Should we ration extracorporeal membrane oxygenation during the COVID-19 pandemic?

Supady, Alexander; Badulak, Jenelle; Evans, Laura; Curtis, J. Randall; Brodie, Daniel

doi:10.1016/s2213-2600(21)00131-4

Cited by 32 publications

(41 citation statements)

References 9 publications

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“…We therefore continuously applied conventional selection criteria for ECMO unchanged from criteria used before the COVID-19 pandemic. 2 , 3 We agree that patients receiving ECMO support have worse outcomes the longer they are mechanically ventilated before initiation of ECMO. In our centre, in line with Extracorporeal Life Support Organization recommendations, prolonged mechanical ventilation is considered a relative contraindication for ECMO (>7 days), but we do not consider a specific time on mechanical ventilation as an absolute contraindication.…”

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confidence: 91%

Cytokine adsorption and ECMO in patients with COVID-19 – Author's reply

Supady

2021

The Lancet Respiratory Medicine

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confidence: 91%

Cytokine adsorption and ECMO in patients with COVID-19 – Author's reply

Supady

2021

The Lancet Respiratory Medicine

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“…There are still few published studies that perform comparative analyzes of the effects of ECMO in patients with COVID-19, so the choice must be based on scientific evidence already available. [5] Indications for ECMO are: acute and reversible lung disease, P/F ratio lower 50-80 with FIO2=1, patient with Murray score=lower 3.0, lower ph 7.2 due to refractory hypercapnia with little metabolic acidosis. Relative contraindications for ECMO are: prolonged period of mechanical ventilation longer than 7 days, age over 65 years, post-cardiac arrest coma, advanced cancer, incoercible bleeding and central nervous system hemorrhage.…”

Section: Resultsmentioning

confidence: 99%

“…Equipped with a membrane capable of oxygenating the blood, in addition to a continuous pulse pump, it drives blood through venous and/or arterial cannulas. [5] It is an advanced form of life support as it works directly on the heart and lungs. It may be indicated in cases of severe acute heart or lung failure that is potentially reversible and does not respond to conventional treatment.…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in the COVID-19 Pandemic

Assunção¹,

Santos²,

Oliveira³

et al. 2021

IJAERS

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Objective: This study aims to discuss the risks and benefits of ECMO in the treatment of patients with severe COVID-19. Method: This is a narrative review study of the literature with a qualitative approach, carried out in the PubMed, MEDLINE, LILACS, SciELO and Google Scholar databases in April 2021. Results: The analysis of the literature shows the importance of applying conventional treatment before opting for ECMO, and should be considered when other measures that have been

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“…It should be noted that provision of ECMO entails a resource demand that is typically higher than that of mechanical ventilators—particularly with respect to ICU staffing. When demand for ICU staffing surpasses available resources, limitation or cessation of ECMO provision may result in more non-ECMO patients being treated [ 37 ], and Supady et al [ 38 ] argue that a decision to curtail or continue ECMO in this context should be ethically deliberate and consistently applied with use of triage guidelines. Although we did not further characterise the change in ECMO bed availability in participants’ units as it was outside the scope of our study, it is an ethically important topic that would benefit from further research.…”

Section: Discussionmentioning

confidence: 99%

Ethical factors determining ECMO allocation during the COVID-19 pandemic

et al. 2021

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Background ECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations. Methods An online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic. Results When initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%). Conclusions We found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic.

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Should we ration extracorporeal membrane oxygenation during the COVID-19 pandemic?

Cited by 32 publications

References 9 publications

Cytokine adsorption and ECMO in patients with COVID-19 – Author's reply

Cytokine adsorption and ECMO in patients with COVID-19 – Author's reply

Extracorporeal Membrane Oxygenation in the COVID-19 Pandemic

Ethical factors determining ECMO allocation during the COVID-19 pandemic

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