CSECLS Recommendations on extracorporeal support for critically ills with COVID-19 pneumonia

Recommendations on Extracorporeal Life Support for critically ill patients with Coronavirus Disease 2019 (COVID-19) pneumonia from the Chinese Society of Extracorporeal Life Support. Along with the sharp increase in confirmed cases of novel Coronavirus infection, some of the most critically ills will require ExtraCorporeal Membrane Oxygenation (ECMO) support. Based on the clinical data related to COVID-19, as well as on the data from previous clinical studies and on the recommendations from the Extracorporeal Life Support Organization (ELSO), the Committee Board of the Chinese Society of Extracorporeal Life Support (CSECLS) drafted a series of recommendations to guide implementation of extracorporeal support in patients with confirmed infection developing refractory respiratory or cardio-respiratory failure: here a summary, attached the full original version.

ECMO Indications

Acute Respiratory Distress Syndrome (ARDS) is one of the most common indications for extracorporeal support in respiratory failure. While providing extracorporeal gas exchange, respiratory ECMO enables lung protective mechanical ventilation settings, allowing the lung to rest, and eventually to recover. In majority of the patients infected with novel Coronavirus, pneumonia were mild and reversible. However, some of these patients became critically ill, with most of them developing dyspnea and/or hypoxemia in 1 week from the onset. Most severe cases rapidly developed ARDS, deteriorating to multiple organ failure. Some patients presented with concurrent cardiac involvement, eventually evolving in circulatory dysfunction in sickest patients. When cardiogenic shock or cardiac arrest occurs, veno-arterial configuration (VA-ECMO) needs to be considered.

Timing for ECMO support

ECMO could be implemented in patients with ARDS if hypoxemia does not improve despite conventional management strategies, with maximal mechanical ventilation settings (FiO₂≥ 0.8, tidal volume 6 ml/kg, PEEP ≥ 10 cmH₂O), if no contraindication are present, and when at least one of the following conditions is met:
– PaO₂/ FiO₂ < 80 mmHg for more than 6 hours
– FiO₂= 1.0，PaO₂/FiO₂< 100 mmHg.
– arterial pH < 7.25, PaCO₂ > 60 mmHg for more than 6 hours, and respiratory rate > 35 breaths per minute
– respiratory rate > 35 breaths per minute, and arterial pH < 7.2 with plateau pressure > 30 cmH₂O
– coexisting cardiogenic shock or cardiac arrest.

Relative or absolute contraindications for ECMO

combination of irreversible disease, severe damage of central nervous system or advanced stage of malignant tumor.
Mechanical Ventilation at high settings (FiO₂> 0.9, plateau pressure > 30 cmH2O) lasting 7 days or longer;
advanced age in not actually considered a contraindication, it is associated to an increased risk of death;
severe multiple organ failure;
moderate to severe aortic regurgitation and acute aortic dissection could be considered contraindications to VA ECMO support;
pharmacologic immunosuppression (absolute neutrophil count < 0.4 × 10⁹/L);
no vascular access available for ECMO cannulation due to anatomy alterations or pathological changes involving target vessels.

ECMO configuration

COVID-19 patients usually present with a normal cardiac function at the early stage, so veno-venous ECMO to support respiratory function has been the preferential configuration; however, right heart function should be closely monitored during the rung. If cardiogenic shock or cardiac arrest occurs, configuration could be shift to veno-arterial. If differently hypoxemia develops on VA-ECMO, establishing a VAV configuration could be considered.