ECMO during the COVID-19 pandemic: when is it unjustified?
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EDITORIAL
Open Access
ECMO during the COVID-19 pandemic: when is it unjustified? Darryl Abrams1,2, Roberto Lorusso3, Jean-Louis Vincent4 and Daniel Brodie1,2* The coronavirus disease 2019 (COVID-19) pandemic has led to a critical shortage of resources in the hardest-hit areas around the world [1]. Intensive care units (ICUs) overwhelmed by critically ill patients may create non-conventional ICU spaces and even consider triaging invasive mechanical ventilation to those most likely to benefit [2]. In the most severe cases of refractory hypoxemia, extracorporeal membrane oxygenation (ECMO) may be considered, as recommended by the World Health Organization for severe COVID-19. Early data suggest there may be a benefit from ECMO in certain patients with COVID19-associated respiratory failure, though outcomes are likely to be highly dependent on patient selection and timing of ECMO initiation [3]. Whether certain phenotypes of COVID-19 (if present) have differential responses to and prognoses with ECMO remains to be determined [4]. An important question then is whether a resource-intensive therapy is warranted when systems are already strained [5]. The high severity of the respiratory failure in some patients with COVID-19 anticipates the need for ECMO in a large number of patients. However, circumstances that limit otherwise readily available resources raise the threshold for initiating more complex therapies. Therefore, in the context of the COVID-19 pandemic, adherence to evidence-based algorithms is necessary to optimize the allocation of limited resources. Every effort should be made to apply established, less invasive strategies, including prone positioning and optimization of volume status, * Correspondence: [email protected] 1 Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, 622 W168th St, PH 8E, Rm 101, New York, NY 10032, USA 2 Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA Full list of author information is available at the end of the article
prior to consideration of ECMO in these patients [6], but ECMO may still be required. In fact, the limited availability of ECMO, due in part to shortages in ECMO equipment and insufficient capacity at ECMOcapable centers, may lead to the unanticipated benefit of more widespread adoption of these proven therapies that often go underutilized [7]. Perhaps the initial question should not be when, but whether to use ECMO at all in the COVID-19 pandemic. Analyses have demonstrated a benefit from ECMO in severe forms of the acute respiratory distress syndrome (ARDS) [8], though such benefit comes at real costs, and not simply financial ones. In the case of a pandemic requiring crisis standards of care, every resource has the potential to become critical to the functioning of an ICU or the care of critically ill patients. Most prominently, staffing may emerge as a critical bottleneck. The use of ECMO taxes many resources, but none more so than staffing—increased nursing ratios, need for ECMO
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