COVID-19 patient Enes Dedic was very near death when his doctors made the decision to try extracorporeal membrane oxygenation (ECMO) therapy.
The 53-year-old Phoenix man deteriorated quickly after entering the hospital on March 15, and he was no longer supportable with mechanical ventilation at the highest setting.
"When we made the decision to use ECMO he probably had no more than 6 to 8 hours to live without it," said Robert Riley, MD, who is chief of cardiothoracic surgery at Honor Health Deer Valley Medical Center.
After spending 10 days in a medical coma on ECMO, Dedic's doctors woke him up and found him to be so responsive he was soon able to FaceTime with his wife. He remains hospitalized, but he is off mechanical ventilation and is eating, Riley told 鶹ý.
As of April 16, records 370 patients with confirmed COVID-19 on ECMO across the globe, including 254 in North America. In a subset of 58 COVID-19 patients who received the treatment, 21 have been discharged alive.
Similar to a heart-lung bypass machine, ECMO is used to pump and oxygenate the patient's blood outside the body, replacing the function of the lungs and heart.
The highly resource- and labor-intensive treatment requires a surgeon to insert the devices involved, highly trained medical personnel to run the machine, and other support staff who must monitor the patient around the clock.
"ECMO requires an enormous collaborative effort," Riley said, adding that its use was feasible because the Phoenix hospital system where Dedic is being treated has not yet experienced a large surge of COVID-19 patients.
A second COVID-19 patient at the hospital was successfully removed from ECMO on Thursday, but that patient remained on mechanical ventilation.
In an effort to better define the potential role of ECMO in the COVID-19 pandemic setting, several medical groups have recently weighed in, offering guidance to clinicians.
Among them are Steven Keller, MD, PhD, and Raghu Seethala, MD, of Brigham and Women's Hospital and Harvard Medical School, Boston, who recently in Annals of the American Thoracic Society.
Seethala told 鶹ý that the goal in the pandemic setting is to optimize resources in response to the specific challenges faced at the time.
"In the pandemic setting our goal is to do the greatest good for the greatest number, so in centers where the surge of COVID patients is very high it may not make sense to do ECMO," he said.
"Centers need guidance about how to think about this highly resource intensive therapy during a pandemic when they may be stretched to their limits," Seethala said.
"If you only have one COVID patient to treat you can do everything under the sun for them," he said. "But when you have 50 or 100 patients, the issue becomes how to apply this limited resource."
Seethala and Keller advised hospitals with ECMO centers to clearly define criteria for initiating ECMO support during the COVID-19 pandemic to give physicians on the front lines clear guidance.
"Preparing guidelines in advance eliminates subjectivity and inconsistency between individual providers making allocation of intensive therapies more equitable and ethical," they wrote in the guideline.
They added that given the increased demand, "this policy must clearly define criteria for cessation of support to reduce futile care and enable allocation of limited resources."
"During situations of mass critical care, it may be ethically permissible to withdraw ECMO to reallocate support to patients with higher likelihood of benefit," they wrote.
ECMO should only be considered for patients who have the best chance for survival, such as younger patients with severe respiratory failure but without other major comorbidities or multiple organ failure, Seethala and Keller recommended.
Last month, the international (ELSO) published guidance for ECMO use in COVID-19 patients, which also stressed the importance of careful patient selection, noting that patient age and comorbidities are key considerations when deciding which patients to place on ECMO.
"Moreover, several variables, such as reversibility of the pulmonary disease process, risk of secondary pulmonary infections and the role of antiviral drugs and other disease-modifying factors, might affect outcomes with ECMO," the ELSO guidance group wrote.
Addressing ethical challenges associated with ECMO decision making in a pandemic outbreak, the group noted uncertainties "regarding the potential benefit and duration of ECMO in this context, which might be dynamic as the outbreak evolves and would require regular review."
"All aspects of a patient's treatment plan should be regularly reviewed, including the need to continue or terminate ECMO," they wrote. "The decision to stop treatment should not be made purely on the basis of duration of ECMO therapy, but only after achieving consensus within the treating team that the patient has minimal potential to recover."
Primary Source
Annals of the American Thoracic Society
Seethala R, Keller SP "ECMO resource planning in the setting of pandemic respiratory illness" Ann Am Thorac Soc 2020; DOI: 10.1513/AnnalsATS.202003-233PS.