The Saudi Critical Care Society extracorporeal life support chapter guidance on utilization of veno-venous extracorporeal membrane oxygenation in adults with acute respiratory distress syndrome and special considerations in the era of coronavirus disease 2019

Abstract

Extracorporeal membrane oxygenation (ECMO) is considered as a supportive treatment that provides circulatory and ventilatory support and can be thought off as a bridge to organ recovery. Since 2009, it has been applied as a rescue treatment for patients with severe adult respiratory distress syndrome (ARDS) mainly due to viral causes. In December 2019, several patients presented with a constellation of symptoms of viral pneumonia in China. A new strain of the corona virus family, called COVID-19, has been discovered to be the cause of this severe mysterious illness that was named severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2). This new virus continued to spread across the globe leading to the World Health Organization announcing it as a pandemic in the early 2020. By the end of March 2021, the number of COVID-19 cases worldwide exceeded 126 million cases. In Saudi Arabia, the first confirmed case of COVID-19 was reported in the 2nd March 2020. By the end of March 2021, the total number of confirmed COVID-19 cases in Saudi Arabia is just above 360,000. In anticipation of the need of ECMO for the treatment of patients with SARS‑CoV‑2 based on the previous Middle East respiratory syndrome coronavirus pandemic experience, the Saudi Extra-Corporeal Life Support (ECLS) chapter that is under the umbrella of the Saudi Critical Care Society (SCCS) convened a working group of ECMO experts. The mission of this group was to formulate a guidance for the use of ECMO as a last resort for patients with severe ARDS, especially with COVID-19 based on available evidence. The ECLS-SCCS chapter wanted to generate a document that can be used to simple guide, with a focus on safety, to provide ECMO service for patients with severe ARDS with a special focus on SARS‑CoV‑2.

Keywords: ARDS; Covid-19; ECMO; adult; respiratory failure.

Figure 1

- The extracorporeal strategies that can be used for supporting patients with ARDS. ECMO: extracorporeal membrane oxygenation (ECMO). ECCO₂R: extracorporeal CO₂ removal

Figure 2

- General demonstration of the standard components of an extracorporeal membrane oxygenation (ECMO) circuit.

Figure 3

- Common venvenous(VV) extracorporeal membrane oxygenation (ECMO) configurations. A) Conventional VV ECMO, fem–IJ configuration. B) Fem–fem VV ECMO. C) Single cannula with dual ports, one for drainage and another for return that directs oxygenated blood toward the tricuspid valve.

Figure 4

- Anticoagulation on veno-venous extracorporeal membrane oxygenation. INR: International Normalized Ratio, aPTT: activated partial thromboplastin time, ACT: activated clotting time, CBC: complete blood count

Figure 5

- Management of veno-venous ECMO and the ventilator PEEP: peek end expiratory pressure, Pplat: plateau pressure, ECMO: extracorporeal membrane oxygenation, ARDS: acute respiratory distress syndrome, FiO2: oxygenation, IBM: ideal body mass, IBW: ideal body weight, H₂0: water, RR: respiratory rate, PaO2: partial pressure of oxygen

Figure 6

- Low O₂ saturation on ECMO. LDH: lactate dehydrogenase, ECMO: extracorporeal membrane oxygenation, PEEP: peek end expiratory pressure, IV: FiO₂: fraction of inspired oxygen, Hb: hemoglobin, PO2: partial pressure of oxygen, DIC: disseminated intravascular coagulation, SVC: superior vena cava, IV: intravenous

Figure 7

- Assessment of patient readiness for weaning off veno-venous ECMO PEEP: peek end expiratory pressure, Pplat: plateau pressure, ECMO: extracorporeal membrane oxygenation, ARDS: Acute Respiratory Distress Syndrome, FiO2: oxygenation, ABG: arterial blood gasses

Figure 8

- Process of liberation from veno-venous ECMO. peek end expiratory, Pplat: plateau pressure, ECMO: extracorporeal membrane oxygenation, ARDS: Acute Respiratory Distress Syndrome, FiO2: oxygenation, IBW: ideal body weight, RSC; respiratory system compliance, H: hours, ABG: arterial blood gasses, CXR: chest x-ray, PEEP: peek end expiratory pressure

Figure A1

- Variable flow on veno-venous extracorporeal membrane oxygenation (ECMO).

Figure A2

- Pump failure. VV: veno-venous, VA: veno-arterial, ECMO: extracorporeal membrane oxygenation, ICU: intensive care unit, ACLS: advanced cardiac life support

Figure A3

- Circuit rupture. VV: veno-venous, VA: veno-arterial, ECMO: extracorporeal membrane oxygenation, ICU: intensive care unit, ACLS: advanced cardiac life support

Figure A4

- Accidental decannulation VV: veno-venous, VA: veno-arterial, ECMO: extracorporeal membrane oxygenation, ICU: intensive care unit, ACLS: advanced cardiac life support

Figure A5

- Accidental decannulation VV: veno-venous, VA: veno-arterial, ECMO: extracorporeal membrane oxygenation, ICU: intensive care unit, ACLS: advanced cardiac life support

Figure A6

- The first Saudi extracorporeal life support (ECLS) chapter statement for extracorporeal membrane oxygenation (ECMO) support in COVID-19 patients, released April 9, 2020.

Figure A7

- The second Saudi extracorporeal life support (ECLS) chapter statement for extracorporeal membrane oxygenation (ECMO) support in COVID-19 patients, released May 1, 2020.