SEARCHGUIDELINEScritical care, pulmonology

guidelines·critical care, pulmonology, cardiology, infectious disease, emergency medicine, anesthesiology, thoracic surgery·PMC10152433

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Annals of Intensive Care · 22 authors, 24 centres

AI SUMMARY

FIDELITY 100%

POPULATIONCOVID-19 patients with severe ARDS requiring ECMO

INTERVENTIONExpert consensus recommendations on patient selection, ECMO management, operational logistics, and ethics

COMPARISONNot applicable (consensus study, no comparator)

This summary was generated by AI from a single paper. It has not been reviewed by a clinician and is not clinical advice. Verify against the source before acting on it.

AGENT 01 · STRUCTURED SUMMARY

TRACE TO SOURCE

“

TL;DR

This international Delphi study achieved consensus on 14 statements across four domains (patient selection, ECMO management, operational/logistics, and ethics) for using venovenous ECMO in COVID-19-related severe ARDS. Key findings include that duration of mechanical ventilation should not be the primary determinant for ECMO candidacy, existing non-COVID-19 scoring systems should not be used for prognostication in COVID-19 patients, and ECMO futility should not be determined solely by run duration. The consensus provides practical guidance for ECMO practitioners during future pandemics, though no consensus was reached on anticoagulation, pregnancy, immunocompromised cases, or cost of services.

Full summary

4,897 CHARS

**Background:** The COVID-19 pandemic created an urgent need for guidance on using venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe ARDS, but high-quality evidence was lacking. This international expert consensus aimed to address controversial topics in ECMO for COVID-19 patients and provide guidance for future pandemics.

**Methods:** The coordinating center was the ECMO center at King Saud Medical City (Riyadh, Saudi Arabia) through the Saudi Arabia Ministry of Health National ECMO program. The scientific committee comprised five chairpersons with >5 years of ECMO experience. Thirty-two experts were invited; the faculty included 22 panelists representing both sexes, various countries and ethnicities, with half not active members of ELSO. The process used a mix of modified Delphi technique rounds and nominal group technique (NGT) through three face-to-face meetings and anonymous voting. The project was conducted in compliance with CREDES and SQUIRE standards. Five phases were completed over approximately 8 months (December 2021–August 2022): identifying knowledge gaps, validation, statement formulation, voting, and drafting. Voting used a 10-point scale (1–3 low, 4–7 intermediate, 8–10 high agreement). Strong consensus required >80% high scores or mean >8; weak consensus required 70–80% or mean 7–8; no consensus was <70% or mean <6.

**Key Results:** In Phase I, 52 questions were identified. After Phase II validation, 32 questions across nine domains remained (validation rate >75%). In Phase III, 25 questions were used to formulate 14 statements; six questions achieved no consensus. After two voting rounds (R1: June 25, 2022; R2: July 12, 2022), 14 statements reached consensus across four domains. In R1, 10 statements reached strong consensus; four reached weak consensus and were modified. In R2, two of those four reached strong consensus. The final 14 statements: Domain 1 (Patient Selection) — Statement 1: Duration of IMV before ECMO should not be the primary determinant for candidacy (strong consensus, mean 8.2, 90.4%). Statement 2: No validated scoring system exists for COVID-19 ECMO prognosis; non-COVID-19 scores should not be used (strong consensus, mean 7.9, R2 81%). Statement 3: Days on NIMV/HFNC should not be used alone for selection (strong consensus, mean 8.3, 80.9%). Statement 4: Cutoff age may vary by resource availability; national/regional policy advised (strong consensus, mean 9.1, 90.4%). Statement 5: EOLIA criteria should be followed without deviation (strong consensus, mean 8.7, 85.7%). Domain 2 (ECMO Management) — Statement 6: Prone positioning may be considered during ECMO in experienced centers with sufficient resources (weak consensus, mean 7.9, R2 71.9%). Statement 7: Lung transplantation for late COVID-19 respiratory failure is feasible but should be considered only after prolonged ECMO without recovery (weak consensus, mean 7.4, R2 76.2%). Statement 8: Post-ECMO follow-up should be initiated (strong consensus, mean 9.1, 95.2%). Statement 9: Weaning strategy including spontaneous breathing during ECMO is feasible (strong consensus, mean 8.5, 76.1%). Domain 3 (Operational/Logistics) — Statement 10: Starting a new centralized ECMO service pre-pandemic is feasible (strong consensus, mean 8.7, 85.7%). Statement 11: Establishing new ECMO programs in areas lacking services is feasible with precautions (strong consensus, mean 8.5, 80.9%). Statement 12: Transport of COVID-19 patients on ECMO does not pose appreciable risk to trained teams with appropriate PPE (strong consensus, mean 9, 95.2%). Domain 4 (Ethics) — Statement 13: ECMO futility should not be determined solely by run duration; withdrawal not advised until recovery, transplantation, or irreversible multiorgan failure (strong consensus, mean 9, 85.7%). Statement 14: No evidence-based scoring system guides ECMO prioritization during resource limitations; factors predicting poor outcomes may be used (strong consensus, mean 7.9, R2 85.7%).

**Clinical Implications:** This consensus provides practical guidance for ECMO practitioners on patient selection, clinical management, operational logistics, and ethics during pandemics. The panel emphasized that pre-ECMO ventilation duration should not be the primary determinant for candidacy, that existing prognostic scores developed for non-COVID-19 patients should not be applied to COVID-19 patients, and that ECMO should not be withheld or withdrawn based solely on run duration. Regional centralization of ECMO services is recommended. Important topics where no consensus was reached include anticoagulation, pregnancy, immunocompromised cases, cost of services, supply chain solutions, ECMO team models during resource scarcity, and pediatric/neonatal ECMO for COVID-19. The authors acknowledge that consensus does not replace guidelines, randomized trials, or clinical judgment.

PICO

PPOPULATION

COVID-19 patients with severe ARDS requiring ECMO

IINTERVENTION

Expert consensus recommendations on patient selection, ECMO management, operational logistics, and ethics

OOUTCOME

Consensus achievement (strong or weak) on 14 statements; validation rates of questions

STUDY TYPE

guidelines

SPECIALTY

critical care

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10152433

Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

Annals of Intensive Care

READ THE FULL PAPER

ABSTRACT

Background The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. Objectives To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. Methods The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel’s questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. Results In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1 ). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. Conclusion Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-023-01126-9.

CITATION EXPORT

Ahmed A. Rabie, Alyaa Elhazmi, Mohamed H. Azzam et al.. Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study. Annals of Intensive Care. (2023). https://doi.org/10.1186/s13613-023-01126-9

AUTHORS

22 · 24 CENTRES

Ahmed A. Rabie, Alyaa Elhazmi, Mohamed H. Azzam, Akram Abdelbary, Ahmed Labib, Alain Combes, Bishoy Zakhary, Graeme MacLaren, Ryan P. Barbaro, Giles J. Peek, Marta Velia Antonini, Kiran Shekar, Abdulrahman Al‐Fares, Pranay Oza, Yatin Mehta, Huda Alfoudri, Kollengode Ramanathan, Mark Ogino, Lakshmi Raman, Matthew Paden, Daniel Brodie, Robert Bartlett

1grid.415998.80000 0004 0445 6726Critical Care Department-ECMO care Unit (ECU), Riyadh Region Cluster1, King Saud Medical City, Riyadh, Saudi Arabia
2grid.412140.20000 0004 1755 9687Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
3grid.513094.aAdult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Jeddah, Saudi Arabia
4grid.7776.10000 0004 0639 9286Critical Care Department, Cairo University, Cairo, Egypt
5grid.413548.f0000 0004 0571 546XHamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar
6grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, 75013 Paris, France
7grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013 Paris, France
8grid.5288.70000 0000 9758 5690Oregon Health and Science University, Portland, OR USA
9grid.412106.00000 0004 0621 9599Cardiothoracic ICU, National University Hospital, Singapore, Singapore
10grid.214458.e0000000086837370Division of Pediatric Critical Care and Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI USA
11grid.15276.370000 0004 1936 8091Congenital Heart Center, University of Florida, Gainesville, FL USA
12grid.411482.aGeneral Intensive Care Unit, University Hospital of Parma, Parma, Italy
13grid.415184.d0000 0004 0614 0266Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD Australia
14grid.1024.70000000089150953Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
15grid.415706.10000 0004 0637 2112Department of Anesthesia, Critical Care Medicine and Pain Medicine, Ministry of Health, Kuwait City, Kuwait
16grid.415706.10000 0004 0637 2112Al‐Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
17Riddhi Vinayak Multispecialty Hospital, Mumbai, India
18grid.429252.a0000 0004 1764 4857Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, 122001 Haryana India
19grid.415706.10000 0004 0637 2112Department of Anaesthesia, Critical Care, and Pain Management, Al‐Adan Hospital Ministry of Health, Hadiya, Kuwait
20grid.414196.f0000 0004 0393 8416Chief Partnership Officer, Nemours Children’s Health, Delaware Valley, USA
21grid.267313.20000 0000 9482 7121Division of Paediatric Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX USA
22grid.189967.80000 0001 0941 6502Division of Paediatric Critical Care, Emory University, Atlanta, GA USA
23grid.21729.3f0000000419368729Department of Medicine, Columbia University College of Physicians & Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian/Columbia University Medical Center, New York, USA
24grid.214458.e0000000086837370University of Michigan, Ann Arbor, MI USA