ECMO Can Play a Key Role for Sickest COVID-19 Patients

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Extracorporeal membrane oxygenation (ECMO) can play an essential role in the management of the sickest COVID-19 patients, said Jeffrey A. Katz, MD, director of critical care services at the NorthShore University HealthSystem in Evanston, Illinois.

To date, more than 2500 COVID-19 patients around the world have received ECMO as part of their therapy, according to numbers tracked by the Extracorporeal Life Saving Organization (ELSO), and the rate of survival to hospital discharge has been 53%.

What ECMO offers patients “is time,” Katz told the audience during his presentation at the virtual COVID-19: What’s Next conference, organized by the Society of Critical Care Medicine.

“It gives patients time to heal themselves. It gives the providers time to give patients antibiotics to clear infections. ECMO doesn’t treat the underlying problem, but ECMO is the ultimate in supportive care,” he explained.

Typically, only large tertiary hospitals have the staff and equipment to use ECMO in the management of COVID-19 patients, and results can vary across hospitals.

At NorthShore, the rate of survival to discharge is 66% for COVID-19 patients on ECMO, Katz reported. At another center in the Chicago area, Advocate Christ Medical Center, the rate is 75%. Both rates are well above the global average.

“The most important thing — bar none — is patient selection,” he told Medscape Medical News, adding that ELSO offers guidelines on patient selection and other aspects of ECMO use for patients with COVID-19.

“If you’re putting people on ECMO who have pre-existing conditions or who are in septic shock, on vasopressors, and have severe kidney injury, liver injury, or cardiac issues, those patients are just not going to do as well,” he explained.

COVID-19 patients younger than 50 years with severe acute respiratory distress syndrome (ARDS) who don’t have any underlying conditions are among the best candidates, he advised.

Staffing is also key, particularly specialized nurse staffing, he said. During the pandemic surge at NorthShore, they have tried to have a 1:1 nurse to patient ratio in the ICU, with a floating nurse for the handful of ECMO patients they have at any time, he said.

And cardiopulmonary bypass perfusionists should be available to help with ECMO circuit issues, he added.

One thing the ECMO team at NorthShore has changed as they prepare for a second wave is to switch from benzodiazepine- to dexmedetomidine-based sedation, Katz said.

“There’s less chance of delirium, although it doesn’t produce the same level of sedation,” he explained, noting that delirium has been a particular problem for patients coming off ECMO.

Providers at NorthShore are getting more comfortable using ECMO for COVID-19 patients. But use during the second wave will depend on the size of the surge, Katz said, because the therapy requires a large commitment of personnel and equipment.

The use of ECMO is increasing in other places as well, said Pauline Park, MD, professor of surgery at Michigan Medicine in Ann Arbor.

“COVID was very frightening early on; we didn’t know who was going to get better. The fact that ECMO helped some of the sickest patients get better gave us a lot of hope,” she told Medscape Medical News.

The focus of reports from Asia and Europe at the beginning of the pandemic were on shortages of personal protective equipment and ventilator support; there was little talk of ECMO.

“We didn’t know enough about the disease early on to commit to that kind of resource,” Park said.

But, “as a medical community, we gained more experience, and it seemed there were appropriate cases to try ECMO. The apparent increase in survival reflects the progress we’ve made in the last few months,” she said.

Only a small fraction of COVID-19 patients — the sickest — are considered for ECMO, she reiterated.

ECMO programs at Michigan Medicine and in most other places are very conservative in their use of ECMO to treat COVID-19 patients because of the considerable risk and the resource drain, Park explained.

The need to make such critical decisions during the pandemic has underscored the value of collaboration, as teams have to consider number of beds, nurse staffing, and specialist staffing, she said. At Michigan Medicine, the entire ECMO team evaluates patients to determine who could truly benefit.

Social Justice Concerns

The cost of ECMO is another consideration.

With the consent of the patient, Katz told the story of a man he cared for with COVID-19 — a father of four with diabetes and obesity — whose imaging results were “as close as you can get to gross pathology in a patient.”

The patient was on ECMO for 33 days, was discharged, and is now awaiting inpatient rehabilitation placement.

“No question. He would not have survived his ARDS without VV [veno-venous] ECMO,” Katz said.

But the expense of ECMO raises a social justice question. The care for that particular patient over more than a month cost $1.3 million.

“Given the scope of the pandemic, in the second wave, we have to ask ourselves whether ECMO is a justified use of both financial resources and personnel resources,” Katz said. “I don’t have the answer; I’m not sure that anybody does. But this is something your institution needs to think about before the second wave if you’re going to do ECMO.”

COVID-19: What’s Next. Preparing for the Second Wave. Presented September 12, 2020.

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