On National Doctor’s Day, Prof Anjan Trikha, Department of Anesthesiology, Pain Medicine and Critical Care, Chairperson, Clinical Managerial Group, JPNTC Designated COVID Hospital, AIIMS New Delhi and Dr Vineeta Venkateswaran, Assistant Professor Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi caution fellow medical practitioners that portraying modalities like ECMO and lung transplants as last-ditch rescue therapy capable of salvaging dying patients must be discouraged as scientifically inaccurate and socially irresponsible. Failure to do so may have far-reaching consequences for the medical fraternity, the public and policymakers
The widespread havoc caused by the COVID-19 pandemic has led the medical fraternity, policymakers and the public to scramble for an effective cure. Several medications and treatment modalities have been introduced over the past 18 months for COVID-19 treatment. While many of these were introduced amidst much enthusiasm and showed promise initially, most turned out to be damp squibs later. The latest kids on the block appear to be extracorporeal membrane oxygenation (ECMO) and lung transplantation. However, the actual on-ground benefit afforded by these modalities, and feasibility with respect to expense and resources, remain unclear.
ECMO is a technique by which the patient’s blood is drawn out into a machine, oxygen added, carbon dioxide removed, and then returned to the patient’s body. Much like a cardio-pulmonary bypass machine that takes over the function of the heart and lungs for a short period, ECMO effectively takes over the function of the lungs. In COVID-19, it has been hypothesised to act by allowing a period of rest to the lungs, reducing inflammation, and allowing an increase in oxygen content of the blood. However, unlike cardiopulmonary bypass, which is needed only for a few hours, ECMO is usually applied for days to weeks depending on the patient’s condition. In fact, an ECMO run over 300 days has been reported in literature!
This has led to the belief that ECMO is a ‘saviour’ in severe COVID-19 patients when all other therapies have failed. Recent times have seen desperate families running pillar to post for ECMO facilities in hospitals, in the misguided belief that ECMO can cause a dramatic turnaround in the clinical course of their loved ones and potentially save dying patients. However, these beliefs are not supported by the available literature or recommendations of international regulatory bodies. Extracorporeal Life Support Organization (ELSO), the international registry of ECMO centres worldwide, clearly recommends ECMO for COVID-19 patients to be offered only in established ECMO centres already accustomed to high volumes of ECMO procedures. The body emphatically recommends against the setting up of new ECMO centres for COVID treatment. Further, the body recommends prioritising non-COVID ECMO patients over COVID patients, and young patients with a short expected ECMO run over older and sicker patients. Similarly, the USA-based Society for Critical Care Medicine recommends against attempting ECMO in patients on prolonged mechanical ventilation. This is also supported by guidelines from the National Institutes of Health (NIH), USA, which state that there is insufficient data to recommend the use of ECMO in COVID-19. If considered, it may be viewed only as short-term rescue therapy in a selected patient subset.
A recent review of the literature on ECMO in COVID-19 patients found reports of mortality rates as high as 83-100 per cent in some cases. Benefit, if seen, is likely in young patients with isolated respiratory failure, with poor oxygenation despite effective use of conventional techniques of mechanical ventilation and prone positioning. ECMO must also be used within a week of initiation of mechanical ventilation, to be of any use. The ideal candidate for ECMO, i.e. young, otherwise healthy, and with no other failing organs, also represents the patient group with the best chance of survival in COVID. anyway. In other words, would these patients survive anyway even without the use of ECMO? It is difficult to speculate.
An important part of any discussion on ECMO is the cost and logistics. One needs to consider the judiciousness of pouring money and resources into setting up and running an ECMO unit in a developing country like India, where the vast majority of the population is unable to access or afford even basic healthcare facilities. The cost of a single ECMO machine can be over Rs 35 lakh. After factoring in the cost of the single-use components like circuits, the procedure can cost Rs 1.5 lakhs to Rs 3 lakhs per day. This is apart from charges for the trained personnel needed for this skill- and labour-intensive procedure, who are also in short supply.
According to a global ranking of average wages prepared by Picodi.com, in 2020, the average monthly wage in India is Rs 32,800. Thus, the financial implications of ECMO for the patient’s family are immense. Coming times may see families exhausting their financial savings or being pushed into severe debt while chasing the idea of a miraculous cure for their loved ones. Medical practitioners have reported receiving multiple inquiries each day, regarding ECMO facilities from anxious family members desperate for treatment for their dying kin. This is a worrisome trend. The implications for the medical fraternity are immense as well. We live in a time when the trust divide between patients and relatives is high, and in a country where doctors routinely face violence at the hands of patient’s relatives. In this situation, it is easy to imagine that doctors would be blamed or even beaten up for advising what may be deemed expensive treatments with dubious results if the patient dies later.
ECMO is in its infancy in India, and the concept of lung transplantation for COVID-19 patients is still in the womb! Lung transplantation in COVID-19 patients consists of surgical removal of both diseased lungs and replacing them with lungs from a cadaver. Due to the nature of the procedure, the lungs must be transplanted into the patients within six hours of harvesting them from a suitable deceased donor. Lung transplantation has been suggested in patients with severe post-COVID lung fibrosis, which interferes with oxygenation and carbon dioxide elimination from the blood. It is vital to emphasise here that lung transplantation is not considered a cure for COVID-19 illness, but a way to deal with its sequelae, after the infection settles. Indeed, current guidelines mandate two negative RT PCR tests 24 hours apart before the surgery. There are very few reported cases worldwide of lung transplantation in post-COVID patients during the past 18 months of the COVID-19 pandemic.
The conclusion is that both ECMO and lung transplantation are far from being the pillars of mainstream COVID-19 management. ECMO may offer some benefit in a small subset of patients, but the infrastructure requirements, cost and stringent patient selection mean that it should not be portrayed as a routine part of COVID-19 care, like mechanical ventilation. Its portrayal as a last-ditch rescue therapy capable of salvaging dying patients must also be discouraged as scientifically inaccurate and socially irresponsible. Failure to do so may have far-reaching consequences for the medical fraternity, the public and policymakers. When it comes to the future evolution of these techniques and their effectiveness in COVID-19, the jury is still out.