FRONTIERS IN MEDICAL CASE REPORTS - Volume 2; Issue 6, (Nov-Dec, 2021)

Pages: 1-19
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Care Management for Patients with Covid-19 Receiving Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review

Author: Valdir Assis dos Reis Filho, Karina Aparecida Antonelli Novello, Amanda Sayuri Miyamae, Kelly Christine Stutz, Fernando Oliveira e Sales Cyrino, Cristiane Célia Pereira, Gilberto de Oliveira Scuciato, Nadia Maria Rocha Mendes, Mariana Leticia Matias

Category: Health Care

Abstract:

Extracorporeal membrane oxygenation (ECMO) is recommended in individuals experiencing COVID-19 with refractory hypoxemia and no response to mechanical ventilation (MV). The support should be given according to predetermined protocols and care management of these patients are under the responsibility of a specialized multiprofessional team. The present review provides information to the multiple health professionals about care and treatment of COVID-19 patients on ECMO.

Keywords: Extracorporeal Membrane Oxygenation, COVID-19, Hypoxia, Mechanical Ventilation

DOI URL: http://dx.doi.org/10.47746/FMCR.2021.2611

Full Text:

Introduction

Patients under serious conditions experiencing COVID-19 usually develop respiratory failure and acute respiratory distress syndrome (ARDS). Since there is a high mortality rate for patients receiving mechanical ventilation, the use of extracorporeal membrane oxygenation (ECMO) in some serious ARDS cases may decrease those rates (Bartlett et al., 2020; Badulak et al., 2021).

The World Health Organization (WHO) recommends the use of extracorporeal membrane oxygenation in patients experiencing COVID-19 with refractory hypoxemia and no response to mechanical ventilation (MV). The support should be promptly started as soon as the patient meets all eligibility criteria to ECMO [1]. Extracorporeal membrane oxygenation is a salvage therapy for these patients, and the veno-venous (VV) support can be considered (Henry, 2020; Alshahrani et al., 2018).

ECMO is a valuable therapeutic option for patients with acute lung failure, each case should be analyzed, according to different factors, such as financial, professional resources, government and hospital policies (Bartlett et al., 2020). The VV ECMO is the choice for patients experiencing COVID-19, and venoarterial (VA) ECMO may also be considered if COVID-19 is associated with serious heart failure. ECMO should be used in patients with favorable prognosis for such a support (Shekar et al., 2020). In this narrative review provides important information to the multiple health professionals about care and treatment of COVID-19 patients on extracorporeal membrane oxygenation.

Patient Selection

The patient undergoing support should be chosen based on a rigorous and extremely fair selection, always considering the possibility of making it even more restrict (Badulak et al., 2021).

Indication

Specific criteria for ECMO initiation:

PaO₂: FiO₂ < 50 mmHg > 3 hours;

PaO₂: FiO₂ < 80mmHg > 6 hours;

arterial pH <7.15 due to respiratory acidosis with PaCO2 > 60 mmHg.

Contraindications

There are no absolute contraindications for the support; the risks and benefits are individually assessed for each patient; However, there are conditions that may be considered as a relative contraindication (Bartlett et al., 2020); [2].

High mechanical ventilation settings $\ge$ 10 days (may not be applicable to some specific patients);

Serious neurological injury;

Prolonged cardiac arrest;

Multiple comorbidities or multiple organ dysfunction.

Cannulation

The cannulation of patients with COVID-19 should be performed preferably in an isolated place of the hospital. During the procedure, the patient must be sedated, and neuromuscular blocking agents should be given. Lastly, it is recommended use of x-ray, vascular ultrasound, and echocardiography (transthoracic or transesophageal) to help with the cannulation. The cannulas used have different sizes, according to the patient’s weight and optimum blood flow (Table 1) (Shekar et al., 2020; Broccoli et al., 2018).

Table 1: Cannulas according to the patient’s weight.

ECMO Configurations

VV ECMO:

• It is recommended the use of a multi-stage, large-size drainage cannula (23 Fr for adults) or a single-stage cannula from 19 to 23 Fr.
• As for the cannulation site, it is recommended a jugular-femoral configuration.

VA ECMO:

• In the VA modality, it is recommended to use the femoro-femoral configuration, with backflow cannula in the distal portion of the limb, in order to prevent ischemia.

Anticoagulation

Due to the hypercoagulable state of patients receiving ECMO, the anticoagulation parameters should be kept within an upper limit from the normal values. It is strictly recommended to avoid flows lower than 2000 ml/min due to an increased risk of thrombogenic episodes in the circuit [3].

Table 2: Heparin infusion based on aPTT.

50 to 100 IU/kg of unfractionated heparin (UFH) bolus is used to perform the cannulation. The initial monitoring is carried out using the activated clotting time (ACT); when ACT is decreased to 300 sec values, the heparin infusion is therefore started, with a dosage from 7.5 to 20 IU/kg/h. ACT should be kept within a 180 to 220 seconds range throughout the period the patient continues receiving the ECMO support. After the ACT values become steady, the heparin infusion should be guided based on the activated partial thromboplastin time (aPTT) (Table 2) (Broccoli et al., 2018; Chaves et al., 2019) [3].

Mechanical Ventilation

COVID-19 pandemic imposed huge challenges to the management of mechanical ventilation due to inflammatory storm, angiotensin-converting enzyme 2 (ACE2) regulation failure and immune response. Clinically, the disease is translated into pneumonia/ARDS associated with inflammatory damage due to edema, changes in hypoxic vasoconstriction reflex, and tissue hypoxia (Bartlett et al., 2020).

The main focus of the MV in ARDS is to provide the proper gas exchange, therefore decreasing the risk of injuries. Incorrect management of mechanical ventilation may lead to ventilator-induced lung injury (VILI), in addition to inadequate diaphragm muscle effort, that can be poor (P0.1 - inspiratory pressure generated in 100 ms < 2.0 cmH20) or excessive (P0.1 > 4.0 cmH20), which may lead to diaphragm atrophy or myotrauma, respectively. The monitoring of both the respiratory drive and patient effort is crucial to minimize the patient self-inflected lung injury (P-SILI) during spontaneous breathing (Abrams et al., 2020) [4].

ECMO is commonly indicated in cases of serious hypoxemia or hypercapnic acidosis refractory to conventional ventilator management strategies. A highly protective ventilation strategy may be used in patients receiving ECMO since the device membrane can maintain the oxygen and carbon dioxide rates within the desired values (Bartlett et al., 2020; Abrams et al., 2020)

Reduced lung volumes are recommended, a predicted tidal volume (Vt) of 4 ml/kg is associated with lower mortality, reduces pulmonary inflammation, and has the potential to increase days without ventilation in patients with PaO₂ / FiO₂ $\le$150. However, they increase the atelectasis areas, leading to increased unbalance of the ventilation/perfusion ratio. Therefore, elevated positive end-expiratory pressure (PEEP) values are usually recommended; however, this PEEP should be enough to sustain the alveolar recruitment without causing hyperdistension (Badulak, 2020). Patients should be assessed individually, considering the heart and hemodynamic limitations. The positive airway pressure affects the pre- and post-load of both the right ventricle (RV) and left ventricle (LV). Patients receiving ECMO who are experiencing RV failure may be adversely affected due to the high positive end-expiratory pressure levels, while patients experiencing LV failure may benefit from the high PEEP levels, therefore reducing the probability of pulmonary edema. The highly protective strategy may also decrease the plateau pressure (Pplat), driving pressure (ΔP), mechanical power, and respiratory rate (RR). (Abrams et al., 2020; Badulak, 2020) [4].

After the ECMO is connected, the patient remains sedated and curarized for the initial adjustments in the ventilation parameters and PEEP titration. During the period the patients receive the controlled mechanical ventilation, it is possible to maintain the inspiratory time and expiratory time ratio (I:E), which can be reversed in 2:1, in order to optimize the gas exchange (Table 3). As the patient experiences hemodynamic improvement and recovers from hypoxemia and acidosis, the sedation levels may be reduced and the I:E ratio should be maintained as close as possible to the physiological one, which is approximately 1:2 (Table 4) (Abrams et al., 2020; Badulak, 2020) [4].

Table 3: Initial ventilation parameters for patients receiving ECMO.

Table 4: Ventilation monitoring for patients with COVID-19 in the controlled mechanical ventilation modality and spontaneous MV modality.

The ECMO ventilation and gas management should be conducted by a specialist professional, and the decisions are made by a multidisciplinary team. The ventilation strategy is complementary and should be in line with the oxygenation and CO2 removal strategies through the membrane. Therefore, the actions have to be concomitantly planned, executed, and monitored. For example, during the ECMO weaning, if the blood flow deviated to the device is reduced, it will lead to limited gas exchange as a result of the arterialization blood flow decrease and, at that moment, the ventilation strategy should gradually return to more physiological parameters [4].

Nursing Management

The nurse is exclusively accountable for the direct care of individuals receiving ECMO [5]. In light of the nurse’s perception of the care required, it is important to establish specific nursing care interventions according to the priority health needs of the patient (Silva et al., 2020; do Nascimento Pereira et al., 2017).

Clinical approach is the tool that provides systematized, reflexive, and humanized care, promoting specific care; the systematization of nursing care (SNC) is at the nurse’s discretion, and through it, it is possible to operationalize and document the nursing process, fostering the health promotion, prevention, recovery, and rehabilitation, whenever the nursing interventions are applicable throughout this process (Ferreira et al., 2016; Oliveira et al., 2017) [6].

The main nursing intervention in patients receiving ECMO refer to the monitoring of hemodynamic parameters, bleeding prevention and/or control care, change of position, neurological, ventilation, gas, and diuresis volume follow up and monitoring, glucose control, and observation of patient clinical changes. (Board 1) (Chaica et al., 2020; Martorelli et al., 2019).

Board 1: Nursing interventions and diagnoses in patients receiving ECMO.

Blood Component Replacement Therapy

Due to several factors, blood component replacement in patients receiving ECMO is often required. 8 In some cases the transfusion is applied to maintain the clinical stability; however, a rigorous assessment of the real needs of the patient should be performed (Table 5) (Romano et al., 2017; Shekar et al., 2020).

Table 5: Hemoderivative transfusion.

Continuous Renal Replacement Therapy

Patients receiving ECMO often develop acute kidney injure (AKI) and volume overload. The incidence of AKI and respective complications in these individuals increase the hospital mortality rates (Lee et al., 201). In patients experiencing COVID-19, there is not a clear consensus about AKI; however, the cause may be attributed to multiple factors associated, such as hemodynamic changes, inflammatory response, hypercoagulability, and cytotoxicity due to SARS-CoV-2 (Costa et al., 2021). The continuous renal replacement therapy (CRRT) is commonly used to compensate this clinical condition. CRRT is the safest and most reliable option for patients receiving ECMO and the most used configurations are conventional filtration, continuous hemofiltration, and CRRT machine (Seczynska et al., 2021; Poveda et al., 2018).

Conventional Filtration and Continuous Hemofiltration

The hemofilter is used for conventional ultrafiltration, with the purpose of removing volume from patients, and may also be used as a continuous hemodialysis, with the purpose of removing fluids and solutes. The specific configuration is implemented from the line that delivers blood to the hemofilter, which is connected to the ECMO circuit in the post-pump; the blood returns from the hemofilter to the venous portion in the pre-pump position. When the hemodialysis is performed, the dialysis solution is implemented, and the infusion is made in the opposite direction to the blood flow in the hemofilter. To monitor the hemofilter output volumes and in cases of dialysis solution infusion, continuous infusion pumps are required in order to control the volume input and output (Fig. 1) (Broccoli et al., 2018; Poveda et al., 2018).

CRRT Machine with ECMO Circuit

It can be performed through a venous access, but it is often used only when the patient has a previous vascular access. However, the use of this modality depends on the discretion of the clinical staff. In sites where it is possible to use a CRRT therapy machine, the connection is made through the venous line of the post-pump circuit, with the blood flow returning to the pre-pump access. (Fig. 2) or, yet a CRRT machine flow input configuration through the post-pump access returning to the pre-membrane position (Fig. 3) (Poveda et al., 2018).

Figure 1: ECMO configuration, showing the hemofilter output and input access points, as well as the infusion pump for dialysis solution and volume removal.

Figure 2: ECMO configuration, showing the CRRT machine output and input access points, with access in a post-pump pathway and return through the pre-pump.

Figure 3: ECMO configuration, showing the CRRT machine output and input access points, with access in a post-pump pathway and return through the pre-membrane.

Prone Position During ECMO

The prone position helps treating the pulmonary side effects of patients receiving ECMO, and may be safely performed whenever needed, from a therapeutic point of view (Kimmoun et al., 2013). Prone position a patient leads to positive oxygenation effects and helps reducing pulmonary lesions induced by protective mechanical ventilation (Guervilly et al., 2019). The prone procedure in individuals receiving VV ECMO for periods exceeding 12 hours results in increased alveolar recruitment, respiratory compliance, PaO₂/FiO₂ ratio, and may influence the survival of these patients (Dalmedico et al., 2019).

Patients may be proned to 180º once every 24 hours, for the suggested period from 8 to 12 hours. They should be manually positioned by a team of 4-5 professionals, which should consist in a physician, a nurse, a physiotherapist, a nursing technician, and perfusionist. The lines and tuber should be carefully handled, following the sagittal plane (Kipping et al., 2013).

Transportation Of Patients Receiving ECMO

There are situations in which it is required to remove the patient to another place, whether to other hospital areas, such a surgical center and for imaging, or to transfer them to another reference site (Broccoli et al., 2018).

If the patient needs to be transferred to another hospital, it is important to check the distance between the places and the geography of the route since these factors have influence and determine the type of vehicle to be used. It is worth noting that, regardless of the vehicle chosen, all of them should have the appropriate electrical apparatus for the ECMO circuit and remaining equipment required during the transfer (Table 6) [7].

Table 6: Types of vehicles used according to the distance and capacity of personnel allocation.

Personnel

It is crucial the presence of a multiprofessional team that had received the appropriate training to transport patients receiving ECMO [7]. Therefore, the team should consist in:

• Cardiothoracic surgeon (responsible for the cannulation)
• Physician with experience in ECMO
• Perfusionist
• Nurse
• Nursing technician
• Physiotherapist

Materials and Equipment for The Transportation

• Centrifugal pump
• Membrane oxygenator
• Hand crank
• Heater /cooler machine
• Oxygen tank
• Saline solution 0.9% (1000 ml)
• Heparin infusion pump
• Anticoagulation monitoring equipment
• Tubing clamp forceps (Henry, 2020)

Whenever the patients needs to be transported, it will be required to check the battery level of the equipment and if a hand crank is available, as well as if the latter is working properly. Also, the oxygenator output device should be occluded throughout the patient transportation (Broccoli et al., 2018).

The oxygen tank is directly connected to the membrane oxygenator and the blender disconnected. The transportation is made with a multi-parameter monitor for a continuous assessment of heart rate, arterial blood pressure, and pulse oximetry. The pressure monitors and hemodialysis filtration solutions should be disconnected (Broccoli et al., 2018). The following EPIs are required: long-sleeve apron, medical gloves, protection goggles, and/or face shields, face mask, and medical cap [8].

ECMO Complications

ECMO has several advantages, but can also lead to different complications since it is an invasive, highly complex and specific device (Nakasato et al., 2018). Basically, there are 2 types of complications: clinical and mechanical; those related to clinical outcomes are most frequent ones observed, like vascular, neurological, renal, hemorrhagic, and infectious outcomes (Board 2) (Cheng et al., 2014; Broccoli et al., 2018).

Board 2: Clinical complications.

The mechanical complications are not so frequent, but if they occur, their consequences can be catastrophic. The mechanical complications more commonly observed include clotting formation, cannula displacement, embolism, rupture of connectors, circuits bending, oxygenator failure, and improper pump function (Board 3) (Broccoli et al., 2018).

Board 3: Mechanical complications.

Weaning of ECMO

VV ECMO:

It is necessary to check the oxygen once a day so as to assess the patient gas exchanges. The test is made by increasing the mechanical ventilator FiO₂ to 100% and, after 30 minutes, perform the arterial blood gas collection. If the patient pO2 presents values over 150 – 200 mmHg, it suggests improved pulmonary function, therefore, the care weaning can be started (Broccoli et al., 2018).

The VV ECMO weaning starts by gradually reducing care until reaching 30 – 40 ml/kg/min, of gas flow and oxygen concentration, reaching the minimum parameters of 0.05 – 0.1 LPM sweep and 21% FiO₂ (Broccoli et al., 2018). ECMO FiO₂ should be reduced from 100% to 60%, then 30%, and 21%; each step should take from 5-10 minutes, with monitoring of clinical and laboratory parameters. The weaning may be stopped if the patient experiences instability (Vasques et al., 2019).

Subsequently, the autonomy test should be applied, which checks if it is possible to remove the support. To perform it, the ECMO sweep should be 0 L/min, or the gas tube should be disconnected and pinched, and the ventilation patterns must be configured as follows: Tidal volume $\le$6-8 ml/Kg, PPLAT $\le$ 30 cmH2O, PEEP $\le$16 cmH2O, FiO₂ $\le$ 50%, pH > 7.30 and SatO2 > 88%, or adjusted as required. If the gas exchange is adequate during 2 to 4 hours, the patient can have the cannula removed. 6 It is worth noting that, during the decannulation, heparin should be disconnected from 30 to 60 minutes before the procedure [9].

VA ECMO:

VA ECMO is used if, in addition to pulmonary impairment, heart failure is concurrently diagnosed. Its weaning should be gradually and relatively fast, with reduction of 5 to 10 ml/kg rate per hour, in order to minimize the venous blood shunting in the arterial path created by the circuit. When reaching at least 20 to 30 ml/kg/min, the blender gas stream is disconnected and the clamping is performed. If the patient has normal clinical and laboratory parameters, the decannulation is realized (Broccoli et al., 2018).

Clinical Practice for Other Health Professionals

Nutrition Support

Nutrition therapy for critically ill patients is difficult due to hemodynamic instability. The hypotensive state leads to compromised splanchnic perfusion, which is a prerequisite for the possible start of nutritional support. On the other hand, ECMO can provide favorable circulatory support, which reduces the risk of gastrointestinal hypoperfusion and mesenteric ischemia. Thus, the nutritional management of the patient in ECMO should follow the same guidelines as other critical patients (Farías et al., 2015; Broccoli et al., 2018).

Nutritional support can be started when the patient presents hemodynamic stability, which usually occurs after the first 6 to 12 hours the start of ECMO assistance (Farías et al., 2015; Broccoli et al., 2018). Early enteral feeding of low-dose (trophic) nutrition therapy is recommended. The enteral nutrition (EN) is important to regulates gastrointestinal motility, in addition is generally well tolerated by most patients; serious adverse events is not reported, such as intestinal ischemia, gastrointestinal bleeding or other complications. Enteral nutrition intolerance is common in clinical practice, and can be demonstrated by residual gastric volume (> 500 ml), vomiting and abdominal distension, in these cases, total parenteral nutrition (TPN) is considered (Rocha et al., 2020; Toh et al., 2021).

Oral Healthcare

The presence of oral healthcare professionals for critically ill patients is important. Efficient oral hygiene is able to reduce bacterial colonization and minimize the risk of Ventilator-associated pneumonia. The oral microbiota remains in balance for about 48 hours after admission in ICU; however, the composition of the microbiota is vulnerable to change. Thus, it is necessary implementing oral hygiene to reduce bacterial oropharyngeal colonization and dental plaque (Lima et al., 2021).

In the context of COVID-19, oral health and care for critically ill patients has been even more necessary due to imbalance of the oral microbiota and immunosuppress developed for SARS-CoV-2 infection. This situation can allow secondary viral and fungal infections, such as herpes simplex virus (HSV-1) (Furtado et al., 2021; dos Santos Júnior et al., 2020).

Psychological Monitoring

Psychological care is linked to the effectiveness of physical treatment and must be given priority. Thus, the inclusion of the psychologist in the intensive care team aims to add to their knowledge so that they can promote ample support for the life of the patient and their family (Ferreira and Mendes, 2013).

The ICU team must be ready to attend the demands of patients and their families. It is important to emphasize that the actions within an ICU must be performed by an entire multidisciplinary team with the objective of contemplating the humanization of the environment and care; guarantee the necessary information, as well as the suppression of pain, privacy, comfort, individualization, embracing emotions, assistance to the family and the choice and effectiveness of treatment (Ferreira and Mendes, 2013).

Conclusion

The careful patient selection, appropriate management and experience of the multidisciplinary team are factors affecting the efficacy of ECMO support in the COVID-19 pandemic. Therefore, all decisions should be made following established protocols to provide a favorable outcome for the patient.

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