key: cord-0702853-uk7pry4v
authors: Odish, Mazen F.; Yi, Cassia; Chicotka, Scott; Genovese, Bradley; Golts, Eugene; Madani, Michael; Owens, Robert L.; Pollema, Travis
title: Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation (ECMO) Program in the United States during the Coronavirus Disease 2019 (COVID-19) Pandemic
date: 2021-05-26
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.05.047
sha: 691042141ddce99454068a20702704c77c8fc56b
doc_id: 702853
cord_uid: uk7pry4v

The coronavirus disease 2019 (COVID-19) pandemic began in the United States around March 2020. With limited access to extracorporeal membrane oxygenation (ECMO) in our region, we implemented a mobile ECMO team by April 2020 to serve patients with COVID-19. Several logistical and operational needs were assessed and addressed to ensure a successful program, including credentialing, equipment management, and transportation. A multi-disciplinary team was included in the planning, decision making, and implementation of mobile ECMO. From April 2020 to January 2021, we provided mobile ECMO to 22 patients in 13 facilities across four southern California counties. The survival to hospital discharge of patients with COVID-19 who received mobile ECMO was 52.4% (11/21) compared to 45.2% (14/31) for similar patients cannulated in-house. No significant patient or transport complications occurred during mobile ECMO. There were no unprotected exposures or Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections to our ECMO or transport teams. Here we reviewed the implementation of our mobile ECMO team and described the patient characteristics and outcomes.

Extracorporeal membrane oxygenation (ECMO) is an advanced mechanical circulatory support therapy for refractory cardiac and/or respiratory failure. 1 This technology has been increasingly utilized for adults in the United States since the 2009 H1N1 influenza pandemic and again in 2020 due to the coronavirus disease 2019 (COVID- 19) pandemic. 2 Mobile ECMO is deployed when critically ill patients at outside facilities are too clinically unstable to transfer to a regional ECMO center. Mobile ECMO has been safely and successfully used in both the pediatric and adult population in many countries for decades. [3] [4] [5] [6] [7] [8] Southern California has only a few ECMO centers serving a large geographical region which has been disproportionately affected by COVID-19. 9- 11 We describe our process and outcomes of implementing a mobile ECMO team during the COVID-19 pandemic to ensure equitable care throughout the region. [12] [13] [14] [15] Methods

Clinicians at outside facilities consulted the ECMO team through our hospital transfer center and completed our ECMO-specific transfer document, see supplement ( Table S1 ). The transfer center then contacted the ECMO coordinator who organized a multidisciplinary conference with a pulmonary intensivist and cardiothoracic (CT) surgeon within 60 minutes.

ECMO candidacy was determined using our internal and regional shared ECMO criteria based on Extracorporeal Life Support Organization (ELSO) guidelines, see supplement (Table S2) . 16 If the mobile ECMO team was activated, the mode of transportation was determined in collaboration with the contracted air and ground transport services. This was done by assessing the number of team members required, total weight of individuals and equipment, and distance from our center. A summary of these considerations that we adapted from the Extracorporeal Life Support Organization (ELSO) transport guidelines was provided in the supplement (Table   S3) . 20 The mobile team could be deployed from initial consult to leaving our center as quickly as 90 minutes. Deployment time depended on the severity of patient illness, staffing and bed availability, insurance approval, and the hospital transfer agreement. bedside chest x-ray. Once the patients were on ECMO support, they were placed on partial rest ventilator settings (i.e., respiratory rate and tidal volumes are reduced). Positive end-expiratory pressure was maintained or only mildly reduced to prevent oxygen desaturation during transport.

The goal oxygenation saturation was >94% prior to transfer back our center. The arterial partial pressure of carbon dioxide (P a CO 2 ) was adjusted by the ECMO sweep gas flow rate to maintain normal pH (7.35-7.45). Mild to moderate respiratory acidosis was tolerated in an effort to reduce rapid P a CO 2 changes due to concern for increased neurologic complications in patients on ECMO. 22, 23 Two separate arterial blood gases were reviewed prior to transport to adjust the ECMO sweep gas flow rate. Our mobile ECMO team then oversaw the transport of the patient back to our center.

Our institution contracted with air and ground transport services for ECMO transport.

Prior to our mobile ECMO team inception, high fidelity mock ECMO transfers were conducted with the ambulance and air transport teams utilizing actual transport vehicles (including helicopters). These mock scenarios included our center specific ECMO equipment as well as other patient support devices such as infusion pumps, chest tubes, intra-aortic balloon pumps, 

From April 2020 to January 2021, we activated the mobile ECMO team 22 times, see Table 1 for patient characteristics. Mobile ECMO was deployed to 13 different facilities, in four Southern California counties (supplement, Figure S2 ). Multidisciplinary assessment for patient selection and mobile ECMO deployment is essential. Team decision-making for ECMO candidacy prevents the burden of decision on a single provider, and may reduce the moral distress of triaging and allocating a limit resource for critically ill patients. 18 It further ensures that appropriate ECMO criteria is followed. Due to the COVID-19 pandemic, our ECMO criteria was shared with the other local ECMO centers (Southern California ECMO Consortium) to ensure there was equitable access to ECMO across our region. Since ECMO patient census was shared within the county, our center never turned down a mobile ECMO due to equipment or ICU bed limitations. The criteria (supplement , Table   S2 ) prioritized maximal community benefit of ECMO, during the pandemic. ECMO mortality and complications increase with age, however our ECMO criteria did not have a specified age cutoff due to concerns for ageism, although ELSO criteria has age above 65 as a relative contraindication. 16, 19, 29 Similar to other regional ECMO centers, ECMO was rarely offered to a patient with COVID-19 over the age of 65. Finally, multidisciplinary decisions on candidacy help establish buy-in and commitment from the CT surgery and intensivist teams, who are providing the long-term care for these patients at our institution.

To minimize complications and cannulation time, it is essential that the mobile team is trained together and is comprised of physicians and specialists that have extensive experience in ECMO cannulation and management. 30 Mobile ECMO team members vary across centers, usually based on local expertise. These teams may include CT surgeons, intensivists (pulmonary or anesthesia), interventional cardiologists, and emergency medicine physicians who perform the cannulation with an assisting ECMO specialist or perfusionist. 31 Due to the relatively low number of mobile ECMO activations, the specialty make-up is likely not as important as physician ECMO experience. Since the mobile ECMO team formed out of necessity during the COVID-19 pandemic, our cannulating team remained intentionally small to limit practice variation and to limit team member exposure to SARs-CoV-2. In order to streamline our processes and troubleshoot unforeseen issues, we did not initially utilize our existing ECMO call structure. However, we are now expanding our mobile program to utilize the standard on-call ECMO team members.

Our ECMO program had been in existence for over a decade but was restructured and more formalized in 2017. Due to being an established program, no new service line was created to start the mobile ECMO team. The team does not accrue any additional cost to the institution.

All ECMO supplies, transport, and perfusion personnel are billed to the patient (or insurance).

We recognize that maintaining a robust mobile ECMO program inevitably requires more team members and institutional compensation of team members' time and efforts.

We had no significant complications with cannulations, all of which were performed in the patient's ICU room. Previous mobile ECMO reports have had complications in up to 21% of cannulations, with the majority performed in operating rooms in some countries. 13 One common complication during cannulation was guidewire kinking, occurring once in our cohort, thus we utilized an Amplatz superstiff wire (supplement, to previous reports, were safe and well tolerated. 33 Each center should determine the appropriate transport modality based on travel time, personnel capacity, and equipment considerations. We found that helicopter transfers may save minimal to no time when compared to ambulance transfers if the center was less than 100 minutes (accounting for local traffic patterns) via ambulance from our center. The ELSO transport guidelines for ECMO patients highlight many transport issues that may be encountered, see supplement (Table S3) . 20 Ultimately, ECMO experience varies among medical transport teams, highlighting the importance of training.

We described our experience and outcomes in the first 10 months of developing and deploying a mobile ECMO team during the COVID-19 pandemic. Our hope is that our experience may help other centers establish their own mobile ECMO team.

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Table 1. Patient Characteristics and Outcomes Patient Characteristics Median age

%) ECMO complications Digit or limb ischemia requiring amputation

Table 1. Patient characteristics and outcomes. a ECMO recannulation 96 hours post initial decannulation due to worsening ARDS. b Length of stay at ECMO center. c One patient with ARDS due to EVALI. ARDS, acute respiratory distress syndrome. EVALI, E-cigarette or Vaping Product Use-Associated Lung Injury

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work