Outcomes of Patients Denied ECMO During the COVID-19 Pandemic in Greater Paris, France
To the Editor:
Venovenous extracorporeal membrane oxygenation (ECMO) was considered early in the pandemic to rescue the most severe forms of coronavirus disease (COVID-19)–associated acute respiratory distress syndrome (ARDS). The 90-day survival of these patients was 60–64% in the largest cohorts of studies published to date (1, 2). To prevent a shortage of resources and avoid compassionate use and futility, an ECMO hub-and-spoke network organization was created in Greater Paris, France. Guidelines for ECMO indications and management were developed by a task force and disseminated by the regional health administration. These criteria did not change during the study period. All ECMO indications were validated by the Pitié-Salpêtrière Hospital ECMO team. Patients being considered for ECMO had to fulfill EOLIA (ECMO to Rescue Acute Lung Injury in Severe ARDS) trial ARDS severity criteria (3) despite the optimization of mechanical ventilation, a trial of prone positioning, and the use of neuromuscular-blocking agents. Contraindications for ECMO were age >70 years (case-by-case discussion for those aged 65–70 yr), serious comorbidities (including immunosuppression, chronic lung diseases, and extreme obesity), multiple organ failure, and ongoing mechanical ventilation for >10 days. Although our network organization and outcomes after ECMO have been described elsewhere (4), the outcome of patients denied ECMO is still unknown.
In this context, we prospectively collected the characteristics of all patients proposed for ECMO at the ECMO–COVID-19 hub between March 8, 2020, and June 3, 2020. At least two intensivists discussed each patient’s case and decided among the following: “ECMO, yes” (i.e., prompt cannulation by a local or a mobile ECMO team); “ECMO, no, not yet” because criteria for ECMO were not met; or “ECMO, no, never,” because of an anticipated poor prognosis despite ECMO (5). When an “ECMO, no, not yet” decision was made, advice to optimize patients’ management and mechanical ventilation settings were given, with a possibility to reevaluate later ECMO indication.