BackgroundAcute respiratory distress syndrome due to coronavirus disease 2019 (COVID-19) is associated with high mortality. Several studies have reported that the microcirculation responds adequately to hypoxia in COVID-19 patients by increasing oxygen availability, in contrast to the inadequate response observed in patients with bacterial sepsis. Red blood cells (RBCs), the key cells for oxygen transport, and notably their rheology, are altered during bacterial sepsis, but few data are available in patients with COVID-19.MethodsIn this prospective, non-interventional study, shape was assessed on admission (or inclusion for the volunteers) using Pearson’s second coefficient of dissymmetry (PCD) on the histogram obtained with a flow cytometer technique. A null value represents a perfect spherical shape. RBC deformability was determined using ektacytometry by the elongation index in relation to the shear stress (0.3 to 50 Pa) applied to the RBC membrane. A higher elongation index indicates greater RBC deformability. Results were compared across groups. Scanning electronic microscopy was performed on RBCs from COVID-19 patients. RBC shape and deformability were also assessed on days 3 and 7 in COVID-19 patients.ResultsForty-nine ICU patients were included (30 with COVID-19 ARDS and 19 with bacterial sepsis). ARDS was more severe in patients with COVID-19 than in those with sepsis (PaO2/FiO2 99 [73–154] vs. 270 [239–295] mmHg p