Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization

Abstract

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.

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

“…Our results showing satisfactory results after ECMO initiation in these newly formed centers are reassuring. Accordingly, the most recent ELSO guideline recommending starting new ECMO centers in selected cases and under appropriate supervision [ 9 ] is supported by our findings.…”

“…Some of these guidelines recommended against establishing new ECMO centers [ 8 ]. However, with a better understanding of the disease and the increasing need for ECMO in regions that lacked this service, the updated version of the recommendation on this topic was less stringent, allowing for the creation of new ECMO centers in selected cases [ 9 ]. During the current pandemic, several case series and large cohort registries were published and discussed ECMO provision and utility [ 10 – 16 ].…”

The Right Ventricle in COVID-19

“…Early reports on ECMO in COVID-19 reported unfavorable outcomes, with mortality rates up to 90% [164], raising concerns on the justification of this therapy in conditions of a global pandemic with major strains on health care resources [165]. However, improved patient selection and ECMO program organization over time allowed for obtaining much better results than initially reported, and the role of VV-ECMO in COVID-19 is constantly evolving with the continuous release of new data [166].…”

“…These considerations imply that very strict and unified criteria for VV-ECMO implementation in COVID-19 be applied together with stringent contraindications, and that well-coordinated ECMO referral centers be organized within geographic regions. All these aspects have been recently extensively reviewed by the ELSO, which has provided complete updated guidelines for the use of ECMO in COVID-19 patients with severe cardiopulmonary failure, to which we refer the interested reader [166].…”

COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) guidelines; revisiting the Western New York approach as the pandemic evolves

“…Left ventricular dysfunction or myocarditis was present in 55.3% (95% CI, 42.4–68.2) and the pooled prevalence of coronary artery aneurysm or dilatation was 21.7% (95% CI, 12.8–30.1) [ 66 ]. The recent updated COVID-192021 ECMO guidelines from the Extracorporeal Life Support Organization (ELSO) recommends applying similar known principles that are currently published in ELSO guidelines for patient selection of pediatric COVID-19 associated respiratory failure and cardio-circulatory failure related to MIS-C [ 71 ]. While mortality was similar in acute pulmonary COVID-19 and MIS-C requiring ECMO, organ support requirements and therapeutic strategy certainly differ between the two syndromes.…”