Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation

Abstract

Objectives: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. Design: Retrospective review of the literature and expert consensus. Setting: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. Subjects: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. Interventions: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. Measurements and Main Results: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. Conclusions: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Rescue therapy with inhaled nitric oxide and almitrine in COVID-19 patients with severe acute respiratory distress syndrome

“…Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for the coronavirus disease 2019 (COVID-19) pandemic is causing a massive influx of patients presenting with severe acute respiratory distress syndrome (ARDS) to intensive care units (ICUs) worldwide [1]. For the most severe cases, refractory ARDS may lead to a discussion regarding the use of extracorporeal membrane oxygenation (ECMO), an expensive and invasive life support resource, available in limited numbers in expert centers [2,3]. Since the possibilities cannot fit with the large-scale outbreaks, alternative solutions should be proposed [4].…”

Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program

“…In the isolated case of bleeding and hematoma formation, vascular surgery was consulted and involved in the management despite lack of need for surgical intervention. Although no emergent surgical intervention was required in any patients within the intensivist group, this support upheld prior recommendations for physicians to practice within their trained skill set and be prepared to address complications including support for intrathoracic surgical emergencies (7). The success was also fostered by the commitment and support of the hospital executive leadership.…”

“…A 3-year timeline was established to develop critical care faculty with expertise in venovenous ECMO management and transition to medical intensivist-led cannulation after that period. Intensivist-led percutaneous cannulation is both effective and safe in both venovenous and venoarterial ECMO with surgical backup support (7)(8)(9). This timeline was accelerated due to risk of infection to healthcare workers and a relative limitation of resources in the surge of the COVID-19 pandemic (10)(11)(12).…”

Extracorporeal Membrane Oxygenation for COVID-19 Treatment in a Community Hospital

“…Lung protective ventilation strategy was followed per best practice guidance protocols. 3 An infectious disease consultant guided any indicated anti-bacterial or anti-viral treatment. VV ECMO was discontinued and patients were decannulated at their bedsides once ventilator support settings were acceptable per published guidelines.…”