Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization

The role of extracorporeal membrane oxygenation (ECMO) support for patients with cardiopulmonary failure due to coronavirus disease 2019 (COVID-19) is evolving. A prominent feature of COVID-19 in critically ill patients is acute respiratory distress syndrome (ARDS). Early in the pandemic, data on ECMO use was limited, and guidance was offered based on best practices at the time. Very limited case series available at the onset of the pandemic seemed to indicate poor survival for patients with ARDS placed on ECMO. However, the role of ECMO for COVID-19–related ARDS and other indications has become more apparent as the pandemic unfolds and evidence is generated.

A multicenter French study of 83 patients with COVID-19–related ARDS managed with ECMO revealed an estimated 60 day mortality of 31%. Subsequently, data from the Extracorporeal Life Support Organization (ELSO) Registry reported an estimated cumulative incidence of in-hospital mortality 90 days after ECMO initiation of 37.4%. This report included 1,035 patients with COVID-19 who received ECMO in 36 countries. An additional observational study reported 45% mortality for 1,531 patients from 177 centers in Europe and Israel.

According to prepandemic historical data from the ELSO registry, venovenous (V-V) ECMO results in an approximate mortality of 40%, venoarterial (V-A) 55%, and extracorporeal cardiopulmonary resuscitation (ECPR) 71%. Mean V-V run duration is generally longer (12 days) than V-A (7 days). For patients with COVID-19, mortality is similar to historical V-V ECMO mortality; however, mortality is still being determined with ongoing data collection and may be increasing. Median (14 days⁷ and 20 days) and mean (18 days) run duration appears to be longer.

In the great majority (>90%) of reported cases, V-V ECMO was utilized for COVID-19. Some patients with COVID-19 develop myocarditis, massive pulmonary embolism, stress cardiomyopathy, arrhythmias, and acute coronary syndrome, which may require mechanical circulatory support such as V-A ECMO. Data on V-A ECMO for COVID-19 are limited in the ELSO Registry study and may be found in small case series, making the utility of V-A ECMO for COVID-19–related cardiogenic shock less clear. As a general guide to practice, we recommend the use of ECMO for patients with COVID-19 and severe cardiopulmonary failure who meet traditional criteria and when appropriate resources are available.

Given the paucity of available data when prior ECMO guidelines were published, this guideline has been created to summarize currently available literature and offer recommendations to update select areas within the previous guidelines. This document will focus on care specific to COVID-19 patients receiving ECMO and recommended alterations in the utilization of ECMO during a pandemic. We recommend referral to existing guidelines for general ECMO practices.