Role of ECMO in most critically ill COVID-19 patients

Nearly 2 years into the pandemic, the role of ECMO for COVID-19 is slowly coming into focus. As of November 2021, more than 10 500 patients with COVID-19 have been treated with ECMO and reported to the Extracorporeal Life Support Organization. The optimal distribution of resources between critically ill patients with COVID-19 treated or not treated with ECMO, however, cannot be precisely adjudicated because of the current, uncontrolled evidence base. Therefore, Dr Daniel Brodie and his team provided 3 approaches to manage ECMO use in critically ill covid patients.

♦ Firstly, they noted that clinicians should regularly review the criteria used to determine ECMO candidacy to minimize ECMO use in patients unlikely to survive, including those with advanced age or severe multiorgan failure.

♦ Secondly, they noted that based on the existing supply, regional ECMO capabilities should be optimized by sharing resources and coordinating referrals.

• They insist on the fair and rational use of ECMO, expediting the transfer of patients to ECMO centres with appropriate capacity, and keeping ECMO teams informed as to utilization rates across each region in real-time.
• They further advised increasing the ECMO capability by establishing new ECMO centres.

♦Thirdly, they suggested more robust study designs to evaluate the potential benefits of ECMO for COVID-19. They recommended adaptive trail design with outcomes of interest beyond short- and longer-term mortality including resource consumption, cost, functional outcome and quality of life.

The authors wrote, "There are rapidly increasing treatment options beyond supportive care, including antiviral therapies, monoclonal antibodies, and immunosuppressants. Both current and future treatments are expected to be more successful than in the prevaccination phase of the pandemic and may obviate the need for ECMO in many patients."

They concluded, "ECMO remains a therapy of last resort for COVID-19, used for highly selected patients with refractory ARDS who have failed trials of lung-protective ventilation strategies and prone positioning. Regional health care networks and governments should continue to monitor outcomes for patients with COVID-19 treated with ECMO and work toward judiciously managing ECMO resources for all critically ill patients."

They further added, "The use of ECMO has become increasingly established for patients with COVID-19–related ARDS. Nonetheless, it is likely that the optimal place for ECMO in the algorithm for COVID-19 will continue to evolve, as it joins a widening spectrum of increasingly available treatments in a changing patient population."

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DOI:10.1001/jama.2021.22580