ECMO for Severely Morbidly Obese Patient with COVID-19

Introduction It was traditionally taught that extracorporeal membrane oxygenation (ECMO) should be avoided in the morbidly obese due to the higher risk of mortality. Recently, a few case reports have shown that the mortality risk among this population is not significantly different than in the general population, though there may be selection bias. Veno-venous (VV) ECMO has been a useful technique to improve mortality among those afflicted with the severest forms of acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia, caused by the SARS-CoV-2 virus. Case reports of ECMO therapy for ARDS due to COVID-19 in the severely morbidly obese are lacking. This is a case of a male with a body mass index (BMI) of 75 who suffered from severe ARDS and was treated with VV-ECMO successfully. Case A 54-year-old male with a past medical history of severely morbid obesity (BMI of 75), hypertension, diabetes mellitus type II, and obstructive sleep apnea presented to the emergency room with three days of fatigue, cough and dyspnea. His initial vitals revealed a fever of 101.3F, 30 breaths per minute, and hypoxia requiring 4 L O2 via nasal cannula. Initial chest xray demonstrated bilateral multifocal opacities. COVID-19 PCR testing was positive. The patient was started on dexamethasone, remdesivir, and convalescent plasma. He was also treated for community acquired pneumonia. The patient, initially admitted to the floor, continued to decompensate with worsening hypoxia requiring BIPAP and was transferred to the intensive care unit (ICU) three days after admission. Due to persistent oxygen saturations in the mid-80s on CPAP of 20 with FiO2 of 100%, patient was intubated eight days after admission. He continued to decompensate with saturations in the 70s despite maximum inhaled epoprostenol and VV-ECMO was initiated. His ECMO course was without significant events and was decannulated fifteen days after initiation. His course was complicated by an acute kidney injury which eventually required dialysis, as well as prolonged encephalopathy. Stroke work-up was negative. The patient remained ventilator dependent, underwent a tracheostomy and was discharged to a long-term acute care hospital fifty-six days after admission. He eventually was decannulated at the long-term acute care hospital. Discussion This case describes a successful VV-ECMO therapy in a severely morbidly obese 54 year-old male with ARDS due to COVID-19, which has not been previously described in case reports. Obesity should not be considered a contraindication for VV-ECMO in a select group of patients.