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Background  In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics.    Methods  This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO 2 ) removal (ECCO 2 R). Arterial blood gas values (oxygen saturation [SpO 2 ], partial pressure of oxygen [PaO 2 ] and of carbon dioxide [PaCO 2 ]) and cerebral oxygenation (rSO 2 ) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients.    Results  Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57–69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO 2  and PaCO 2  values, but cerebral oxygenation decreased significantly (52 [51–54]% vs. 49 [47–50]%,  p  < 0.001). After PP, a significant increase was observed in PaO 2  (from 62 [56–71] to 82 [76–87] mmHg,  p  = 0.005) and rSO 2  (from 53 [52–54]% to 60 [59–64]%,  p  = 0.005). The use of iNO increased PaO 2  (from 65 [67–73] to 72 [67–73] mmHg,  p  = 0.015) and rSO 2  (from 53 [51–56]% to 57 [55–59]%,  p  = 0.007). The use of ECCO 2 R decreased PaO 2  (from 75 [75–79] to 64 [60–70] mmHg,  p  = 0.009), with reduction of rSO 2  values (59 [56–65]% vs. 56 [53–62]%,  p  = 0.002). In the whole population, a significant relationship was found between SpO 2  and rSO 2  ( R  = 0.62,  p  < 0.001) and between PaO 2  and rSO 2  (R0 0.54,  p  < 0.001).    Conclusions  Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs.   Registration  The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).    Supplementary Information  The online version contains supplementary material available at 10.1186/s13054-021-03537-1.

critical care

Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study