Commentary: Therapeutic plasma exchange in COVID-19 pediatric patients: Is there a role?

Central MessageThis 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. 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.1Di Nardo M. Hoskote A. Thiruchelvam T. Lillie J. Horan M. Belda Hofheinz S. et al.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: 121-124Crossref PubMed Scopus (30) Google Scholar, 2Davies P. Evans C. Kanthimathinathan H.K. Lillie J. Brierley J. Waters G. et al.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: 669-677Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar, 3Dufort E.M. Koumans E.H. Chow E.J. Rosenthal E.M. Muse A. Rowlands J. et al.Multisystem inflammatory syndrome in children in New York State.N Engl J Med. 2020; 383: 347-358Crossref PubMed Scopus (986) Google Scholar, 4Feldstein L.R. Rose E.B. Horwitz S.M. Collins J.P. Newhams M.M. Son M.B.F. et al.Multisystem inflammatory syndrome in U.S. children and adolescents.N Engl J Med. 2020; 383: 334-346Crossref PubMed Scopus (1769) Google Scholar In their case report, Kakuturu and colleagues5Kakuturu J. McCluskey C. Casey III, F.L. 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: 265-266Scopus (5) Google Scholar 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 failure6Busund R. Koukline V. Utrobin U. Nedashkovsky E. Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial.Intensive Care Med. 2002; 28: 1434-1439Crossref PubMed Scopus (263) Google Scholar and has been applied to adult patients with fulminant COVID-19 infection as rescue therapy.7Kamran S.M. Mirza Z.E.H. Naseem A. Liaqat J. Fazal I. Alamgir W. et al.Therapeutic plasma exchange for coronavirus disease-2019 triggered cytokine release syndrome; a retrospective propensity-matched control study.PLoS One. 2021; 16: e0244853Crossref PubMed Scopus (40) Google Scholar,8Keith 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; ([Epub ahead of print])Crossref PubMed Google Scholar 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.9Morath 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: 481Crossref PubMed Scopus (43) Google Scholar,10Gluck W.L. Callahan S.P. Brevetta R.A. Stenbit A.E. Smith W.M. Martin J.C. et al.Efficacy of therapeutic plasma exchange in the treatment of Penn class 3 and 4 cytokine release syndrome complicating COVID-19.Respir Med. 2020; 175: 106188Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar 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.11Patel 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-e89Crossref PubMed Scopus (61) Google Scholar 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. Extracorporeal membrane oxygenation to treat a 15-year-old patient with severe coronavirus disease 2019 (COVID-19) respiratory failureJTCVS TechniquesVol. 7PreviewSevere acute respiratory distress syndrome (ARDS) secondary to a novel coronavirus, coronavirus disease 2019 (COVID-19; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]), was first reported in Wuhan, China, in December 2019, and quickly spread to become a global pandemic. Children are less commonly affected but those with complex medical histories may be susceptible to severe forms of disease, with a mortality rate of almost 5%.1 We present the case of a pediatric patient with multiple comorbidities who presented with SARS-CoV-2 and was successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). Full-Text PDF Open Access

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