Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure

The Extracorporeal Life Support Organization (ELSO) and all of the ELSO worldwide chapters have prepared this document to describe when and how to use extracorporeal membrane oxygenation (ECMO) in COVID-19 patients during this pandemic. It is a consensus guideline intended for experienced ECMO centers.

COVID-19 is a disease caused by the novel SARS-CoV-2 virus which appeared in December 2019 and is now a worldwide pandemic. Because it is a new viral disease, this guidance document is based on limited experience and written with the intention to be updated frequently as new information becomes available. A link to the latest version of this document will be found at http://covid19.elso.org.

Although most COVID-19 patients have moderate symptoms and recover quickly, some patients develop severe respiratory failure and acute respiratory distress syndrome (ARDS) requiring intensive care admission. The mortality in COVID-19 patients who require mechanical ventilation is high. Extracorporeal membrane oxygenation can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. Initial experience in Japan and South Korea with ECMO in >50 COVID-19 cases has had survivors, with many still receiving treatment.

An overview article in Lancet Respiratory Medicine examines the role of ECMO and ECMO centers during the COVID-19 pandemic.¹ Additionally, guides detailing the requirements for an ECMO program are available in both the medical literature² and the ELSO website.³ The Society of Critical Care Medicine also has promulgated guidelines for the management of COVID-19 patients and recommends the use of ECMO when conventional management fails.⁴ Due to the intensive hospital resource utilization, substantial staff training, and multidisciplinary needs associated with starting an ECMO program, ELSO recommends against starting new ECMO centers for the sole purpose of treating patients with COVID-19. As mentioned in a recent article by ELSO leaders in JAMA,⁵ for inexperienced centers, “ECMO is not a therapy to be rushed to the front lines when all resources are stretched during a pandemic.” A list of experienced ECMO centers is provided on the ELSO website.⁶ During the COVID-19 surge, it is reasonable to concentrate those patients with the greatest chance of benefit from receiving ECMO in a hospital where an experienced ECMO team is available.

Extracorporeal membrane oxygenation indications, access, and management are described in the ELSO Guidance for Adult Respiratory and Cardiac failure on the ELSO web site (https://elso.org). Extracorporeal membrane oxygenation is indicated in patients who have a high risk of mortality. There are several ways to measure mortality risk in ARDS. All include PaO2/FiO2 below 100, despite and after optimal care. For adult respiratory failure, the recently published EOLIA trial contains three indications that define severe ARDS where ECMO may be useful.⁷ Many standardized algorithms for ARDS therapies, such as Figure 1 below, have been published and may be of aid to clinicians.⁸ When patients meet indications, ECMO should be initiated immediately in an experienced center, and not days later.