Background
Allocation
Should ECMO treatment be considered for COVID-19 patients?
ECMO for non-COVID-19 patients during the pandemic
Patient prioritization
Standard operating procedures and exclusion criteria of COVID-19 positive ECMO candidates
Personal protective equipment (PPE)
Exclusion criteria for ECMO implementation in COVID-19 patients
Absolute contraindications | Relative contraindications |
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Rejection by the patient | Age >65 yearsa (depending on the biological age) |
Pre-existing severe neurological deficit, advanced dementia | Ventilation duration prior ECMO >7 days |
End-stage disease (life expectancy <1 year) | Relevant immunosuppressive therapies |
Known severe brain injury | Systemic hematologic disorders |
Age >75 years or age >70 plus ≥2 relative contraindicationsa | Additional organ failure (except kidney) |
End-stage lung disease | Frailty [10] |
Disseminated malignancy | Severe aortic regurgitation (VA ECMO) |
Child-Pugh C liver cirrhosis | Severe peripheral vascular disease (VA ECMO) |
<1 year after allogeneic stem cell transplantation | Chronic heart failure NYHA IV (without option for heart transplantation or ventricular assist device) |
Venovenous ECMO (respiratory ECMO)
Principle
Indications and contraindications
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Absolute contraindications refer explicitly to patients with severe lung failure due to present SARS-CoV‑2 infection.
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Relative contraindications describe factors associated with a worse outcome in patients with need for respiratory ECMO. In case of present relative contraindications, ECMO treatment should only be applied in exceptional cases!
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For each point, individual assessment is needed.
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The presence of multiple relative contraindications worsens the prediction of patient outcome substantially.
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Relative contraindications are evaluated in accordance to resources and capacities.
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Ideal ECMO candidates would be patients <65 years without pre-existing diseases and single organ failure (lung).
Cannulation
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We recommend a cannulation strategy with greatest experience for each center, for example: femorojugular configuration.
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Cannula size is to be selected according to the expected blood flow demand (goal: ECMO blood flow >60% of the patient’s cardiac output).
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COVID-19 patients qualifying for ECMO are those with the most severe lung failure (rescue ECMO), therefore almost complete lung replacement is to be expected, therefore we recommend to choose a bigger drainage cannula (in normal sized adults with ultrasound assessed venous diameter of ≥10 mm at least 23 F, ideally 25 F).
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The perfusion cannula chosen is usually 2–4 F smaller in diameter.
Veno-arterial ECMO in COVID-19 patients (cardiac ECMO)
Choice of cannulation strategy
Circulatory failure in VV ECMO
Special clinical scenario: extracorporeal cardiopulmonary resuscitation (eCPR)
Aim: Time from cardiac arrest to hospital admission <60 min, if |
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Witnessed cardiac arrest |
Bystander resuscitation or first medical contact <5 min |
Age under 70 years |
Shockable initial rhythm or return of spontaneous circulation at any time during resuscitation |
Body mass index <35 |
A persistant end tidal carbon dioxide >14 mm Hg |
Pupils not anisocoric/unequal/mydriatic |
No end-stage disease |
No severe peripheral vascular disease |