Original Article

Organization of extracorporeal membrane oxygenation services for COVID-19

Asian Cardiovascular & Thoracic Annals 0(0) 1–5 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0218492320962932 journals.sagepub.com/home/aan

Lowell Leow , Evangelos Papadimas, Senthil K Subbian, Graeme MacLaren and Kollengode Ramanathan

Abstract Background: Extracorporeal membrane oxygenation has been used for COVID-19 patients with refractory hypoxemia. Methods: We share our institution’s experience in organizing extracorporeal membrane oxygenation services in Singapore during the COVID-19 pandemic. We also share our first COVID-19 extracorporeal membrane oxygenation case report. Results: We encountered initial difficulties in providing extracorporeal membrane oxygenation services in Singapore in view of the considerations of managing COVID-19 patients. By adopting rigorous planning, patient selection, staff training, adhering to infection control measures and preparing transport essentials, we were able to reorganize the extracorporeal membrane oxygenation services to serve the nation’s needs. This culminated in our first successful COVID-19 extracorporeal membrane oxygenation retrieval case. Conclusions: Extracorporeal membrane oxygenation is an option for COVID-19 patients but preparation must be taken to prepare the extracorporeal membrane oxygenation teams to deal with this pandemic and future challenges. Keywords Coronavirus infections, COVID-19, extracorporeal membrane oxygenation, pandemics, practice guidelines as topic, Singapore

Introduction The World Health Organization has recommended extracorporeal membrane oxygenation (ECMO) for patients with severe COVID-19 who have refractory hypoxemia.1 ECMO has been used effectively in the management of patients with COVID-19-related acute respiratory distress syndrome.2–9 However, the use of ECMO is resource-intensive and must be adopted judiciously to avoid over-stretching resources and overwhelming healthcare systems.8,10 Non-ECMO centers should not be initiating capabilities during a pandemic.11 Singapore reported its first case of COVID-19 on 23 January 2020.12 As of 12th August 2020, there have been 55395 cases and 27 deaths. There are 5240 active cases of which none are in a critical condition. There have been 5 patients who have had ECMO. The growing numbers might overwhelm our resources. In an attempt to preempt this, our center contributed towards a nationwide initiative to enhance

efficiency. We outline the components and key tenets of the provision of ECMO services implemented at a national and institutional level in Singapore during the COVID-19 outbreak.

Preparing a national ECMO response We outline the components and key tenets of the provision of ECMO services implemented at a national and institutional level in Singapore during the COVID-19 outbreak.

Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, Singapore Corresponding author: Kollengode Ramanathan, 5 Lower Kent Ridge Road, Singapore 119074. Email: [email protected]

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Planning ECMO services and patient selection Prior to the pandemic, Singapore’s Ministry of Health reorganized its ECMO programs. There were 2 ECMO centers supporting the other public hospitals within Singapore, serving a combined population of 5.6 million. These centers performed around 120 cases a year; 40%–45% of cases were for respiratory support. In preparation for COVID-19, ECMO services within these centers had to continue retrievals and also extend services to the National Centre for Infectious Diseases (NCID), our national Communicable Diseases Centre. The 2003 severe acute respiratory syndrome outbreak created a national impetus for improving capabilities. Drawer plans were formulated and biannual drills were conducted by the NCID. Outreach ECMO support to the NCID was planned on a rotating 2-week cycle between the two centers, consisting of ECMO intensivists, surgical teams, ECMO-trained intensive care nurses, and perfusionists to support the native intensivists (Figure 1). Criteria for ECMO selection similar to that used in the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial was used for both venovenous (VV) and venoarterial (VA) ECMO.13 All decisions for initiating ECMO and the progress of the patients were discussed and tracked nationally. In our experience, most referred patients responded to proning and could avoid an ECMO run. A high threshold for initiation was adopted to avoid futile attempts in patients with multiorgan failure. There was a clear directive that ECMO services would cease if the surge capacity overwhelmed hospital resources. The decision for discontinuation in the event of futility was discussed on case-by-case basis. Staff segregation was planned to divide staff along all levels into “clean” and “COVID” teams, depending on their contact with confirmed or suspected cases. Once first contact was made, strict adherence to this segregation was enforced and the same team continued in the management throughout. Staff who had contact with COVID patients and developed symptoms were evaluated by an occupational health specialist, then placed in home isolation for 2 weeks if necessary.

Staff training Personnel training in personal protective equipment (PPE) use was expedited to ensure all staff who would be involved in COVID-19 patient care were trained to use powered air-purifying respirators (PAPR) and fitted with N95 masks. Staff were educated on the infection control measures required. Use of PPE was mandated for personnel entering the negativepressure rooms. Each hospital took responsibility for providing the necessary PPE and enforcing infection

Figure 1. Schematic diagram showing hub and spoke model for extracorporeal membrane oxygenation support of peripheral hospitals: Ng Teng Fong General Hospital (NTFGH), Alexandra Hospital (AH), Khoo Teck Phuat Hospital (KTPH), Tan Tock Seng Hospital (TTSH), Seng Kang Hospital (SKH), and Changi General Hospital (CGH) by extracorporeal membrane oxygenation centers: National University Hospital (NUH) and Singapore General Hospital (SGH) as well as an extracorporeal membrane oxygenation team outreach support to the National Centre for Infectious Diseases (NCID) by both extracorporeal membrane oxygenation centers.

control measures before, during, and after ECMO initiation. ECMO simulation drills were conducted to audit and train staff on the nuances of ECMO management and emergency scenarios with PPE donned. Participants who donned PPE and PAPR were assessed for their reaction times for priming the circuit, management of pump failure, cardiac arrest, deairing the circuit, and desaturation episodes on a high-fidelity manikin. They were debriefed on the additional precautions and challenges of managing these events while wearing PPE. A cannulation simulator enabled the operators to attempt cannulation with PAPR donned. This gave them a better understanding of the difficulties encountered with PPE use. Tactile sensation and fine-motor dexterity were compromised when having to don sterile attire on top of PPE. Verbal communication was impaired because of the noise generated by the PAPR, and field of vision and neck movements limited by the hoods. Such problems were apparent after having experienced them in a simulation setting and better prepared the team (Figure 2). Outreach ECMO drills from the NCID were conducted to audit response times and test communication channels. These were helpful in troubleshooting potential pitfalls and operational obstacles which could be addressed before an actual activation.

Infection control measures We opted for PAPR use during ECMO insertion in view of the prolonged contact staff would have with

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Figure 2. Difficulties encountered with the use of personal protective equipment (PPE) and powered air-purifying respirators.

the patient and potential exposure to biohazardous liquid and aerosolized materials during cannulation. Otherwise, PPE consisting of N95 mask, face shield or goggles, full body gown, gloves, and shoe protectors were used in addition to WHO guidelines.14 A buddy system was established to countercheck on the appropriateness of PPE before entering the room. In a prolonged pandemic, healthcare worker fatigue predisposes to lapses and a buddy system enabled an additional layer of safety. Shared PAPR are potential fomites and were wiped down with 70% isopropyl alcohol wipes prior to and after utilization. Patients with COVID-19 were admitted to a dedicated COVID-19 intensive care unit. Ventilators were kept within the patient’s room until the patient was de-isolated. Other equipment such as bedside ultrasound machines were used exclusively for COVID-19 patients. We found that in managing such isolated patients, a lower threshold for intervention was necessary. This allowed us to factor in time taken for a response, given the need to don and doff PPE.

Transport essentials In collaboration with the other ECMO center, we devised eligibility criteria for inter-hospital transfer and shared them with referral centers. An experienced ECMO clinician evaluated referrals and enacted retrieval plans. The retrieval teams were aware of local resources and cooperated to not deplete referring center supplies. Guidance on preparing the patient was communicated to the referring center to shorten turnaround time. The usual approach of right femoral vein drainage and right internal jugular vein return was standardized. This allowed referring institutions to insert their invasive lines accordingly. Transfer of

patients being retrieved for ECMO was discussed, and predetermined principles for safe transport were adhered to.15 A closed ventilator system was ensured by the transporting team to avoid aerosolizing of the virus. The transport team consisted of 1 intensivist, 1 surgeon, 2 perfusionists, and 1 intensive care trained nurse. A housekeeping team followed the patients to perform terminal cleaning of the path and elevators used both at the sending and receiving hospitals. Upon arrival at the tertiary center, the patient followed a predetermined route to the COVID-19 intensive care unit. Additional space was created for segregation of different hospital clinicians during handover so as to minimize cross-institution healthcare worker transmission. As far as possible, patients were not transported unnecessarily out of the negative-pressure rooms, except for essential investigations requiring transfer to the radiology suite or cardiac catheterization. Mobile operating theatre support was enlisted for cannulation and decannulation.

Case report Our first patient was a 54-year-old gentleman admitted for upper respiratory tract symptoms to a peripheral hospital and diagnosed COVID-19 positive. He acutely deteriorated on the 9th day of illness, and within 24 hours, developed refractory hypoxemia requiring prone ventilation. In view of progressive lung failure despite proning, a decision was made for ECMO support. Because he was initially hemodynamically stable with preserved cardiac function, the decision was made for VV ECMO. Percutaneous femorojugular VV ECMO was attempted at the bedside in the intensive care unit but the patient suffered pulseless electrical activity, necessitating cardiopulmonary resuscitation

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Asian Cardiovascular & Thoracic Annals 0(0) Table 1 Key tenets of an extracorporeal membrane oxygenation service during a pandemic. Key tenets

Implementation measures

Planning and patient selection

Nationalization of resources Selection criteria based on surge capacity National tracking of patients needing ECMO Staff segregation

Staff training

Mask fitting for N95 PPE/PAPR training at different sites Simulation drills PAPR for ECMO insertion Pre-allocated equipment Lower thresholds for intervention Appropriate PPE for all personnel Predetermined route of transfer Closed ventilator system Housekeeping team trailing patient to perform terminal cleaning

Infection control measures

Transport essentials

EMCO: extracorporeal membrane oxygenation; PAPR: powered air-purifying respirators; PEE: personal protective equipment.

for 16 minutes. In view of this hemodynamic compromise, the patient was initiated on femoral VA ECMO instead. The cause of the collapse was quickly diagnosed as tension pneumothorax, for which a chest tube was inserted. Once inserted, the patient’s cardiac function improved. Equipment required for cannulation was present within the room at the start of the procedure and additional equipment on standby in the anteroom. The patient was transferred along a predetermined and sheltered route that minimized exposure to other patients and healthcare workers. All members of the team wore PAPR during the transfer due to prolonged exposure in the enclosed ambulance. As the patient’s cardiac function continued to improve independent of his acute respiratory distress syndrome, he developed differential hypoxemia and required conversion to veno-arteriovenous (V-AV) ECMO on day 1. He was weaned off to VV ECMO on day 5 and eventually explanted on day 7. He had an unremarkable run, good neurological recovery, and was discharged home thereafter.

Conclusion While ECMO is a viable rescue option for managing patients with acute respiratory distress syndrome, we must be discerning in the utilization of ECMO in a pandemic.13 Patients requiring ECMO for COVID-19 will likely be initiated on VV ECMO; however, fulminant myocarditis and heart failure may occur, which may necessitate VA ECMO.16 Provisions must be made to initiate VA ECMO expediently if the patient deteriorates. Preplanning, staff training, and simulation drills ensure that ECMO teams are well

prepared when called upon.17 National and global collaboration in the sharing of knowledge and resources is encouraged to ensure the best clinical outcomes for patients during pandemics.8,17,18 Table 1 summarizes the strategies for organizing ECMO services and retrievals in future pandemics. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs Lowell Leow https://orcid.org/0000-0002-2578-752X Kollengode Ramanathan https://orcid.org/0000-00031822-9455

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