Commentary: Heroic tales from a national tragedy

Jacob A. Klapper, MD, FACS

Central Message.

VV ECMO continues to be an invaluable resource in the treatment of ARDS. This fact has perhaps never been more relevant than in our fight against COVID-19.

See Article page 1071.

The manuscript by Shih and colleagues¹ is an excellent description of a large institution's experience using extracorporeal membrane oxygenation (ECMO) during the first 6 months of the pandemic. In so doing, they have highlighted a number of key elements to realizing success with this resource as it is deployed in the fight against the virus.

First, multidisciplinary involvement is essential when considering patients for potential transfer from an outside institution or an affiliated hospital within the system. As the authors demonstrate, it takes an organized, multidisciplinary team to determine the appropriateness of ECMO deployment. This, of course, begins with a collegial discussion with the outside provider that includes pulmonologists, surgeons, and perfusionists. The benefits of multiple providers fielding such calls is that each practitioner's individual expertise enables the team to select appropriate patients for transfer.

The downstream implications of deliberate patient selection are significant for multiple reasons. First, ECMO is, of course, a limited resource, as are the beds these patients occupy. ECMO use in patients for whom there is very little chance for meaningful recovery has the potential to be both dispiriting to the team and may give family members false hope. In addition, every ECMO deployment in a patient who is unlikely to survive means that one less bed, perfusionist, machine, or skilled nurse is available for the next patient who may truly benefit.

Speaking of intensive resource use, reading this comprehensive review serves as a firm reminder of how this virus impacts the system as a whole, particularly the emotional well-being of patient and care providers alike. For instance, of the 37 patients included in this analysis, 56.8% survived to discharge, but 12 of these patients required discharge to a long-term acute care or rehab hospital and 2 of these individuals required readmission for ventilator weaning. Although one-third of those who survived were discharged directly home, we can assume that their recuperation continued for a significant length of time. In sum, the pandemic has exacted a toll not only on its victims but also on those who survive and the nurses and doctors who make exhaustive efforts to save a life.

Postpandemic, I believe that the role of venovenous (VV) ECMO in rescuing any number of patients who are positive for coronavirus disease 2019 will be heralded as a success story. As the authors mention, they chose not to include in their analysis the 2 patients who were initiated on venoarterial (VA) ECMO. Undoubtedly, the effectiveness of VA ECMO for this disease will not mirror that of VV ECMO. While a consensus statement from the ELSO Guideline Working Group does not specifically recommend against VA ECMO, enhanced discretion must be taken when selecting these patients, as anecdotal evidence has not been encouraging.²

The authors should be commended for their hard work in taking care of their patients and describing their experience. Unfortunately, this paper is just further evidence for what hasn't been done on a larger scale to prevent human suffering. What could have been will never be. Tragic.