Author: M Velia Antonini

Characteristics of & main lessons from COVID-19

Characteristics of & main lessons from COVID-19 Coronavirus outbreak in China: summary of a report of 72314 cases (data from Chinese CDC), with comparison of COVID-19 with SARS and MERS, and response to the novel Coronavirus epidemic.
Here some of the key findings:
age: 87%: 30-79 years, 1% respectively 10-19 & <10 years
spectrum of disease (confirmed cases): 81% mild, 14% severe, 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
case-fatality rate (confirmed cases): 2.3%, 14.8% in patients aged ≥80 years, 49.0% in critical cases.
Next steps? As global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries, proactive investment in public health infrastructure & capacity crucial to effectively respond to epidemics; persisting in improving international surveillance, cooperation, coordination, & communication, is critical to be better prepared to respond to future new public health threats. Full text open access on JAMA.
Also check the epidemiological characteristics of outbreak COVID-19 on China CDC Weekly.

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/FiO< 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

  1. combination of irreversible disease, severe damage of central nervous system or advanced stage of malignant tumor.
  2. Mechanical Ventilation at high settings (FiO2> 0.9, plateau pressure > 30 cmH2O) lasting 7 days or longer;
  3. advanced age in not actually considered a contraindication, it is associated to an increased risk of death;
  4. severe multiple organ failure;
  5. moderate to severe aortic regurgitation and acute aortic dissection could be considered contraindications to VA ECMO support;
  6. pharmacologic immunosuppression (absolute neutrophil count < 0.4 × 109/L);
  7. 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-arterialIf differently hypoxemia develops on VA-ECMO, establishing a VAV configuration could be considered.

Follow CSECLS on WeChat 中国医师协会体外生命支持专业委员会

Clinical characteristics of Covid-19

Clinical characteristics of patients with 2019nCoV (now properly defined by World Health Organization (WHO) Covid-19) in these 3 papers.

Data extraction on 1,099 patients with laboratory-confirmed #Covid-19 from 552 hospitals in 31 provinces/provincial municipalities through January 29th, 2020. Authors reported 5% of patients admitted to #ICU, 2.18% requiring invasive ventilation, and 1.36% death rate. Extracorporeal membrane oxygenation implemented in 5 severe cases (0.5%). Read additional data (detailed clinical characteristics, radiographic & laboratory findings, complications, treatment & outcome, distribution of patients across China), open access text. Note article is a preprint/not peer-reviewed.

Data from 138 hospitalized patients infected with 2019 novel coronavirus in Wuhan, China also published on JAMA, reporting 26.1% of cases transferred to the intensive care unit, 47.2% received invasive ventilation, 4 patients were switched to #ECMO support; overall mortality 4.3%. Open access text

Clinical characteristics of 137 2019-nCoV-infected patients from tertiary hospitals in Hubei Province, reporting no extracorporeal support (authors relate this finding to the fact that they reported about cases admitted to respiratory departments, with data from ICUs/other departments missing). Open access on Chinese Medical Journal.

WHO Critical Care Training Short Course for SARI

The World Health Organization has launched a free open access course, the WHO Critical Care Training Short Course for Severe Acute Respiratory Infection (SARI), including content on clinical management of patients with a severe acute respiratory infection, intended for clinicians working in ICUs in low and middle-income countries involved in critical care management of adult and pediatric patients with severe forms of SARI, including severe pneumonia, ARDS, sepsis and septic shock, during outbreaks of influenza virus (seasonal) human infection due avian influenza virus (H5N1, H7N9), MERS-CoV, nCoV or other emerging respiratory viral epidemics.
Visit OpenWHO to enrol and take the course. Here a list of the topics covered by the course:
introduction to the 2019nCoV and infection prevention for patients with Severe Acute Respiratory Infections (SARI);
clinical syndromes and pathophysiology of sepsis and ARDS;
triage and early recognition of patients with SARI, with role-playing scenarios;
monitoring patients with SARI;
differential diagnosis, specimen collection and diagnostic tests for SARI;
oxygen Therapy;
antimicrobial therapy and its modification after diagnostic test interpretation;
how to deliver targeted resuscitation for sepsis and septic shock;
mechanical ventilation: how to deliver lung-protective MV in ARDS;
sedation: how to manage pain, agitation and delirium;
best practices to prevent complications;
weaning from mechanical ventilation;
quality in critical care;
pandemic preparedness and ethical considerations.

Additional details and enrolment at OpenWHO

Imaging in 2019nCov infection

Early recognizing imaging features of novel Coronavirus infection: mandatory for promptly implement treatment/support strategies, but also for isolating case and performing an effective public health monitoring/response; some open access paper have been published on Radiology, starting with a series reviewing chest CT scans of symptomatic patients infected with 2019-nCoV, with emphasis on identifying & characterizing the most common findings, including bilateral pulmonary parenchymal ground-glass & consolidative pulmonary opacities, sometimes with rounded morphology and peripheral lung distribution. Notably, cavitation, discrete pulmonary nodules, pleural effusions, lymphadenopathy reported as absent. In seven over eight subjects, follow-up imaging (during study time window) often demonstrated mild or moderate progression of disease as manifested by increasing extent and density of opacities. Open access full text
Key points for radiologists in this related editorial, suggesting to consider in the proper clinical setting, 2019-nCoV as a possible diagnosis as detecting bilateral ground-glass opacities or consolidation at chest imaging (but normal chest CT scan does not exclude the diagnosis!): keep an high level of suspicion and collect detailed potential exposure/travel history. Open access full text

Additional cases, same journal, with interesting CT scans images/movie at
link & link

Novel coronavirus (nCoV) infection

Trending topic

The WHO is distributing an Interim Guidance document for the “Clinical management of severe acute respiratory infection when Novel coronavirus (nCoV) infection is suspected.” The medical community is closely monitoring the outbreak. The WHO guidance document includes a statement to “consider referral patients with refractory hypoxemia despite lung-protective ventilation. . . in settings with access to expertise in ECLS.”
Where ECLS expertise is available, extracorporeal support should be considered according to the standard management algorithm for ARDS in supporting patients with viral lower respiratory tract infection. However, clearly at this time, there is little worldwide experience with using ECMO to support nCOV-infected patients. ELSO will continue to collect data through our member centers and provide recommendations as additional information becomes available.
Dr. Mark Ogino, ELSO – Extracorporeal Life Support Organization President.

The World Health Organization (WHO) Interim Guidance full text open access.

In this first report published on The Lancet, available data (to date) about the recent cluster of pneumonia cases caused by a novel betacoronavirus in Wuhan, China, with the epidemiological, clinical, laboratory, radiological characteristics of these patients, including treatment (n=2, 5% of all reported cases, 15% of the patients requiring ICU care, supported with ECMO) and clinical outcomes. Open access text

A second study on the same journal includes all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data, with outcomes followed up until Jan 25, 2020; 23% admitted to ICU, 17% developed ARDS, 3% treated with extracorporeal support, 11% worsened in a short period of time and died of multiple organ failure. Open access text

On The Lancet also a study reporting epidemiological, clinical, laboratory, radiological, and microbiological findings of 5 patients in a family cluster who presented with unexplained pneumonia after returning to Shenzhen, Guangdong province, China, after a visit to Wuhan, and an additional family member who did not travel to Wuhan, with findings consistent with person-to-person transmission of this novel coronavirus in hospital
and family settings, and the reports of infected travellers in other geographical regions. Open access text
… and some interesting comments:
About novel coronavirus outbreak of global health concern Open access text
on data sharing and outbreaks: best practice exemplified Open access text
… and emerging understandings of 2019-nCoV. Open access text

.

Consider reading this report on The New England Journal of Medicine, about 3 adult patients presented with severe pneumonia admitted to a hospital in Wuhan at the end of December, with details on detection, isolation and characterization of the Novel Coronavirus. Abstract
NEJM has also published an editorial, focusing on this zoonotic coronavirus, which (third time in 3 decades, after evere acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]) has crossed species to infect human populations. Open access text
Moreover, on same journal, a viewpoint on key questions for impact assessment of this new emerging Coronavirus. Open access text

NEJM published data on the first 425 confirmed cases of novel coronavirus infected pneumonia (NCIP) in Wuhan, reporting informations collected on demographic characteristics, exposure history, and illness timelines of laboratory-confirmed cases by January 22, 2020, with estimation of key epidemiologic time-delay distributions. Open access text

The report of a case of importation and human-to-human transmission of nCoV in Vietnam ia also available. Open access link

Moreover, a dedicated page has been created on New England Journal of Medicine, and a special set of practices that will be applied to all submitted manuscripts describing the 2019-nCoV outbreak, has been announced in this editorial, to promote fast publishing.

JAMA published another viewpoint highlighting the perpetual challenge of emerging infectious human diseases caused by pathogens from viral families (formerly thought to be relatively benign) and the importance of sustained preparedness. Open access text
Moreover, another editorial refers about control measures in China, and control measures by governments worldwide, nonpharmaceutical interventions, and role of WHO. Open access text

A dedicated page is available on Centers for Disease Control and Prevention (CDC) website, with outbreak of respiratory illness caused by the novel coronavirus reporting:
– situation news & summary;
– informations/interim guidance for healthcare professionals, including criteria to guide evaluation of patients under investigation (PUI) for 2019-nCoV; recommendations for reporting, testing, and specimen collection; healthcare infection prevention and control recommendations for PUI for 2019-nCoV, and checklists for HCPs/hospitals;
– interim guidance for laboratory professionals working with specimens from PUI for human infections with 2019-nCoV.

An online dashboard for tracking worldwide spread of novel Coronavirus has been built & is regularly updated by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University; the map is freely available! link

But how setting up an ICU to cope with novel Coronavirus infection? read about this experience from Sichuan region, China: ‬
‪equipment preparation ‬
‪education & training of staff‬
‪protection of the staff‬
‪early recognition/classification of disease severity‬
‪restriction of patient contact‬
‪full text open access on ICM

The ELSO – Extracorporeal Life Support Organization will persist in publishing additional evidence and advices, as available, on all our social media channels and on our website, in order to actively contribute to the updating of our community about this topic. 

ELSO Cannulation Workshop

Need to improve your cannulation skills?? Want to act faster & safer next time you need to implement extracorporeal support? Join the ELSO Cannulation Workshop! This focused course, taught by a ELSO ECMOed Education Committee using realistic cannulation models, will train physicians to safely perform percutaneous #ECLS cannulation. All attendees will learn all aspects of cannulation in a small-group hands-on format; specific content includes: equipment selection, #POCUS vessel assessment, #ultrasound-guided vascular access, serial dilation, catheter placement and securement. Instructors will emphasize the value of imaging & address complication troubleshooting. At the conclusion of the course participants will be prepared to perform percutaneous veno-venous, veno-arterial, and bi-caval ECMO cannulations at their institution. Save the date! September 21st or 22nd, 2020 Hilton Waikoloa Village Big Island of Hawai’i… Registration opening soon!!& do not forget, same venue, following the workshop, #ELSO2020 the 31st Annual ELSO – Extracorporeal Life Support Organization Conference: a special event at a special place, September 23-26, 2020! https://www.elso.org/Education/2020Hawaii.aspx

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Transcript of the first ELSO ECMO education twitter chat!

The first ELSO ECMOed ECMO education twitter chat has been held few hours ago, involving participants from all Continents: Lots of interesting comments, questions, idea and suggestions have been shared, focused on the target to standardize ECMO education making it globally available & properly train/certify providers. Here, nearly (as feasible) complete transcript of the chat… some hints:
implement the ELSO ECMO education dedicated guidelines
focus on (a partially) online education strategy to improve worldwide accessibility, to be integrated with high fidelity #simulation/practice
increasing availability of free open access resources ie dedicated webinars, conference talks
organize a social media based platform to discuss interesting ECMO cases (with a proper management of sensitive data)…
Improving cost and sustainability of education & training, particularly in low income Countries and for low income HCPs, without negatively impact on quality seems an important issue! investing in ECMO team education/updating is an investment towards patients/program outcome improvements.
mandatory certifications? using something like ACLS/ALS model or not?

to view original posts, reply & comment search for #ECMOedPP hashtag on twitter, enjoy!

About ELSO ECMOed

@EcmoDiaz The goal of this Taskforce is to take further what ELSO has done in education: standarization in curriculum, evaluation, simulations and education research with the best team work: international collaboration.
@kshekar01 There is so much variation in ECMO practice and outcomes that high quality education can have a huge impact on all aspects of ECMO care – huge gains to be made with education as things stand.
@HerxxAU The ECMOed framework is a great start and builds the framework for future structures. National and regional solutions are next.
@bishoy_zakhary. We hope the global framework will help guide organization at the national levels.
@EcmoDiaz Exactly! collaboration is the first step to get the framework
@slthomps12 Need to standardize the expectations, medical knowledge, technical knowledge, and troubleshooting of ECMO. Having a standard to meet in order to care for ECMO patients is needed that is comparable across all centers.
@JenelleBadulak Agree that this will also be essential for unifying ECMO practice better enabling meaningful clinical research: if we do it similarly in multiple institutions, we can study it across multiple institutions.
@ecmocare I fully agree to fact that ECMO education should be standardised and supported. The ECMOedPP chat is a right initiative, but we need to further structure the initiative.
@kshekar01 Agree – ongoing educational research will help optimise/calibrate educational content and delivery both and to measure impact over time. With representation from all ELSO chapters, ECMOed can enable every chapter to build capacity in terms of both endorsed courses and trainers; all the suggested options for affordability etc sound good.
@KrKrramanathan That would ensure quality education for sure. Basic standards are needed not just for learners but also for trainers and on how training it is imparted.
@g_alinier The collective experience & wiseness of ELSO ECMOed taskforce is impressive! Really honoured to have been invited to be part of this. All together we can really have an impact, and improve ECMO patient care through better education

How to provide highly accessible, high quality ECMO education? is online ECMO education the answer??

@EcmoNinja How do you ensure that everyone has equal access to education, not just those at big ECMO centers that have resources to send people to meetings?
@JenelleBadulaK web-based didactic education will help extend the reach of standardized education and make in-person simulation sessions able to be shorter (and cheaper!) focusing on hands-on skills.
@jkukutschka Online education is a great option for this and will definitely have a greater outreach at a lower cost in a blended training model or for CME.
@FOAMecmo How to match free open spreading of ECMO education resources, to make these globally available, with high content quality and economical sustainability? Think the use of (partly) online strategy by ELSO ECMOed experts could be really effective to support spread of standardized high quality/highly accessible also meaning low cost ECMO education.
@g_alinier So true that cost is often a barrier to education & training but that is often a false economy! ignorant unskilled uninformed unprepared workforce cost money (in hospital beds through extended patient stays, additional treatment/procedures) & in patients’ lives. Online education needs to be followed up by hands-on face to face activities as ECMO relies also so much on good technical & communication skills to provide optimal care. ELSO and ELSO ECMOed are the key coordinating channels for dissemination!
@kshekar01 Agree – the non-technical skills are so important too – other big area is for providers to open up their minds to idea of shared decision making and team work that’s so critical for ECMO.
@jkukutschka Absolutely! A blended (online + onsite) model for training ECMO practitioners.
@bishoy_zakhary this is a very important challenge without easy solutions. Widespread ELSO endorsement can be a helpful step but ultimately Online Education may be a viable option.
@KrKrramanathan Great question. The answer may not be straightforward. Basic ECMO knowledge can be streamlined online or via e-learning; we are striving towards that. However the skill component would be tricky- you can achieve that with experience or only with high fidelity simulation.
@kshekar01 We need to change thinking; access to ECMO = access to ECMO for patients + access to ECMO education for providers. What are your thoughts to help to make this happen?
@EcmoNinja It will have to be multi-modal. Heavy use of online content that is controlled. Using the hub center to train the spokes/referring centers has generally worked well in my practice. @kshekar01 Great question – the hub and spoke model for ecmo service delivery should also work for education, hope we can use qualitative research tools to study these models of education over time!
@ecmocare More webinars. The ELSO courses to be available online, the conference proceedings to be available live as webcast: free up knowledge, involve more participants!
@bishoy_zakhary Yes webinars have a great potential for reach and exposure!

@HerxxAU As supposed to ALS – ECMO delivery has regional differences and something which works in Seattle is not practical in Japan
@kshekar01 Agree: standardising what we can may provide a good starting point for local providers to work with – we are organising focus groups across all Chapters to understand the local expectations and challenges.
@bishoy_zakhary This is true but at the sample time there is a minimal competency level that is across chapters and applicable to all ECMO practitioners.
@EcmoNinja Agree: different indications, different patient populations, different technologies. All important factors to consider. What doesn’t work is other mandatory certifications (think ACLS or ATLS) – the training is mandatory for those that need it the least and often doesn’t reach the true target audience.
@mamoon Accredited & well thought in situ simulation program development should be a priority, as you tend to miss latent threats in your own working environment.
@JenelleBadulaK A certification from an organization like @ELSOOrg may help set a certain standard but content needs to evolve and change with the technology and integrate continued curricular evaluation & meet the needs of the learner. Otherwise risk content stagnation! @kshekar01 Certification is one area where we need a lot of feed back as there are so many models of ecmo care and multidisciplinary provider
@bishoy_zakhary The challenge we are facing is the explosive growth in the number of ECMO centers that often outpaces the capability of courses to provide training!

@precordialthump Mastery learning should be a feature of a standardized approach to ECMO education (suggested reading: Cheng A et al. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2018 open access link https://www.ahajournals.org/doi/10.1161/CIR.0000000000000583). Also, while a standardized ALS type entry course is important, so is ongoing spaced practice to guard against deskilling. Likely to need 6 monthly refreshers. In situ simulation for team training is likely even more important than courses though! Finally, I’d like to see “after action reviews” standardized after ECMO events (clinical debriefing) to maximize learning from real world events and contribute to a culture of learning.
@foamecmo Important points! doing ECMO course once is not enough! certification matters but re-certification too… the less you practice/the lowest your ECLS volume, the most you need to run (simulation based/whole team) training & do no forget (online FOAMed?) updates in a moving so fast field.
@succenyl impressive work by ELSO ECMOed: thanks for supporting ECMO community. I suggest adding another hashtag for weekly case presentation for open discussion from different aspects and controversies raised!
@FOAMecmo Discussing interesting ECMO cases on Socia Media? could be effective to look for expert support/offer alternative viewpoints/diffuse ECMO centers results, providing every precaution is taken to protect patient’s privacy/confidentiality of personal information and image; what about consent? needed/feasible?
@KrKrramanathan Difficult cases get discussed at the ELSO ECMOed blog!

@ArpanCh21458537 The help from industry should be there. They have their own mannequins/ simulators. We can take support of that. Guidelines should include the industry participation also.
@ECMONinja Industry is limited what they can do in the US because most products used for ECMO don’t carry that FDA designation- they are used off label.
@kshekar01 A low cost sim can be locally developed; maybe we need to make this knowledge accessible and support centres with their basic sim program – a sim should hopefully be incorporated into any ECMO program along with wet drills etc.
@ecmocare Need support and knowhow to develop a low cost sim.
@MooreElizabethA Would there be interest in creating an ECMO simulation “know how” session to a future ELSO conference?
@ecmocare There should be definitive guidelines for the trainers as well. The ELSO need to publish more clinical guidelines too.
@jkukutschka ELSO provides Train the Trainers courses… Next one will be this march in Barcelona
@FOAMecmo Considered to attend to the ELSO ECMOed Train the Trainers course to learn how to educate and train in the ECMO field… experts from all ELSO chapters will be involved!
@kshekar01 Every ECMO centre ideally should have one or two trainers who have done the train the trainer course who can then champion local education- it is easy to set up basic simulation and organise basic in-house training
@ecmocare Totally agree The train the trainers courses should be more frequent, should be more accessible and affordable. Can ELSO subsidize registration or offer travel grants or any other programme to encourage young minds?

@ecmocare The cost of the ELSO ECMOed courses in each Country or region to vary. Can’t keep same fee structure everywhere. Remember a huge number of participants are perfusionists and nurses.
@KrKrramanathan Good suggestion. It is a daunting task as cost of resources vary from country to country
@kshekar01 cost and sustainability are important issues – we will have to enable local providers to provide education tailored to local flavour while maintaining quality of education.

About ELSO ECMOed endorsement for ECMO educational initiatives

@ecmocare More centers should be endorsed to conduct the courses. At least one center in every country needs to be endorsed. Larger countries need to have multiple centers.
@JenelleBadulak Completely agree! Creating a standardized curriculum that we can distribute and utilize train the trainer courses will enable us to make this standardized curriculum available worldwide. Also essential to this will be web-based didactics #ECMOedPP@kshekar01 I think the process for endorsement is in place and is an important area for ECMOed.
@bishoy_zakhary Agree! There is a need for ELSO endorsement of ECMO courses across all the chapters so ECMO practitioners can have easy access to standardized material.
@HajiJumana to standardise training, and streamline the ELSO endorsement process, would help if ELSO puts up some pre-endorsement guidelines and prerequisites for newer centres to model their training on the website.
@HajiJumana It would help if ELSO puts up some pre endorsement guidelines and prerequisites for newer centres to model their training on the website. This would help to standardise training and streamline the endorsement process.
@KrKrramanathan certainly some thing to ponder about!
@FOAMecmo Seems ELSO ECMOed advices needed for “young” ECMO centers to adapt/organize ECLS education! meanwhile , consider checking the ELSO ECMO specialists education & training guidelines, open access and the the ELSO guidelines for ECMO centers, open access.
@ECMOed For all centers/groups interested in or willing to ask for ELSO ECMOed endorsement, to ensure potential learners ELSO standard is met for your ECMO courses, simulation-based courses, workshops, check our
dedicated post

Learning from other ECMO education experiences

@ArpanCh21458537 We have to think for the awareness educations to the General practitioners. They should be properly educated also regarding the timing of referral. They are the backbones of Indian Healthcare system. Short courses on ECMO can be designed for them also.
@bishoy_zakhary This is an important suggestion that can have a significant impact on ECMO outcomes. ECMO Workshops targeting the Non-ECMO Practitioner is a great idea. Do you have this?
@ArpanCh21458537 I am doing regular awareness campaigns to the various suburbs and districts. A gathering of local practitioners are interacting with us. Basic discussions on ECMO and its success stories are shared with them for early referrals. Sometimes We are engaging survivors.
@bishoy_zakhary This is a good effort – especially with involvement from prior patients and families!
@MooreElizabethA this could be an excellent idea to engage survivors. We have much to learn of their experiences post ECMO!
@gracebichara My previous program in Brasil has a 1 day course for pediatric intensivist 2-3 times a year. We have amazing feedback! We focus on indications, #ECMO basics, outcomes, etc.
@ecmocare At ECMO Kolkata we conduct awareness programmes for GPs, do basic training of residents, fellows and attendings at Med schools of the region. They participate more in case based discussion. Interested young minds come over to witness live cases. ECMO isn’t part of basic clinical curriculum in Med Schools yet. We can make basic #ECMO knowledge compulsory in undergrads and basic proficiency in ECMO in Residencies and fellowships (pediatrics, anesthesia, medicine, pulmonology, critical care, cardiac surgery). I fully agree to fact that ECMO education should be standardised and supported. The ECMOedPP is the right initiative. But we need to further structure the initiative.
@bishoy_zakhary How would you envision structuring the initiative?
@ecmocare The ESOI ECMO Society of India fellowship structure can be followed. There online webinars, log books, thesis, compulsary attendance of one comprehensive #ECMO workshop and a conference, 15 days training in an ECMO center, live case videos and discussions
@kshekar01 This can be well embedded in a hub abs spoke model
@ecmocare Can we have a definitine course like the ACLS/BLS model as well have the same literature circulated in every #ECMO workshop?
@kshekar01 One possible model as it’s a lot of effort to design and run courses and it’s wasted energy , time and money for everyone to write their own content
@bishoy_zakhary We are trying to implement something similar to the BLS/ACLS model by using ELSO Course Endorsement to increase the reach and impact of the ECMO curriculum worldwide. What are your thought on the effectiveness?
@kshekar01 This is something we can test in the research domain.
@KrKrramanathan interesting thought. We are trying streamlining this aspect at ELSO ECMOed. What should be the content of the course, duration of the course, how to assess participants and how to certify? We are getting there.

@HajiJumana I’m sharing the results of an ongoing survey I am conducting in India. Lack of training, lack of physician and patient awareness about ECMO as treatment option pretty in India, and lack of ELSO-registered centers, observed.
@kshekar01 Great work: there is huge opportunity here for ELSO ECMOed, SWAAC ELSO, APELSO to collaborate with the ECMO community in India and work on many of these identified areas.

(Most) active participants & their twitter handles (alphabetical order)

Ahmed Rabie @succenyl
Arpan Chakraborty @ArpanCh21458537
Bishoy Zakhary @bishoy_zakhary
Chris Nickson @precordialthump
Dipanjan Chatterjee @ecmocare
Elizabeth A. Moore @mooreelizabetha
Grace Bichara @Gracebichara
Guillaume Alinier @g_alinier
Hergen Buscher @HerxxAU
Jeannie Kukutschka @jkukutschka
Jenelle Badulak @JenelleBadulak
Jumana Haji @HajiJumana
Kiran Shekar @kshekar01
Mamoon @mamoon
Ramanathan KR @KrKrramanathan
Rodrigo Diaz @EcmoDiaz
Shaun Thompson @slthomps12
Velia Antonini @FOAMecmo

ELSO @ELSOOrg
ELSO ECMOed @ECMOed
APELSO @APELSO.org
EuroELSO @EuroELSO
LATAM ELSO @ElsoLatam
SWAAC ELSO @Swaacelso

ECMOedPP twitter chat!

Global ECMO education & agenda for the future: read the ELSO ECMOed Taskforce position paper on Critical Care Medicine at http://bit.ly/ECMOedpospaper
& prepare your questions/comments! a dedicated twitter chat under the hashtag #ECMOedPP will be held on Jan 9 2020, with all the ECMOed Workgroups representatives and members! at
9.00 -10.00 pm CST
10.00 – 11.00 pm EST
7.00 – 8.00 pm PST
4.00 – 5.00 am CET/3.00 – 4.00 am UTC/GMT (Jan 10)
2.00 – 3.00 pm AEDT (Jan 10)
etc…

Are you inexperienced with twitter & twitter chats?? in the picture some advices… do not forget to mention ELSO @ECMOed & add the official hashtag #ECMOedPP in all your replies, questions, comments!!

First authors Bishoy Zakhary @bishoy_zakhary & Kiran Shekar @kshekar01
Chat moderator Velia Antonini @foamecmo
Critical Care Medicine twitter account @CritCareMed

Here twitter handles of ECMOed members (alphabetical order!)
Ait Hssain: @AiHssain
Assad Sassine: @Assad_sassine
Bishoy Zakhary: @bishoy_zakhary
Cara Agerstrand: @caraagerstrand
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ECMO year in review: veno-venous ECMO

VV-ECMO: reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures; a review summarizing results of most recent trials and elaborating on the unmet needs: future trials should be designed to optimize patients management while on extracorporeal support.

Schmidt M, Franchineau G, Combes A. Recent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Curr Opin Crit Care. 2019 Feb;25(1):71-76. link

ECMO & ECCO2R for acute respiratory failure, a review: terminology, basics of ECLS, indications, potential indications and contraindications, goals & complications, regionalization at expert centers & mobile ECLS, historical perspective & future, current and future research priorities. Extracorporeal support evolved rapidly in recent years from niche technology to a mainstream strategy of respiratory & (right) heart support: as development of new ECLS technologies holds the promise of changing the approach respiratory failure, and role of ECLS will no doubt continue growing, the need for high-quality research to guide this evolution has never been greater.

Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA. 2019 Aug 13;322(6):557-568. link

A systematic literature review about animal models combining features of experimental ARDS with ECMO, developed to support translational research, to better understand this complex setting: significant heterogeneity in both design & reporting creates difficulty in assessing results and in generalizing findings to clinical settings. The introduction of a minimum data set for pre-clinical ECMO studies could achieved the standardization of reporting.

Millar JE, Bartnikowski N, von Bahr V, Malfertheiner MV, Obonyo NG, Belliato M, Suen JY, Combes A, McAuley DF, Lorusso R, Fraser JF; European Extracorporeal Life Support Organisation (EuroELSO) Innovations Workgroup; National Health Medical Research Council Australia Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving Organ Support (NHMRC CREACTIONS). Extracorporeal membrane oxygenation (ECMO) and the acute respiratory distress syndrome (ARDS): a systematic review of pre-clinical models. Intensive Care Med Exp. 2019 Mar 25;7(1):18. doi: 10.1186/s40635-019-0232-7 Open access link

Veno-venous extracorporeal support: from rescue high-flow VV ECMO, to low-flow or minimally invasive ECCO2R. In this open access review, options for VV ECLS, from cannulation to blood flow; rationale of the different settings, from rescue intervention for tissue hypoxia, primarily due to respiratory failure, to reduction of mechanical ventilation and related damages in ARDS, status asthmaticus, COPD exacerbation; timing: when to start and when to stop extracorporeal gas exchange.

Gattinoni L, Vassalli F, Romitti F, Vasques F, Pasticci I, Duscio E, Quintel M. Extracorporeal gas exchange: when to start and how to end? Crit Care. 2019 Jun 14;23(Suppl 1):203. Open access link

Mechanical ventilation on ECMO support

Should patients with ARDS on veno-venous ECMO have ventilatory support reduced to the lowest tolerable settings? here a debate…

How to manage MV in ARDS patients on VV ECMO? The lower, the better?? yes according to this perspective: as extracorporeal support facilitate protective ventilation, reducing ventilatory support to the lowest tolerable seems prudent, as best available evidence suggests no safe ventilatory limits exist, & lower settings associated with improved outcomes… waiting data from studies evaluating different ventilatory strategies in this population.

Zakhary B, Fan E, Slutsky A. Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? Yes. Crit Care Med. 2019 Aug;47(8):1143-1146. link

Here a different viewpoint of extreme reduction in ventilatory settings in patients on VV #ECLS! Do not ignore potential risks of extreme reduction in MV settings on VV ECMO! No controversy on trying to limit the mechanical power delivered to the lungs, minimizing the risk of VILI. Achieving this, eg through proning, decreasing plateau & driving pressures, avoiding excessive PEEP, is paramount on extracorporeal support,… but risk-to-benefit ratio of maximal lung rest strategies warrant further consideration. In this paper, different viewpoint on how to manage mechanical ventilation in ARDS patients on veno-venous ECLS.

Shekar K, Brodie D. Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? No. Crit Care Med. 2019 Aug;47(8):1147-1149. link

Breathing & ventilation on ECMO support, how to find the balance between rest and load?? What creates the best conditions for the lungs, used to rhythmically expanding & relaxing, to heal, more rest or more movement?
How much unloading of the lungs is most beneficial for healing and repair in ARDS patients on ECLS, and what’s best ventilatory pattern on ECMO support? Some considerations about LIFEGARDS study, ventiLatIon management oF patients with Extracorporeal membrane oxyGenation for Acute Respiratory Distress Syndrome, an international prospective study about current practices regarding MV in patients on ECLS for severe ARDS.

Quintel M, Busana M, Gattinoni L. Breathing and Ventilation during Extracorporeal Membrane Oxygenation: How to Find the Balance between Rest and Load. Am J Respir Crit Care Med. 2019 Oct 15;200(8):954-956. Open access link

(this the link to the LIFEGARDS study by Schmidt et al.)

Mechanical ventilation on ECLS in ARDS: goal? decrease its intensity to reduce ventilator-induced lung injury, major contributor to morbidity & mortality, maximizing potential benefit of ECMO support, allowing for reducing the mechanical forces contributing to VILI. All conventional management strategies as lung-protective MV, prone positioning, PEEP titration, conservative fluid balance, and (perhaps) neuromuscular blockade should be optimized before consideration of extracorporeal support. MV strategies employed in the EOLIA trial represent a reasonable standard of care on ECMO, although authors suggest lower respiratory rates.

Abrams D, Schmidt M, Pham T, Beitler JR, Fan E, Goligher EC, McNamee JJ, Patroniti N, Wilcox ME, Combes A, Ferguson ND, McAuley DF, Pesenti A, Quintel M, Fraser J, Hodgson CL, Hough CL, Mercat A, Mueller T, Pellegrino V, Ranieri VM, Rowan K, Shekar K, Brochard L, Brodie D; International ECMO Network (ECMONet). Mechanical Ventilation for ARDS During Extracorporeal Life Support: Research and Practice. Am J Respir Crit Care Med. 2019 Nov 14. link

Lung recruitability in severe ARDS on ECMO support: may greater potential for lung recruitment be associated with more favorable outcome? wide range of recruitability observed in this study in patients with severe acute respiratory distress syndrome requiring ECLS; high potential for lung recruitment associated with shorter ICU stay & shorter ECMO run.

Camporota L, Caricola EV, Bartolomeo N, Di Mussi R, Wyncoll DLA, Meadows CIS, Amado-Rodriguez L, Vasques F, Sanderson B, Glover GW, Barrett NA, Shankar-Hari M, Grasso S. Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. Crit Care Med. 2019 Sep;47(9):1177-1183. link

Resting the lungs with ultra-protective MV on ECMO? According to the results of this single center RCT studying mechanical ventilation strategies to limit injuries & protecting the lung of patients with severe ARDS on veno-venous ECMO, an ultra-protective ventilation strategy, based on significantly decreased plateau pressure, driving pressure and Vt (markedly lowered from 5.7 mL/kg PBW to 3.3 mL/kg PBW), led to significantly reduced pulmonary biotrauma vs standard protective-lung ventilation, once on ECLS. However, plasma cytokine and bronchoalveolar lavage sRAGE levels did not differ among the different MV settings tested during the run.

Rozencwajg S, Guihot A, Franchineau G, Lescroat M, Bréchot N, Hékimian G, Lebreton G, Autran B, Luyt CE, Combes A, Schmidt M. Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. Crit Care Med. 2019 Nov;47(11):1505-1512. link

Integrating MV & ECMO in severe ARDS open access commentary…
Shekar K, Schmidt M. Integrating Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2019;200(2):265–266. Open access link

to this study testing the old concept of near apneic ventilation and its effects on lung injury/fibroproliferation in an experimental model of severe ARDS on veno-venous ECLS
Araos J, Alegria L, Garcia P, Cruces P, Soto D, Erranz B, Amthauer M, Salomon T, Medina T, Rodriguez F, Ayala P, Borzone GR, Meneses M, Damiani F, Retamal J, Cornejo R, Bugedo G, Bruhn A. Near-Apneic Ventilation Decreases Lung Injury and Fibroproliferation in an Acute Respiratory Distress Syndrome Model with Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med. 2019 Mar 1;199(5):603-612. link

… and the authors’ reply Araos J, Bruhn A. Reply to Shekar and Schmidt: Integrating Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2019;200(2):266. Open access link

Current practices regarding MV in patients treated with ECMO support for severe ARDS in this international, multi-center, prospective cohort study: ultra-protective lung ventilation on ECMO largely adopted across medium to high case-volume centers; vs previous observations, no association with prognosis.

Schmidt M, Pham T, Arcadipane A, Agerstrand C, Ohshimo S, Pellegrino V, Vuylsteke A, Guervilly C, McGuinness S, Pierard S, Breeding J, Stewart C, Ching SSW, Camuso JM, Stephens RS, King B, Herr D, Schultz MJ, Neuville M, Zogheib E, Mira JP, Rozé H, Pierrot M, Tobin A, Hodgson C, Chevret S, Brodie D, Combes A. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019 Oct 15;200(8):1002-1012. link

Tracheostomy on ECMO support

Investigating the safety of tracheostomy placement on ECMO support, and its impact on fluid intake & on the use of sedative, analgesic, vasoactive drugs: in this single-center experience, TT may result in a reduction in vasopressor and inotropic requirement, and analgesic usage, with no increase in major bleedings, and can be safely performed in selected ECLS patients in whom benefits outweigh the risks.

Grewal J, Sutt AL, Cornmell G, Shekar K, Fraser J. Safety and Putative Benefits of Tracheostomy Tube Placement in Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience. J Intensive Care Med. 2019 Mar 21:885066619837939. link

here a comment: Lother A, Bode C, Staudacher DL. Tracheostomy in Patients on Extracorporeal Membrane Oxygenation: Is it Really Safe? J Intensive Care Med. 2019 May 23:885066619851067. link

and, in the authors’ reply, steps to enhance procedure safety. Grewal J, Sutt AL, Shekar K, Fraser JF. Steps to Enhance Safety of Tracheostomy on ECMO. J Intensive Care Med. 2019 May 19:885066619851074. link

Tracheostomy on ECMO support: in this experience with open & percutaneous tracheostomies in 127 ECLS patients (largest series to date), the procedure appears safe as performed by an experienced team at an experienced center; excellent outcome reported, with no procedural mortality or significant morbidity. Periprocedural maintenance, or short suspension, of systemic anticoagulation seems not to be associated with significant bleeding or thrombotic events.

Salna M, Tipograf Y, Liou P, Chicotka S, Biscotti M 3rd, Agerstrand C, Abrams D, Brodie D, Bacchetta M. Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support. ASAIO J. 2019 Aug 16. link

RV & hemodynamics on VV-ECMO

RV hypertrophy: common in patients with acute respiratory distress syndrome on VV ECMO; this finding could be related to persistent increased right ventricular afterload (a well-known contributor for the development of hypertrophy), but mechanism(s) involved in its genesis are still to be elucidated. RV hypertrophy may predispose to RV ischemia or infarction, worsening outcome, and this condition may influence clinical management. Here findings from a case series, suggesting that RV hypertrophy is common in #ARDS pts before extracorporeal support, and that it could increase after #ECLS implementation; also, some, but not all, the normal RVs become hypertrophied on ECMO support, maybe indicating other factors beyond increased afterload likely contribute to RV hypertrophy.

Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Chiostri M, Fulceri G, Peris A. Right Ventricular Hypertrophy in Refractory Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth. 2019 Aug 27. link

Routine echocardiographic assessment of RV size & function in patients with severe acute respiratory distress syndrome requiring veno-venous ECMO? it would be advisable, given the importance of right ventricular dysfunction and acute cor pulmonale for managing this population & prognosticating outcomes. Here, ultrasound data from a large cohort.

Pettenuzzo T, Pichette M, Douflé G, Fan E, Right Ventricular Hypertrophy in Patients Undergoing Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. J Cardiothorac Vasc Anesth. 2019. link

Hemodynamic monitoring on VV ECMO, could be challenging! a couple of papers here…CO estimation? mandatory to assess cardiac function and to evaluate BF/CO ratio; authors of this study report good agreement/low percentage of error between an uncalibrated pulse-contour analysis and TTE measurements; a pulsewave-derived method can be provide continuous cardiac output monitoring, integrating echocardiography (with POCUS providing lot additional information, even if non-continuous!!).

Bond O, Pozzebon S, Franchi F, Zama Cavicchi F, Creteur J, Vincent JL, Taccone FS, Scolletta S. Comparison of estimation of cardiac output using an uncalibrated pulse contour method and echocardiography during veno-venous extracorporeal membrane oxygenation. Perfusion. 2019 Nov 10:267659119883204. link

Transpulmonary thermodilution? in this analysis a marked increases in global end-diastolic volume index, GEDVI, & extra-vascular lung water index, EVLWI, have been observed after ECMO implementation, more pronounced in case of femoral vs jugular indicator injection; these findings are consistent with the hypothesis of a potential loss of indicator into the extracorporeal circuit; CI & haemodynamic parameters not derived from TPTD seems not substantially affected.

Herner A, Lahmer T, Mayr U, Rasch S, Schneider J, Schmid RM, Huber W. Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit. J Clin Monit Comput. 2019 Nov 5. link

Awake ECMO

ECMO support… it’s not just about the technique! this group describes an unconventional not-medication based successful intervention to manage anxiety in an awake patient on veno-venous ECLS.

Blair GJ, Kapil S, Cole SP, Rodriguez S. Virtual reality use in adult ICU to mitigate anxiety for a patient on V-V ECMO. J Clin Anesth. 2019 Aug;55:26-27. link

Awake neonatal ECMO support? may offer significant advantages over traditional management in certain scenarios! In this open assess report of cases appears safe, preventing MV induced lung/airway trauma, and could solve air leaks with no invasive drainage, enable de-sedation, and limit deconditioning, while improving family bonding. Awake neonatal ECMO is a practice requiring significant team preparation, commitment & readiness/capacity to manage evolution, and family support, along with careful balance of the potential risks versus benefits on individualized basis, considering anticipated duration of ECLS run.

Costa J, Dirnberger DR, Froehlich CD, Beaty CD, Priest MA, Ogino MT. Awake Neonatal Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Jul 12. link

Sedation & analgesia on ECMO support

An international survey to assess practices regarding the monitoring & management of pain, agitation, delirium in adults on VV ECMO for severe ARDS beyond initial cannulation. Most respondents reported use of validated scales to assess, along with protocols (although very few addressing this population) to help with management. Targeting a deep level of sedation, and propofol being used for any level of sedation were mostly referred. More than half of respondents, commonly from high-volume centers, reported extubation during the veno-venous ECLS run.

Dzierba AL, Abrams D, Madahar P, Muir J, Agerstrand C, Brodie D. Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation. J Crit Care. 2019 Oct;53:98-106. link

Sedation in neonates on ECMO support: not well described & no universal guidelines; this retrospective analysis examines types & median doses, describing practices for neonatal patients requiring ECLS. Opioids and benzodiazepine frequently administered, and some patients also required adjunct therapies to maintain desired level of sedation. Most commonly used continuous infusions included morphine, midazolam, hydromorphone, sometimes dexmedetomidine & ketamine; doses typically escalated over time. Pain scores did not correlate with sedation or analgesic administrations. According to the authors, an ECMO dedicated sedation assessment tool & RN driven algorithm may better determine sedation use in this population.

Franciscovich CD, Monk HM, Brodecki D, Rogers R, Rintoul NE, Hedrick HL, Ely E. Sedation Practices of Neonates Receiving Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Aug 6. link

Individualizing Sedation in ARDS patients on ECMO support.
Shekar K, Grewal J, Lisa Sutt A, Fraser J. Individualizing Sedation in Acute Respiratory Distress Syndrome Patients on Extracorporeal Membrane Oxygenation. ASAIO J. 2019 May/Jun;65(4):e44-e45. Open access link

a comment to this (2018) study aiming to characterize sedation management in adults with severe respiratory distress syndrome treated with veno-venous ECLS
deBacker J, Tamberg E, Munshi L, Burry L, Fan E, Mehta S. Sedation Practice in Extracorporeal Membrane Oxygenation-Treated Patients with Acute Respiratory Distress Syndrome: A Retrospective Study. ASAIO J. 2018 Jul/Aug;64(4):544-551. Open access link

& the authors’ reply
deBacker J, Fan E, Mehta S. Individualizing and Minimizing Sedation on Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Patients, a Reply. ASAIO J. 2019 May/Jun;65(4):e46.Open access link

Predicting and improving survival

Physiologic variables at the start and during the ECMO run to understand & describe clinical evolution in severe ARDS. Trend of specific parameters might provide prognostic indications along the course of extracorporeal support, and could be used to monitor the evolution of lung injury and differentiate survivors vs non survivors. In this retrospective observation, worsening extrapulmonary organ dysfunction seems associated with mortality, potentially prompting to reconsider the utility of ECLS.

Spinelli E, Mauri T, Carlesso E, Crotti S, Tubiolo D, Lissoni A, Bottino N, Panigada M, Tagliabue P1, Rossi N, Scotti E, Conigliaro F, Gattinoni L, Grasselli G, Pesenti A. Time-Course of Physiologic Variables During Extracorporeal Membrane Oxygenation and Outcome of Severe Acute Respiratory Distress Syndrome. ASAIO J. 2019 Jul 12. link

A network meta-analysis to compare & rank different therapeutic strategies, identifying the interventions associated with a reduction in mortality in adults with moderate to severe ARDS. Among 25 randomized clinical trials evaluating 9 interventions, prone positioning & veno-venous ECMO associated with significantly lower 28-day mortality, compared with lung protective MV alone. These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other.

Assessment of Therapeutic Aoyama H, Uchida K, Aoyama K, Pechlivanoglou P, Englesakis M, Yamada Y, Fan E. Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis. JAMA Netw Open. 2019 Jul 3;2(7):e198116. Open access link

Veno-venous ECMO support for respiratory failure: Do we need to consider age? according to the results of this retrospective, single center study, including 182 pts, age is an independent predictor of survival to discharge, with in-hospital mortality increasing incrementally over 45 years of age. Patients <45 years have significantly greater survival (84.6%.) vs patients ≥45 years (67%;), as those ≥55 years (57.1%). Patients 65 years & older have very low rates of survival (16.7%), and authors suggest to carefully weight the decision to implement VV ECLS in this population.

Deatrick KB, Mazzeffi MA, Galvagno SM Jr, Tesoriero RB, Kaczoroswki DJ, Herr DL, Dolly K, Rabinowitz RP, Scalea TM, Menaker J. Outcomes of Venovenous Extracorporeal Membrane Oxygenation When Stratified by Age: How Old Is Too Old? ASAIO J. 2019 Nov 18. link

Does Weight Matter in ECLS? Outcomes of VV ECMO support for acute hypoxic or hypercarbic respiratory failure in adults: to in this single center observation, no differences in survival to discharge or length of stay were detected as patients are stratified by BMI; evidence for the “obesity paradox” in this population may be supported by these data. Authors suggest that obesity alone should not exclude candidacy for ECMO.

Galvagno SM Jr, Pelekhaty S, Cornachione CR, Deatrick KB, Mazzeffi MA, Scalea TM, Menaker J. Does Weight Matter? Outcomes in Adult Patients on Venovenous Extracorporeal Membrane Oxygenation When Stratified by Obesity Class. Anesth Analg. 2019 Oct 28. link

A review of the ELSO Registry data on prolonged extracorporeal support (≥14 days) in patients with respiratory failure, aiming to identify specific predictors of mortality, and including ECMO complications in a new predictive model, to improve discrimination, assisting in determination of which patients should continue the run. According to the Registry, prolonged support is required for ~1 in every 5 adult patients on ECMO for respiratory failure, and 51.3% will survive to discharge. Although survival in prolonged ECLS is 10% less than shorter runs patients, there has been a significant improvement in survival in recent years. Expansion of the ELSO registry for additional data collection in prolonged ECMO patients could furtherly advance understanding of factors potentially impacting on outcome.

Posluszny J, Engoren M, Napolitano LM, Rycus PT, Bartlett RH; ELSO member centers. Predicting Survival of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Sep 30. link

Extended veno-venous ECMO for ARDS/ARF have similar survival rates vs short ECMO runs: time on extracorporeal support should not be the sole determining factor to stop ECLS, consider overall clinical conditions, including eventual MOF, & reversibility of the lung disease! Data from a high volume ECMO referral center.

Menaker J, Rabinowitz RP, Tabatabai A, Tesoriero RB, Dolly K, Cornachione C, Stene E, Buchner J, Kufera J, Kon ZN, Deatrick KB, Herr DL, O’Connor JV, Scalea TM. Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: How Long Is Too Long? ASAIO J. 2019 Feb;65(2):192-196. link

Is muscle mass an important factor in the potential for recovery & outcome of patients requiring ECMO support for severe respiratory failure?? in this large retrospective observation, sarcopenia predicted worse 1 year mortality in pts who underwent veno-venous ECLS.

Cho WH, Choi YY, Byun KS, Lee SE, Jeon D, Kim YS, Han J, Yeo HJ. Prognostic Value of Sarcopenia for Long-Term Mortality in Extracorporeal Membrane Oxygenation for Acute Respiratory Failure. ASAIO J. 2019 Apr 18. link

Interesting case reports, series & experiences with selected indications

605 days (20 months!) on extracorporeal support for total acute lung failure & associated RV failure: read about the long journey to recovery of lung & heart function, 3 years after profound injury, through five different configuration of ECLS, from veno-arterial to veno-venous ECMO, then RVAD + membrane lung, & finally extracorporeal CO2 removal. A pediatric case report from the Johns Hopkins University School of Medicine.

Nelson-McMillan K, Vricella LA, Stewart FD, Young J, Shah AS, Hibino N, Coulson JD. Recovery from Total Acute Lung Failure After 20 Months of Extracorporeal Life Support. ASAIO J. 2020 Jan;66(1):e11-e14. Open access link

Extracorporeal support targeting for hypocapnia (25–30 mmHg) to reduce respiratory drive/effort in thoracic trauma, allowing for internal pneumatic stabilization and healing with synchronous positive pressure mechanical ventilation: open access case of an awake and cooperative patient with extensive bilateral flail chest (21 rib fractures) undergoing ECMO for bilateral pulmonary contusions & ARDS for 2 weeks and low-flow ECCO2R for the last 4 weeks with active rehabilitation. Extracorporeal carbon dioxide removal targeting hypocapnia is a potential adjunct in extensive flail chest injury undergoing nonsurgical management avoiding paradoxical movement and impairment of recovery.

Wells AH, Oswald TJ, Samra N, Scott LK, Conrad SA. Extracorporeal Carbon Dioxide Removal in the Management of Complex Bilateral Flail Chest Injury. ASAIO J. 2019 Sep/Oct;65(7):e75-e77. Open access link

Traumatic tracheo-bronchial injuries: potentially life-threatening conditions requiring early approach to provide adequate gas exchange. ECMO support represents a life-saving safe an effective additional arrow, when emergent intubation of the distal trachea and conventional MV is impossible, useful to both surgeon & anesthesiologist/intensivist to manage patients with severe airway lesions until/during repair. Report of a case of traumatic intrathoracic tracheal transection, with experts considerations about cannulation approach and configuration, intra & postoperative anticoagulation, cardio-pulmonary bypass CPB option.

Carretta A, Ciriaco P, Bandiera A, et al. Veno-venous extracorporeal membrane oxygenation in the surgical management of post-traumatic intrathoracic tracheal transection. J Thorac Dis. 2018;10(12):7045–7051. Open access link

& its comment. Aprile V, Korasidis S, Ambrogi MC, Lucchi M. Extracorporeal membrane oxygenation in traumatic tracheal injuries: a bold life-saving option. J Thorac Dis. 2019;11(7):2660–2663. link

ECMO assisted intratracheal tumor resection & carina reconstruction to support gas exchange without tracheal intubation, maintaining a clearly visible surgical field and improving the accuracy of anastomosis: simple & safe technique compared to traditional methods according to this case report!

Qiu Y, Chen Q, Wu W, Zhang S, Tang M, Chen Y, Zhang C, Zhou N, Jiang N, Feng J, Xia M, Wang H. Extracorporeal membrane oxygenation (ECMO)-assisted intratracheal tumor resection and carina reconstruction: A safer and more effective technique for resection and reconstruction. Thorac Cancer. 2019 May;10(5):1297-1302. Open access link

Emergency laparotomy to manage acute intrabdominal pathologies while on ECMO support for severe respiratory failure: prevalence, outcomes & complications of this high risk procedure in a high volume ECLS experienced center. Most patients presenting with acute abdomen signs, and found to have bowel ischemia requiring resection. Survival feasible but mortality higher vs patients not requiring laparotomy (supposed to be related to the severity of underlying organ failure). Authors suggest considering access to general surgery when planning to provide ECMO support.

McCann C, Adams K, Schizas A, George M, Barrett NA, Wyncoll DLA, Camporota L. Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study. J Crit Care. 2019 Oct;53:253-257. link

Drainage failure/lowering BF in severe #trauma patient on veno-venous ECMO support (TRALI + lung contusion) what would you do? consider measuring intra-abdominal pressure IAP & go for decompressive laparotomy if needed!

Matsumoto S, Morizane M, Matsuo K, Yamazaki M, Kitano M. Pitfalls when using extracorporeal life support in trauma patients. Trauma Surg Acute Care Open. 2019;4(1):e000298. Open access link

ECLS in respiratory failure for polytrauma patients: data collected from the 5 UK Respiratory ECMO centers suggest that does not exacerbate primary injury, even if anticoagulation administration is initiated, & may confer a survival benefit. Authors suggest not to consider neurological injury as an absolute contraindication to extracorporeal support in this population.

Kruit N, Prusak M, Miller M, Barrett N, Richardson C, Vuylsteke A. Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review. J Trauma Acute Care Surg. 2019 Jun;86(6):967-973. link

ECMO in foreign body aspiration: case series, review of the ELSO Registry, & systematic literature review; ECLS feasible and safe to stabilize children with life-threatening FBA before, during, after bronchoscopic removal, and the early use of extracorporeal support can improve the outcome increasing survival of these critically ill patients.

Anton-Martin P, Bhattarai P, Rycus P, Raman L, Potera R. The Use of Extracorporeal Membrane Oxygenation in Life-Threatening Foreign Body Aspiration: Case Series, Review of Extracorporeal Life Support Organization Registry Data, and Systematic Literature Review. J Emerg Med. 2019 May;56(5):523-529. link

Beta-blockers administration in refractory hypoxemia on VV ECMO, to decrease the Extracorporeal Blood Flow/Cardiac Output ratio, decrease the intra-pulmonary shunt & also provide myocardial protection. In this experience, BB therapy appears well tolerated and resulted in a significant increase in arterial oxygenation (but this may not increase DO2, due to the CO reduction).

Bunge JJH, Diaby S, Valle AL, Bakker J, Gommers D, Vincent JL, Creteur J, Taccone FS, Reis Miranda D. Safety and efficacy of beta-blockers to improve oxygenation in patients on veno-venous ECMO. J Crit Care. 2019 Oct;53:248-252. link

but maybe also consider advanced hemodynamic monitoring… a reply Giani M, Bronco A, Bosa L, Rona R, Foti G. Beta blockers during veno-venous ECMO to improve oxygenation: A case report. J Crit Care. 2019 Dec;54:269-270. link

Extended ECMO as bridge to lung transplantation: appropriate use of a precious resource? yes, according to this experience! Successful Tx after extracorporeal support could be achieved, with similar survival in high-risk recipients as in patients without ECMO, even in patients with prolonged runs: BTT time of less than 30 days seems crucial for success; the ECLS team experience and graft quality may be important factors for favorable outcome. Encouraging outcome in the (small) proportion of awake ECMO-BTT.

Langer F, Aliyev P, Schäfers HJ, Trudzinski FC, Seiler F, Bals R, Wilkens H, Lepper PM. Improving Outcomes in Bridge-to-Transplant: Extended Extracorporeal Membrane Oxygenation Support to Obtain Optimal Donor Lungs for Marginal Recipients. ASAIO J. 2019 Jul;65(5):516-521. link

2 decades of experience with ECLS as bridge to lung #transplantation: #ECMO support from an acute rescue therapy to a semi-elective procedure; stratified outcome analysis of this large institutional database revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.

Benazzo A, Schwarz S, Frommlet F, Schweiger T, Jaksch P, Schellongowski P, Staudinger T, Klepetko W, Lang G, Hoetzenecker K; Vienna ECLS Program. Twenty-year experience with extracorporeal life support as bridge to lung transplantation. J Thorac Cardiovasc Surg. 2019 Jun;157(6):2515-2525.e10. link

Extracorporeal Life Support for severe Legionella pneumonia: appears associated with a high rate of survival, permitting diagnostic evaluation & time for antibiotics to exert effect; early ECLS may improve outcomes in this subset of patients. ECMO support is a beneficial tool for appropriate candidates with rare disease and the ELSO registry may be a helpful depot for information about these experiences.

Dorfman MV, Clark JD, Brogan TV. ECLS for Legionella: All Ages Welcome in the ELSO Registry. ASAIO J. 2019 Mar 13. link

Extracorporeal CO2 removal

Physiology & technique of extracorporeal CO2 removal: physiology of carbon dioxide, control of respiratory drive, ECCO2R systems and cannulas, pump technology, membrane lung technology, blood flow rates/treatment goals.

Karagiannidis C, Hesselmann F, Fan E. Physiological and Technical Considerations of Extracorporeal CO2 Removal. Crit Care. 2019 Mar 9;23(1):75. Open access link

Feasibility & safety of extracorporeal carbon dioxide removal to facilitate ultraprotective ventilation, VT 4 mL/kg and PPLAT ≤ 25 cmH2O in patients with moderate acute respiratory distress syndrome ARDS: The SUPERNOVA (Strategy of Ultra-Protective lung ventilation with Extracorporeal CO2 Removal for New-Onset moderate to severe ARDS) study results demonstrating that ultra-protective ventilation supported by ECCO2R is feasible & mitigates respiratory acidosis.

Combes A, Fanelli V, Pham T, Ranieri VM; European Society of Intensive Care Medicine Trials Group and the “Strategy of Ultra-Protective lung ventilation with Extracorporeal CO2 Removal for New-Onset moderate to severe ARDS” (SUPERNOVA) investigators. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med. 2019 May;45(5):592-600. Open access link

Here, the secondary analysis of SUPERNOVA study. Data suggest decreasing VT to 4 mL/ kg & PPLAT to ≤25 of cmH2O are consistently achievable only with higher extraction ECCO2R devices. According to the authors opinion, future RCTs assessing benefit/harm of ultraprotective MV should be carried out with larger membrane lungs & blood flows between 800 and 1000 mL/min.

Combes A, Tonetti T, Fanelli V, Pham T, Pesenti A, Mancebo J, Brodie D, Ranieri VM. Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study. Thorax. 2019 Dec;74(12):1179-1181. link

Continuous monitoring of membrane lung CO2 removal on ECMO: does it help in estimating the oxygenator performance, in terms of V’CO2ML & VDsML? Results of an experimental in-vivo model of veno-arterial ECLS testing a capnometer prototype.

Montalti A, Belliato M, Gelsomino S, Nalon S, Matteucci F, Parise O, de Jong M, Makhoul M, Johnson DM, Lorusso R. Continuous monitoring of membrane lung carbon dioxide removal during ECMO: experimental testing of a new volumetric capnometer. Perfusion. 2019 Oct;34(7):538-543. link