Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 May 1;67(5):485-495.
doi: 10.1097/MAT.0000000000001422.

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

Jenelle Badulak  1   2 , M Velia Antonini  3   4 , Christine M Stead  5 , Lara Shekerdemian  6 , Lakshmi Raman  7 , Matthew L Paden  8 , Cara Agerstrand  9   10 , Robert H Bartlett  11 , Nicholas Barrett  12   13 , Alain Combes  14   15 , Roberto Lorusso  16 , Thomas Mueller  17 , Mark T Ogino  18 , Giles Peek  19 , Vincent Pellegrino  20 , Ahmed A Rabie  21 , Leonardo Salazar  22 , Matthieu Schmidt  23   24 , Kiran Shekar  25 , Graeme MacLaren  26 , Daniel Brodie  9   10 ; ELSO COVID-19 Working Group Members
Affiliations

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

Jenelle Badulak et al. ASAIO J. .

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.

PubMed Disclaimer

Conflict of interest statement

Disclosure: Dr. Stead is a chief executive officer of the Extracorporeal Life Support Organization (ELSO). Dr. Paden is a president of the ELSO. Multiple patents and intellectual property regarding a novel renal replacement device to be used with extracorporeal membrane oxygenation (device not discussed in this article). Dr. Bartlett serves on ELSO’s board of directors. Dr. Barrett received grants from Getinge and ALung. Dr. Combes received grants from Getinge and personal fees from Getinge, Baxter, and Xenios outside the submitted work. Dr. Lorusso is a consultant for Medtronic, LivaNova, and Eurosets (all honoraria paid to the University). Dr. Ogino is a past-president of the ELSO; he serves on ELSO board of directors. Dr. Schmidt receives lecture fees from Getinge, Xenios, and Drager outside the submitted work. Dr. Shekar acknowledges research support from Metro North Hospital and Health Service. Dr. MacLaren serves on ELSO’s board of directors. Dr. Brodie receives research support from ALung Technologies. He has been on the medical advisory boards for Baxter, Abiomed, Xenios, and Hemovent. He is the President-elect of the ELSO. The remaining authors have no conflicts of interest to report.

Figures

Figure 1.
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.
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.
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.
See this image and copyright information in PMC

References

    1. Bartlett RH, Ogino MT, Brodie D, et al. . Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure. ASAIO J. 2020; 66:472–474 - PMC - PubMed
    1. Extracorporeal Life Support Organization. ECMO and ECLS > Resources > Guidelines. Available at: https://www.elso.org/Resources/Guidelines.aspx. Accessed December 27, 2019
    1. Ramanathan K, Antognini D, Combes A, et al. . Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med. 2020; 8:518–526 - PMC - PubMed
    1. Shekar K, Badulak J, Peek G, et al. . Extracorporeal life support organization COVID-19 interim guidelines: A consensus document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers. ASAIO J. 2020; 66:707–721 - PMC - PubMed
    1. Henry BM, Lippi G. Poor survival with extracorporeal membrane oxygenation in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19): Pooled analysis of early reports. J Crit Care. 2020; 58:27–28 - PMC - PubMed