INTRODUCTION:

Corona virus disease 2019 (COVID-19) is defined as illness caused by a completely unique corona virus now called severe acute respiratory syndrome corona virus 2 (SARS-CoV-2; formerly called 2019-nCoV), which was first identified amid an epidemic of respiratory disease cases in Wuhan City, Hubei Province, China.¹ It was initially reported to the WHO on New Year's Eve, 2019. On January 30, 2020, the WHO declared the COVID-19 outbreak a worldwide health emergency.^2,3 On March 11, 2020, the WHO declared COVID-19 a worldwide pandemic, its first such designation since declaring H1N1 influenza an epidemic in 2009.⁴ Illness caused by SARS-CoV-2 was termed COVID-19 by the WHO, the acronym derived from "corona virus disease 2019."

The name was selected to prevent stigmatizing the virus's origins in terms of populations, geography, or animal associations.^5,6

What is ECMO?

ECMO stands for extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation (ECMO) is a life support machine. A person’s life can be saved by an ECMO machine, but it does not cure the disease or injury that led to the heart and lung failure. The ECMO machine replaces the function of the heart and lungs.¹² When the patient is connected to an ECMO, blood flows through tubing to an artificial lung in the machine that adds oxygen and takes out carbon dioxide; then the blood is warmed to body temperature and pumped back into your body.⁷

There are two types of ECMO. The VA ECMO is used when there are problems with both the heart and lungs and is connected to both a vein and an artery and is used. The VV ECMO is used when the problem is only with the lungs and is connected to one or more veins, usually beside the heart.⁷

Clinical Indications for Establishment of Ecmo Support:

VA-ECMO:

· Weaning from cardio respiratory bypass when heart surgery

· Bridge to heart transplantation

· Acute myocardial inflammation

· Intractable cardiopathy

· Post-cardiac arrest (as a part of advance life support)

· Local anaesthetic toxicity

· Pulmonary high blood pressure

VV-ECMO:

· Any probably reversible acute metastasis failure

· ARDS related to respiratory illness (viral or bacterial)

· Failed respiratory organ transplant graft

· Trauma (pulmonary contusion)

· Pulmonary embolism.⁸

Contra Indications:

· Any condition or organ dysfunction that may limit the chance to get benefit of ECMO like severe, irreversible brain injury or untreatable pathologic process like cancer

· Patient has contra indications to anticoagulation therapy

· Limited vascular access

VA-ECMO

· Severe aortic regurgitation

· Aortic dissections

VV-ECMO

· Severe pulmonary hypertension

· Severe right/left heart failure

· Cardiac arrest.⁹

Procedure:

ECMO needs a surgical procedure but mostly it is done in a patient's unit. The ECMO catheters are inserted by a surgeon, assisted by members of surgical team into either an artery or vein. To make sure the catheters are in the right place, an x-ray is taken. Usually a patient on the ECMO therapy will also be on a ventilator, which helps to heal the lungs.

When the patient on ECMO, will be monitored by specially trained nurses and respiratory therapists, as well as the surgeon and surgical team. The patient may be given certain medications including: anticoagulant to stop blood clots; antibiotics to halt infections; sedatives to reduce movement and induce sleep; diuretics to assist the urinary organ to eliminate fluids; electrolytes to maintain the proper balance of salts and sugars; and blood products to replace blood loss. Since the patient will be sedated, supplemental nutrition will be provided either intravenously or through a nasal-gastric tube.¹⁰ Deoxygenated blood is drawn by the ECMO pump from a vein and is sent it into the machine’s artificial lung, or oxygenator, where carbon dioxide is removed from the blood and oxygen is added. Darker red deoxygenated blood is changed into bright red when oxygen is added to it. As the red blood leaves the oxygenator it is warmed before returning to the patient.¹¹

Discontinuing ECMO needs a surgery to remove the catheters. Multiple Lab investigations are usually done before termination of ECMO therapy to ensure that the patient’s heart and lungs are ready to do its function. After removing of ECMO cannulas, the vessels will be repaired. This can be done either at the patient area or in the OT. Small stitches will be done to close the spot where the tubes were placed. The patient will be asleep and monitored for this process. Even though the patient is off the ECMO, the patient still ought to get on a ventilator.¹⁰

Complication:

· Bleeding

· Kidney Failure

· Infection

· Leg Damage

· Stroke¹²

Recommendation to use ECMO therapy in COVID-19:

April 7, 2020 - The Guidance has been issued by U.S. Food and Drug Administration (FDA) to provide a policy help to expand the availability of devices used in extracorporeal membrane oxygenation (ECMO) therapy to address the novel coronavirus (COVID-19, SARS-CoV-2) a public health emergency.¹³ In March 2020 the WHO released the guidelines that recommends ECMO to support the cardio respiratory system in patients who has ARDS with failure of conventional therapy. V-V ECMO is the best option for COVID patients particularly in severe respiratory failure. The Society of Critical Care Medicine also has promulgated guidelines for the management of COVID-19 patients and recommends the use of ECMO when conventional management fails.¹⁴

Success Rate of ECMO therapy in COVID-19:

In China Zeng et al. conducted case study on COVID-19 critically ill patients who were given ECMO therapy. Totally 12 patients were under treatment among which 3 patients were weaned successfully from ECMO, 5 died, and 4 remained alive with ECMO (but 2 were in a coma).¹⁵

The ELSO (Extracorporeal Life Support Organization) provides the information that 143 COVID-19 respiratory ECMO running systems are available worldwide, mostly being in Europe and the United States. As of April 4, 2020, COVID-19 survey/study showed 253 ongoing VV ECMO patients while 52 have been successfully weaned from ECMO support. Until June 3^rd 2020 almost 131 COVID 19 patients were under ECMO treatment in the SWAAC region among 53 patients survived.^16,17

Registered ECMO centers in India:

ECMO society of India was established in the year 2010. It was founded by two ECMO practitioners Dr. Pranay Oza, and Dr. Venkat Goyal with a support of interested clinicians all over the country. South and West Asia chapter of ELSO was established in the year 2013by the combined efforts of members of ECMO society of India and ELSO. In 2015 SWAC becomes SWAAC after adding Africa representing South Asia, West Asia, and Africa.¹⁸

SWAAC ELSO registered Indian ECMO centers as on July 2020

Sl. No.	Name of the city	Name of the hospital
1.	Bangalore	1. Fortis hospital 2. Aster CMI hospital 3. Manipal hospital, Whitefield 4. Narayan institute of cardiac sciences.
2.	Gurgoan	1. Fortis memorial research institute
3.	Ludhiana	1. Dayanand Medical College
4.	Mumbai	1. Kokilaben Dhirubai Ambani Hospital 2. Riddivinayak Critical Care and Cardiac Center
5.	New Delhi	1. The Simulation Society (TSS) at AIIMS 2. Holy Family Hospital
6.	Secunderabad	1. Krishna institute of medical sciences
7.	Hyderabad	1. Krishna institute of medical sciences 2. Rainbow Children’s hospital 3. Star hospital 4. Yashoda hospital 5. AIG hospital
8.	Surat	1. Unique hospital
9.	Chennai	1. Apollo hospital 2. Sri ramachandra institute of higher education and research centre
10.	Lucknow	1. Dr. ram manohar zohia institute of medical sciences
11.	Kolkota	1. Medica super specialty hospital

CONCLUSION:

Even though 100% success is not proved by using ECMO therapy there are chances of increased number of recovery. There are very few hospitals having ECMO facility the government should establish more ECMO centers and therapists where the poor people can also afford this treatment. For analyzing its importance and success rate more studies to be done to prove its effectiveness so that the mortality rate can be reduced due to COVID-19.

REFERENCE:

1. CDC. 2019 Novel Coronavirus, Wuhan, China. CDC. Available at https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. January 26, 2020; Accessed: January 27, 2020.

2. Gallegos A. WHO Declares Public Health Emergency for Novel Coronavirus. Medscape Medical News. Available at https:// www.medscape.com/viewarticle/924596. January 30, 2020; Accessed: January 31, 2020.

3. Ramzy A, McNeil DG. W.H.O. Declares Global Emergency as Wuhan Coronavirus Spreads. The New York Times. Available at https://nyti.ms/2RER70M. January 30, 2020; Accessed: January 30, 2020.

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6. WHO Director-General's remarks at the media briefing on 2019-nCoV on 11 February 2020. Available at https://www.who.int/ dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020. February 11, 2020; Accessed: February 13, 2020.

7. Extracorporeal membrane oxygenation: Available from: https:// www.ucsfhealth.org/treatments/extracorporeal-membrane-oxygenation

8. Guillermo Martinez, MD, Alain Vuylsteke, MD FRCA FFICM. Extracorporeal membrane oxygenation in adults. Continuing Education in Anaesthesia Critical Care and Pain. 2012 April; 12(2): 57–61: Available from: https://academic.oup.com/bjaed/ article/12/2/57/251128

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11. A family guide to ECMO|University of Iowa Hospitals and Clinics: Available from: https://uihc.org/health-topics/family-guide-ecmo

12. What is ECMO? American journal of respiratory and critical care medicine; 193(6): P9–P10: Available from: https:// www.thoracic.org/patients/patient-resources/resources/what-is-ecmo.pdf

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14. “Surviving Sepsis Campaign COVID-19 Guidelines.” Society of Critical Care Medicine. Available at: https://sccm.org/ SurvivingSepsisCampaign/Guidelines/COVID-19. Accessed March 25, 2020.

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Received on 09.01.2021 Modified on 27.01.2021

Asian J. Nursing Education and Research. 2021; 11(2):299-301.

DOI: 10.5958/2349-2996.2021.00072.0