Extracorporeal life support provision in COVID-19 patients -An international EuroELSO 2022 update survey

A surge of patients with acute respiratory distress syndrome (ARDS) due to pandemic SARS-CoV-2 disease 2019 (COVID-19) strained healthcare systems worldwide. Severely affected patients with COVID-19-related ARDS (CARDS) could be offered extracorporeal life support (ECLS) as a bridge to lung recovery, and ECLS usage increased during the pandemic. To better understand ECLS usage for adult and pediatric patients with respiratory or cardiac support in COVID-19, the authors conducted an international EuroELSO survey to provide insight into indications, practices, and organizational aspects.

The EuroELSO Scientific and Steering Committees approved the questionnaire. The survey was promoted via the EuroELSO website, newsletter, social media, and at the 10th EuroELSO Congress in London (May 4–6, 2022). Data entry was open May 1–31, 2022. The online SurveyMonkey (v3.0.1) questionnaire comprised 26 multiple-choice questions covering center characteristics (location, ECLS modes, age groups, number of runs since December 2019) and clinical/organizational practices (transport/retrieval, indications/contraindications, complications, therapies, anticoagulation, configuration changes, rehabilitation, and withdrawal criteria). One response per center was acknowledged; duplicates were merged and implausible responses excluded. No patient-identifiable data were collected; IRB review was waived and GDPR compliance ensured. Results were summarized using descriptive statistics.

• Responses: 69 questionnaires representing 62 centers across 22 European countries and 7 centers across 5 non-European countries (after excluding 8 duplicates and 6 implausible responses). Most responses from Europe; 40% from Italy (9), Germany (8), and Spain (8).
• ECLS programs: 85.5% (59/69) provided both respiratory and cardiac support; 10.1% (7/69) respiratory-only; 4.3% (3/69) cardiac-only. No major geographical differences reported.
• Volume (since Dec 2019): Respiratory support runs: 68% of centers performed ≥31 runs (15.9% >100; 29.0% 51–100; 23.2% 31–50). Cardiac support runs: 10.1% performed ≥31 runs (2.9% >100; 4.3% 51–100; 2.9% 31–50); 46.4% had 1–10 and 15.9% no runs.
• Age groups: >95% of centers performed adult ECLS. Neonatal ECLS for COVID-19 in 2 centers (2.9%); pediatric in 18 centers (26.1%), mostly <10 runs. Adult runs were higher: 20.3% >100; 27.5% 51–100; 21.7% 31–50; 20.3% 11–30.
• Retrieval/transport: 66.7% provided regional/national retrieval including transport on ECLS; 26.1% provided retrieval without transport on ECLS but cannulated in referral hospitals; 5.8% provided ECLS only to in-house patients.
• Configurations: VV-ECLS predominated; hybrid V-AV ECLS used in ~23% for refractory hypoxemia. At least 10.1% of centers reported ≥31 cardiac support runs.
• Contraindications: Age considered important—~50% regarded >65 years as a relative contraindication; ~16% as absolute; 24% set no strict cutoff, using biological age/individual assessment. 72.5% considered multiorgan failure (including cardiac failure with high-dose vasopressors) a contraindication. 69.6% considered prolonged invasive ventilation (>10 days) a contraindication.
• Medical therapy/anticoagulation: 68.1% routinely used dexamethasone 6 mg for ≥10 days. 72.5% used therapeutic anticoagulation; 56.5% used heparin targeting aPTT 50–60 s. Despite this, 63.8% observed higher need for circuit changes due to clotting in COVID-19 vs non-COVID ARDS.
• Management in hypoxemia on VV-ECLS: frequent measures included deep sedation (58.0%), increasing blood flow to ≥6 L/min (55.1%); configuration change with additional drainage cannula (46.4%); neuromuscular blockade (81.2%); prone positioning (79.7%); open lung recruitment (53.6%); inhaled nitric oxide (42.0%).
• Rehabilitation/awake ECLS: Practice varied widely. Awake ECLS considered rarely possible by 51.5% (limited lung compliance/high respiratory drive) yet aimed for in all patients by 29.4% of centers. Variability also in tracheotomy, mobilization, physiotherapy.
• Withdrawal criteria: 92.6% would withdraw in irreversible brain damage (e.g., bleeding, ischemia). Smaller proportions would consider withdrawal after 4 weeks without lung improvement, very low compliance (<15 mL/cmH2O), or proven invasive aspergillosis (~5.9%).

Survey findings align with earlier reports but reflect substantial evolution over the two years of the pandemic. Compared with an earlier EuroELSO survey (2020) and early ELSO Registry data, participating centers now report markedly higher ECLS volumes in adults and broader deployment of retrieval services, including transport on ECLS. VV-ECLS remains the dominant mode for respiratory failure, but there is increasing use of cardiac support and hybrid V-AV configurations for refractory hypoxemia, potentially underutilized given COVID-19’s systemic effects including cardiomyopathy and coagulopathies. Anticoagulation practices generally follow standard heparin protocols, yet centers observed higher circuit clotting in COVID-19 than non-COVID ARDS, consistent with the disease’s inflammatory and procoagulant profile. Evidence-based adjuncts (e.g., dexamethasone) were not universally applied, possibly due to patient heterogeneity and sepsis/MOF concerns. Rehabilitation during ECLS is feasible but variably implemented, influenced by sedation, cannulation strategy, and infection control burdens. Contraindications and withdrawal practices largely mirror non-COVID ECLS, particularly for catastrophic neurologic injury. However, optimal duration of support and long-term outcomes (including impacts of critical illness and long COVID) remain uncertain, complicating uniform withdrawal criteria.

Most COVID-19 patients supported with ECLS received respiratory (VV) support, with adult patients predominating. Indications and contraindications generally align with available ELSO guidance; many centers consider age >65 years or biological age as relative or absolute contraindications. Retrieval including transport on ECLS is common, and hybrid configurations are used for refractory hypoxemia. Given the unknowns surrounding long-term outcomes and the impact of critical illness and long COVID, standardized withdrawal criteria remain challenging. Future research should address long-term outcomes after ECLS in COVID-19, refine patient selection (including cardiac support indications), optimize anticoagulation to mitigate circuit loss, and standardize rehabilitation and awake ECLS practices.

• Open survey with broad announcement; response rate cannot be calculated.
• Fewer responses than the prior EuroELSO survey; non-European centers underrepresented and spread over multiple continents.
• Only descriptive statistics; no cross-country comparisons or inferential analyses.
• No outcome data collected (e.g., survival, ICU discharge); no linkage to center characteristics, age groups, or modes for outcome analyses.
• Pediatric data limited and not generalizable, reflecting lower pediatric COVID-19 burden during the pandemic.
• Potential reporting bias and heterogeneity in practices across centers.