Corresponding author:
Sandeep Sainathan
90 SW, 3rd street
Apt 2006
Miami, FL 33130
Ssainathan@outlook.com
Abstract : ECMO is a selectively available therapeutic option,
generally available in a large-size referral healthcare system. In a
single-center experience of use of veno-venous ECMO for COVID-19 ARDS in
a medium-size healthcare system during the pandemic, West and colleagues
in their study have convincingly demonstrated that ECMO can become a
broadly available therapeutic option without compromising quality.
Commentary : COVID-19 is an ongoing pandemic. It has exposed the
vulnerability of the existing healthcare infrastructure and model of
care. The traditional flow in the healthcare system is from a limitedly
equipped, generally smaller healthcare system to a comprehensively
equipped, larger referral healthcare system for specialized care. ECMO
(Extracorporeal membrane oxygenation) is in the realm of such a transfer
of care. Central to the success of the CESAR trial, a randomized
multicenter trial that showed a survival benefit of ECMO over
conventional mechanical ventilation in adults with ARDS (Acute
Respiratory Distress Syndrome), was based on this transfer of care
model 1. COVID-19 has become the leading cause of ARDS
and has markedly increased its incidence. While the precise role of ECMO
in COVID-19 ARDS is still evolving, ECMO now has become a necessity due
to the increased incidence of ARDS2. Thus, the format
of the transfer of care model espoused by the CESAR trial has
become flawed due to this sudden change in the ARDS incidence, resulting
in a saturation of resources of the specialized referral healthcare
systems. West and colleagues, in their study, have nicely shown how
high-quality ECMO can be done beyond the confines of a specialized,
large healthcare system, thus meeting this new challenge posed by the
COVID-19 pandemic3.
Over ten months, they placed 41 patients on veno-venous ECMO for
refractory respiratory failure due to ARDS from COVID-19. They used
either a single or a double site cannulation strategy and modified it as
per the clinical response from the patient. 42% of the patients were
cannulated using ultrasound and fluoroscopic guidance at the bedside and
was particularly useful early in the pandemic where infectiousness of
the virus was poorly understood and there was limited availability of
personal protective equipment. Later in their experience, they used a
right atrial to pulmonary artery jugular venous cannula with the ability
to support right ventricular function, particularly in patients with
associated right ventricular dysfunction. None of the patients required
conversion to veno-arterial ECMO. To note, need or conversion to
veno-arterial ECMO in COVID-19 ARDS patients increases the risk for
mortality2. 30 % of the patients were extubated while
on ECMO. They did not shy away from complex patients, such as morbidly
obese patients with BMI> 40. ECMO may be particularly
beneficial in obese patients due to the inherent limitations posed by
traditional modes of ventilation in this vulnerable population. Their
results have been outstanding, with 63% of their patients surviving to
discharge from the hospital. Instrumental to their success was a
multi-disciplinary approach, an early cannulation strategy during the
disease process, accelerated training on ECMO competence of medical
intensive care nursing staff, and a 24-hour advanced practice provider
coverage. However, their outcomes were observational without a
comparator group where conventional methods were used, and thus the
relative efficacy of ECMO cannot be ascertained from this study. Also,
they were not a completely ECMO naive institution as they were
performing ECMO prior to the pandemic but to a lesser extent. They had a
basic infrastructure on which they could scale up. Nevertheless, this
scaling up was accomplished despite the resource crunch imposed by the
pandemic. Hence, the team needs to be congratulated for meeting the
challenge.
While ECMO did influence immediate survival, its impact on the long-term
outlook of these patients is unknown. Nevertheless, this study
demonstrates that ECMO can become a broadly available rather than a
selectively available therapeutic option without compromising quality.