Transition from VV to VA or hybrid ECMO: An ELSO Overview

Objective: Extracorporeal membrane oxygenation (ECMO) has a role in selected patients with COVID-19 related acute hypoxaemic respiratory failure. The reported usual duration of ECMO is 7-10 days. However, increasing reports documented prolonged duration ECMO (> 14 days) patients with high survival rate (50- 70%) and native lung recovery. Prolonged ECMO (P-ECMO) often causes physicians to question the utility of this costly treatment. We report a case of prolonged V-V ECMO duration in patient with COVID-19 (984 hours, 41 days) Methods: A 57 years-old man with no past medical history presented to the emergency department progressive hypoxemia requiring rapid sequence intubation and a nasopharyngeal swab were found COVID-19 positive. Chest computed tomography (CT)-revealed multifocal consolidation and subpleural thickening. After an initial improving of the clinical conditions, the patient developed worsening hypoxemia/hypercapnia and progressed to septic shock. On day 18 from the admission a femoro-jugular V-V ECMO (Vf dx 23 Fr-Vj dx 21 Fr) was instituted. During the run on day 15, 25 and 35 the oxygenator was changed out for signs of haemolysis and increasing of trans-membrane pressure. The patient remained neurologically full intact during all the period with no evidence of hypoxic injury. On day 51 was weaned -off and on day 65 was discharged to rehabilitation center with full native lung recovery. Results: In literature ECMO duration itself does not indicated poor prognosis or should not be used as a guide to determine when treatment has become futile and should be withdrawn. Conclusions: Providing complex therapies such as V-V ECMO during a pandemic has its challenges and P-ECMO poses unique ethical issue. In contrast to allocating resources solely guided by expected outcomes and maximization of net utility we propose a focus on a process of accountability for reasonableness with transparency and obbligation to respect the patient and work toward a common goal.