Venovenous Extracorporeal Membrane Oxygenation: In for a Penny, In for a Pound

The study by Chandel et al (1) published in this issue of Critical Care Medicine will directly impact clinical care and current venovenous extracorporeal membrane oxygenation (VV ECMO) practice. The data presented by the authors challenge the somewhat nebulous philosophical concept of VV ECMO transitioning from a "bridge to recovery" to a "bridge to nowhere" for patients with prolonged runs. Until now, we have used our historic understanding of the expected duration of VV ECMO complemented by physician judgment and shared decision-making with families when declaring failure of VV ECMO. Here, the authors strongly challenge our normative frame of reference in this equation. Over the past few years, we have seen a rise in VV ECMO duration run-time, particularly with COVID-induced acute respiratory distress syndrome (ARDS) (2). Much to our surprise many of these long-run cases had good survival not too dissimilar to short-run VV ECMO; which thus resulted in the question: should we offer prolonged VV ECMO support in our patients with protracted ARDS? We see several areas where this study can help clinicians in management of patients on VV ECMO. First, this analysis illuminates potential parameters for the initial consent process for VV ECMO. More often than not, patient's families provide consent for VV ECMO rather than the patient themselves. This is a reasonable moment in time to set expectations for the duration of the VV ECMO as well as the need for added procedures, such as a tracheostomy. One of the lessons learned here is that perhaps a cutoff of 21 days may be too short to declare failure and family expectations counseling should extend out to 6–12 weeks. Second, it important to understand that a large number of these long-run VV ECMO patients require lung transplantation. Not all VV ECMO programs offer lung transplantation. Lung transplantation requires specialized expertise and a team of dedicated advanced lung physicians, thoracic surgeons and cardiac intensivists that can manage VV ECMO as a bridge to transplantation. Data have demonstrated that mobility and sedation weaning represent two of the most important protective factors when considering VV ECMO as a bridge to transplantation (3). Therefore, timely referral and transfer of patients on VV ECMO to a transplant center can help progress patients to evaluation and possible listing for lung transplantation. One of the essential aspects of long-run VV ECMO that has emerged in the last 3 years, not addressed in the article, is the use of oxygenated right ventricular support, termed venopulmonary (VP) ECMO. As patients remain on VV ECMO several groups have demonstrated that progressive right ventricular failure complicated by liver and renal failure can commonly occur leading to late death on VV ECMO. It will be interesting to see the survival outcomes in the years to come, as more centers adopt VP ECMO in select patients who have long-run VV ECMO course for ARDS. We suspect that conversion of patients on VV ECMO to VP ECMO may be able to shorten the length of time to recovery in a select group of patients. A very important concept that this article raises is that clinician and ICU staff burnout can exist when taking care of extremely sick patients for an extended period of time. For those patients at 120 days or more of VV ECMO, this represents grueling months of ICU care, with nursing, pharmacy, ICU, and nurse practitioner staff dedicated to patient care. Burnout is real in our subspeciality. We know that providers who take care of ECMO patients, in particular, have reported lower levels of personal achievement (4). In addition, lack of resources and ICU beds begs us to ask a fundamental question with regards to appropriate resource allocation. We suspect that readers outside the United States may have differing opinions on 4- to 6-month VV ECMO duration in particular for those cases who may become futile. There may be a small appetite to care for these high-cost cases. That leads to the conundrum that needs to be address. Is there a way for us to identify those patients who will require long-run VV ECMO support as well as ways to mitigate those variables. If we are able to identify variables associated with reduced VV ECMO time, perhaps we can intervene on them to reduce the time to recovery. Future studies should also systematically assess factors associated with optimal functional recovery beyond mere survival (5). This article finally should prompt further discussion about reimbursement and resource allocation for these patients with severe and prolonged critical illness. As a group of ECMO physicians, we practice in an environment where insurance agencies try to limit reimbursement. This article offers credence and defense for higher reimbursement for patients on VV ECMO due to continued survival. A compelling case example illustrates many of these salient points. Just over 10 years ago, the senior author had the great privilege of leading team that performed the first adult trans-Atlantic ECMO transport for a young woman with severe ARDS due to fungal pneumonia (6). Through her prolonged ECMO run of 80 plus days, the patient demonstrated extreme resilience and a strong desire to recover. She eventually walked the hallways and performed treadmill workouts with the support of the military ICU and rehabilitation teams. Her lung recovery stalled due to severe parenchymal damage, but our regional partner transplant program at the University of Texas Health Science Center at San Antonio accepted her in transfer when donor lungs came available. She went on to have a complete functional recovery soon thereafter resulting in a very happy reunion with her family and her many ICU caregivers. So, although the course of illness may be protracted for some VV ECMO patients like this young woman, this study supports our hope that even more patients can survive to meaningful hospital discharge in the future so long as all stakeholders—health systems, critical care teams, families, and patients—are in for a penny, in for a pound.