Extracorporeal membrane oxygenation in COVID-19-related acute respiratory distress syndrome-a Euroelso international survey

ABSTRACT

RATIONALE There is ongoing dispute whether COVID-19 related Acute Respiratory Distress Syndrome (CARDS) has unique physiology, setting it apart from 'classic' ARDS. While ECMO has proven valuable in the treatment of acute lung failure, little is known about when and how it should be used to support critically ill COVID-19 patients. METHODS We performed an international email survey to assess how ECMO providers worldwide have previously used ECMO during the treatment of critically ill patients with COVID-19. Questions targeted indications to begin ECMO, technical specifications, anticoagulation strategy and reasons for treatment discontinuation. RESULTS 276 centers worldwide responded that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECMO was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECMO varied between less than two and more than four weeks. The main reason to discontinue ECMO treatment prior to patient's recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators were responsible for the discontinuation of ECMO support. Most ECMO physicians (66% ± 26%) agreed that patients with COVID-19 induced ARDS benefitted from ECMO. Overall mortality of COVID-19 patients on ECMO was estimated to be about 55%, scoring higher than what has previously been reported for Influenza patients on ECMO (29-36%). Most ECMO providers agreed that, while COVID-19 patients were longer on ECMO compared to patients with ARDS of different origin, supposed hypercoagulation was hardly an issue during ECMO therapy and oxygenator change was not required more frequently than they were used to. CONCLUSION ECMO has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure, despite initial recommendations from scientific societies were mostly reluctant. Age and multimorbidity limited the use of ECMO. Triage situations were rarely a concern. ECMO providers stated that patients with severe COVID-19 benefitted from ECMO. An increasing use in patients with respiratory failure in a future stage of the pandemic may be expected. Early apprehensions that COVID-19 related hypercoagulation would result in severe thromboembolic complications during extracorporeal circulation were mostly mitigated judging from survey experience.