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[Artigo] Planning and provision of ECMO

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

Who interim guidelines recommend offering extracorporeal membrane oxygenation (ECMO) to eligible patients with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The number of patients with COVID-19 infection who might develop severe ARDS that is refractory to maximal medical management and require this level of support is currently unknown. Available evidence from similar patient populations suggests that carefully selected patients with severe ARDS who do not benefit from conventional treatment might be successfully supported with venovenous ECMO. The need for ECMO is relatively low and its use is mostly restricted to specialised centres globally. Providing complex therapies such as ECMO during outbreaks of emerging infectious diseases has unique challenges. Careful planning, judicious resource allocation, and training of personnel to provide complex therapeutic interventions while adhering to strict infection control measures are all crucial components of an ECMO action plan. ECMO can be initiated in specialist centres, or patients can receive ECMO during transportation from a centre that is not specialised for this procedure to an expert ECMO centre. Ensuring that systems enable safe and coordinated movement of critically ill patients, staff, and equipment is important to improve ECMO access. ECMO preparedness for the COVID-19 pandemic is important in view of the high transmission rate of the virus and respiratory-related mortality.

Introduction

The WHO-declared pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing clusters
of fatal pneumonia from coronavirus disease 2019 (COVID-19), with reports of some patients receiving extracorporeal membrane oxygenation (ECMO) support. WHO interim guidelines for the management of suspected COVID-19 recommend administering venovenous ECMO to eligible patients with COVID-19- related acute respiratory distress syndrome (ARDS) in
expert centres with sufficient case volumes to ensure clinical expertise. However, its effectiveness will be influenced by the initial experience and preparedness of the health-care system. Although there are observational data on the use of rescue ECMO during previous outbreaks of emerging infectious diseases, mainly in the context of influenza A(H1N1) ARDS, the real need for ECMO during such outbreaks is unclear. For reference, the incidence of ECMO use in patients with 2009 influenza A(H1N1) ARDS in Australia and New Zealand was estimated to be 2·6 cases per million, whereas 5·8% of the critically ill patients in Saudi Arabia were supported with ECMO for Middle East respiratory syndrome coronavirus-related ARDS.7,8 Therefore, the overall impact of the COVID-19 outbreak on potential ECMO use is currently unclear, but there could be an increased need for ECMO worldwide.

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