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Extracorporeal membrane oxygenation (ECMO) can play an important position within the administration of the sickest COVID-19 sufferers, stated Jeffrey A. Katz, MD, director of essential care companies on the NorthShore College HealthSystem in Evanston, Illinois.
Up to now, greater than 2500 COVID-19 sufferers world wide have obtained ECMO as a part of their remedy, in response to numbers tracked by the Extracorporeal Life Saving Group (ELSO), and the speed of survival to hospital discharge has been 53%.
What ECMO gives sufferers “is time,” Katz instructed the viewers throughout his presentation on the digital COVID-19: What’s Subsequent convention, organized by the Society of Essential Care Drugs.
“It offers sufferers time to heal themselves. It offers the suppliers time to offer sufferers antibiotics to clear infections. ECMO would not deal with the underlying downside, however ECMO is the final word in supportive care,” he defined.
Sometimes, solely giant tertiary hospitals have the employees and tools to make use of ECMO within the administration of COVID-19 sufferers, and outcomes can range throughout hospitals.
At NorthShore, the speed of survival to discharge is 66% for COVID-19 sufferers on ECMO, Katz reported. At one other heart within the Chicago space, Advocate Christ Medical Middle, the speed is 75%. Each charges are effectively above the worldwide common.
“An important factor — bar none — is affected person choice,” he instructed Medscape Medical Information, including that ELSO gives tips on affected person choice and different features of ECMO use for sufferers with COVID-19.
“Should you’re placing folks on ECMO who’ve pre-existing situations or who’re in septic shock, on vasopressors, and have extreme kidney harm, liver harm, or cardiac points, these sufferers are simply not going to do as effectively,” he defined.
COVID-19 sufferers youthful than 50 years with extreme acute respiratory misery syndrome (ARDS) who have no underlying situations are among the many finest candidates, he suggested.
Staffing can also be key, significantly specialised nurse staffing, he stated. Through the pandemic surge at NorthShore, they’ve tried to have a 1:1 nurse to affected person ratio within the ICU, with a floating nurse for the handful of ECMO sufferers they’ve at any time, he stated.
And cardiopulmonary bypass perfusionists ought to be obtainable to assist with ECMO circuit points, he added.
One factor the ECMO crew at NorthShore has modified as they put together for a second wave is to modify from benzodiazepine- to dexmedetomidine-based sedation, Katz stated.
“There’s much less probability of delirium, though it would not produce the identical stage of sedation,” he defined, noting that delirium has been a specific downside for sufferers coming off ECMO.
Suppliers at NorthShore are getting extra comfy utilizing ECMO for COVID-19 sufferers. However use throughout the second wave will rely on the scale of the surge, Katz stated, as a result of the remedy requires a big dedication of personnel and tools.
Using ECMO is rising somewhere else as effectively, stated Pauline Park, MD, professor of surgical procedure at Michigan Drugs in Ann Arbor.
“COVID was very horrifying early on; we did not know who was going to get higher. The truth that ECMO helped a number of the sickest sufferers get higher gave us lots of hope,” she instructed Medscape Medical Information.
The main focus of reviews from Asia and Europe originally of the pandemic have been on shortages of private protecting tools and ventilator assist; there was little speak of ECMO.
“We did not know sufficient concerning the illness early on to decide to that form of useful resource,” Park stated.
However, “as a medical neighborhood, we gained extra expertise, and it appeared there have been acceptable instances to strive ECMO. The obvious improve in survival displays the progress we have made in the previous few months,” she stated.
Solely a small fraction of COVID-19 sufferers — the sickest — are thought of for ECMO, she reiterated.
ECMO applications at Michigan Drugs and in most different locations are very conservative of their use of ECMO to deal with COVID-19 sufferers due to the appreciable threat and the useful resource drain, Park defined.
The necessity to make such essential selections throughout the pandemic has underscored the worth of collaboration, as groups have to contemplate variety of beds, nurse staffing, and specialist staffing, she stated. At Michigan Drugs, the complete ECMO crew evaluates sufferers to find out who may really profit.
Social Justice Issues
The price of ECMO is one other consideration.
With the consent of the affected person, Katz instructed the story of a person he cared for with COVID-19 — a father of 4 with diabetes and weight problems — whose imaging outcomes have been “as shut as you may get to gross pathology in a affected person.”
The affected person was on ECMO for 33 days, was discharged, and is now awaiting inpatient rehabilitation placement.
“No query. He wouldn’t have survived his ARDS with out VV [veno-venous] ECMO,” Katz stated.
However the expense of ECMO raises a social justice query. The take care of that individual affected person over greater than a month price $1.three million.
“Given the scope of the pandemic, within the second wave, we’ve to ask ourselves whether or not ECMO is a justified use of each monetary sources and personnel sources,” Katz stated. “I haven’t got the reply; I am undecided that anyone does. However that is one thing your establishment wants to consider earlier than the second wave if you are going to do ECMO.”
COVID-19: What’s Subsequent. Making ready for the Second Wave. Offered September 12, 2020.
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