Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Crisis Standards of Care

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has placed extraordinary strain on global healthcare systems. Use of extracorporeal membrane oxygenation (ECMO) for patients with severe respiratory or cardiac failure attributed to COVID-19 has been debated due to uncertain survival benefit and the resources required to safely deliver ECMO support. We retrospectively investigated adult patients supported with ECMO for COVID-19 at our institution during the first 80 days following New York City’s declaration of a state of emergency. The primary objective was to evaluate survival outcomes in patients supported with ECMO for COVID-19 and describe the programmatic adaptations made in response to pandemic-related crisis conditions. Twenty-two patients with COVID-19 were placed on ECMO during the study period. Median age was 52 years and 18 (81.8%) were male. Twenty-one patients (95.4%) had severe ARDS and seven (31.8%) had cardiac failure. Fifteen patients (68.1%) were managed with venovenous ECMO while 7 (31.8%) required arterial support. Twelve patients (54.5%) were transported on ECMO from external institutions. Twelve patients were discharged alive from the hospital (54.5%). Extracorporeal membrane oxygenation was used successfully in patients with respiratory and cardiac failure due to COVID-19. The continued use of ECMO, including ECMO transport, during crisis conditions was possible even at the height of the COVID-19 pandemic.

Coronavirus Disease-2019 and Heart Failure: A Scientific Statement From the Heart Failure Society of America

“… 72 In one report of 22 patients with COVID-19 on ECMO, 21 patients had respiratory failure while 7 had cardiac failure requiring arterial support. 73 Ultimately, 12 patients (54.5%) survived hospitalization. ELSO suggests that pre-pandemic criteria for selection for ECMO candidates should be used; however, these may not be universally applicable if resources are constrained.…”

MUlticenter STudy of tissue plasminogen activator (alteplase) use in COVID‐19 severe respiratory failure (MUST COVID): A retrospective cohort study

“…The risk of ICH in this multi‐institutional series was 1.3%, much smaller than those reported in recent reviews of the ICH risk associated with extracorporeal membrane oxygenation (ECMO), the next likely treatment intervention for these patients if the hospital has such extensive resources. Recent reports of ICH in ECMO for the treatment of COVID‐19‐associated respiratory failure varied from 6% in the Extracorporeal Life Support Organization registry (36 countries) to 9% in a New York, US, institution, and 12% in the report of the ECMO network for Greater Paris (17 intensive care units) to 33% in two US academic centers 26‐29 . Further, it is unclear whether this complication could have been mitigated with pre‐tPA neurologic examination or cross‐sectional imaging of the brain (e.g., computed tomography; Table 4).…”

“…10,25 The results of this study provide evidence that fibrinolytic therapy (36 countries) to 9% in a New York, US, institution, and 12% in the report of the ECMO network for Greater Paris (17 intensive care units) to 33% in two US academic centers. [26][27][28][29] Further, it is unclear whether this complication could have been mitigated with pre-tPA neurologic examination or cross-sectional imaging of the brain (e.g., computed tomography; Table 4).…”

Extracorporeal membrane oxygenation for coronavirus disease 2019-related acute respiratory distress syndrome

“…Networks allowed for coordination of referrals, pooling of resources, the ability to quickly disseminate evolving recommendations and educational materials, and to have unified indications and contraindications [ 30 ▪▪ ]. In New York, nontraditional staffing models contributed to the ability to maintain operations within an existing ECMO program [ 31 ].…”