ECMO FOR COVID-19

PRESENTER : DR UMMU YASMIN
SUPERVISOR : DR FITRY

Objectives:

  • ECMO techniques
  • Outcomes of ECMO
  • Indication/Contraindication of ECMO
  • Management strategy in ECMO
  • Pathophysiology of severe COVID-19 patients and ECMO-related therapeutic effects and complications
  • ECMO related complications in COVID-19 patients

Learning points:

  • Describe indications of ECMO in management of severe respiratory or circulatory failure.
  • Address considerations in general management of the patient on ECMO.
  • Recognize major indications and contraindications of venovenous ECMO.
  • Identify common problems and major complications of ECMO.
  • Differentiate the interaction ECMO has on various patient organ systems.

Discussion:

  • There are two types of ECMO, venovenous (VV) and venoarterial (VA). VV ECMO is used in patients with respiratory failure, while VA ECMO is used in patients with cardiac failure. 

 

  • Reasonable target for ECMO:
    • An arterial oxyhaemoglobin saturation of >90 percent for VA ECMO, or >75 percent for VV ECMO
    • A venous oxyhaemoglobin saturation 20 to 25 percent lower than the arterial saturation
    • Adequate tissue perfusion, as determined by the arterial blood pressure, venous oxygen saturation, and blood lactate level
    • Anticoagulation is sustained during ECMO
    • Platelet counts should be maintained greater than 50,000/microliter
    • Haemoglobin is maintained over 12 g/dL in ECMO patients 
    • Plateau airway pressures should be maintained less than 20 cm H2O and FiO2 less than 0.5
    • early tracheostomy 

 

  • CESAR trial-The group referred to the ECMO centre had significantly increased survival without disability at six months compared to conventional management (63 versus 47 %). 

 

  • EOLIA-ECMO resulted in improved oxygenation, more days free of renal failure (46 versus 21%), and fewer patients with ischemic stroke (0 versus 5 %). 



  • ECMO is the only recourse available if conventional therapy fails. It permits ultra-lung-protective strategies on mechanical ventilation, avoiding ventilator-induced lung injury while allowing the pulmonary parenchyma and function to recover with time.

 

  • Indications of ECMO in COVID-19: 
    • Severe acute respiratory distress syndrome with PaO2:FiO2 ratio < 100 despite high positive end-expiratory pressure (8–10 cm H2O) and FiO2 > 80%
    • Trial of paralytics and prone positioning attempted

 

  • Absolute contraindications in ECMO:
    • Advanced age
    • Clinical Frailty Scale category ≥ 3
    • Terminal disease with short expected survival
    • End-stage malignancy
    • Severe neurologic damage
    • Severe multiorgan failure
    • Mechanical ventilation > 10 days
    • Unable to accept blood products
    • Contraindications to anticoagulation
    • Do-not-resuscitate status
  • Relative contraindications in ECMO:
    • Age ≥ 65
    • Obesity (body mass index ≥ 40 kg/m2)
    • Multiple comorbid conditions
    • Severe immunosuppression
    • Septic shock



  • Patients with COVID-19 are mainly predominant by respiratory failure. SARS-CoV-2 directly attacks enough alveoli epithelial cells via the ACE2 receptor to cause pulmonary oedema, collapse of lobular of the lungs, HPV failure, pulmonary embolism and abnormal immune response may also contribute to the development of ARDS. The benefit of V-V ECMO mainly provides therapeutic benefits to the respiratory system by improving oxygenation and promoting lung-protective ventilation.

 

  • CVS failure is the second cause of death after respiratory failure in COVID-19 patients. There are several possible mechanisms contributing to cardiac injury; It can be direct injury from viral toxicity, oxygen supply-to-demand mismatch which cause damage to myocardial cells, abnormal coagulation, and microvascular dysfunction and plaque rupture. V-A ECMO can support highly selected cases but ECMO itself could bring cardiovascular complications, including atrial thrombosis, and fatal arrhythmia.

 

  • ECMO can cause abnormal blood coagulation function, which can also lead to thrombosis and bleeding events. Thrombosis events in COVID-19 patients receiving ECMO treatment is more common. It is worth noting that adequate level of anticoagulant therapy with unfractionated heparin during ECMO is a very huge challenge clinically, because of the COVID-19-related prothrombotic state and the high risk of HIT trigger.

 

  • ECMO related complication:
    • Bleeding 
    • Thrombosis
    • Affect blood coagulation function
    • Mechanical-related complications; including pump failure, oxygenator dysfunction, and circuit embolism, have also been reported in COVID-19 patients

 

  • Outcomes with delayed ECMO initiation may be worse and run duration may be longer, offsetting any potential benefit from attempted conservation of resources.

 

  • ECMO should be used preferentially for a certain group of patients (young age, absence of comorbidities, low risk of bleeding, ischaemia, and infectious complications) because they have higher survival rates.
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