Extracorporeal membrane oxygenation for COVID-19-related acute respiratory distress syndrome: a narrative review

Alessandri, Francesco; Nardo, Matteo Di; Ramanathan, Kollengode; Brodie, Daniel; MacLaren, Graeme

doi:10.1186/s40560-023-00654-7

Cited by 18 publications

(8 citation statements)

References 77 publications

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“…Following these two pandemics, the efficacy of ECMO in providing respiratory support to patients with severe ARDS and refractory hypoxia is indisputable [ 55 ]. However, challenges in patient selection and clinical and operational management existed with a lack of solid evidence to support one regimen regardless of the significantly higher number of research publications compared to the H1N1 pandemic [ 56 ]. As a result, this consensus of expert opinion revealed all areas of uncertainty regarding the role of ECMO, which may encourage researchers to conduct high-quality research in the coming years to fill this knowledge gap.…”

Section: Discussionmentioning

confidence: 99%

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Rabie

Elhazmi

Azzam

et al. 2023

Ann. Intensive Care

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Background The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. Objectives To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. Methods The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel’s questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. Results In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. Conclusion Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.

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Section: Discussionmentioning

confidence: 99%

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Rabie

Elhazmi

Azzam

et al. 2023

Ann. Intensive Care

Self Cite

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“…Thus, clinicians often referred to the original guidelines established by ELSO for patient management throughout the pandemic. Preliminary data seems to support the use of VV-ECMO for refractory hypoxemia due to COVID-19-related ARDS, with Bertini et al citing a mortality rate of ~39% (vs. 46% in the EOLIA trial), however, more research is needed to draw a definitive conclusion [ 26 , 27 ]. In addition, studies have shown that factors such as age, severity of hypoxemia, and duration/intensity of mechanical ventilation can be significant modifiers of treatment effectiveness in the COVID-19-related ARDS patient population [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

Neutrophil-to-Lymphocyte Ratio as a Predictor of Mortality for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Extracorporeal Membrane Oxygenation Therapy

Lu,

Karwoski,

Abdulrahman

et al. 2023

Cureus

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Background: The neutrophil-to-lymphocyte ratio (NLR) has been studied as an indicator of systemic inflammation and as a prognostic tool in multiple areas of medicine. Previous research has suggested that higher NLR and rapid increase to peak NLR are associated with poorer outcomes in patients with coronavirus disease 2019 (COVID-19), particularly in those experiencing acute respiratory distress syndrome (ARDS). Within vascular surgery, there is data to suggest a positive correlation between elevated pre-extracorporeal membrane oxygenation (ECMO) NLR and higher rates of mortality following major procedures. This study explores the prognostic value of peri-ECMO NLR in patients requiring veno-venous ECMO (VV-ECMO) therapy for COVID-19-related ARDS. The objective of this study was to explore the utility of pre-ECMO NLR as an easily accessible prognostic factor for patients suffering from COVID-19-associated ARDS that require VV-ECMO. Methods: This was a retrospective cohort study within a tertiary care hospital conducted between April 2020 and January 2021. Patients requiring VV-ECMO therapy for COVID-19-associated ARDS were included. Peri-ECMO NLR values, length of stay (LOS), duration on VV-ECMO, and discharge status were recorded. Receiver operating characteristic (ROC) curve analysis and Youden’s J statistics were performed to calculate a cut-off value of 11.005 for pre-ECMO NLR and 17.616 for on-ECMO NLR. Pre-ECMO and on-ECMO Kaplan-Meyer curves were generated for two groups of patients, those above and below NLR cutoff thresholds. Two-sample T-test was performed to test for significant differences in LOS and duration on VV-ECMO. Results: Twenty-six patients were included in the study for final analyses. There was an overall mortality of 39% (n = 10). ROC curve analysis and Youden’s J statistic revealed an optimal cut-off value of pre-ECMO NLR = 11.005 and on-ECMO NLR = 17.616. Results showed that the patient group placed on VV-ECMO with a pre-ECMO NLR less than 11.005 experienced no mortality (n = 7) and a median LOS of 28 days (IQR = 14.5-64.5 days). The patient group on VV-ECMO with a pre-ECMO NLR greater than 11.005 (n = 19) included all mortality (n = 10) and had a median LOS of 49 days (IQR = 25.5-63.5 days). The patient group with on-ECMO NLR less than 17.616 also conferred a survival advantage. There was no significant difference in LOS or duration on VV-ECMO between the two groups, pre-ECMO or on-ECMO. Conclusions: A pre-ECMO NLR cutoff was identified and offered statistically significant prognostic value in predicting mortality. A lower on-ECMO NLR value also indicated a survival advantage. Future studies should include NLR within multivariate models to better discern the effect of NLR and elucidate how it can be factored into clinical decision-making. Importantly, this data can be expanded to assess the predictive value of NLR pertaining to the COVID-19-induced ARDS population and matched cohorts.

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“…ECMO is recommended for severe COVID-19-related acute respiratory distress syndrome to reduce mortality [16]. Currently, there is no evidence-based ethical guidance for prioritizing ECMO when resources are limited during the COVID-19 pandemic [17].…”

Section: Principal Findingsmentioning

confidence: 99%

Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis

Hsieh,

Lin,

Huang

et al. 2024

JMIR Med Educ

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Background The emergence of the COVID-19 pandemic has posed a significant ethical dilemma in the allocation of scarce, life-saving medical equipment to critically ill patients. It remains uncertain whether medical students are equipped to navigate this complex ethical process. Objective This study aimed to assess the ability and confidence of medical students to apply principles of medical ethics in allocating critical medical devices through the scenario of virtual patients. Methods The study recruited third- and fourth-year medical students during clinical rotation. We facilitated interactions between medical students and virtual patients experiencing respiratory failure due to COVID-19 infection. We assessed the students’ ability to ethically allocate life-saving resources. Subsequently, we analyzed their written reports using thematic analysis to identify the ethical principles guiding their decision-making. Results We enrolled a cohort of 67 out of 71 medical students with a mean age of 34 (SD 4.7) years, 60% (n=40) of whom were female students. The principle of justice was cited by 73% (n=49) of students while analyzing this scenario. A majority of them expressed hesitancy in determining which patient should receive life-saving resources, with 46% (n=31) citing the principle of nonmaleficence, 31% (n=21) advocating for a first-come-first-served approach, and 25% (n=17) emphasizing respect for patient autonomy as key influencers in their decisions. Notably, medical students exhibited a lack of confidence in making ethical decisions concerning the distribution of medical resources. A minority, comprising 12% (n=8), proposed the exploration of legal alternatives, while 4% (n=3) suggested medical guidelines and collective decision-making as potential substitutes for individual ethical choices to alleviate the stress associated with personal decision-making. Conclusions This study highlights the importance of improving ethical reasoning under time constraints using virtual platforms. More than 70% of medical students identified justice as the predominant principle in allocating limited medical resources to critically ill patients. However, they exhibited a lack of confidence in making ethical determinations and leaned toward principles such as nonmaleficence, patient autonomy, adherence to legal and medical standards, and collective decision-making to mitigate the pressure associated with such decisions.

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Extracorporeal membrane oxygenation for COVID-19-related acute respiratory distress syndrome: a narrative review

Cited by 18 publications

References 77 publications

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Neutrophil-to-Lymphocyte Ratio as a Predictor of Mortality for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Extracorporeal Membrane Oxygenation Therapy

Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis

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