Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India

Abstract

Purpose Extracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient’s outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers. Methods This is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type. Results Three hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37–52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% ( p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05–3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75–3.67)). Conclusions During pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06451-w.

Increased mortality in patients with COVID-19 receiving extracorporeal respiratory support during the second wave of the pandemic

“…In the earliest phases of the pandemic, the use of extracorporeal life support in patients with severe coronavirus disease 2019 (COVID-19) was associated with disastrous outcomes. However, later series have shown better results, with hospital mortality ranging from 30 to 60% [ 1 – 3 ]. These series included patients receiving support during the first wave of the pandemic.…”

Extracorporeal membrane oxygenation support for SARS-CoV-2: a multi-centered, prospective, observational study in critically ill 92 patients in Saudi Arabia

“…In patients with respiratory failure from SARS-CoV-2 infection who required the use of ECMO, the mortality rate varied considerably between studies ranging from 31 to > 80% [ 25 – 29 ]. We report a higher mortality rate (48.9%) in severe SARS-CoV-2 patients treated with ECMO due to ARDS; compared to the rates reported by three studies in Paris, France (31%) [ 25 ], Michigan, USA (< 40%) [ 26 ], and an international study conducted in the Middle East and India (41.7%) [ 29 ].…”

“…In patients with respiratory failure from SARS-CoV-2 infection who required the use of ECMO, the mortality rate varied considerably between studies ranging from 31 to > 80% [ 25 – 29 ]. We report a higher mortality rate (48.9%) in severe SARS-CoV-2 patients treated with ECMO due to ARDS; compared to the rates reported by three studies in Paris, France (31%) [ 25 ], Michigan, USA (< 40%) [ 26 ], and an international study conducted in the Middle East and India (41.7%) [ 29 ]. Nevertheless, we report a very similar and slightly lower survival rate (51.1%) compared to the previous study done in the USA (53.8%) [ 30 ], which was compatible to the data from the European branch of the Extracorporeal Life Support Organization international survey [ 31 ].…”

“…Nevertheless, we report a very similar and slightly lower survival rate (51.1%) compared to the previous study done in the USA (53.8%) [ 30 ], which was compatible to the data from the European branch of the Extracorporeal Life Support Organization international survey [ 31 ]. Very high mortality rates (> 80%) were reported in the earliest studies which investigated ECMO benefit for ARDS due to COVID-19 in China [ 28 ] and Europe [ 27 ]; however, most subsequent studies shown more promising results [ 20 , 23 , 25 , 26 , 29 , 30 , 32 – 38 ]. In our study, regional variation in hospital mortality is likely multifactorial and might be related to the initial burden of the pandemic in Saudi Arabia, which was greatest in Riyadh and Jeddah.…”

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

“…Initial recommendations suggested that starting up a new ECMO center during the pandemic was not advisable [ 23 ]. One study that challenged this notion was a retrospective, multicenter, observational study of 307 patients who received ECMO for COVID-19 from 19 ECMO centers across five countries in the Middle East and India [ 32 ]. Whereas overall survival was 45%, survival at new ECMO centers was 55%, exceeding the 41% survival at established ECMO centers [odds ratio (OR) 1.65; 95% CI 0.75–3.67], albeit with a wide confidence interval and the almost certain presence of residual confounding including in patient selection [ 32 ].…”