Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance recent multivariable analysis confirmed older age, higher Sequential Organ Failure Assessment (SOFA) score and d-dimer > 1 µg/L on admission were associated with higher mortality. This study also observed a median duration of viral RNA detection of 20.0 days (IQR 17.0-24.0) in survivors, but COVID-19 virus was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days (3,4).Building on evidence-informed guidelines developed by a multidisciplinary panel of health care providers with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS and MERS, as well as sepsis and ARDS, this guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials (5,6).There are few data on the clinical presentation of COVID-19 in specific populations, such as children and pregnant women. In children with COVID-19 the symptoms are usually less severe than adults and present mainly with cough and fever, and coinfection has been observed (7, 8). Relatively few cases have been reported of infants confirmed with COVID-19; those experienced mild illness (9). There is currently no known difference between the clinical manifestations of COVID-19 pregnant and non-pregnant women or adults of reproductive age. Pregnant and recently pregnant women with suspected or confirmed COVID-19 should be treated with supportive and management therapies, as described below, taking into account the immunologic and physiologic adaptations during and after pregnancy. * See Global Surveillance for human infection with coronavirus disease (COVID-19) for latest case definitions.

Disclaimer: This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19–related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19–related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.

Objectives: The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization. Design: Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication. Setting: In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education. Patients: None. Interventions: None. Measurements and Main Results: The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development. Conclusions: Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.

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The contribution of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to systemic oxygen delivery is determined by the ratio of total extracorporeal blood flow (trueQ˙EC) to cardiac output (trueQ˙). Thermodilution-based measurements of trueQ˙ may be compromised by blood recirculating through the ECMO (recirculation fraction; Rf). We measured the effects of trueQ˙EC and Rf on classic thermodilution-based measurements of trueQ˙ in six anesthetized pigs. An ultrasound flow probe measured total aortic blood flow (trueQ˙A0) at the aortic root. Rf was quantified with the ultrasound dilution technique. trueQ˙EC was set to 0–125% of trueQ˙A0 and trueQ˙ was measured using a pulmonary artery catheter (PAC) in healthy and lung injured animals. PAC overestimated trueQ˙ (trueQ˙Pa) at all trueQ˙EC settings compared to trueQ˙A0. The mean bias between both methods was 2.1 L/min in healthy animals and 2.7 L/min after lung injury. The difference between trueQ˙Pa and trueQ˙A0 increased with an trueQ˙EC of 75–125%/trueQ˙A0 compared to QEC <50%/trueQ˙A0. Overestimation of trueQ˙Pa was highest when trueQ˙EC resulted in a high Rf. Thus, thermodilution-based measurements can overestimate cardiac output during VV ECMO. The degree of overestimation of trueQ˙Pa depends on the trueQ˙EC/trueQ˙A0 ratio and the recirculation fraction.