Extracorporeal membrane oxygenation, or ECMO, is one of the most serious life support measures offered at a hospital, with critically ill patients often receiving both heart and lung support for a number of days or weeks during organ and respiratory failure.
During the initial months of the COVID-19 pandemic, patients sickened most severely with the virus were moved to ECMO after ventilation failed, with a 50% survival rate.
A new study in The Lancet Respiratory Medicine tracks outcomes among ECMO patients from Sept 15, 2020, when the first wave of the pandemic ended, until the declared end of the pandemic on March 21, 2023, by the World Health Organization. The primary outcomes of the study were in-hospital death and death 6 months after ECMO initiation.
The authors of the study looked at ECMO patients seen at 98 centers in 21 countries, all part of EuroECMO-COVID, a prospective observational study developed by the European Extracorporeal Life Support Organization.
On average, time from hospital presentation to intensive care unit admission was 8 days, and the median time from intubation to ECMO start was 3 days. The chief indication for being placed on ECMO was acute respiratory distress syndrome—for 81.1% of the patients—and 53.4% required tracheostomy.
56% in-hospital mortality rate
In total, there were 3,860 ECMO patients over the age of 16 years included in the study (69.7% men and 30.3% women; median age, 51 years). In-hospital mortality was 55.9% (2,158), with 81.2% of deaths occurring during ECMO support.
For both survivors and non-survivors, the median number of days on ECMO was 18.
For those who survived ECMO, almost all, 99.7%, were alive 6 months post-discharge. During the first wave of the pandemic, 95% of those who survived ECMO were still alive 6 months after their hospitalization.
Those in the study who died were more likely to suffer co-morbidities, including diabetes, high blood pressure, sepsis, and renal failure. They were also more likely to have a longer time between intubation and ECMO placement.
"This study demonstrates that a high rate of complications is strongly associated with in-hospital mortality," the authors wrote. "Data from the second COVID-19 wave onwards confirmed the role of older age, co-morbidities, pre-ECMO indicators of hemodynamic instability (inotropes and vasopressors), longer intubation time before ECMO start, configuration change and complications in contributing to in-hospital mortality."
Few survivors return to work by 6 months
Among those who survived, few had fully recovered at 6 months post-discharge. Only 11.4% of survivors resumed full-time work at that point, while 12.0% went back to part-time work.
Also, a significant number of survivors had lasting symptoms at 6 months. Among survivors at that time point, 32.0% had difficulty breathing, 7.8% had cardiac symptoms, and 10.7% had neurocognitive issues.
Survival is a prolonged process.
In a commentary on the study, J. W. Awori Hayanga, MD, MPH, MHL, and Heather Kaiser Hayanga, MD, MPH, both of West Virginia University, said these lasting symptoms expand the clinical understating of post-ECMO life for patients.
"There is a growing need to address the post-decannulation existence of patients after recovering from severe life-threatening respiratory illness," they write. "Survival is a prolonged process."
