|Year : 2020 | Volume
| Issue : 4 | Page : 115-118
Extracorporeal membrane oxygenation in COVID-19: The Saudi ECLS-Chapter perspective
Hani N Mufti1, Hussam Bahudden2, Zohair A Al Aseri3, Mohamed Azzam4
1 Division of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City; Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences; Department of Intensive Care, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
3 Department of Emergency Medicine and Department of Critical Care, College of Medicine, King Saud University, Riyadh; Department of clinical sciences, College of medicine, Dar Al Uloom University; Department of Adult Critical Care Services, Ministry of Health, Jeddah, Saudi Arabia
4 Department of Critical Care, King Abdullah Medical Complex, Ministry of Health, Jeddah, Saudi Arabia
|Date of Submission||30-Sep-2020|
|Date of Decision||10-Nov-2020|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||31-Dec-2020|
Hani N Mufti
Division of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, P.O. Box: 9515, Jeddah 21423
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mufti HN, Bahudden H, Al Aseri ZA, Azzam M. Extracorporeal membrane oxygenation in COVID-19: The Saudi ECLS-Chapter perspective. Saudi Crit Care J 2020;4:115-8
|How to cite this URL:|
Mufti HN, Bahudden H, Al Aseri ZA, Azzam M. Extracorporeal membrane oxygenation in COVID-19: The Saudi ECLS-Chapter perspective. Saudi Crit Care J [serial online] 2020 [cited 2021 Jan 21];4:115-8. Available from: https://www.sccj-sa.org/text.asp?2020/4/4/115/305821
Extracorporeal membrane oxygenation (ECMO) is considered a modified portable version of the cardiopulmonary bypass machine. ECMO has two main components that define its function: A pump and an oxygenator that are connected to the patient circulation through large cannulas. The pump simulates the function of the heart of delivering oxygenated blood to vital organs, while the oxygenator mimics the function of the lungs gas exchange that is necessary for all biological functions (oxygen extraction and CO2 removal). Based on this, ECMO can be configured based on the pathology being treated; veno-venous ECMO (VV-ECMO) is mainly applied to patients with respiratory failure while veno-arterial ECMO for patients with cardiac failure.
Before 2009, ECMO was mainly utilized in the neonatal and pediatric population with limited numbers in the adult population. With the emergence of the novel influenza A (H1N1) virus in 2009, more adult patients were placed on VV-ECMO as rescue therapy after failing conventional medical therapy with lung protective strategy.,, The CESAR trial demonstrated that patients with severe acute respiratory distress syndrome (ARDS) on optimum conventional management that are transferred to an ECMO center had better survival with no disability. In 2012, the Middle East respiratory syndrome (MERS) emerged, which was caused by the novel coronavirus (MERS-CoV). Four years later, the WHO labeled the MERS-CoV as an outbreak that was associated with high mortality up to 35%. At the peak of MERS-CoV in 2016, patients who develop severe ARDS had high mortality (up to 41%). Although most patients would respond to conventional therapy (lung protective strategy, neuromuscular blockage, prone position… etc.), a small proportion of patients with severe ARDS who do not respond.,,, VV-ECMO have been used as a rescue therapy for patients with severe ARDS who are failing conventional therapy. Since the late 1970s, several randomized clinical trials had conflicting conclusions.,, However, several observational trials during the H1N1 and MERS-CoV influenzas pandemics have confirmed the improved survival of a subset of patients that were placed on VV-ECMO after failing conventional therapy for ARDS.,,, [Table 1] summarizes major studies in the field of ECMO in ARDS.
|Table 1: Major extracorporeal membrane oxygenation in acute respiratory distress syndrome studies|
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In December 2019, a cluster of patients who were suffering from pneumonia due to an unknown cause was noticed in the city of Wahan, Hubei province, China. Over the next few weeks, the number of confirmed cases was increasing rapidly across the globe. The World health Organization announced in early 2020 that these cases of pneumonia of unknown cause is due to a new novel coronavirus that was identified on genetic sequencing and it would be named short for coronavirus disease 2019 (COVID-19) that can cause the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)., While most patients who contract the virus are asymptomatic.,, However, based on a recent meta-analysis of almost 25,000 patients who develop symptoms, 32% of patients require admission to the intensive care unit (ICU) with a pooled mortality of 39% for the ones who are admitted to the ICU.
During the first quarter of 2020, several patients have been placed on ECMO as a last resort therapy with conflicting outcomes.,,,,,,,,,,,, Early experience from Wahan, China, have shown that 5 out of six patients who were placed on ECMO for SARS-CoV-2 have suffered a mortality. Other sporadic case reports reported successful weaning.,,, A small case series from Italy demonstrated that 2 out of 4 patients survived. With the increasing number of critical cases, demand on ECMO, lockdown and travel ban; limitations of this finite and complex supportive modality are a concern. The Extracorporeal Life Support Organization (ELSO) is an international nonprofit consortium dedicated to the development and evaluation of novel therapies for supporting failing organ systems with a focus on ECMO (www.elso.org). On March 23, 2020, ELSO have released an official guidance document entitled “ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure” with a central message that “ECMO is not a therapy to be rushed to the front lines when all resources are stretched during a pandemic.”,
As the pandemic continues to evolve, the global medical community and health authorities continues to gain more understanding of the pathophysiology of COVID-19, especially SARS-CoV-2, and update the management based on the best available evidence.,, The global experience of patients placed on ECMO for SARS-CoV-2 have increased as well, with better understanding of the management of these patients on ECMO. [23,35-38] ELSO have developed and online portal with free access to all ECMO specialized to enable collection of as many patients who were placed on ECMO for SARS-CoV-2 (https://www.elso.org/COVID19.aspx). By the August 28, 2020, 2352 patients that had SARS-CoV-2 were supported with ECMO and 54% of patients who had off ECMO were discharged. [Table 2] shows a snapshot of available experience in the literature on ECMO in COVID-19.
|Table 2: A snapshot of available cases in the literature on extra-corporeal membrane oxygenation in Coronavirus disease 2019|
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The Saudi ECLS chapter, which is under the Saudi Critical Care Society, have been monitoring the situation locally and globally. At early April 2020 at the beginning of the pandemic in the country and because the outlook of the pandemic was not clear, the Saudi ECLS released a statement with strict selection criteria. The aim was to limit the use of ECMO to patients who are more likely to survive. As the status of the pandemic unraveled and became clearer, a revised second version from the Saudi ECLS statement was released with more relaxed yet decisive criteria based on local experts' opinions and international best available evidence. By August 28, 2020, more than 100 patients with SARS-CoV-2 have been placed on ECMO in several regions throughout the country.
In Saudi Arabia, ECMO utilization across the country is overseen by the national COVID 19-ECMO task force, which is led by qualified ECMO intensivist with a membership of regional ECMO leaders assigned by different health regions. COVID 19-ECMO task force meets regularly to discuss all regions' situations and appropriate actions are taken according to ECMO capacity. The task force is responsible for mobilizing extra resources, opening new ECMO services, extending services to periphery by assigning mobile clinical team to provide support and guidance for regions with need of ECMO. The national COVID 19 ECMO task force generates and publishes local ECMO protocols and guidelines, receives regular report from each region, and exchanges experiences as needed. The national critical care referral hotline 1937 is covered by ECMO intensivists to discuss any case that may need a referral to an ECMO center or medical opinion that cannot be provided in hospitals without on-site ECMO services.
As ECMO is a supportive therapy that helps the lungs by allowing some time for recovery while optimizing oxygenation and metabolic functions, it needs to be remembered that this is a very advanced, expensive, temporary and finite intervention that have been shown to support a subset of these extremely critically ill patients.
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[Table 1], [Table 2]