This simplified diagram of the type of ECMO application in almost all COVID-19 patients shows the flow of blood out of the body, through the components of the circulatory system, and back into the body. Photo credit: University of Michigan
It saved lives in previous epidemics of lung-damaging viruses. According to a new international study, the life support option known as ECMO appears to be doing the same for many of the seriously ill COVID-19 patients who receive it.
The 1,035 patients in the study were at a surprisingly high risk of death because ventilators and other personal care products did not support their lungs. After they were inducted into the ECMO, their actual death rate was below 40%. This is comparable to the rate in patients treated with ECMO for previous outbreaks of lung-damaging viruses and other severe forms of viral pneumonia.
The new study published in The Lancet offers strong support for the use of ECMO – short for extracorporeal membrane oxygenation – in eligible patients as the pandemic continues worldwide.
It can help more hospitals with ECMO capabilities understand which of their COVID-19 patients could benefit from technology that circulates blood from the body into a circuit of devices that directly add oxygen to the blood before it is back in regular circuit is pumped. Small studies published at the start of the pandemic had cast doubt on the usefulness of the technique.
However, the international team of authors warns that patients who show signs of advanced life support should be given it in hospitals with experienced ECMO teams, and that hospitals should not attempt to expand ECMO capability during the pandemic.
Global collaboration to achieve results
The study was made possible by a rapidly generated international registry that has been providing intensive care experts with near real-time data on the use of ECMO in COVID-19 patients since the beginning of the year.
The registry is hosted by the ELSO organization for the Extracorporeal Life Support Organization and contains data submitted by 213 hospitals on four continents whose patients were included in the new analysis. The paper includes data on patients 16 years of age and older who started ECMO between January 16 and May 1, and follows them through to death, discharge from hospital, or August 5, whichever came first . The team will present the results at the ELSO annual conference on September 26th.
“These results from hospitals experienced in delivering ECMO are similar to previous reports from ECMO-assisted patients with other forms of acute respiratory distress syndrome or viral pneumonia,” said co-lead author Ryan Barbaro, MD, MS, of Michigan Medicine , the University of Michigan Academic Medical Center. “These results support recommendations to consider ECMO in COVID-19 if the ventilator fails. We hope these results will help hospitals make decisions about this resource-intensive option.”
Co-lead author Graeme MacLaren, MBBS, of the National University Health System in Singapore, notes, “Most of the centers in this study did not have to use ECMO very often for COVID-19. By bringing together data from over 200 international centers into the In In the same study, ELSO has deepened our knowledge of the use of ECMO for COVID-19 in a way that would be impossible for individual centers to learn on their own. “
Insights into patient outcomes
Seventy percent of the patients in the study were taken to the hospital where they received ECMO. Half of these were actually launched on ECMO – likely by the receiving hospital team – before they were transferred. This highlights the importance of communication between ECMO-enabled hospitals and non-ECMO hospitals that may have COVID-19 patients who could benefit from ECMO.
The new study could also help identify which patients will benefit most from being treated with ECMO.
“Our results also show that the risk of mortality increases significantly with the age of the patient and that those who are immunocompromised, have acute kidney injuries, poorer ventilation outcomes or COVID-19-related cardiac arrests are less likely to survive,” continues Barbaro, who chairs the meeting at ELSO is a member of the COVID-19 registration committee and offers ECMO care as a pediatric intensive care doctor at UM’s CS Mott children’s hospital. “Those who need ECMO to replace both heart and lung function have also deteriorated. All of this knowledge can help centers and families understand what patients might experience when put on ECMO.”
“The lack of reliable information at the onset of the pandemic has affected our ability to understand the role of ECMO in COVID-19,” says Dr. Daniel Brodie, co-senior author, New York Presbyterian Hospital. “While the results of this large-scale international registration study offer little definitive evidence, they do provide a real understanding of the potential of ECMO to save lives in a highly select population of COVID-19 patients.” Brodie shares lead authorship with Roberto Lorusso, MD of Maastricht University Medical Center in the Netherlands and Alain Combes, MD of Sorbonne University in Paris.
A robust statistical approach
Since the ELSO database does not record what happens to patients when they are discharged home, to other hospitals and in facilities for long-term acute care or rehabilitation, a statistical approach was used in the study that was based on mortality in hospital up to 90 days after the patient was based, ECMO was placed. In this way, the team can also take into account the 67 patients who were still in the hospital as of August 5, regardless of whether they were still in the ECMO, in the intensive care unit or in lowering units.
Philip Boonstra, Ph.D., of the UM School of Public Health, helped design the study using a “competitive risk” approach based on his experience in statistical design and analysis of long-term clinical trial data for cancer.
“We used 90-day mortality in the hospital because it is the period with the highest risk and because it allows us to take full advantage of the information available to us, even if we do not know the final result for each patient” said he says.
It was important to have data by August, when only a small number of the patients in the study stayed in the hospital – although data on a small number of patients are missing. And while patients discharged to their homes or rehab facility are likely to have a long recovery from intensive treatment with ECMO, based on previous data, they will likely survive. However, the fate of those who went to LTAC facilities that provide long-term care at the intensive care unit level is less certain.
More about the study and next steps
More than half of the patients in the study were treated in hospitals in the United States and Canada, including Michigan Medicine’s own hospitals. Robert Bartlett, Professor Emeritus of Surgery and co-author of UM’s new paper, is considered a key figure in the development of ECMO, including its first use in adults in the 1980s. Bartlett led the development of the first guidance on the use of ECMO in COVID-19.
“ECMO is the final step in the algorithm for treating life-threatening lung failure in advanced intensive care units,” says Bartlett. “Now we know it is effective in COVID-19.”
By August 5, 380 of the patients in the study had died in the hospital, more than 80% of them within 24 hours of a proactive decision to discontinue ECMO treatment because of a poor prognosis. Of the remaining patients, 57% had gone home or to a rehabilitation center (311 patients); had been discharged to another hospital or a long-term acute care center (277 patients). The rest were still in the hospital but had reached 90 days after starting ECMO.
The new study complements the information used to compile ELSO’s published ECMO COVID-19 guidelines, which are based in part on previous randomized controlled trials on the use of ECMO in ARDS.
Barbaro and others examine the longer-term effects of ECMO care on each patient. He leads a team that recently received a National Institutes of Health grant for a long-term study in children who survived after treatment with ECMO.
In the meantime, the ELSO registry continues to track care for patients placed on ECMO due to COVID-19. Christine Stead, the managing director of ELSO, praised the quick turn and the intensive teamwork between the ECMO centers and their employees for the strength of the new paper.
“We started a WeChat dialogue with teams in China who were able to exchange knowledge and help their colleagues in Japan prepare for diffusion in their country,” she says. “We asked all centers participating in ELSO to change their practice and enter data on patients once they were admitted to ECMO instead of waiting to be discharged from the hospital. This has enabled us to achieve something that this makes possible.” will help hospitals make better informed decisions based on better data as the pandemic continues. ”
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The Lancet (2020). DOI: 10.1016 / S0140-6736 (20) 32008-0, www.thelancet.com/journals/lan… (20) 32008-0 / Full text Provided by the University of Michigan
Quote: The life support option of last resort helped the majority of seriously ill COVID-19 patients survive (2020, September 25). Retrieved September 25, 2020 from https://medicalxpress.com/news/2020-09-last-resort-life-option- mehrheitskritisch.html
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