Half-empty or half-full?-interpretation of the EOLIA trial and thoughts for the future

Veno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic

Rapid global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resultant clinical illness, coronavirus disease 2019 (COVID-19), drove the World Health Organization to declare COVID-19 a pandemic. Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) is an established therapy for management of patients demonstrating the most severe forms of hypoxemic respiratory failure from COVID-19. However, features of COVID-19 pathophysiology and necessary length of treatment present distinct challenges for utilization of VV-ECMO within the current healthcare emergency. In addition, growing allocation concerns due to capacity and cost present significant challenges. Ethical and legal aspects pertinent to triage of this resource-intensive, but potentially life-saving, therapy in the setting of the COVID-19 pandemic are reviewed here. Given considerations relevant to VV-ECMO use, additional emphasis has been placed on emerging hospital resource scarcity and disproportionate representation of healthcare workers among the ill. Considerations are also discussed surrounding withdrawal of VV-ECMO and the role for early communication as well as consultation from palliative care teams and local ethics committees. In discussing how to best manage these issues in the COVID-19 pandemic at present, we identify gaps in the literature and policy important to clinicians as this crisis continues.

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VV-ECMO may successfully treat respiratory failure due to COVID-19.

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The coronavirus pandemic necessitates judicious use of this resource-intensive therapy.

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Unique features of COVID-19, including isolation from surrogates, present challenges.

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Providers face difficult triage decisions that must be communicated appropriately.

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We review available resources and support tools for clinicians considering VV-ECMO.

Indications and contraindications for extracorporeal life support for severe heart or lung failure: a systematic review

INTRODUCTION

The effectiveness of extracorporeal life support (ECLS) in critically ill patients remains unclear despite a substantial increase in its use. This study critically assesses existing ECLS guidelines, consensus statements, and position papers to systematically review them for agreements and differences regarding indications and contraindications for ECLS.

EVIDENCE ACQUISITION

The aims of this review were to identify available indications and contraindications for ECLS and to evaluate the quality of the evidence on which they are based. Documents containing recommendations regarding indications and/or contraindications for ECLS in adults (aged 18+) were identified through Medline, EMBASE, and CENTRAL searches. Additional documents were identified from guideline-specific databases and the internet websites of professional societies. Based on the Appraisal of Guidelines for Research and Evaluation (AGREE II), four independent reviewers assessed the rigor of development and quality of the documents.

EVIDENCE SYNTHESIS

Eleven documents met the inclusion criteria. Three documents received an average score of ≥50% in all domains. However, the Editorial independence domain only scored <50% in most of the documents. Overall, 13 cardiac and 13 pulmonary ECLS indications, and 23 cardiac and 14 pulmonary contraindications were identified. Indications and contraindications for ECLS use are variable across the documents included and leave considerable room for interpretation.

CONCLUSIONS

The documents included for review show considerable variability, with little consensus on indications and contraindications. This lack of consensus may reflect a lack of clarity regarding ECLS utility. Additionally, it may reveal the necessity for individualized, patient-dependent criteria supported by the best evidence available.