Extracorporeal membrane oxygenation for patients with COVID-19: a trainees’ perspective

On 5 February 2020, we began our placement on the Cardiothoracic Critical Care Unit at Wythenshawe Hospital, Manchester, one of only five adult extracorporeal membrane oxygenation (ECMO) centres in England. Most trainees will not be lucky enough to pass through such a centre in their careers, let alone during a global pandemic.

Before the pandemic, there were approximately two or three patients on venovenous-ECMO at any one time with ARDS and respiratory failure secondary to asthma, influenza or bacterial pneumonia. Retrieving a patient with mobile ECMO requires a highly skilled and coordinated team to transfer extremely sick patients. Although when we started our rotation we had a basic understanding of what ECMO entailed, we soon learnt that ‘super-advanced’ cardiorespiratory support, and the last available supportive option, is no easy undertaking and not without major risks.

We admitted our first patient with COVID-19 on 14 March; soon after the ECMO team was getting 5-10 referrals per day, with a total of 34 retrievals over the next three months. At its height, 20 bed spaces were allocated for patients with COVID-19 having ECMO. All referrals were discussed between two or more ECMO consultants, with borderline cases also discussed with other ECMO centres on a daily basis. Admission criteria were broadly in keeping with those set out in a recent editorial [1]. We were faced with managing the most severe cases of a new disease with minimal evidence on which to protocolise care, and we adapted our practices based on experiential learning. The clinical course of patients with COVID-19 having ECMO has been entirely different to those with other pathologies [2], and it is rare as a trainee to encounter a group of consultants who have no experience of a clinical problem.

We soon grasped the concepts of ‘flow’, ‘revs’ and ‘sweep’ (Figure 1), and management principles summarised in five key learning points (Box 1). It was surreal witnessing the stillness of multiple patients without any chest movement. We would balance seeing patients on ECMO vs. ‘NECMO’ (a term coined by our consultants) as we tackled two very different types of workload. Not only were we managing the more mechanical aspects of organ support, but we had to learn about complex systems within haematology, rheumatology and steroid management. There was no time to study in-depth in a rapidly changing situation. Transferring data and handing over in- and out- of the zones was tricky enough, before gruelling board rounds examining the most intricate of laboratory results and X-rays. Arguably, managing these patients and prescribing was more difficult with extracorporeal circuits involved.

Figure 1

As we moved to emergency rotas, the consultants, nurses and perfusionists increased their shifts in a unique way. There were two consultants and two registrars on the unit every night, with many more during the day. There was a large influx of non-ICU-trained staff including ward and outpatient nurses, ODPs, theatre scrub and recovery staff, pharmacists, physiotherapists and healthcare assistants. Versatility was key and the teamwork was outstanding.

Many of the patients were young and previously healthy, with predominantly single-organ failure. Some seemed like perfect ECMO candidates, but did not survive. Some seemed borderline at first, but are now back at home with their families. Some were colleagues or friends-of-friends. Further disease manifestations became apparent, and complications such as bleeding into the airways, lungs or brain were frequent [3]. The ethics and mechanics of providing ECMO are fraught with difficulty at the best of times; for those with COVID-19, no decision on any aspect of their management was taken lightly, and everyone was encouraged to have a say.

The question of futility was raised numerous times in situations of prolonged ECMO runs and extreme disease manifestations. Discussions with family members over the phone were difficult. We battled with fibrosis and steroids versus bacteraemia, whilst proning and deproning. A haemothorax was not uncommon, with some patients requiring thoracotomy on ECMO; this has never happened in our centre before. What was really in these patients’ interests? The last thing we wanted was to cause undue harm or distress through interventions.

The night of our first admission was surreal; we will not forget the image of the retrieval team advancing up the corridor in full PPE. As training rotations were suspended, we gained further invaluable experience of ECMO in the most challenging of times, and we are now fully realising just how well supported we have been. The spotlight has shone on ECMO during the COVID-19 pandemic, and it has been a privilege to have had such a rare glimpse into this world.

Ozerah Choudhry
ST5, Intensive Care Medicine

Eryl Davies
ST5, Anaesthesia and Intensive Care Medicine
Wythenshawe Hospital, Manchester

Twitter: @erylann

References

1. Zochios V, Brodie D, Charlesworth M, Parhar KK. Delivering extracorporeal membrane oxygenation for patients with COVID-19: what, who, when and how? Anaesthesia 2020 Apr 22; doi 10.1111/anae.15099.
2. Rajagopal K, Keller SP, Akkanti B et al. Advanced pulmonary and cardiac support of covid-19 patients: emerging recommendations from ASAIO - a “living working document.” ASAIO Journal 2020; 66: 588-98.
3. Thachil J, Agarwal S. Understanding the COVID-19 coagulopathy spectrum. Anaesthesia 2020 May 21; doi 10.1111/anae.15141.