Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization

Abstract

This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.

Figure 1.

Algorithm for management of acute respiratory distress syndrome, including indications for ECMO. *With respiratory rate increased to 35 breaths per minute and mechanical ventilation settings adjusted to keep a plateau airway pressure of <32 cm H₂O. †Consider neuromuscular blockade. ‡There are no absolute contraindications that are agreed upon except end-stage respiratory failure when lung transplantation will not be considered; exclusion used in the EOLIA trial can be taken as a conservative approach to ECMO contraindications. ∫For example, neuromuscular blockade, high PEEP strategy, inhaled pulmonary vasodilators, recruitment maneuvers, and high-frequency oscillatory ventilation. ¶Recommend early ECMO as per EOLIA trial criteria; salvage ECMO, which involves deferral of ECMO initiation until further decompensation (as in the crossovers to ECMO in the EOLIA control group), is not supported by the evidence but might be preferable to not initiating ECMO at all in such patients. Credit: Abrams et al.. ECMO, extracorporeal membrane oxygenation; EOLIA, Extracorporeal Membrane Oxygenation to Rescue Lung Injury in Severe Acute Respiratory Distress Syndrome; PaCO₂, partial pressure of carbon dioxide in arterial blood; PaO₂:FiO₂, ratio of partial pressure of oxygen in arterial blood to the fractional concentration of oxygen in inspired air; PEEP, positive end-expiratory pressure.

Figure 2.

Contraindications algorithm for V-A and V-V ECMO use (COVID-19 and non-COVID-19) during a pandemic based on system capacity. *The impact of duration on high-flow nasal cannula and/or noninvasive mechanical ventilation in addition to invasive mechanical ventilation is unknown. COVID-19, coronavirus disease 2019; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; PaCO₂, partial pressure of carbon dioxide in arterial blood; PaO₂:FiO₂, ratio of partial pressure of oxygen in arterial blood to the fractional concentration of oxygen in inspired air; PEEP, positive end-expiratory pressure; V-A, venoarterial; V-V, venovenous.

Figure 3.

Recommendations for ongoing care for patients with COVID-19 receiving ECMO. ARDS, acute respiratory distress syndrome; CAR, chimeric antigen receptor; COVID-19, coronavirus disease 2019; DVT, deep venous thrombosis; ECMO, extracorporeal membrane oxygenation; ELSO, Extracorporeal Life Support Organization; ML, membrane lung; PPE, personal protective equipment; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; V-V, venovenous.