Summary The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia, but is rarely available in low‐income countries. The aim of this study was twofold: to measure the prevalence of capnography in the operating theatres and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low‐income country. This is the first project to do this. Forty capnographs were donated to eight hospitals in Malawi. Thirty‐two anaesthesia providers received a 1‐day capnography training course with pre‐ and post‐course knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow‐up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating theatre had a capnograph. Overall, 97% and 100% ‘capnography gaps’ were identified in the theatres and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed that capnography had saved lives. This study has shown it is feasible to introduce capnography in a low‐income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low‐income countries in 2007, we believe this is one of the most important projects in anaesthesia safety in the last decade.

Summary Bleeding and thrombosis are major complications in patients supported with extracorporeal membrane oxygenation (ECMO). In this multicentre observational study of 152 consecutive patients (≥18 years) with severe COVID‐19 supported by veno‐venous (VV) ECMO in four UK commissioned centres during the first wave of the COVID‐19 pandemic (1 March to 31 May 2020), we assessed the incidence of major bleeding and thrombosis and their association with 180‐day mortality. Median age (range) was 47 years (23–65) and 75% were male. Overall, the 180‐day survival was 70·4% (107/152). The rate of major bleeding was 30·9% (47/152), of which intracranial bleeding (ICH) was 34% (16/47). There were 96 thrombotic events (63·1%) consisting of venous 44·7% [68/152 of which 66·2% were pulmonary embolism (PE)], arterial 18·6% (13/152) and ECMO circuit thrombosis 9·9% (15/152). In multivariate analysis, only raised lactate dehydrogenase (LDH) at the initiation of VV ECMO was associated with an increased risk of thrombosis [hazard ratio (HR) 1·92, 95% CI 1·21‐3·03]. Major bleeding and ICH were associated with 3·87‐fold (95% CI 2·10–7·23) and 5·97‐fold [95% confidence interval (CI) 2·36–15·04] increased risk of mortality and PE with a 2·00‐fold (95% CI1·09–3·56) risk of mortality. This highlights the difficult balancing act often encountered when managing coagulopathy in COVID‐19 patients supported with ECMO.

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Although an established practice in potentially reversible severe respiratory failure, extracorporeal membrane oxygenation (ECMO) support remains controversial. Over the last 50 years, only 4 large scale randomised controlled trials relating to ECMO have been conducted in patients with ARDS. A meta-analysis of only 2 studies has demonstrated survival benefit in those supported with ECMO compared to optimal conventional therapy. With the advent of the COVID pandemic, ECMO utilisation increased, the guidelines evolved, and an unprecedented number of patients were referred for and managed with ECMO support. Approximately 15,000 patients have been supported to date, predominantly using veno-venous ECMO, with an overall in-hospital 90-day mortality of 47%. Although published data reported an increase in ECMO mortality to nearly 60% as the pandemic progressed, this was likely multifactorial, as subsequent data has demonstrated more promising mortality results. This highlights the unique challenges pertaining to patient selection and implementation of this finite support amid an evolving pandemic with many unknowns. Judicious and ethical patient selection is essential to ensure use for the greatest benefit. In this chapter we will outline the unique pathophysiology and clinical features of COVID-ARDS, indications for ECMO referral and patient selection, and implementation during the COVID-19 pandemic.

The National ECMO Service for patients in acute severe respiratory failure in England responded to the challenge of the coronavirus pandemic by implementing a central electronic referral system within days. Prior to this, each ECMO centre managed independently around 20 ECMO referrals per month. Early during the pandemic, we recognised the need for a referral system to co-ordinate the anticipated increased number of referrals. We implemented rapidly a referral system with universal access across England. This allowed the five National ECMO centres to manage over 1000 referrals in the first seven weeks of the pandemic. Key benefits of the new system included facilitated communication and collaboration between centres; data on demand; and capacity shared in real-time. We believe this was instrumental in allowing us to continue to provide for the whole country, respond at scale, and facilitate our collaborative work as a multidisciplinary team.