Ahmed Labib Shehatta

Background/Objectives: Reported infection rates during extracorporeal membrane oxygenation (ECMO) vary widely, partly because case definitions are applied inconsistently. We synthesized the prevalence and prognostic association of nosocomial and bloodstream infection (BSI) acquired during adult ECMO. Methods: PubMed/MEDLINE, Embase, Scopus and CENTRAL were searched through December 2025 for observational studies of at least 10 adults on ECMO with an explicit infection definition. We classified case definitions by the criteria actually applied. We pooled crude mortality odds ratios (ORs) and patient-level BSI prevalence in studies applying laboratory-confirmed criteria, assessed risk of bias with ROBINS-I and the JBI checklist, and rated certainty with GRADE. Results: Forty-seven reports (46 cohorts; 11,573 patients) were included. Pooled BSI prevalence was 25.8% (95% CI 17.3–36.5%; 7 studies, 1193 patients), 18.2% in pre-pandemic and 39.2% in COVID-19 cohorts (post hoc). Infection was associated with higher crude odds of death (OR 1.65, 1.33–2.04; prediction interval 0.95–2.85; 24 studies), but analyses modeling infection as time-varying were inconsistent, including no association in a multistate model (adjusted hazard ratio 1.00, 0.79–1.26), and small-study effects were suggested. Certainty was very low for both outcomes. Conclusions: Roughly one in four adults on ECMO developed laboratory-confirmed BSI, more often in COVID-19 cohorts. Whether infection acquired on ECMO increases mortality remains uncertain.

The Interfacility transportation of critically ill patients is a common practice in modern medical care. Transportation of patients may be necessary for clinical or hospital capacity issues. Patient transfers are typically conducted by specialized teams via ground emergency medical services (GEMS) using emergency medical vehicles (i.e. ambulances) or helicopter emergency medical services (HEMS) using rotary-wing air ambulances. The primary objective of this study is to compare the efficacy of HEMS and GEMS in terms of the duration of time-critical interfacility transfers. This is a retrospective observational study of emergency interfacility transfer of critically ill adult patients in Qatar between 2018 and 2022. Data on patient demographics, facilities' locations, and multiple mission-related time parameters were collected from the Ambulance Service database and the hospitals' centralized electronic medical records and analyzed. Patients with non-emergency conditions, incomplete transfer data, or HEMS activation delays exceeding 30 minutes were excluded. Data of 518 emergency interfacility transfers (355 GEMS and 163 HEMS) was collected and analyzed. Patients' median age was 45 years old. For transfers shorter than 50 km, HEMS was used in 50.2% (109/217) of cases, while for transfers over 50 km, GEMS was used in 82.1% (247/301) of cases (p < 0.001). The GEMS transfers had a significantly shorter call-to-departure time by 21.9 minutes, whereas HEMS had a significantly shorter departure-to-arrival time by 23.6 minutes. However, the difference in total mission time was not significant (p > 0.05). In transfers less than 50 kilometers, HEMS had a longer call-to-departure time by 18.4 minutes and a shorter departure-to-arrival time by 12.3 minutes (both p < 0.001). Similar trends were observed in both short (50 km) transfers. Ground ambulance may offer a comparably as efficient option for emergency patient transfers over short and medium distances, as no significant difference was found in the total transfer times and clinical patient outcomes were not assessed. The results obtained in Qatar's context may not be universally generalizable. Helicopter ambulance may be advantageous when the patient needs to be transferred very quickly over a longer distance.

Background: The impact of the duration of invasive mechanical ventilation (IMV) before venovenous extracorporeal membrane oxygenation (VV ECMO) on patient outcomes in COVID-19 remains unclear. Methods and setting: Data from the COVID-19 Critical were used to investigate whether the duration of IMV prior to VV ECMO initiation was associated with ICU mortality between January 1st 2020 and December 31st, 2022. Multivariable Cox regression models were used to evaluate the role of the duration of IMV before ECMO on patient outcomes after adjusting for calendar date and key patient covariates. Results: 919 adult patients with median age 50 and severe COVID-19 infection requiring IMV and VV ECMO were included in the analysis. The ICU mortality for ECMO performed on the same day as IMV was 43%, compared to 47% when ECMO was initiated between 1 and 7 days and 54% when ECMO was initiated at 8+ days. The 8+ day group of IMV received more prone positioning (71%), neuromuscular blockade (80%), and vasopressor support (74%). The multivariable analysis showed the mortality risk increased when ECMO was initiated within the first 7 days from commencement of IMV (Hazard ratio, HR: 1.37; 95% CI: 1.08 to 1.73) or later (HR: 1.51; 1.02 to 2.22), compared with same-day initiation. Conclusion: Analysis indicated a positive association between time on IMV before VV ECMO initiation and ICU mortality, but effects sizes exhibited high uncertainty after adjusting for other patient characteristics. Further studies are needed to confirm our findings.

Background: Severe coronavirus disease 2019 (COVID-19) infection can lead to severe acute respiratory syndrome for which extracorporeal membrane oxygenation (ECMO) could be used in selected cases. Most Jehovah’s witnesses (JWs) do not accept transfusion of blood and/or blood products. The use of ECMO for the management of JWs during the pandemic was challenging. Case report: We present a case of a JW with severe COVID-19 infection and multiple organ failure necessitating ECMO support for 20 days. We discuss the management challenges in patients who do not accept blood transfusions. A significant drop in the patient’s haemoglobin and platelet count was observed throughout ECMO duration. An anti-coagulation-free ECMO circuit was maintained, and we did not observe any major circuit or patient complications. Conclusion: Management strategies to minimize blood loss, avoid bleeding, augment haemoglobin production, maintain ECMO circuit integrity without systemic anticoagulation, and reduce blood loss during ECMO decannulation are helpful in the management of JW followers on ECMO. We recommend treatment in such a situation at experienced centres with the involvement of a haematologist within an interprofessional team.

Background: Liberation from sedation may be beneficial for patients with acute respiratory distress syndrome supported by veno-venous (VV) extracorporeal membrane oxygenation (ECMO). Currently, there is limited evidence to support this approach. Therefore, this study aimed to compare the 90-day patient mortality of different sedation strategies in COVID-19 patients supported with VV ECMO. Methods: Retrospective, observational sub-study of the COVID-19 Critical Care Consortium database including COVID-19 patients supported with VV ECMO. Two cohorts were compared: high sedation patients who received neuromuscular blocking agents (NMBAs) throughout ECMO and low sedation patients who did not receive NMBA consistently. Patients’ level of sedation during ECMO was also considered. The primary outcome was 90-day in-hospital mortality and was assessed using cause-specific Cox proportional hazard models. Results: 224 low and 104 high sedation patients were included. Pre-ECMO respiratory condition prior was similar between groups, except for the ratio of partial pressure of oxygen to inspired fraction of oxygen, which was lower in the high sedation group at 93 [61–130] than the low sedation group at 106 [69–140]. No difference was observed in disease severity scores between cohorts. Low sedation patients had longer ECMO runs, more circuit changes, but lower infectious and hemorrhagic complications. Higher sedation was associated with a hazard ratio for death of 3.23 (95% CI 2.16–4.83) compared to low sedation. Conclusions: Reduced sedation in COVID-19 ECMO patients is feasible and may be associated with improved survival and reduced complications compared to continuous paralysis, albeit with longer ECMO runs.

The use of extracorporeal membrane oxygenation (ECMO) to support the pregnant patient and fetus requires a complex decision-making process. Peripartum ECMO requires coordinated and informed decision-making between an interdisciplinary team of experts, incorporating the unique considerations and, at times, competing physiologic priorities of the pregnant patient. It is often confounded by a scarcity of local relevant experience engendered by its rare occurrence. No event has made the need for an organized approach to the utilization of ECMO in pregnant patients more pressing than the COVID pandemic. The conditions affecting pregnant patients that warrant ECMO consideration are high stakes and, at times, ethically challenging, although outcomes are favourable compared to the general population. This review provides background information and context, followed by a practical approach to the care and specific medical management of patients who are facing life-threatening conditions warranting ECMO while pregnant.

Disclaimer: This Extracorporeal Life Support Organization guideline describes early rehabilitation or mobilization of patients on extracorporeal membrane oxygenation (ECMO). The guideline describes useful and safe practices put together by an international interprofessional team with extensive experience in the field of ECMO and ECMO rehabilitation or mobilization. The guideline is not intended to define the delivery of care or substitute sound clinical judgment. The guideline is subject to regular revision as new scientific evidence becomes available.