrate only on supportive treatment of lung failure and other
complications.
The virus is highly contagious and infection results in a relevant number of deaths. Due to
very uncertain data on the spread of the virus in the population, it is difficult to estimate
the mortality rate - the case fatality rate is about 4% based on the known case numbers.
In reports on the treatment of the first cases in Wuhan (Hubei Province, China) in January
2020, the need for intensive care treatment is described for about a quarter of the inpatient
cases, 10-17% had to be ventilated invasively, and veno-venous extracorporeal membrane
oxygenation (vv-ECMO) was necessary in 2-4% of the inpatient cases. Patients requiring ECMO
have an extremely high mortality rate of 83-100% in the studies published, so far.
In severe cases a pronounced release of vasoactive cytokines was repeatedly observed.
Excessive release of these vasoactive mediators ("cytokine storm") can result in severe
vasodilatation and membrane leakage, which can ultimately lead to vasoplegic shock that is
difficult to control. Ruan et al. and Zhou et al. have identified high interleukin 6 (IL-6)
levels as a potential predictor of a fatal outcome when compared between survivors and
patients who died of COVID-19 disease.
IL-6 is also an important factor in the pathophysiology of severe septic shock and excessive
immune response in hemophagocytic lymphohistiocytosis (HLH) - for both indications has been
shown, that the extracorporeal adsorption of IL-6 and other vasoactive substances in a
CytoSorb® adsorber (CytoSorbents Corporation, Monmouth Junction, NJ, USA) leads to a
significant reduction of these cytokines in the patient blood. Clinical experience and
(previously unpublished) data from our monocentric registry study show that cytokine
adsorption in a CytoSorb® Adsorber can also be safely integrated into a vv-ECMO system.
Device: vv-ECMO + cytokine adsorption (Cytosorb adsorber)
in COVID-19-diseased vv-ECMO patients additional treatment with cytokine adsorption using a Cytosorb adsorber will be randomized (vs. control group)
Device: vv-ECMO only (no cytokine adsorption)
COVID-19-diseased treated with vv-ECMO
Inclusion Criteria:
- SARS-CoV-2-infection with COVID-pneumonia
- vv-ECMO therapy
Exclusion Criteria:
- known patient will against participation in the study or against the measures applied
in the study
- a decision (made prior to inclusion of the patient into this trial) to terminate the
treatment within the next 24 hours
University Clinic Freiburg
Freiburg, Germany
Klinikum Ibbenbueren
Ibbenbueren, Germany
Klinikum Ludwigsburg
Ludwigsburg, Germany
Alexander Supady, Dr., MPH, Principal Investigator
University Clinic Freiburg