Survey Results: Challenges Faced During ECMO Cannulation for Patients with COVID-19

Survey Title: Challenges Faced During ECMO Cannulation for Patients with COVID-19
Institution: Seattle Children’s Hospital

We conducted an anonymous survey to gain a broader understanding of the challenges faced by extracorporeal life support (ECLS) providers when initiating ECLS for patients with COVID-19. A total of 17 survey responses was collected from April to July of 2020. About 80% of respondents reported providing venovenous ECLS for a total of 43 COVID-19 positive patients at their institutions. The majority (95%) of COVID patients supported by ECMO were cannulated in an atypical setting (i.e. in an ICU room or negative pressure/isolation room), vascular access for ECLS was achieved percutaneously in all of these cases, and 15 to 30% of cannulations were performed by non-surgically trained staff (intensivists, CCM fellows, interventional cardiologists/radiologists).

When asked about specific challenges encountered during ECMO cannulation or cannula positioning/repositioning that have arisen as a result of the COVID-19 pandemic, survey responses were related to five broad categories: limited space, challenges with personal protective equipment (PPE), barriers to clear communication, obstacles with staffing and/or supplies, and patient specific challenges (e.g. hypercoagulability and rapid decompensation). Respondents described difficulties with access to crucial supplies during cannulation, limited physical space for equipment and personnel in patient rooms, and communication challenges related to PPE or the use of an antechamber (in the setting of an isolated patient).

Another unique challenge described in the survey was that these patients are often in a prone position prior to cannulation and can rapidly decompensate during cannulation, or the cannula can dislodge or migrate when repositioning a patient on ECLS. Although we only collected a small number of survey responses early during the pandemic, the challenges described by these providers are likely experienced by other ECLS teams caring for patients with COVID-19 around the world. Some advice offered by respondents to help overcome these obstacles included: careful planning, clear communication, and keeping personnel to a minimum during ECMO cannulation to minimize exposure risks.

Survey Questions and Responses:
1. Has your institution provided ECMO support for patients suspected of or positive for COVID-19 infection?

• 14 of 17 respondents reported yes

2. How many patients suspected or positive for COVID-19 infection have required V-V ECMO at your institution?

• Of 14 respondents, total of 43 patients reported (average of 3.58 patients/respondent)

3. Of the patients requiring V-V ECMO, how many have been cannulated in an atypical setting? (e.g. a negative pressure/isolation room converted into an ICU room specifically for treating patients with COVID-19)

• 41 of 43 (95%) of cannulations performed in an atypical setting

4. If there were any cannulations performed in atypical settings, how many were performed percutaneously?

• 100%

5. If there were any cannulations performed in atypical settings, how many were performed by non-surgical staff? (i.e. intensivists, critical care fellows, interventional cardiologists/radiologists)

• 10 cannulations (between 15-30% of 43 reported patients)