Extracorporeal Membrane Oxygenation Transport in the Wake of the Pandemic Is Feasible and Safe.

There are quarter of a million articles in PubMed since the wake of the COVID-19 pandemic with about fifteen hundred articles on extracorporeal membrane oxygenation (ECMO) alone. Those that are entrenched in the field of ECMO and Mechanical Circulatory Support have been privileged to use these lifesaving technologies in a select few patients albeit the percentage of patients saved is miniscule compared with the sheer enormity of deaths sustained in the pandemic.[1] Since the pandemic, we have all had the privilege to advance this technology in the setting of advanced respiratory failure unlike any other time since the birth of the cardiopulmonary bypass pump by John Gibbon in 1953[2] and subsequent perfection of ECMO technology over decades by Bartlett et al.[3,4] Several guidelines have since been published about rescuing patients with refractory respiratory failure and cardiogenic shock in the setting of COVID-19.[5-7] The pandemic has also placed a significant strain on resources on the critical care teams. Using a systematic approach in caring for these patients including the ability to transport ECMO patients to hub hospital from community hospitals that ensures not just the safety of the patients but that of the personnel is crucial to the success of those programs. To really understand the significance of risk involved in caring for these COVID-19 patients, we need to recognize the countless lives lost in the early months of the pandemic where there was no reassurance of vaccines, adequate personal protective equipment (PPE), or grave recognition of inherent personal risk. According to a private site that tracks death of clinicians, there have been more than 3500 clinicians that have succumbed to the pandemic as they rendered care by April 2021.[8] There remained answered questions if providing such care posed an inherent risk to the critical care transport team. Additionally, when crew members are COVID-19 positive with breakthrough infections, it poses a significant threat to the hospital systems in their ability to deliver high caliber care efficiently.

In this issue of the ASAIO Journal, Javidfar et al[9] on behalf of the COVID-19 Critical Care Consortium describe results of safety outcomes of personnel who delivered care to 113 patients with severe COVID-19 patients that were cannulated with ECMO at outside facility and brought to the main hub.[9] In this retrospective study which includes five quaternary care centers, the cannulation team adhered to strict airborne contact precautions with eyewear and PPE that included face shield, goggles, N95s, and extra care was taken to avoid disruption of closed ventilator circuits once the patient was placed on transport ventilators. In this study, most patients were transported by ground ambulance, and about ten patients were transported by air ambulance. The average transport time was around 134 minutes, and the distance traveled was 40 miles. The team members were followed for three weeks for development of any symptoms since the original transport. They found that even though social distancing could not be followed during vehicular transport, there were no documented transmissions of the virus. This is in alignment with other studies published about this topic including our own experience in Houston and elsewhere.[10-13]

Some of the best practices on transportation of ECMO patients in the setting of contagious diseases include having a stringent systematic approach to the transport of such patients. Such a process should be part of the ECMO Quality Assurance and Performance Improvement plan for the designated hub hospital and constantly be revised based on the lessons learnt of the previously transported patients. Each phase of transport needs to be given individual attention: Preparation, Transportation, Assessment and Cannulation, Retrieval, Transport to COVID-ICU and Decontamination.[10] When possible, schedules can be done in a stacked manner, where when one team is exposed and quarantined, the second crew can take over. Such predeveloped guidelines can be used for ground and air transport and need to be in alignment with FAA for air ambulance transports.[14]

The strengths of this study include the novelty given uncertain understanding of the COVID-19 pandemic, the reassuring outcomes, and the potential wide applicability given five independent programs in different hospital systems with the same outcomes. The limitation of this study is the retrospective nature of the study, and the study was done early in the pandemic when widespread testing was not immediately available, and it is not certain if certain crew members could have had infections but remained asymptomatic. Future studies could consider surveillance testing to confirm that the risk is negligible and include patients that undergo long-distance fixed wing flight transport. The results of this study are nevertheless promising and open the possibility of critical care transport of other contagious diseases in the future.