The History of Extra Corporeal Membrane Oxygenation
(ECMO) From Start to COVID
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MEDICAL PROCEDURES, TESTING AND TECHNOLOGY
THE HISTORY OF EXTRA-
CORPOREAL MEMBRANE
OXYGENATION (ECMO)
FROM START TO COVID
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MEDICAL PROCEDURES,
TESTING AND TECHNOLOGY
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MEDICAL PROCEDURES, TESTING AND TECHNOLOGY
THE HISTORY OF EXTRA-
CORPOREAL MEMBRANE
OXYGENATION (ECMO)
FROM START TO COVID
MICHAEL S. FIRSTENBERG
EDITOR
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CONTENTS
Preface The Practice and Principles of
Extra-Corporeal Membrane Oxygenation
(ECMO) – Volume 3 vii
Jeffrey Phillip Jacobs and Eric Yates Pruitt
Introduction The History of Extra-Corporeal Membrane
Oxygenation From Start to COVID xiii
Ahmed S. Said and Kenneth E. Remy
Chapter 1 The Genesis and Evolution of Extracorporeal
Membrane Oxygenation 1
Benjamin Smood, Asad A. Usman, Mark Helmers,
Christian Bermudez and
Rita Carrie Karianna Milewski
Chapter 2 An Introduction to VA-ECMO: Physiology,
Indications, and Principles of Management 25
Benjamin Smood, Matthew Woods,
Jason J. Han, Christian Bermudez
and Rita Carrie Karianna Milewski
vi Contents
Chapter 3 Disaster Preparedness for ECMO Programs and
Adapting ECMO Programs
to Face the COVID19 Pandemic 117
Allison Ferreira and Kim Delacruz
Chapter 4 Special Considerations for ECMO Cannulation
and Decannulation for COVID-19 Patient 131
Joseph Dovidio and Hitoshi Hirose
Chapter 5 The Use of ECMO for Treatment of Severe ARDS
Due to Coronavirus Disease 2019 151
Olivia Giddings and Rana Hejal
Chapter 6 Frontline Experience with Extracorporeal Life
Support for COVID-19 Patients 163
Vitali Karaliou, Jennifer Hanna,
Matthew N. Libby, Courtney Petersen,
William M Novick and Michael S. Firstenberg
Chapter 7 Extracorporeal Membrane Oxygenation (ECMO)
in COVID-19: The Role of Lung Transplantation 187
Asishana Osho, Jerome Crowley,
Philip J Spencer, Masaki Funamoto,
Nathaniel Langer and Mauricio Villavicencio
About the Editor 199
Index 201
PREFACE: THE PRACTICE AND PRINCIPLES
OF EXTRA-CORPOREAL MEMBRANE
OXYGENATION (ECMO) – VOLUME 3
Jeffrey Phillip Jacobs, MD and Eric Yates Pruitt, MD
Department of Surgery, University of Florida, Gainesville, Florida, US
INTRODUCTION
Dr. Michael Firstenberg is to be congratulated for creating and editing
an essential three volume compendium about extracorporeal membrane
oxygenation (ECMO) entitled, “The Practice and Principles of Extra-
Corporeal Membrane Oxygenation (ECMO)”. It is our honor to write this
Preface to Volume 3 of this magnificent summary of the state of the art and
science of ECMO. We recommend all three volumes of this textbook as
essential reading for all health care professionals with interest in ECMO.
The first 2 volumes of this compendium cover all of the details of
ECMO overall, describing both basic and advanced concepts. This third
volume discusses the early history of ECMO and then includes five
chapters discussing the extremely timely topic of the role of ECMO in the
treatment of patients diagnosed with Coronavirus Disease 2019 (COVID-
viii Jeffrey Phillip Jacobs and Eric Yates Pruitt
19). Volume 3, therefore, in many ways, spans the start of ECMO, to the
current state of ECMO today: ECMO from start to finish! However, the
status of ECMO in this very moment is in no way the actual finish, because
ECMO will continue to evolve in parallel with the evolution of medicine
and humanity.
All of us have had our very existence impacted by the COVID-19
pandemic; indeed, life as we know it has changed dramatically and
stunningly and rapidly and globally. The evolution of the treatment of
patients with COVID-19 is unlike any event ever seen in medicine. As of
October 24, 2020, 42,299,535 patients around the world have been
diagnosed with COVID-19, with 1,145,739 associated deaths (2.71%
mortality worldwide) [1]. Meanwhile, in the United States of America, as
of October 24, 2020, 8,497,011 patients have been diagnosed with
confirmed COVID-19, with 224,005 associated deaths to date (2.64%
mortality in the USA) [1]. Most deaths in patients with COVID-19 are due
to severe respiratory failure, with a smaller group succumbing to combined
pulmonary and cardiac failure. Several recent publications have
documented that ECMO facilitates salvage and survival of select critically
ill patients with COVID-19 [2, 3, 4, 5]. Early data from Wuhan, China
reported an alarmingly high rate of mortality of 83% (5 out of 6) in
COVID-19 patients supported with ECMO [6, 7]; however, more recent
data reveal improved survival of COVID-19 patients supported with
ECMO [2, 3, 4, 5]. Both recent individual institutional reports [2, 3, 5], as
well as recent reports from multi-institutional registries [4], have
demonstrated promising results and improvements in survival. Indeed, it is
clear that ECMO facilitates salvage and survival of select critically ill
patients with COVID-19. It is a fact that much remains to be learned about
the treatment of patients with COVID-19 and the role of ECMO in this
treatment.
Clinical guidelines for the management of patients with COVID-19
have been released by the World Health Organization (WHO) [8] and the
Centers for Disease Control and Prevention (CDC) of the United States [9].
The Extracorporeal Life Support Organization (ELSO) [10] and The
American Society for Artificial Internal Organs (ASAIO) [11] have also
Preface ix
both published guidelines regarding the role of ECMO in treating patients
with COVID-19. Nevertheless, the role of ECMO in the management of
these challenging patients remains promising but unclear.
Volume 3 of this three-volume compendium about ECMO entitled,
“The History of Extra-Corporeal Membrane Oxygenation (ECMO) – From
Start to COVID” provides a treasure chest of information about the use of
ECMO to support the sickest of patients with COVID-19. This information
is valuable and will save lives!!! Moreover, many of the lessons that we
learn about the use ECMO in patients with COVID-19 will be applicable to
all patients supported with ECMO regardless of their underlying disease.
We congratulate Dr. Firstenberg and all of the authors for the publication
of this timely and valuable information, and we encourage all health care
professional with an interest in ECMO to read these important
contributions.
REFERENCES
[1] Coronavirus COVID-19 Global Cases by the Center for Systems
Science and Engineering (CSSE) [https://coronavirus.jhu.edu/map.
html]. Accessed October 4, 2020.
[2] Jacobs JP, Stammers AH, St Louis J, Hayanga JWA, Firstenberg
MS, Mongero LB, Tesdahl EA, Rajagopal K, Cheema FH, Coley T,
Badhwar V, Sestokas AK, Slepian MJ. Extracorporeal Membrane
Oxygenation in the Treatment of Severe Pulmonary and Cardiac
Compromise in Coronavirus Disease 2019: Experience with 32
Patients. ASAIO J. 2020 Jul;66(7):722-730. doi: 10.1097/MAT.00
00000000001185. PMID: 32317557.
[3] Kon ZN, Smith DE, Chang SH, Goldenberg RM, Angel LF, Carillo
JA, Geraci TC, Cerfolio RJ, Montgomery RA, Moazami N,
Galloway AC. Extracorporeal Membrane Oxygenation Support in
Severe COVID-19. Ann Thorac Surg. 2020 Jul 17:S0003-
4975(20)31152-8. doi: 10.1016/j.athoracsur.2020.07.002. Epub
ahead of print. PMID: 32687823; PMCID: PMC7366119.
x Jeffrey Phillip Jacobs and Eric Yates Pruitt
[4] Barbaro RP, MacLaren G, Boonstra PS, Iwashyna TJ, Slutsky AS,
Fan E, Bartlett RH, Tonna JE, Hyslop R, Fanning JJ, Rycus PT,
Hyer SJ, Anders MM, Agerstrand CL, Hryniewicz K, Diaz R,
Lorusso R, Combes A, Brodie D; Extracorporeal Life Support
Organization. Extracorporeal membrane oxygenation support in
COVID-19: an international cohort study of the Extracorporeal Life
Support Organization registry. Lancet. 2020 Sep 25:S0140-
6736(20)32008-0. doi: 10.1016/S0140-6736(20)32008-0. Epub
ahead of print. PMID: 32987008; PMCID: PMC7518880.
[5] Jacobs JP, Stammers AH, St Louis J, Hayanga JWA, Firstenberg
MS, Mongero LB, Tesdahl EA, Rajagopal K, Cheema FH, Patel K,
Esseghir F, Coley T, Sestokas AK, Slepian MJ, Badhwar V. Multi-
institutional Analysis of 100 consecutive patients with COVID-19
and Severe Pulmonary Compromise treated with Extracorporeal
Membrane Oxygenation (ECMO): Outcomes and Trends Over Time.
The Annals of Thoracic Surgery. In Review.
[6] Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, Zhang L, Yu Z,
Fang M, Yu T, Wang Y, Pan S, Zou X, Yuan S, Shang Y. Clinical
course and outcomes of critically ill patients with SARS-CoV-2
pneumonia in Wuhan, China: a single-centered, retrospective,
observational study. Lancet Respir Med. 2020 Feb 24. pii: S2213-
2600(20)30079-5. doi: 10.1016/S2213-2600(20)30079-5. [Epub
ahead of print] Erratum in: Lancet Respir Med. 2020 Apr;8(4):e26.
PMID: 32105632.
[7] Henry BM. COVID-19, ECMO, and lymphopenia: a word of
caution. Lancet Respir Med. 2020 Apr;8(4):e24. doi: 10.1016/S2213-
2600(20)30119-3. Epub 2020 Mar 13. PMID: 32178774.
[8] World Health Organization. Clinical management of severe acute
respiratory infection (SARI) when COVID-19 disease is suspected.
Interim guidance. 3 March 2020. [https://www.who.int/docs/default-
source/coronaviruse/clinical-management-of-novel-cov.pdf].
Accessed April 7, 2020.
[9] Interim Clinical Guidance for Management of Patients with
Confirmed Coronavirus Disease (COVID-19). [https://www.cdc.gov/
Preface xi
coronavirus/2019-ncov/hcp/clinical-guidance-management-
patients.html]. Accessed April 7, 2020.
[10] Bartlett RH, Ogino MT, Brodie D, et al. Initial ELSO guidance
document: ECMO for COVID-19 patients with severe
cardiopulmonary failure. ASAIO J 66:472–474, 2020
[11] Rajagopal K, Keller S, Akhanti B, et al. Advanced pulmonary and
cardiac support of COVID-19 patients: Emerging recommendations
from ASAIO - A “Living Working Document.” ASAIO J 66:588–
598, 2020.
Introduction
THE HISTORY OF EXTRA-CORPOREAL
MEMBRANE OXYGENATION
FROM START TO COVID
Ahmed S. Said1 and Kenneth E. Remy1,2,
1
Department of Pediatrics, Division of Pediatric Critical Care,
Washington University, St. Louis, MO
2
Department of Internal Medicine, Division of Pulmonary and Critical
Care, Washington University, St. Louis, MO
INTRODUCTION
I remember it like it was yesterday. Called to an outside hospital to
meet a previously healthy 7 year old girl that now was nearing the end of
her young life with septic shock. She was maintained on 3 vasopressors
and 1 inotrope, struggling in the Emergency Department with significant
hypoxemia, decreased pallor, and mom and dad praying by her bedside.
Prior to my arrival, I had already alerted our surgeon-in chief, if we could
Corresponding Author’s E-mail: [email protected].
xiv Ahmed S. Said and Kenneth E. Remy
get her back to our hospital on the 25 minute ambulance ride, she needed
immediate cannulation. After conferring with my fellow, who was
readying the patient for her journey, my six foot nine inch frame crept
down on the ER floor, looked both parents in their eyes, and let them know
that their child had a high likelihood of dying, but transferring her now for
ECMO was her only shot at life. They agreed and strategically maneuvered
back to our hospital with immediate cannulation. Forty-nine days later she
was decannulated. Three weeks later she walked out of the hospital, alive
with an entire life of smiles ahead of her.
They called the pandemic the worst they had seen perhaps since the
1918 influenza pandemic. Some 91 years later, the H1N1 virus was
wreaking havoc on many patients under my care in the adult and pediatric
ICUs in New York City. I remember when this 23 year old woman entered
the hospital in fulminant hypoxemic respiratory failure and 20 weeks
pregnant. She was not only H1N1 positive but had evidence of
Staphyloccocus aureus co-infection. And we couldn’t oxygenate her. No
matter how many different modes of ventilation, recruitment maneuvers,
attempts at increasing pulmonary blood flow, or red blood cell
transfusions, our patient would not increase her saturation above 75%.
With a high likelihood of death for her and her unborn child, we were
faced to a difficult decision, to cannulate or not. In the pediatric world, this
would have been an easier decision as years of ECMO didn’t see the same
level of intracranial hemorrhage or complications as seen in our adult
counterparts. And yet in 2009 in The Lancet Cesar was published [1] and
we learned that adults could be placed on ECMO with new protocols and
survive without disability at 6 months. We had no other option. We
cannulated her for VV ECMO without anticoagulation to protect her
unborn child from possible hemorrhage. Almost ten years later, I still
remember a year later from that 2 week episode when she walked into the
ICU with her 9 month old in arms alive. ECMO saved two lives and many
more during a pandemic.
I thought I would never see another pandemic like the one I
remembered from H1N1 in NYC or my time with Ebola in Africa. The
world is now thrust 11 months into the greatest pandemic in over one
