Lack of ECMO treatment costs lives during delta surge

Speaking from his hospital bed at Vanderbilt University Medical Center in Nashville, Tennessee, James Perkinson’s voice was hoarse. In February, he had just been removed from ECMO, the latest life-saving treatment in which a machine outside the body does the work of the heart and lungs.

Full recovery is expected to take a year or more for Perkinson.

“If it weren’t for the ECMO and the doctors who were put in at the right time with the right knowledge, I wouldn’t be here,” he, along with his wife, Kacie, told its ratings.

“Could there have been a miracle and he could have lived had he not had [ECMO]? Perhaps. But the odds were absolutely slim to none,” Kacie said.

New research from Vanderbilt shows she’s probably right about those odds.

During the outbreak of the delta variant of covid-19 late last summer, ECMO therapy was rare in the South. Vanderbilt’s unit was getting 10 to 15 calls a day from hospitals without ECMO looking for an open bed. Even the families of the patients were calling on behalf of their dying loved ones.

“’There are no beds. There are no nurses. There are no machines. There just aren’t enough. Physically, we just can’t,” nurse practitioner Whitney Gannon told people calling from hospitals across the South. “It’s the worst feeling in the world.”

But Gannon became curious about what happened to the patients she had to turn away – especially those who were young and healthy, like Perkinson, who was 28. She started checking in informally.

Many of them were dead, including a pregnant woman.

So, within weeks, she helped launch a formal study. And Gannon’s team started taking all calls, even when no beds were available.

“We wanted to know: is this patient really medically eligible for ECMO? Would we provide ECMO? And if we didn’t, we wanted to know what happened to that patient,” Gannon said.

The findings, published in the American Journal of Respiratory and Critical Care Medicine, are grim. Nearly 90% of those who did not find a place in an ECMO center died. And these patients were under 60 and previously healthy, with a median age of 40.

During the pandemic, hospitals have struggled to decide who gets priority when ECMO, which stands for extracorporeal membrane oxygenation, is in short supply. It’s not an exact science. And there are very few ECMO beds, especially when some patients linger for months on the machine, to die.

Perkinson was a good candidate because he is young and – before he fell ill with covid – relatively healthy. A machinist from Greenbrier, Tennessee, and father of two, he caught covid after making an appointment to get his first dose of the vaccine, he said.

Without vaccine protection, he did not resist the virus well. He was put on a ventilator just after Christmas and a few days later climbed into an available ECMO bed as his blood oxygen levels dropped.

For almost two months, his blood flowed through a tube in his neck to the ECMO unit, which infused him with oxygen, removed the carbon dioxide and returned it to his body. . He was sedated the entire time, increasing his risk of long-term organ damage and disability.

The use of ECMO has increased during the pandemic. It has never been so widely used, but the data remains limited. And a study published in The Lancet in September 2021 found that the number of covid patients dying on ECMO had increased by 15% since the start of the pandemic.

Even at first, only half survived. And as the pandemic dragged on, more and less experienced hospitals were using ECMO, and some expanded criteria to include older patients or those with risk factors like obesity who are not doing well. as well.

Hospital capacity issues were at the heart of the debate, as ECMO requires a small village of nurses and respiratory therapists. And sometimes patients stay on treatment for months, not just weeks.

A patient currently at Vanderbilt, which has only seven ECMO beds, has been there since last year’s delta surge, Dr. Jonathan Casey said.

“So you can imagine how little it takes to fill that resource, even during a small wave,” Casey said.

Even during the omicron surge, Casey said, Vanderbilt turned down some transfer requests for ECMO.

While the chances of survival for patients with critical covid are still around 50-50, the Vanderbilt study shows what happens if therapy is not available.

“I try to convince people that this is a resource worth investing in, and then I hope people will invest in these resources over time,” said Casey, l lead author of the study.

Until there is wider access to ECMO, Casey said, the country also needs to find a better way to decide who is prioritized for treatment, similar to how organ transplant allocation works. organs. There is a national ECMO organization called Extracorporeal Life Support Organization, but it is not yet involved in patient triage.

Some hospitals will agree to try ECMO on someone over 70, if the family pushes hard enough. Others turn away patients over 50, especially if they have underlying diabetes or heart disease.

Small-scale cooperative efforts are underway. In Minnesota, hospitals agreed to use the same strict criteria for patients and a statewide referral process.

Decisions are always “ethically nuanced”, said Dr Matthew Prekker, who helped set up the consortium before the pandemic emerged. Cooperation could mean giving an ECMO bed to a statewide patient instead of someone at your own hospital.

The goal is simply for more patients to survive.

“It requires a lot of cooperation between health systems and state leaders,” he said. “But I think doctors and communities have more of an appetite for it now than before.”

This story is part of a partnership that includes WPLN, NPR and KHN.

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