A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management

Abstract

(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.

COVID-19 outcomes of venovenous extracorporeal membrane oxygenation for acute respiratory failure vs historical cohort of non-COVID-19 viral infections

“…The decision to cannulate a patient for VV ECMO is made in a multi-disciplinary fashion by a small cohort of experienced physicians based on our institutional criteria. 15 The institutional preferred cannulation strategy is a peripheral, two site cannulation with a femoral vein cannula for drainage and a separate internal jugular vein cannula for return of blood. No dual lumen catheters were used during the study period.…”

Challenges Faced During Extracorporeal Membrane Oxygenation (ECMO) Management of COVID-19 Patients in India: A Retrospective, Multicentered, Observational Study

“…Dave et al observed similar challenges in their study. 9 Another major problem faced was transporting the patients, as there were huge demand and limited ECMO centers, many patients were retrieved from the nearby states and from the two-tier cities. Also, there were many patients on prolonged ECMO who were transported to other institutes for probable lung transplants.…”

“…In 2021, Shah et al, 9 in their experience of 40 COVID-19 patients on VV-ECMO, have reported lessons learned from COVID-19 about ECMO planning and clinical management. They found the safety of the ECMO team was of paramount importance during the cannulation of COVID-19 patients.…”

“…It itself is very challenging as there is a limited number of available centers with experienced personnel and well-equipped facilities, protection of team, difficult communication through PPE kits, cannulation problems, and COVID-19-related thromboembolism. 9,10 ECMO program in India has done tremendous development in the last 10 years and overcame many hurdles. Many centers in India have been offering ECMO for COVID- 19.…”

Challenges in the Extracorporeal Membrane Oxygenation Era

“…As described in the papers by Montrucchio et al [11] and Dave et al [12], COVID-19 forced a reorganization of the intensive care departments, which involved care teams, spaces and required adequate planning. Furthermore, as discussed by Shah and colleagues [13], intensivists had to face new clinical challenges. The shortage of mechanical ventilators pushed clinicians to investigate the possibility of sharing a ventilator, which raised a number of physiological questions such as circuit cross-flows and patient interactions, as discussed by Colombo et al [14].…”