Veno-Venous ECMO Feasible and Beneficial for Respiratory Failure in COVID-19
Key findings
- In March 2020, a team at Massachusetts General Hospital created an internal protocol for using veno-venous extracorporeal membrane oxygenation (ECMO) as additional support for COVID-19 patients with respiratory failure
- Veno-venous ECMO is a respiratory support therapy that involves shunting a patient’s deoxygenated systemic venous blood through an external oxygenator and then returning oxygen-rich blood to the patient
- Approval for ECMO must be granted by the ECMO team and medical ICU leadership, who have access to real-time data on health system resource utilization
- As of April 16, 2020, six COVID-19 patients with respiratory failure had been treated with ECMO at Mass General
- Four of the six patients survived decannulation; two were also extubated, and one of them was discharged
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In March 2020, during the early days of COVID-19 in Massachusetts, a team of cardiac and medical intensivists, pulmonologists and cardiac surgeons at Massachusetts General Hospital created an internal protocol for using veno-venous extracorporeal membrane oxygenation (ECMO) as additional support for COVID-19 patients with respiratory failure.
In Annals of Surgery, Yuval Raz, MD, physician in the Division of Pulmonary and Critical Care Medicine at Mass General, Masaki Funamoto, MD, PhD, cardiac surgeon in the Corrigan Minehan Heart Center, and colleagues describe the protocol and the early experience with ECMO for management of COVID-19 at Mass General.
The authors modified the criteria since this publication, and the most recent version is found here.
Indications
The goal of the protocol was to establish clear indication to provide ECMO to the sickest patients without overburdening already stretched resources or excessively exposing health care staff to infection.
A consensus was reached to offer ECMO if:
- Patients had severe impairment of oxygenation (P:F ratio cutoff about 60–80), respiratory instability with prolonged desaturations or lung compliance≤30
- Safe ventilation was not possible despite optimization of ventilator parameters by the primary medical ICU team and attempted prone positioning
- Approval was granted by the ECMO team and medical ICU leadership, who have access to real-time data on health system resource utilization
All intubated patients should be screened daily for ECMO needs and eligibility.
Contraindications
Absolute contraindications were:
- Significant acute organ failure other than cardiopulmonary or renal
- Chronic cardiac, pulmonary, renal or hepatic disease
- Multisystem organ failure
- Unknown neurologic status
- Active malignancy
- ANC <1000
- BMI >40
Relative contraindications were:
- Age >70 for Non-COVID-19 patients
- Age >60 for COVID-19 patients
- Immune suppression
- Chronic cardiac, pulmonary, renal or hepatic disease
- Secondary infections with MDR organisms
- ECPR
- BMI >35 (requires vascular access sufficient for high flows
These criteria correlate well with guidelines for ECMO use in COVID-19 that the Extracorporeal Life Support Organization released in May 2020.
Patient Characteristics
As of April 16, 2020, six COVID-19 patients with respiratory failure had been treated with veno-venous ECMO at Mass General. Four were transferred from outside institutions, but all six patients were cannulated at Mass General.
Patients were intubated early in their admission and the median time from admission to ECMO cannulation was 5.5 days. All patients were cannulated at the bedside in the ICU. The cannulation strategy and principles of management on ECMO are detailed in the article. Patients required high flow rates (4.1–6.0 L/min) and displayed high plateau pressures (21–30 cmH2O) during the ECMO run.
Complications and Short-term Outcomes
At the time the paper was written:
- Four of the six patients (67%) had survived decannulation after median duration on ECMO of 12 days (range, 4–18 days); two patients had also been extubated and one of those patients had been discharged
- One patient had died on day 4 of the ECMO run after the withdrawal of support due to declining neurologic status secondary to a hemorrhagic stroke
- The sixth patient remained cannulated
Four patients had acute kidney injury and three patients had bleeding requiring blood transfusion during ECMO support.
The Importance of the Leadership Team
ECMO is a fundamental rescue strategy for appropriately selected patients with severe acute respiratory distress syndrome due to COVID-19, and this report demonstrates its feasibility and potential benefits.
However, ECMO is resource-intensive and can strain a hospital's infrastructure and human and emotional capital. The Mass General ECMO leadership team convenes regularly to consider whether there is continued ability to meet needs throughout the hospital, and this process lifts decisions about ECMO initiation and continuation off the shoulders of frontline clinicians.
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