Extracorporeal Membrane Oxygenation in COVID-19-Related Acute Respiratory Distress Syndrome - A EuroELSO International Survey

Extracorporeal membrane oxygenation (ECMO) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic Coronavirus Disease 2019 (COVID-19) with ECMO have been restrained. In the meantime, ECMO has been shown to produce similar outcomes in patients with severe COVID-19 compared to existing data on ARDS mortality. Objective: We performed an international email survey to assess how ECMO providers worldwide have previously used ECMO during the treatment of critically ill patients with COVID-19.MethodsA questionnaire with 45 questions (covering e.g. indication, technical aspects, benefit and reasons for treatment discontinuation), mostly multiple-choice, was distributed by email to ECMO centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO). Results: 276 centers worldwide responded that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECMO was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECMO varied between less than two and more than four weeks. The main reason to discontinue ECMO treatment prior to patient’s recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators were responsible for discontinuation of ECMO support. Most ECMO physicians (66% ± 26%) agreed that patients with COVID-19 induced ARDS (CARDS) benefitted from ECMO. Overall mortality of COVID-19 patients on ECMO was estimated to be about 55%, scoring higher than what has previously been reported for Influenza patients on ECMO (29 – 36%). Conclusion: ECMO has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECMO. Triage situations were rarely a concern. ECMO providers stated that patients with severe COVID-19 benefitted from ECMO. An increasing use in patients with respiratory failure in a future stage of the pandemic may be expected. Funding Statement: COVID-19 research was funded by the Federal state of Saarland, Saarland University and Dr. Rolf M. Schwiete Foundation. Declaration of Interests: Robert Bals declares funding from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Grifols, Novartis, CLS Behring, the German Federal Ministry of Education and Research (BMBF) Competence Network Asthma and COPD (ASCONET), Sander-Stiftung, Schwiete-Stiftung, Krebshilfe and Mukoviszidose eV. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. All other authors: No potential conflicts of interest. Ethics Approval Statement: The ethical committee (Arztekammer des Saarlandes) waived the need for a formal approval since the questionnaire did not retrieve actual patient data.