Table 3.

Additional considerations and proposed recommendations for VA-ECMO during the COVID-19 pandemic

Category	Recommendations
Ethical considerations for resource allocation	ECMO should be provided only if institutional resource constraints allow for it. The following groups should be given priority: ✓Sickest first ✓Youngest first ✓Greatest perceived benefit ✓Fewest/no comorbidities ✓Healthcare workers
Patient selection, timing, and management	Determined by standard societal (ELSO, CCS, WHO) and institutional protocols At present, this includes: ✓Case-by-case discussion with interdisciplinary heart team ✓Usual patient selection criteria as for patients without COVID-19 ✓Standard administration, monitoring (eg, POCUS, hematologic parameters) and management of complications ✓Standard adjunctive therapies (eg, lung protective ventilation, CRRT) Patients referred for consideration of VA-ECMO from peripheral centres should be discussed on a case-by-case basis (including the decision to transfer to a specialized center vs cannulate on-site).
Environmental and infection control precautions	Determined by standard institutional protocols: At present, this includes: ✓Patients on ECMO should be in negative pressure isolation rooms when possible ✓N95 masks for aerosol-generating medical procedures only ✓Droplet-contact precautions otherwise including during cannulation and routine rounding
Handling of ECMO equipment	All ECMO equipment should be used and disposed of according to local institutional and infection control policies with attention to practicing strict decontamination.
VA-ECMO during E-CPR	E-CPR should be performed only at experienced institutions (depending on local policy, perceived risk-to-benefit ratio, and availability of resources) because the uncontrolled environment of cardiac arrest can pose significant risk of cross-contamination and transmitting infection.

CCS, Canadian Cardiovascular Society; CRRT, continuous renal replacement therapy; ECMO, extracorporeal membrane oxygenation; E-CPR, extracorporeal membrane oxygenation during cardiopulmonary resuscitation; ELSO, Extracorporeal Life Support Organization; POCUS, point-of-care ultrasound; VA-ECMO, venoarterial ECMO; WHO, World Health Organization.