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COVID-19: Extracorporeal membrane oxygenation (ECMO)

COVID-19: Extracorporeal membrane oxygenation (ECMO)
Literature review current through: Jan 2024.
This topic last updated: Nov 22, 2023.

INTRODUCTION — The pneumonia associated with coronavirus disease 2019 (COVID-19) can lead to acute respiratory failure with profound hypoxemia requiring endotracheal intubation and mechanical ventilation. Myocardial injury associated with COVID-19 may also lead to cardiogenic shock unresponsive to medical management. Patients who do not respond to optimal conventional therapy may be candidates for management with extracorporeal membrane oxygenation (ECMO) in institutions with appropriate resources (equipment and personnel).

This topic will address COVID-19-specific issues associated with the use of ECMO. General concepts regarding ECMO use in adult patients are discussed in other topics.

(See "Extracorporeal life support in adults in the intensive care unit: Overview".)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)".)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)" and "Extracorporeal life support in adults in the intensive care unit: Vascular complications".)

(See "Extracorporeal life support in adults: Extracorporeal carbon dioxide removal (ECCO2R)".)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)" and "Extracorporeal life support in adults in the intensive care unit: Vascular complications".)

(See "Extracorporeal life support in adults in the intensive care unit: The role of transesophageal echocardiography (TEE)".)

(See "Intraoperative problems after cardiopulmonary bypass", section on 'Extracorporeal membrane oxygenation'.)

TERMINOLOGY — Extracorporeal membrane oxygenation (ECMO) is a form of temporary extracorporeal life support that provides gas exchange for patients with respiratory failure and/or cardiac support for patients with cardiac or circulatory failure (table 1). Venovenous (V-V) ECMO (for respiratory failure) or venoarterial (V-A) ECMO (for cardiac failure) are the two most common forms of ECMO used in the intensive care unit (ICU), although more complex configurations are sometimes employed.

INDICATIONS AND CONTRAINDICATIONS

Indications — Indications for extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 are similar to those for other conditions [1-7]. Patients with COVID-19 who fail conventional therapy for acute respiratory failure or acute cardiac failure may be candidates for venovenous (V-V) ECMO and venoarterial (V-A) ECMO, respectively (figure 1 and figure 2) [8,9]. Among the indications, COVID-19-related acute respiratory distress syndrome (ARDS) is the most common indication. Details regarding criteria for select indications and evaluation of suitability for ECMO are discussed separately (table 1):

(See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Type of support needed'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Clinical applications'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Clinical applications'.)

Data to support use of ECMO in patients with COVID-19 are derived from observational series in patients with COVID-19 [1,5,7,8,10-13], as well as indirect data from patients with non-COVID-related illnesses including Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 and influenza A (H1N1) in 2009 [14-18]. Evidence supporting the efficacy of V-V or V-A ECMO is discussed in separate topics:

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Clinical applications'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Clinical applications'.)

Venovenous (V-V) ECMO — During V-V ECMO, blood is removed from the venous system (eg, iliac vein or superior vena cava), passed through an artificial membrane lung, and then returned back to the venous system (eg, superior vena cava or right atrium), where it passes through the lungs (figure 1). V-V ECMO is an option to treat COVID-19-related ARDS that is refractory to conventional ventilator management. Indications for and configurations that may be selected for V-V ECMO are discussed separately:

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Clinical applications'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Venovenous ECMO configurations and sites'.)

Venoarterial (V-A) ECMO — During V-A ECMO, blood is removed from the venous system (eg, iliac vein or superior vena cava), passed through an artificial membrane lung, and then returned to the arterial system (eg, femoral or right subclavian artery) (figure 2), thereby providing both cardiac and pulmonary support [19]. Use of V-A ECMO in patients with COVID-19 is reserved for those with severe acute cardiac dysfunction and hypoxemia refractory to support with V-V ECMO. Clinical conditions in which this may apply include cardiogenic shock (due to several different etiologies), right ventricle dysfunction, acute decompensated pulmonary vascular disease, or cardiopulmonary resuscitation [3,8,20].

(See "COVID-19: Evaluation and management of cardiac disease in adults".)

(See "COVID-19: Myocardial infarction and other coronary artery disease issues".)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Clinical applications'.)

Contraindications — Contraindications to both V-V and V-A ECMO are listed in the table (table 2).

When resources are limited, patients with minor or no comorbidities are typically prioritized [1,8]. When capacity of a hospital system is overwhelmed during a pandemic surge, limitations of institutional or regional resources may contraindicate use of ECMO [8]. (See 'Resource considerations' below.)

Prone positioning is not a contraindication to ECMO in patients with COVID-19 (especially when the patient is cannulated via a jugular vein exclusively for V-V ECMO). (See 'Prone positioning' below.)

CATHETER CONFIGURATIONS AND CANNULATION

Infectious precautions for vascular cannulation — If available, use of an airborne isolation room (ie, negative pressure room) is ideal for vascular cannulation in a patient with COVID-19. Notably, insertion of extracorporeal membrane oxygenation (ECMO) cannulae may be challenging in patients with COVID-19 who develop rapid deterioration [21]. Institution of emergency ECMO requires two separate teams, with one managing sudden clinical changes, while another team accomplishes vascular cannulation and establishes ECMO. Full personal protective equipment (PPE) is necessary for the procedure.

Infectious precautions necessary in a health care setting are discussed separately. (See "COVID-19: General approach to infection prevention in the health care setting" and "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures'.)

ECMO configurations — Techniques and configurations for ECMO are similar to those in non-COVID-19 patients (table 3 and image 1 and image 2 and image 3 and image 4 and image 5 and image 6 and image 7 and image 8) [3,22]. For venovenous (V-V) ECMO we use a two-site femoral vein-internal jugular vein approach, if feasible (figure 1) [8]. For venoarterial (V-A) ECMO, we use an approach that has femoral venous drainage and femoral or subclavian arterial reinfusion (figure 2). Further details regarding these configurations are described separately:

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Catheter insertion'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Catheter insertion'.)

These configurations are preferred in patients with COVID-19 since cannulation is often needed under urgent or emergent circumstances, and the vessels are percutaneously accessible at the bedside. In addition, these configurations obviate the need for patient transport to a fluoroscopy suite. Avoiding transport of patients for catheter placement under fluoroscopy minimizes the number of health care personnel who are exposed to infection risk and avoids disconnection from the intensive care unit (ICU) ventilator that can result in alveolar derecruitment and cardiopulmonary instability [23].

We typically use transesophageal echocardiography (TEE) at the bedside to ensure correct positioning of the cannulae. Although TEE in nonintubated patients is considered to be an aerosol-generating procedure, the infectious risk is reduced after endotracheal intubation since the airway has been secured. Furthermore, appropriate PPE is donned by the echocardiographer, and protection for the ultrasound equipment can be used [24-29]. (See "Extracorporeal life support in adults in the intensive care unit: The role of transesophageal echocardiography (TEE)" and "Transesophageal echocardiography: Indications, complications, and normal views", section on 'COVID-19 precautions'.)

Other peripheral cannulation strategies are shown in the table (table 3). For patients with COVID-19 who may require ECMO support, we perform point-of-care ultrasound and/or transthoracic echocardiography to detect development of thrombosis at potential cannulation sites [30].

COVID-SPECIFIC CONCERNS FOR ECMO MANAGEMENT — Discussed below are considerations specific for extracorporeal membrane oxygenation (ECMO) management in patients with COVID-19 [8].

Oxygenation and ventilation — Goals for maintaining oxygenation and ventilation and managing circuits during venovenous (V-V) and venoarterial (V-A) ECMO are the same as those for non-COVID-19 patients. Details are discussed separately:

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Initial settings and titration'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Daily assessment and circuit monitoring'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Initial settings and titration'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Daily assessment and circuit monitoring'.)

Maintenance of anticoagulation — Anticoagulation is particularly important since both COVID-19 and ECMO support are risk factors for thrombosis. As with all patients on ECMO, continuous anticoagulation is required to maintain the ECMO circulation [8,31].

However, there is no consensus regarding optimal intensity of anticoagulation in patients with COVID-19 who require ECMO support. Experts use different agents and different parameters to achieve anticoagulation, always with vigilant monitoring to ensure continuous anticoagulation and maintenance of adequate ECMO flow. We use a continuous infusion of unfractionated heparin for patients with COVID-19 on ECMO in our center, with an activated partial thromboplastin time (aPTT) target that is 70 to 100 seconds or at least 1.5 times the institutional control value for V-V ECMO or 2.0 times the control value for V-A ECMO. Some centers select a higher target (eg, 2.0 to 2.5 times the institutional aPTT control value) [32]. However, other centers administer a heparin infusion to a target aPTT of 50 to 60 seconds and withhold anticoagulation up to several days in patients who have a relative contraindication to anticoagulation unless the appearance of clots in the oxygenator compels initiation of anticoagulation.

Activated clotting time (ACT) or viscoelastic tests (eg, thromboelastography [TEG] or rotational thromboelastometry [ROTEM]) may be employed to guide anticoagulation [33-36]. Although not routine, some experts perform daily transthoracic echocardiography or point-of-care ultrasonography in patients with COVID-19 on ECMO to monitor for early signs of acute cor pulmonale due to pulmonary embolism [10,20,37].

Further details regarding anticoagulation management for patients with COVID-19 and on ECMO are provided separately.

(See "COVID-19: Hypercoagulability", section on 'Clotting of intravascular access devices'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Thrombosis and thromboembolism'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Cardiac or aortic thrombosis'.)

Management of anticoagulation during ECMO in non-COVID-19 patients is also discussed separately.

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Anticoagulation'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Anticoagulation'.)

Sedation — As with other mechanically ventilated patients with acute respiratory distress syndrome (ARDS), sedation should be titrated to individual patient needs. Some patients with COVID-19 require more sedation than most critically ill patients due to their younger age, higher respiratory drive, increased sedative drug clearance caused by other medications, and a particularly intense inflammatory response [38-40]. Notably, it may be particularly difficult to wean moderate to heavy sedation during ECMO support of a patient with COVID-19 with severe agitation due to risk of dislodgement of ECMO cannulae, shifts in venous return affecting ECMO flows, or ventilator dyssynchrony [38,39]. On the other hand, some centers will routinely lighten sedation if it is well tolerated and even extubate patients on V-V or V-A ECMO. (See "COVID-19: Management of the intubated adult", section on 'Sedation and analgesia'.)

Prone positioning — Prone positioning for ventilation of patients with COVID-19 with respiratory failure is known to be advantageous during the period of mechanical ventilation before initiation of ECMO. Although prone positioning is not usually performed during ECMO support, it may be used in selected patients, particularly if ECMO weaning is necessary due to bleeding or cannulation site infection [41]. Under these circumstances, studies have shown that the prone position improves oxygenation and is safe during ECMO in patients with COVID-19 with minimal risk of cannula dislodgement [42-44].

Data supporting prone positioning in patients with COVID-19 who are not receiving ECMO are provided separately. (See "COVID-19: Management of the intubated adult", section on 'Low tidal volume ventilation in the prone position'.)

V-V to V-A ECMO conversion — Occasionally, conversion of V-V ECMO to V-A ECMO is appropriate in selected patients with COVID-19 [8,11]. This includes patients who develop cardiopulmonary failure with inadequate tissue perfusion or shock manifested by hypotension and low cardiac output despite adequate intravascular volume and treatment of vasoplegia [45]. This may be due to right ventricular dysfunction in patients with severe ARDS or pulmonary embolism [37,46,47], persistent malignant arrhythmias, or cardiogenic shock in patients with acute myocardial infarction or myocarditis [19,48]. In addition, in some patients with severe hypoxemia despite V-V ECMO, we consider switching to V-A ECMO to improve oxygenation.

Details regarding management of coexistent heart failure in patients on V-V ECMO or coexistent respiratory failure in patients on V-A ECMO are provided separately:

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Managing concomitant cardiac failure'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Concomitant respiratory failure'.)

Tracheostomy — Tracheostomy is often considered after initiation of ECMO in patients who have respiratory failure without a COVID-19 diagnosis, as this may improve patient comfort and allow lightening of sedation. However, in patients with COVID-19, tracheostomy may be reasonably deferred for up to 14 days or longer since aerosol generation will be increased during and following this procedure. Also, sedation requirements may remain high despite presence of a tracheostomy rather than an orotracheal tube [8,38,49]. COVID-19-secific issues for tracheostomy are discussed separately. (See "COVID-19: Management of the intubated adult", section on 'Tracheostomy' and "Tracheostomy: Rationale, indications, and contraindications", section on 'COVID-19' and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'COVID-19'.)

Duration of support and ECMO weaning — In our experience, longer durations of ECMO support may be necessary in patients with COVID-19 compared with non-COVID-19 patients. As such, we perform continuous risk-benefit evaluation of ECMO therapy over time [1,8]. Some centers have reported use of ECMO for as long as three to six weeks [1,5,10,50]. For patients who improve, our institutional weaning protocols are shown in the algorithms, although such protocols vary by institution (algorithm 1 and algorithm 2) [8,10,51]. Although definitions of futility are institution specific, some centers consider returning to conventional management if no lung or cardiac recovery is noted after approximately 21 days (sometimes longer), while others consider early lung transplantation referral, especially when patients have single-organ respiratory failure [52]. In some patients, referral for lung transplantation is appropriate, and successful transplantation has been reported [52].

COMPLICATIONS — The complications of extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 are similar to those in non-COVID-19 patients. These complications are listed in the table (table 4). However, bleeding and possibly thrombosis may be more common in patients with COVID-19 than in non-COVID-19 patients undergoing ECMO, but accurate data are lacking:

Bleeding rates may be higher in patients with COVID-19 than in other populations receiving ECMO. One report suggested a high rate of anticoagulation-related intracranial hemorrhage in patients receiving venovenous (V-V) ECMO for COVID-19-related acute respiratory distress syndrome (ARDS) [33]. Another study reported bleeding events in 29 percent of patients with COVID-19 receiving ECMO [53]; in this study, bleeding events, particularly intracranial hemorrhage, were associated with mortality (adjusted odds ratio 2.91, 95% CI 1.94-4.4).

It is unclear whether thrombosis (including intracardiac thrombus) occurs at a higher rate in patients with COVID-19 compared with non-COVID-19 patients [54-56]. One study reported that thrombotic events occurred in 16 percent of patients with COVID-19, but these events were not associated with mortality [53]. We routinely employ point-of-care vascular or cardiac ultrasound and/or transthoracic echocardiography during ECMO support to detect peripheral venous, arterial, or cardiac thrombi that may complicate vascular access or ECMO function [30].

Further details discussing complications of ECMO are provided in separate topics:

(See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Complications'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Complications'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'V-A ECMO-specific complications'.)

PROGNOSIS — Mortality of patients with COVID-19 on extracorporeal membrane oxygenation (ECMO) support are comparable to or slightly higher than that of non-COVID-19 patients on ECMO support.

Early reports from China and Europe had noted very high mortality rates for patients with COVID-19 on ECMO (>80 percent) [57,58]. However, subsequent studies have noted more encouraging results (26 to 50 percent mortality) [1,10,12,22,50,59-66]. A 2022 meta-analysis of 134 studies that included 58,472 patients with COVID-19 reported that the 4044 patients who received ECMO (6.9 percent) had an in-hospital mortality of 39 percent [65]. A subgroup analysis of six studies included in this meta-analysis noted that patients with COVID-19 on ECMO had slightly higher mortality than patients with influenza on ECMO (44 versus 38 percent; risk ratio [RR] 1.34, 95% CI 1.05-1.7). These results are comparable to those in adult patients receiving ECMO support for acute respiratory distress syndrome (ARDS) due to other diagnoses [60,61,67]. In a meta-analysis of 42 observational studies, prognostic factors were similar to non-COVID-19 patients receiving ECMO (eg, age, comorbidities) [68]; other factors included longer duration of symptoms, longer duration of invasive mechanical ventilation, higher partial pressure of arterial carbon dioxide, higher driving pressure, and less previous experience with ECMO. Prognosis of non-COVID-19 patients receiving ECMO is discussed in detail separately. (See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Prognosis and long-term outcomes'.)

Patients with COVID-19 who successfully wean from ECMO typically spend a prolonged period of time in the intensive care unit (ICU), often on mechanical ventilation. Such patients are at risk of developing long-term sequalae associated with ARDS, including post-intensive care syndrome (PICS) [38,50,69,70]. More detailed discussions of long-term outcomes in these patient populations are available in separate topics. (See "Acute respiratory distress syndrome: Prognosis and outcomes in adults" and "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation".)

Limited data describe the outcome in pregnancy. In a systematic review of observational case series reporting outcomes in pregnant females receiving ECMO due to COVID-19, the maternal survival was >80 percent and fetal survival was 67.9 percent [71]. Whether these data apply to patients undergoing ECMO due to COVID-19 from emerging strains is unknown.

RESOURCE CONSIDERATIONS — Extracorporeal membrane oxygenation (ECMO) is a resource-intensive therapy requiring a multidisciplinary team of experienced medical professionals with training and expertise in initiation, maintenance, and discontinuation of ECMO [1,2,8,10,20,51,57,72-76]. Competent planning, resource allocation, and infection control are necessary to assure that ECMO is appropriately used. Thus, it is appropriate that during surges in COVID-19, institutions do not establish a new ECMO program but rather establish consulting and referral relationships with larger health care systems when anticipating that a marked increase in COVID-19 hospitalizations will occur.

Goals – In preparation for patient surges of COVID-19, we focus on personnel, equipment, facilities, and support systems to provide [8,11,22,77-79]:

Assessment of appropriate and safe transfers of critically ill patients from other institutions for ECMO support

Management of resource-intensive daily care for patients receiving ECMO

Optimal care of patients with COVID-19 with severe acute respiratory distress syndrome (ARDS) and/or cardiac failure

Personnel – Availability of a multidisciplinary team with previous experience managing patients with ECMO is critically important for a successful program. This includes clinicians in several specialties (eg, surgeons, intensivists, anesthesiologists) as well as nurses, physician assistants, nurse practitioners, respiratory therapists, and/or perfusionist technologists. All team members require education regarding anesthetic, surgical, and critical care management of patients with COVID-19, including the need to use appropriate personal protective equipment (PPE) [8]. (See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Staffing (ECMO teams)' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)

Equipment – Inventory of available durable and disposable supplies and equipment for initiation and maintenance of ECMO therapy should be determined, with plans for replacement if inventory becomes rapidly depleted during a regional pandemic surge of critically ill patients with COVID-19. Such planning should include routine ECMO maintenance and potential need for emergency exchange of a clotted ECMO oxygenator or for conversion of venovenous (V-V) ECMO to venoarterial (V-A) ECMO. (See 'Maintenance of anticoagulation' above.)

Planning for decontamination of ECMO equipment after use is also necessary. Programs able to offer ECMO for patients with COVID-19 should also be able to manage availability of this support for other indications (eg, cardiogenic shock from myocardial infarction, heart transplant, lung transplant, or severe ARDS from non-COVID-19 disease).

Facilities – Placement of patients with COVID-19 on ECMO support in a single intensive care unit (ICU) location within a facility consolidates expertise of personnel with experience in ECMO and reduces exposure of additional medical personnel to infection risk.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: Extracorporeal membrane oxygenation (ECMO) (The Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – Extracorporeal membrane oxygenation (ECMO) provides temporary gas exchange for patients with respiratory failure and/or cardiac support for patients with cardiac or circulatory failure (table 1). (See 'Terminology' above.)

Indications and contraindications

Indications for ECMO in patients with COVID-19 are similar to indications in other conditions. Failure of conventional therapy for acute respiratory failure due to acute respiratory distress syndrome (ARDS) is the most common indication for venovenous (V-V) ECMO (figure 1). Less commonly, patients with acute cardiac failure (eg, due to acute myocardial infarction) are candidates for venoarterial (V-A) ECMO (figure 2). Patient selection for these ECMO modes is discussed in detail separately.

-(See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Type of support needed'.)

-(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Clinical applications'.)

-(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Clinical applications'.)

Contraindications to both V-V and V-A ECMO are listed on the table (table 2). (See 'Contraindications' above.)

Cannulation and configuration issues

Infectious precautions Use of an airborne isolation room (ie, negative pressure room) is ideal, and full personal protective equipment (PPE) is necessary for vascular cannulation in a patient with COVID-19 in whom ECMO is planned.

Configurations – For V-V ECMO, most experts use a two-site femoral vein-internal jugular vein approach if feasible, similar to that used for most non-COVID-19 patients (figure 1). Similarly, for V-A ECMO, we suggest femoral venous drainage and femoral or subclavian arterial reinfusion (figure 2). These configurations are preferred in patients with COVID-19 since cannulation is often needed under urgent or emergent circumstances and these vessels are percutaneously accessible at the bedside. In addition, they obviate the need for patient transport to a fluoroscopy suite, which increases the risk of virus transmission. (See 'Catheter configurations and cannulation' above.)

These and other commonly used options for patients with COVID-19 are shown in the table (table 3), and discussed in detail separately.

-(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Catheter insertion'.)

-(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Catheter insertion'.)

Maintenance of ECMO support

Oxygenation and ventilation – Goals for maintaining oxygenation and ventilation during ECMO are the same as for non-COVID-19 patients on V-V ECMO. (See 'COVID-specific concerns for ECMO management' above.)

Anticoagulation strategies – All patients require anticoagulation due to the high risk of thrombosis. Our strategy is similar to that for non-COVID-19 patients. We use a continuous infusion of unfractionated heparin to target an activated partial thromboplastin time (aPTT) that is at least 1.5 times the institutional control value for V-V ECMO or 2.0 times the control value for V-A ECMO; some experts use higher targets. (See 'Maintenance of anticoagulation' above.)

Others – Other maintenance issues are discussed separately in other ECMO topics:

-Sedation – (See 'Sedation' above and "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Routine measures' and "COVID-19: Management of the intubated adult", section on 'Sedation and analgesia'.)

-Prone positioning – (See 'Prone positioning' above.)

-V-V to V-A ECMO conversion – (See 'V-V to V-A ECMO conversion' above and "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Managing concomitant cardiac failure'.)

-Tracheostomy – (See "COVID-19: Management of the intubated adult", section on 'Tracheostomy' and "Tracheostomy: Rationale, indications, and contraindications", section on 'COVID-19' and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'COVID-19'.)

-Weaning – Our institutional weaning protocols are shown in the algorithms (algorithm 1 and algorithm 2). (See 'Duration of support and ECMO weaning' above.)

Complications – Rates of bleeding and possibly thrombosis may be higher in patients with COVID-19 than in non-COVID-19 patients on ECMO support. (See 'Complications' above.)

These and other complications are discussed in other ECMO topics (table 4).

(See "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Complications'.)

(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Complications'.)

(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'V-A ECMO-specific complications'.)

Prognosis – Risk for mortality and typical sequalae such as ARDS and post-intensive care syndrome (PICS) after ECMO support are comparable or slightly higher in patients with COVID-19 compared with those without COVID-19. (See 'Prognosis' above and "Extracorporeal life support in adults in the intensive care unit: Overview", section on 'Prognosis and long-term outcomes' and "Acute respiratory distress syndrome: Prognosis and outcomes in adults" and "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation".)

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Topic 127765 Version 24.0

References

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