Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors

Abstract

The Extracorporeal Life Support Organization (ELSO) maintains the world's largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0-28 days), children (29 days-17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.

Figure 1.

Timeline of the Extracorporeal Life Support Organization registry data collection highlights and addenda. New data elements have been added to the main registry and with addenda. These newer data elements include dates and times of procedures and complications, level of mobilization during ECMO, the use of prone positioning before ECMO, and ICU type. Mobilization on ECMO was defined as score of >0 on the ICU mobility scale (IMS), which indicates active or active assisted exercise, such as rolling, bridging or cycle ergometry, or greater. A score of 0 is passive activity/movement. The cardiac addendum contains additional diagnostic, procedural, and echocardiographic data, as well as indications for support, postoperative and cardiac function. Version 1 was designed for neonates and children, a revised cardiac addendum (Version 2) appropriate for adults, will be released in 2023. The ECPR addendum (Version 1) began in 2005 and was revised in January 2020 (Version 2) and now contains precipitating and antecedent events, comorbid conditions, arrest and cannulation location, subsequent intra-arrest management, initial arrest rhythms, details on post arrest clinical management^, and neurologic outcomes. ELSO began collecting data specific to the ECMO care of patients with SARS-CoV-2 in early 2020.^- Dates and times of procedures and complications were added September 15, 2016. Lactate (worst value) was added January 1, 2017, and then transitioned to pre-ECMO value (as defined for other pre-ECMO variables) January 15, 2018. SpO2 was added January 15, 2017. Prone positioning was added December 1, 2017. Mobilization and enteral feeding data were added January 15, 2018.

Figure 2.

Runs over time by age group. Y2-axis shows the number of runs over time by age group (colors), using data from 2009 to 2022 (inclusive). Run counts are indicated in the figure for color (age group) for the first and last years of the chart for reference. Y1-axis shows the number of centers (orange line with box counts in 2009 and 2022). Run counts in 2009 for adult age group: 850. Run counts in 2021: neonatal: 1,527; pediatric: 2,394; adult: 17,975.

Figure 3.

Run count by region over time. Number of runs over time by ELSO chapter (colors), using data from 2009 to 2022 (inclusive). Boxed numbers indicate runs counts for years 2009 and 2022 for visual reference according to color (ELSO Chapter). Run counts in 2009: North American: 2,300; European: 529; Asia-Pacific: 381; Latin American: 45; South and West Asian: 7. Run counts in 2021: North American: 15,430; European: 3,390; Asia-Pacific: 1,542; Latin American: 707; South and West Asian: 827. Run counts in 2022: North American: 12,587; European: 2,248; Asia-Pacific: 959; Latin American: 470; South and West Asian: 539. Center counts in 2009: North American: 124; European: 24; Asia-Pacific: 13; Latin American: 4; South and West Asian: 1. Center counts in 2021: North American: 350; European: 108; Asia-Pacific: 57; Latin American: 45; South and West Asian: 31. Center counts in 2022: North American: 352; European: 107; Asia-Pacific: 43; Latin American: 32; South and West Asian: 31.

Figure 4.

Center-level volume over time, log scale. Distribution of annual center-level volume (log₂-scale) over time by age group (colors). Boxes cover the middle 50% and whiskers cover the middle 80%. Center volume for neonatal/pediatric centers: 2009: median 12, interquartile range (IQR) 6, 23; 2021: 8 (2, 18.5); 2022: 7 (2, 17); Center volume for adult centers: 2009: 4 (1, 12); 2021: 20 (7, 48); 2022: 15 (6, 36).

Figure 5.

Distribution of COVID-19 status in adult receiving respiratory support ECMO in 2020 through 2022. COVID-19 test status is indicated by colors for each of three years. Bar height represents proportion from 0 to 1, shown on the Y-axes.

Figure 6.

Runs over time by age group and support type. Number of runs over time by support type (colors) and age group (panels), from 2009 to 2022 (inclusive). Boxed numbers indicate runs counts for years 2009 and 2022 for visual reference according to color (support type). Run counts: neonatal ECPR (2009): 112; neonatal ECPR (2021): 175; neonatal Cardiac (2021): 589; neonatal Respiratory (2021): 763: neonatal ECPR (2022): 168; pediatric ECPR (2009): 219; pediatric ECPR (2021): 501; pediatric Cardiac (2021): 1,162; pediatric Respiratory; adult ECPR (2009): 86; adult Cardiac (2009): 269; adult Respiratory (2009): 495; adult ECPR (2022): 2,069.

Figure 7.

Proportion of prone positioning use before respiratory support ECMO by age group from 2019 through 2022. Age groups are indicated by colors for each of three years. Bar height represents proportion from 0 to 1, shown on the Y-axes.