Should ECMO treatment be considered for COVID-19 patients?
ECMO for non-COVID-19 patients during the pandemic
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
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
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)
Indications and contraindications
Absolute contraindications refer explicitly to patients with severe lung failure due to present SARS-CoV‑2 infection.
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!
For each point, individual assessment is needed.
The presence of multiple relative contraindications worsens the prediction of patient outcome substantially.
Relative contraindications are evaluated in accordance to resources and capacities.
Ideal ECMO candidates would be patients <65 years without pre-existing diseases and single organ failure (lung).
We recommend a cannulation strategy with greatest experience for each center, for example: femorojugular configuration.
Cannula size is to be selected according to the expected blood flow demand (goal: ECMO blood flow >60% of the patient’s cardiac output).
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).
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
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