2025 ELSO Consensus Statement for the Provision and Management of Nutrition Therapy in Critically Ill Adult Patients Requiring Extracorporeal Membrane Oxygenation

Use of ECMO in Patients With Coronavirus Disease 2019: Does the Evidence Suffice?

Long-term recovery of survivors of coronavirus disease (COVID-19) treated with extracorporeal membrane oxygenation: The next imperative

What is New in ECMO for COVID-19?

Critically ill patients with cardiac and/or respiratory failure may require extracorporeal membrane oxygenation (ECMO) to restore physiological function. The use of ECMO in intensive care units (ICUs) in the United States has increased over the past decade, most recently with the COVID-19 pandemic. In July 2020, an estimated 33 000 patients received ECMO support, with survival rates of 59% (pulmonary) and 43% (cardiac).1 Approaches for ECMO support are either venoarterial or venovenous cannulation aimed at restoring the patient’s cardiopulmonary or pulmonary function. Extracorporeal membrane oxygenation is indicated for severe cardiogenic shock, ventricular arrhythmias, cardiopulmonary resuscitation, and acute respiratory distress syndrome refractory to conventional therapies.2 Its management requires trained and experienced critical care providers (eg, nurses) as well as institutional infrastructure with robust leadership to ensure safety and quality patient care.2,3 The Extracorporeal Life Support Organization (ELSO) recommends that ECMO training should consist of didactic courses, hands-on experience, and continuing education.3 To that end, this column begins with the description of the role of the bedside registered nurse (RN) in ECMO management in the cardiothoracic ICU followed by the acute care nurse practitioner’s (ACNP) leadership in ECMO training tailored to the bedside RN’s educational needs.The management of patients receiving ECMO support is usually orchestrated by critical care multidisciplinary teams. In recent years, bedside RNs in ICUs have increasing responsibility in the technical aspects of ECMO care (ie, management of the ECMO system) (see Figure 1) traditionally performed by cardiovascular perfusionists. The increasing use of ECMO, technological refinements, and ELSO guidelines collectively influence the recent trends of ECMO management by bedside RNs. Unfortunately, there are no data about bedside RNs’ training and outcomes in ECMO care. However, there is consensus in the literature that adherence to ELSO guidelines is essential to quality patient care and outcomes. Notably, nurses at facilities with high or increasing ECMO cases can acquire a wide range of ECMO management skill sets including the associated nursing care.3Bedside RNs must be competent in managing patients receiving ECMO support and are expected to promptly intervene when problems arise, such as adjusting pump speed and flows to prevent complications and/or reduce mortality, as well as manage anticoagulation levels and trend hemodynamics. Thus, bedside RNs require training and continuing education tailored to their competency development, maintenance, and eventually, mastery.4 Nursing management competency for patients supported with ECMO is typically acquired through didactic and hands-on training. Didactic content includes ECMO physiology, procedures, emergencies, and anticoagulation management in patients receiving ECMO support. Although hands-on training varies among institutions, there is consensus that bedside RNs should and could manage ECMO including its circuit (see Figure 1) to meet the immediate needs of these highly acute and complex patient populations.Because of the emerging role of bedside RNs being directly responsible for managing ECMO circuits, there is a need for implementing education and training programs beyond the conventional didactic course (eg, simulation) for ICU RNs that is tailored for optimizing their knowledge, skill, and overall competence with ECMO patient management.As an example, a medical center in the western suburbs of Chicago identified a need to develop and implement an ECMO training program that facilitates the optimization of the ICU bedside RN knowledge and skills (competence) with ECMO. The medical center set this organizational priority because of insufficient ECMO training, needing 24-hour ECMO coverage at the bedside, and ensuring that bedside RNs deliver safe and quality patient care. On the basis of increasing evidence supporting high-fidelity simulation as an effective strategy for training health care providers in the management of ECMO, its circuit, and complications, the medical center selected simulation as the training methodology.4 Providing current evidence-based training to ECMO specialists can improve patient safety and the quality of care by improving communication and teamwork and optimizing confidence among ICU nurses.5 Simulation training provides bedside RNs the opportunity to apply theory into practice, make mistakes, and improve ECMO management skills in a risk-free learning environment. Simulation-based ECMO courses have demonstrated an improvement in cognitive, technical, and behavioral skills by providing active learning experiences.6 Extracorporeal membrane oxygenation simulation training can replicate the ICU room setting and emergent situations (eg, cardiac arrest), allows troubleshooting ECMO circuits in a controlled setting, and provides the ability to debrief. Debriefing allows the ICU team to process and evaluate how they respond in each scenario. In ECMO simulation, ACNPs can share their clinical expertise and experiences and lead the team as well as help the RN/team process, reflect, understand, and modify how they manage patients including responding to ECMO emergencies. It is worth mentioning that doctoral-prepared ACNPs (ie, doctor of nursing practice) are suited for taking on leadership roles in designing ECMO simulation training because of their advanced clinical practice and leadership education and training in critical care.In a rapidly changing health care system, ICU ACNPs can make significant contributions in improving patient care quality outcomes through leading clinical nursing education initiatives.Such training took place in the western suburbs of Chicago at a quaternary care facility designated as a level 1 trauma center with over 500 beds. The CTICU was comprised of about 15 beds and over 50 nurses. Half of the nursing staff was certified in a variety of specialties (eg, CCRN, CSC, CMC). Years of nursing experience ranged from 35 years at the bedside to new graduate nurses.The unit lacked formalized ECMO training and skill competencies for its bedside nurses. The previous training was ever-changing. It consisted of direct observations of senior nursing care to ECMO patients lasting a total of 4 hours. The former training did not meet standards set by ELSO. For instance, ELSO recommends that ECMO centers, certified or not, should have a well-defined program for staff training.2 The program should include didactic lectures, laboratory training, bedside training, and a defined system for testing staff proficiency.2 Bedside RNs must be properly trained to think critically in emergent situations and to adequately and promptly troubleshoot complications.An ECMO training program developed with the support of the ACNP was designed to meet ELSO guidelines. As an initial strategy to systematize formal ECMO training, a survey was conducted to gain insight into the current ECMO training from bedside RNs. Ninety percent of the nurses that participated in the survey were not content with the current training. The survey results indicated that a more robust, innovative training tailored to the needs of the nursing staff caring for patients on ECMO would be beneficial. An ECMO simulation training for ECMO specialists was developed that took into account the lack of ECMO training and education on the unit, as well as the increasing acuity of patients in the CTICU; the training developers also compared the current training to ELSO guidelines. The purpose of this training was to improve the self-efficacy and knowledge of the nursing staff in the CTICU through the implementation of standardized ECMO education and simulation training that met ELSO standards.The proposed training was drafted in collaboration with the chief perfusionist. The CTICU followed an RN-perfusion model of ECMO management. The goal was to train CTICU RNs as ECMO specialists to be able to manage the ECMO circuit as well as the patient’s hemodynamics. The didactic consisted of ECMO physiology, patient care management, and troubleshooting venoarterial and venovenous mechanical components of the ECMO system (see Figure 2). The wet lab was a review of the ECMO circuit and priming. Each nurse was expected to correctly prime the circuit and was checked off individually as correctly completing the task. In the simulation training, nurses were divided into groups and participated in 6 scenarios including a mock code with ECMO cannulation (See Table 1).Following synthesis and evaluation of evidence-based literature, the ACNP presented the simulation training proposal to nursing administration but was met with resistance. The lack of leadership knowledge regarding the complexity of patients requiring ECMO was the main reason for resistance. The CTICU was the only unit capable of caring for patients receiving ECMO support, and the unit lacked a nurse educator; nursing management lacked an ICU background, so there was little understanding among leadership of what was required to care for these patients safely and effectively. Time and cost were also important factors in obtaining approval for implementing the training. Nursing leadership’s concern was with the cost of using the simulation laboratory, scheduling the nursing staff for the training, and compensating the chief perfusionist and ACNP. The chief perfusionist, ACNP, and the RNs who participated in the training volunteered their time without compensation for the training. The simulation laboratory was free of cost to the hospital as this was presented as a pilot study that was part of a DNP project. The costs of miscellaneous educational resources for the nursing staff were covered by the ACNP.The proposal was rejected by nursing administration for being infeasible. The proposal was then presented to members of the hospital executive team. Several meetings were organized with the unit medical director, a cardiac surgeon who served as director of the ECMO program, the president of the hospital, and the vice president of patient safety. The proposal was presented as an opportunity to improve the safety and quality of care provided to patients receiving ECMO therapy. After approval was obtained, the ACNP in collaboration with the chief perfusionist formed an ECMO specialist group and submitted approval to the institutional review board. The ACNP was responsible for developing assessment tools to evaluate knowledge and self-efficacy of the nursing staff.The second phase evaluated nurses’ perceived ability to troubleshoot ECMO before the didactic lectures and required nurses to take an anonymous exam consisting of 20 multiple-choice questions on ECMO physiology and a 10-item Likert scale self-efficacy survey. The goal of the simulation training was to empower nurses by giving them the tools necessary to increase their knowledge base on ECMO and improve their perceived ability to care for these patients.The 2-hour didactic lectures were developed based on ELSO recommendations. The didactic focused on introducing ECMO and advanced ECMO troubleshooting, focusing on ECMO physiology, procedures, emergencies, and anticoagulation management in patients receiving ECMO support.Twenty nurses completed a 1-hour wet lab reviewing the ECMO circuitry, alarm troubleshooting, and priming of the circuit (see Figure 1). The 2-hour simulation training was held at the simulation laboratory at the Midwest academic medical center. The simulated room was set up to resemble an ICU room. Six scenarios of issues commonly encountered in patients receiving ECMO therapy were developed as a part of the simulation training. Twenty nurses completed the 6 scenarios proctored by the ACNP and chief perfusionist. Nurses were able to debrief, allowing them to understand the actions taken and the implications of those actions. After completing the simulation training, each nurse retook the same deidentified ECMO knowledge exam and self-efficacy survey.Twenty nurses (100%) completed the training and surveys; knowledge and self-efficacy both showed significant improvement. Pretraining scores on the knowledge exam averaged 70%. Posttraining knowledge exam scores averaged 85%. Posttraining self-efficacy scores improved on each item of the survey. Refer to Table 2 for changes in confidence before and after training.After implementation of the training, a schedule was created with 2 ECMO specialists scheduled on each shift. Patients receiving ECMO support were preassigned to ECMO specialists for 5 months. During those 5 months, it was noted that there was a significant decrease in the number of pages to perfusionists. Nurses were better able to troubleshoot and prevent detrimental events. An ECMO committee was developed comprised of the ICU medical director, unit manager, chief perfusionist, ACNPs, pharmacist, and cardiac surgeons. The committee met monthly for 5 months. The ICU multidisciplinary team collaboratively developed an ECMO policy, created an order set for ECMO patients, revised an anticoagulation policy, and designated an ECMO cart fully equipped for emergent cannulation be stationed on the unit. Electronic health record documentation of ECMO was also updated to reflect the data provided by the Cardiohelp Console, which includes change in pressure, arterial and venous pressures, hemoglobin levels, hematocrit levels, mixed venous oxygen saturation, and activated clotting time results.Another important change in the unit was in how patients receiving ECMO support were signed out to the oncoming shift. An ECMO circuit check was now mandated at every change of shift. This check included the nurse review settings and cannulation sites, along with hemodynamic trends and the most recent postoxygenator gas levels. One of the most important changes because of this training was the approval for an ECMO coordinator position. This would assure nursing staff would receive formal ECMO training to maintain competencies.The level of stress endured during emergencies influences clinical performance. To ensure safe, high-quality ECMO management during emergencies, bedside RNs need technical, behavioral, and independent decision-making skills. This is essential for outstanding teamwork and improved patient outcomes.7 This simulation training enhanced nurses’ ability to identify and initiate an intervention promptly. There was an improvement in scores of the knowledge exam after training. Nurse self-efficacy was improved as evidenced by the improved percentages in the posttraining self-efficacy survey. These results indicate that nurses improved their self-efficacy and knowledge. Of note, in the simulation laboratory, regardless of years of experience, nurses had difficulty with more complex scenarios, further supporting the need for training and competencies.After training, nurses recognized acute events and intervened before these events could cause harm to patients. An example of the impact of this training was when nurses who participated in the training were able to promptly identify recirculation occurring in a patient receiving venovenous ECMO support. The nurses recalled this ECMO complication from a scenario practiced in the simulation laboratory. They were able to visualize this in a controlled setting and were able to apply what they learned to the bedside. A limitation of this education/training was that the nurses who participated in this training were highly specialized ICU nurses. The outcome of this training might be different in a group of less specialized nurses.This simulation training demonstrated the importance of using ACNPs to increase patient access to care in a critical care setting and to set the standards for care.8 Acute care nurse practitioners are instrumental resources because of their direct patient care skills.8 Both RNs and physicians consider education, research, collaboration, and leadership vital roles of the ACNP that are indispensable in any critical care unit.8 An ACNP with ECMO experience is vital to a CTICU because they can play a role in decreasing hospital lengths of stay and mortality, improving patient care, and promoting continuity of care. Acute care nurse practitioners are a strong liaison between bedside nurses and the ICU multidisciplinary team.This column outlines the essential role of the ACNP in ECMO in a CTICU. The goal of this training was to implement an ECMO simulation training led by an ACNP. Fundamental to this training was that it would improve the knowledge and self-efficacy of bedside RNs. Acute care nurse practitioner– led educational initiatives enhance structural empowerment through leadership and improved communication, which positively influences staff morale. Empowering bedside RNs through education increases staff retention and improves the quality and safety of patient care. The health care system in the United States is dynamic. As nursing leaders, ACNPs are essential resources that can empower bedside RNs to provide safe and quality nursing care to our most complex patients.

The Emerging Role of Bivalirudin for Therapeutic Anticoagulation in Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation Support: Is It Time to Change the Routine Practice?

Long-Term Outcomes Are Important: Extracorporeal Membrane Oxygenation for COVID-19

Commentary: Extracorporeal membrane oxygenation: Is it life-saving and cost effective for all patients?

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

A core set of outcomes have been identified and published, which are essential to include in all clinical research evaluating the use of extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events. The purpose of this international modified Delphi study was to determine which measurement tools and the timing of measurement should be selected for the core outcome set for research evaluating patients receiving extracorporeal membrane oxygenation. This was a two-round international, multidisciplinary web-based, modified Delphi study. Participants were identified from the International Extracorporeal Membrane Oxygenation Network and the Extracorporeal Life Support Organization, including consumers, multidisciplinary clinicians, researchers and industry partners. Measurement tools and the timing of measurement were identified from a systematic review of the literature and clinical trials registrations. The primary outcome was the percentage of respondents who completed each survey and indicated that a measurement tool as well as the timing of the measurement should "always" be included in a core outcome set. Participant response rates were 46 of 65 (71%) and 40 of 46 (87%) for rounds one and two, respectively, with participants representing, researchers, consumers, and industry partners from 15 countries over five continents. Seven measurement tools were identified for the core outcome set of patients on extracorporeal membrane oxygenation. This study has identified appropriate measurement instruments and the timing of measurement to include in the core outcome set for research evaluating patients receiving extracorporeal membrane oxygenation. This was an important final step to standardize and synthesize research efforts internationally.

Antifungal Prophylaxis for Adult Recipients of Veno-Venous Extracorporeal Membrane Oxygenation: A Cautionary Stance During the COVID-19 Pandemic.

Blood transfusion strategies and ECMO during the COVID-19 pandemic – Authors' reply

Extracorporeal Membrane Oxygenation – Crucial Considerations during the Coronavirus Crisis

In existence since 1989, the Registry of the Extracorporeal Life Support Organization (ELSO) has provided an increasingly utilized resource for clinical benchmarking and research on extracorporeal membrane oxygenation (ECMO). With over 130,000 entered cases from 463 member centers worldwide, the ELSO registry is the largest ECMO clinical dataset in the world. Recent improvements in real-time reporting, a dynamic user interface with automated clinical risk adjustment have facilitated institutional benchmarking for member centers. Moreover, as the ELSO registry collects data on patients, clinical management, complications, and outcomes, it provides an unprecedented international, multicenter dataset for research and academic output available at no charge to investigators from member centers. Beyond the provision of data, the ELSO Registry, through its unparalleled facilitation of clinical ECMO research, indirectly drove a need for and then officially established standardized terminology.1 Identifying publications that use ELSO data are challenging. In recent years, the ELSO Data Request Agreement specifies that publications utilizing ELSO data list the "ELSO Registry" or the "Extracorporeal Life Support Organization Registry" in the title or abstract, as a way to ensure appropriate attribution, but this has not always been the case; important publications utilizing ELSO data will not be identified this way.2 Using the terms (Extracorporeal life support organization[tiab] OR ELSO[tiab]) AND (registry[tiab] OR registries[MeSH]), we were able to identify 258 publications in PubMed. Dropping the term "registry" increased this number to 400, of which 310 (by June 2020), were analyses utilizing ELSO registry data. Among the 310 manuscripts we identified, the rate of manuscripts per year remained stable over 20 years since the first published study in 1990, at roughly five per year. In 2010 this began increasing, and by 2017, upwards of 20 publications per year were being published (Figure 1A). In the last 5 years, 173 publications using ELSO data have been published. As ELSO policy does not allow for the release of data for competing analyses at the same time, the sheer number of recently published manuscripts is a testament to the breadth of available data and of the research questions themselves.Figure 1.: Publications using the ELSO Registry: (A) overall, and (B) by age group. 2020 incomplete data. Duplicative counts by age grouping. ELSO, Extacorporeal Life Support Organization.Over 30 years, the types of manuscripts and use of ELSO data have varied. Fifty-two manuscripts utilized ELSO data as comparative benchmark, 254 were multi-center analyses, whereas 56 used single-center data. ELSO data were used for 36 review articles, 25 surveys studies, and 28 predictive models. Four manuscripts merged the ELSO registry with other data for analysis.3–6 The ELSO registry data also serves as evidence in the issuing of clinical guidelines,7,8 statements,1,9–12 and registry reports.13–21 ELSO data has also been utilized for benchmarking, such as for the US Federal Drug Administration approval of the Berlin Heart Ventricular Assist Device, published in the New England Journal of Medicine.22 The ELSO Registry Reports may be the most well-known publications from the ELSO registry.13–21 Released every few years, they provide a review of the counts, utilization characteristics, and survival of patients entered into the ELSO Registry. A 2013 Editorial farewell from outgoing ASAIO Editor in Chief Joseph Zwischenberger noted that the 2004 ELSO Registry report was ASAIO's most cited manuscript at that time.23 Additionally, they introduce new variables and data fields. In addition to the main registry report, specific sub-reports of the neonatal and pediatric population supported with ECMO have been published.21 ELSO endeavors to facilitate junior and first-time investigator research. By not charging analysis or access fees in most cases, ELSO strives to keep the barriers to accessing ELSO registry data low enough to encourage new and junior investigators and not limit access to established groups. The ELSO Registry Scientific Oversight Committee reviews all data requests on the basis of importance, answerability, methodology, and data availability, rather than only on the investigator. This intent has worked; among the 310 peer-reviewed articles, 246 are original research articles from 247 unique first authors who published in 86 unique journals, on 58 themed topics. As the distribution of the ELSO registry cases by age and mode has varied, so too has the analytic population of the manuscripts (Figure 1B). Reflecting the early predominant use of ECMO among neonates and pediatrics, among the 310 manuscripts, 164 and 153 (non-exclusive) manuscripts analyze neonatal and pediatric data, respectively. As the number of adult ECMO cases has exponentially increased and become the majority of cases in the registry in recent years, so too have the topic of the manuscripts. Before 2007, we identified five manuscripts analyzing adult patients from the ELSO registry, whereas by 2016, there were 12 manuscripts of adult data published per year, at >50% of the yearly output. The impact of publications featuring data from the ELSO Registry has also increased over the years, to a total of 7,902 citations (Figure 2). Continued improvements to the ELSO Registry data quality with cataloged data definitions, a data entry exam for new centers or personnel, updated addenda to capture data specific to indications not otherwise represented by the main registry should continue the evolution and utilization of this collated data in order to inform research analyses, institutional quality and benchmarking programs into the future.12Figure 2.: Citations of publications utilizing the ELSO registry. ELSO, Extracorporeal Life Support Organization.Acknowledgment We gratefully acknowledge the contributions of all previous ELSO registry chairs, managers, and directors, including Charles J. Stolar, MD and Thomas F. Tracy Jr, MD.

COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (P = 0.04), procalcitonin levels (P = 0.02), and IL-6 levels (P = 0.05), lower blood pH before and after ECMO (P < 0.01), and higher activated partial thromboplastin times throughout the hospital stay (P < 0.0001). ICH-free survival was lower in COVID-19 patients than in patients on ECMO for ARDS caused by other viruses (49% vs. 79%, P = 0.02). In conclusion, patients with COVID-19 can be successfully bridged to recovery using ECMO but may suffer higher rates of ICH compared to those with other viral respiratory infections.

The use of extracorporeal membrane oxygenation (ECMO) in patients with severe cardiorespiratory failure has seen significant growth in the last decade. Despite this, there is paucity of data surrounding the optimum nutritional management for ECMO patients. This review aimed to describe current nutrition practices in patients receiving ECMO, critically appraise available studies and identify areas for future research. A literature search was conducted in PubMed, MEDLINE, and CINAHL Plus to identify all randomized trials and observational studies published between July 2000 and July 2020 investigating nutrition practices in critically ill adults receiving ECMO. The primary outcomes were nutritional adequacy, gastrointestinal complications, and physical function. Secondary outcomes included mortality, length of stay, and duration on ECMO support. From a total of 31 studies identified, 12 met the inclusion criteria. Nine observational studies were reviewed following eligibility assessment. Early enteral nutrition was deemed safe and feasible for ECMO patients; however, meeting nutritional targets was challenging. Utilizing alternative nutrition routes is an option, although risks and benefits should be taken into consideration. Data on gastrointestinal complications and other clinical outcomes were inconsistent, and no data were identified investigating the effects of nutrition on the physical and functional recovery of ECMO patients. Nutrition therapy in ECMO patients should be provided in line with current guidelines for nutrition in critical illness until further data are available. Further prospective, randomized studies investigating optimum nutrition practices and effects on clinical and functional outcomes are urgently required.