Top

Published in:

01-08-2021 | COVID-19 | Original

Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India

Authors: Ahmed A. Rabie, Mohamed H. Azzam, Abdulrahman A. Al-Fares, Akram Abdelbary, Hani N. Mufti, Ibrahim F. Hassan, Arpan Chakraborty, Pranay Oza, Alyaa Elhazmi, Huda Alfoudri, Suneel Kumar Pooboni, Abdulrahman Alharthy, Daniel Brodie, Bishoy Zakhary, Kiran Shekar, Marta Velia Antonini, Nicholas A. Barrett, Giles Peek, Alain Combes, Yaseen M. Arabi

Published in: Intensive Care Medicine | Issue 8/2021

Abstract

Purpose

Extracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient’s outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers.

Methods

This is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type.

Results

Three hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37–52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% (p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05–3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75–3.67)).

Conclusions

During pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results.

Available only for authorised users

Combes A, Peek GJ, Hajage D, Hardy P, Abrams D, Schmidt M, Dechartres A, Elbourne D (2020) ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med 46(11):2048–2057. https://doi.org/10.1007/s00134-020-06248-3CrossRefPubMed

Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374(9698):1351–1363. https://doi.org/10.1016/s0140-6736(09)61069-2CrossRefPubMed

Rabie AA, Asiri A, Rajab M et al (2021) Beyond frontiers: feasibility and outcomes of prolonged veno-venous extracorporeal membrane oxygenation in severe acute respiratory distress syndrome. ASAIO J 67(3):339–344. https://doi.org/10.1097/MAT.0000000000001367CrossRefPubMed

Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, Da Silva D, Zafrani L, Tirot P, Veber B, Maury E, Levy B, Cohen Y, Richard C, Kalfon P, Bouadma L, Mehdaoui H, Beduneau G, Lebreton G, Brochard L, Ferguson ND, Fan E, Slutsky AS, Brodie D, Mercat A, EOLIA Trial Group, REVA, ECMONet (2018) Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 378(21):1965–1975. https://doi.org/10.1056/NEJMoa1800385CrossRefPubMed

Goligher EC, Tomlinson G, Hajage D et al (2018) Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a post hoc Bayesian analysis of a randomized clinical trial. JAMA 320(21):2251–2259. https://doi.org/10.1001/jama.2018.14276CrossRefPubMed

Bartlett RH, Ogino MT, Brodie D et al (2020) Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure. ASAIO J 66(5):472–474. https://doi.org/10.1097/MAT.0000000000001173CrossRefPubMedPubMedCentral

Alhazzani W, Møller MH, Arabi YM et al (2020) Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 46(5):854–887. https://doi.org/10.1007/s00134-020-06022-5CrossRefPubMed

Shekar K, Badulak J, Peek G et al (2020) ELSO Guideline Working Group. Extracorporeal Life Support Organization Coronavirus Disease 2019 interim guidelines: a consensus document from an International Group of interdisciplinary extracorporeal membrane oxygenation providers. ASAIO J 66(7):707–721. https://doi.org/10.1097/MAT.0000000000001193CrossRefPubMed

JenelleBadulak M, Antonini V, Stead CM et al (2021) Updated 2021 guidelines from the extracorporeal life support organization. ASAIO J 67(5):485–495. https://doi.org/10.1097/MAT.0000000000001422CrossRef

10.

COVID-ICU Group on behalf of the REVA Network and the COVID-ICU Investigators (2020) Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med 47:60–73. https://doi.org/10.1007/s00134-020-06294-xCrossRef

11.

Alshahrani MS, Sindi A, Alshamsi F (2018) Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care 8(1):3. https://doi.org/10.1186/s13613-017-0350-xCrossRefPubMedPubMedCentral

12.

MacLaren G, Fisher D, Brodie D (2020) Preparing for the most critically Ill patients with COVID-19: the potential role of extracorporeal membrane oxygenation. JAMA 323(13):1245–1246. https://doi.org/10.1001/JAMA.2020.2342CrossRefPubMed

13.

Ramanathan K, Antognini D, Combes A et al (2020) Planning and provision of ECMO services for severe ARDS during the COVID-19 Pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med 8(5):518–526. https://doi.org/10.1016/S2213-2600(20)30121-1CrossRefPubMedPubMedCentral

14.

MacLaren G, Combes A, Brodie D (2021) What is new in ECMO for COVID-19? Intensive Care Med 47(1):107–109. https://doi.org/10.1007/s00134-020-06284-zCrossRefPubMed

15.

Mufti H, Bahudden H, Al Aseri Z, Azzam M (2020) Extracorporeal membrane oxygenation in COVID-19: the Saudi ECLS-Chapter perspective. Saudi Crit Care 4(4):115–118. https://doi.org/10.4103/sccj.sccj_55_20CrossRef

16.

Heinsar S, Peek GJ, Fraser JF (2020) ECMO during the COVID-19 Pandemic: when is it justified? Crit Care 24(1):650. https://doi.org/10.1186/s13054-020-03386-4CrossRefPubMedPubMedCentral

17.

Pooboni S (2017) SWAC ELSO: past, present, and future. Qatar Med J. https://doi.org/10.5339/qmj.2017.swacelso.9CrossRefPubMedCentral

18.

Zakhary B, Shekar K, Diaz R, Badulak J, Johnston L et al (2020) Extracorporeal Life Support Organization (ELSO) ECMOed Taskforce. Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: a statement from the Extracorporeal Life Support Organization ECMOed Taskforce. Crit Care Med 48(3):406–414. https://doi.org/10.1097/CCM.0000000000004158CrossRefPubMed

19.

Vincent JL, Moreno R, Takala J, et al, On behalf of the Working Group on Sepsis Related Problems of the European Society of Intensive Care Medicine (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 22(7):707–710. https://doi.org/10.1007/BF01709751CrossRefPubMed

20.

Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138(3):720–723. https://doi.org/10.1164/ajrccm/138.3.720CrossRefPubMed

21.

Schmidt M, Bailey M, Sheldrake J, Hodgson C, Aubron C, Rycus PT, Scheinkestel C, Cooper DJ, Brodie D, Pellegrino V, Combes A, Pilcher D (2014) Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 189(11):1374–1382. https://doi.org/10.1164/rccm.201311-2023OCCrossRefPubMed

22.

Barbaro RP, MacLaren G, Boonstra PS, Iwashyna TJ, Slutsky AS, Fan E, Bartlett RH, Tonna JE, Hyslop R, Fanning JJ, Rycus PT, Hyer SJ, Anders MM, Agerstrand CL, Hryniewicz K, Diaz R, Lorusso R, Combes A, Brodie D, Organization ELS (2020) Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet. https://doi.org/10.1016/S0140-6736(20)32008-0CrossRefPubMedPubMedCentral

23.

Schmidt M, Hajage D, Lebreton G et al (2020) Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study. Lancet Respir Med 8(11):1121–1131. https://doi.org/10.1016/S2213-2600(20)30328-3CrossRefPubMedPubMedCentral

24.

Shekar K, Slutsky AS, Brodie D (2020) ECMO for severe ARDS associated with COVID-19: now we know we can, but should we? Lancet Respir Med 8:1066–1068CrossRef

25.

Lorusso R, Combes A, Coco VL et al (2021) ECMO for COVID-19 patients in Europe and Israel. Intensive Care Med 47:344–348. https://doi.org/10.1007/s00134-020-06272-3CrossRefPubMedPubMedCentral

26.

Di Nardo M, Hoskote A, Thiruchelvam T et al (2020) EuroELSO Neonatal & Pediatric Working Group & Collaborators on COVID-19. Extracorporeal membrane oxygenation in children with COVID-19: preliminary report from the collaborative EuroELSO prospective survey. ASAIO J 67(2):121–124. https://doi.org/10.1097/MAT.0000000000001309CrossRefPubMedCentral

27.

Lebreton G, Schmidt M et al (2021) Extracorporeal membrane oxygenation network organization and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(21)00096-5CrossRefPubMedPubMedCentral

28.

Shaefi S, Brenner SK, Gupta S et al (2021) Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19. Intensive Care Med 47:208–221. https://doi.org/10.1007/s00134-020-06331-9CrossRefPubMed

29.

Diaz RA, Graf J, Zambrano JM et al (2021) ECMO for COVID-19-associated severe ARDS in Chile: a nationwide incidence and cohort study. Am J Respir Crit Care Med. https://doi.org/10.1164/rccm.202011-4166OCCrossRefPubMed

30.

Schmidt M, Stewart C et al (2015) Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Crit Care Med 43(3):654–664. https://doi.org/10.1097/CCM.0000000000000753CrossRefPubMed

31.

Pham T, Combes A et al (2013) Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 187(3):276–285. https://doi.org/10.1164/rccm.201205-0815OCCrossRefPubMed

32.

Schmidt M, Pham T et al (2019) Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome .An international multicenter prospective cohort. Am J Respir Crit Care Med 200(8):1002–1012. https://doi.org/10.1164/rccm.201806-1094OCCrossRefPubMed

33.

Combes A, Schmidt M, Hodgson CL, Fan E, Ferguson ND, Fraser JF, Jaber S, Pesenti A, Ranieri M, Rowan K, Shekar K, Slutsky AS, Brodie D (2020) Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med. https://doi.org/10.1007/s00134-020-06290-1CrossRefPubMedPubMedCentral

34.

Abrams D, Schmidt M, Pham T et al (2020) Mechanical ventilation for acute respiratory distress syndrome during extracorporeal life support. Research and practice. Am J Respir Crit Care Med 201(5):514–525. https://doi.org/10.1164/rccm.201907-1283CICrossRefPubMed

35.

SerpaNeto A, Deliberato RO et al (2018) Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med 44(11):1914–1922. https://doi.org/10.1007/s00134-018-5375-6CrossRef

36.

Noah MA, Peek GJ, Finney SJ et al (2011) Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 306(15):1659–1668. https://doi.org/10.1001/jama.2011.1471CrossRefPubMed

37.

Guervilly C, Prud’homme E, Pauly V, Bourenne J, Hraiech S, Daviet F, Adda M, Coiffard B, Forel JM, Roch A, Persico N, Papazian L (2019) Prone positioning and extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: time for a randomized trial? Intensive Care Med 45(7):1040–1042. https://doi.org/10.1007/s00134-019-05570-9CrossRefPubMed

Title: Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India
Authors: Ahmed A. Rabie
Mohamed H. Azzam
Abdulrahman A. Al-Fares
Akram Abdelbary
Hani N. Mufti
Ibrahim F. Hassan
Arpan Chakraborty
Pranay Oza
Alyaa Elhazmi
Huda Alfoudri
Suneel Kumar Pooboni
Abdulrahman Alharthy
Daniel Brodie
Bishoy Zakhary
Kiran Shekar
Marta Velia Antonini
Nicholas A. Barrett
Giles Peek
Alain Combes
Yaseen M. Arabi
Publication date: 01-08-2021
Publisher: Springer Berlin Heidelberg
Keywords: COVID-19
ECMO
ECMO
Published in: Intensive Care Medicine / Issue 8/2021
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-021-06451-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2021

Severity of hypoxemia may explain indeterminate results in pediatric trials of inhaled nitric oxide

Acute kidney injury in the critically ill: an updated review on pathophysiology and management

Chrysalis

Migration in times of COVID-19

Probiotics and sepsis: separating the signal from the noise

Diagnosis of middle lobe atelectasis with lung ultrasonography