Daniel Brodie

Extracorporeal life support (ECLS), including venovenous extracorporeal membrane oxygenation (VV-ECMO) and extracorporeal carbon dioxide removal (ECCO₂R), is an established treatment for selected patients with acute respiratory distress syndrome (ARDS). In this review, on the 60th anniversary of ARDS, we review the evolution of ECLS as a support strategy in ARDS, the evidence surrounding its efficacy, factors associated with prognosis, management of patients on ECLS, associated complications, and long-term outcomes among survivors. We also highlight existing areas of uncertainty, and ongoing clinical research that will define the next decade and beyond of ECLS for ARDS. Visual abstract

Purpose Obesity is increasingly encountered among patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory or cardiac failure. It alters respiratory and cardiovascular physiology and drug pharmacokinetics and introduces technical and logistical challenges that may complicate patient selection, ECMO initiation, cannulation, anticoagulation, and monitoring. This review summarizes current evidence regarding the epidemiology, physiological implications, outcomes, and management of obesity in patients supported with veno-venous (VV) or veno-arterial (VA) ECMO. Results Available evidence, largely retrospective and based on body mass index classifications, suggests that obesity should not be considered a contraindication to VV-ECMO, with outcomes comparable to or potentially better than those of patients without obesity. However, obesity-related respiratory mechanics may exaggerate the apparent severity of lung injury, emphasizing the need for optimized conventional ARDS management, including appropriate ventilatory strategies and prone positioning, before ECMO initiation. In contrast, outcomes during VA-ECMO are more heterogeneous, particularly in extracorporeal cardiopulmonary resuscitation (ECPR), and may be influenced by patient selection, comorbidities, and timing of support. Obesity also creates important technical challenges requiring individualized cannulation, anticoagulation, and perfusion strategies. Conclusion Obesity alone should not preclude access to ECMO, particularly VV-ECMO. Successful management requires anticipation of obesity-related challenges, appropriate infrastructure, and structured multidisciplinary protocols. Further prospective studies are needed to clarify obesity-specific risks, optimize management strategies, and evaluate long-term outcomes. Graphic abstract

Extracorporeal Life Support (ECLS), including venovenous (VV) extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) is a temporary support option for patients with severe respiratory failure. Current data and recent guidelines support the use of VV ECMO for select patients with very severe respiratory failure as this technique might improve survival in appropriately selected patients. Patient selection criteria, timing of ECMO initiation and optimal management of mechanical ventilation and anticoagulation, and other adjunctive treatment options are a matter of ongoing research.

This workshop identified a set of core system-level care delivery priorities that emerged during the coronavirus disease (COVID-19) pandemic to assist global healthcare systems to respond to future similar emergencies using an informed and systematic approach. Led by a working group (n = 14) of nurses and physicians with diverse clinical and administrative backgrounds, we conducted a literature review of staffing, supplies, and systems in hospital inpatient settings to inform potential candidate priorities of COVID-19 care delivery challenges. We then used a modified Delphi consensus approach to elicit expert opinion from clinicians, healthcare and public health administrators, and health services researchers. Three rounds of online surveys were completed. To retain survey items, we a priori determined a threshold of 75% or greater endorsement for items rated “highly important to essential.” A total of 47 international experts responded. Forty of 71 care delivery priorities were retained. These 40 priorities comprised 25 systems (8 related to infrastructure [e.g., systemic enhanced support from federal resources during a pandemic]; 8 to care delivery [e.g., policies in place and operational for rationing of care]; and 9 to training, infection control, and communication [e.g., training for healthcare workers on protocols and/or processes for rapid testing]), 11 related to supplies (e.g., safe handling of biomedical waste), and 4 related to staffing (e.g., programs and/or systems to support staff retention). By organizing these priorities on the basis of implementation complexity and applying relevant frameworks, the project offers strategies to inform investment and guide global healthcare systems in pandemic preparedness planning for the future.

BACKGROUND: Long-term outcomes and quality of life have been identified as core patient-centered outcomes for venoarterial extracorporeal membrane oxygenation (VA-ECMO) research. The aim of this study is to investigate the incidence of death or new disability at 12 months after the initiation of VA-ECMO. METHODS: Prospective, multicenter, registry-embedded cohort study in 26 hospitals in Australia and New Zealand from February 2019 through April 2023. Adult patients admitted to a participating ICU and who underwent VA-ECMO were included. The primary outcome was death or new disability at 6 and 12 months. All results were adjusted for patient characteristics at the time of ECMO initiation. RESULTS: Among 389 patients who received VA-ECMO (median age, 57 [44–65] years; 35% women), the incidence of death or new disability at 12 months was 70.6% compared with 70.8% at 6 months (adjusted odds ratio for 12 versus 6 months, 0.61 [95% CI, 0.25–1.49]; P =0.27). Compared with 6 months, at 12 months after VA-ECMO more patients were independent in activities of daily living (62.1% versus 48.2%; adjusted odds ratio, 2.84 [95% CI, 1.50–5.36]; P =0.001), and fewer patients were unemployed due to health reasons (32.7% versus 47.4%; adjusted odds ratio, 0.29 [95% CI, 0.13–0.65]; P <0.001). Differences in outcomes were found according to the reason for VA-ECMO initiation. CONCLUSIONS: At 12 months after VA-ECMO, 30% of patients are alive and without disability, with differences in outcome associated with the reason for VA-ECMO initiation. The major burden of disability appears to develop in the first 6 months after VA-ECMO initiation and is sustained between 6 and 12 months. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03793257.