Should we ration extracorporeal membrane oxygenation during the COVID-19 pandemic?

The COVID-19 pandemic has raised challenging questions about the rationing of intensive care unit (ICU) beds, mechanical ventilators, and extracorporeal membrane oxygenation (ECMO).

 Experts have recommended that ECMO be curtailed or even halted when patient numbers surpass an ill defined threshold, wherein demand for critical care outstrips available resources.

 It might seem counterintuitive to reduce the provision of ECMO at precisely the time when demand increases, yet it could be deemed necessary. In this Comment, we argue that a decision to curtail or continue ECMO should be deliberate and reasoned, such that alternatives are actively rejected.

According to a large German registry, approximately 17% of patients with COVID-19 treated in hospital during the first few months of the pandemic required mechanical ventilation and 1% received ECMO.

Both modalities are complex and can entail a prolonged ICU stay; however, the resource intensity of ECMO is typically higher, especially with respect to ICU staffing.

 Therefore, if ICU staff are the primary scarce resource, cessation of an ECMO programme might result in more patients being treated. However, if it is not staff that are scarce, but mechanical ventilators or ICU beds, the same might not hold true.