Welcome to today's plenary session, which will be followed by the continue the conversation session. Please welcome Dr. Jose Diaz Gomez. Hello, I am Jose Diaz Gomez, and it is my pleasure to introduce Dr. Pete Alexander, who will present this year's Masked Harry Well Memorial Lecture. Dr. Alexander is an Australian trained intensive care physician and pediatric cardiologist with expertise in the management of advanced heart failure and mechanical circulatory support. She's an assistant professor in pediatrics at Harvard Medical School, and a staff physician in the Department of Cardiology at Boston Children's Hospital. She is the cardiac extracorporeal membrane oxygenation program medical director, with a focus on optimizing potential circulatory support strategies for patients with congenital and acquired heart disease. She strives for interdisciplinary goal concordant, family oriented, family centered care. She's also the treasurer of the board of directors of ELSO, co-chair of PD-ECMO and the Pediatric ECMO Anticoagulation Collaborative Peace, and is an associate editor of Pediatric Critical Care Medicine Journal. Today, Dr. Alexander will present what has COVID-19 told us about ECMO. Please join me in welcoming Dr. Peter Alexander. I'd like to thank the organizers of the Critical Care Congress, the Society of Critical Care Medicine, for the invitation and the honor of giving the Max Heriwill Memorial Lecture this year. The topic is what has COVID-19 taught us about ECMO? These are my disclosures. As we think about what COVID-19 has taught us about ECMO, it seems relevant to review what we were already learning about ECMO at the time the pandemic arrived. ECMO is a form of modified cardiopulmonary bypass in which venous blood is removed from the body and pumped through an artificial membrane lung in patients who have refractory, respiratory or cardiac failure. The nomenclature of ECMO support was clarified in these papers summarizing international expert opinion. The circuit itself consists of a respiratory membrane through which oxygen is added and carbon dioxide removed and blood is returned to the patient either via another vein to provide respiratory support or via a major artery to provide circulatory support. ECMO is a resource intensive, highly specialized and expensive form of life support with the potential for significant complications, particularly including bleeding, clotting and infection. ECMO wasn't a new therapy introduced during the COVID-19 pandemic. Evolving from the first uses of heart-lung bypass procedures, ECMO utilization has been established as rescue therapy for the most critically ill neonates and children with cardiopulmonary failure. The CSER trial, the efficacy of economic assessment of conventional ventilatory support versus ECMO for severe adult respiratory failure trial was an RCT which found significantly lower mortality or severe disability at six months in patients who were assigned to receive care at an ECMO center compared to those who received their care in non-ECMO centers. The reporting of results in 2009 coincided with improvements in circuit technologies and overall was associated with increased ECMO availability at a number of centers. The advent of the H1N1 pandemic in 2009 to 2011 also saw increases in ECMO utilization with some causal inference observational studies supporting the potential benefit in selected populations with reversible disease before the earlier study was reported in 2018. This is the largest randomized control trial of VVECMO for severe ARDS and it demonstrated a potentially large but not statistically significant mortality benefit of ECMO over conventional management, 35% mortality at 60 days versus 46% mortality in those who didn't receive ECMO with acceptable rates of adverse events. These results along with a post hoc Bayesian analysis of AOLIA helped to establish criteria for ECMO in severe ARDS refractory to conventional management. By 2020, ECMO was largely accepted as an option to support selected patients with respiratory failure. Overlying the timeline with the number of adult respiratory ECMO runs reported to the ELSO registry over time demonstrates the evolution and the use of the support in the lead up to the pandemic. The inclusion criteria for the AOLIA study have become a proxy criteria for clinical care. The World Health Organization declared COVID-19 a public health emergency of international concern on March 11, 2020 and released interim guidelines on patient management. Early reports that emerged from Wuhan, the epicenter of the outbreak, demonstrated that the clinical manifestations of the infection were fever, cough and dyspnea with radiological findings consistent with viral pneumonia. The WHO interim guidelines made general recommendations for treatment of ARDS in this setting, including consideration of referring patients with refractory hypoxemia to expert centers capable of providing ECMO. Doctors McLaren, Fisher and Brody, well-known in the ECMO community, wrote this paper very early in the pandemic, making the point that ECMO is not a therapy to be rushed to the frontline when all resources are stretched in a pandemic. Support with ECMO is for the most critically ill patients in regions with extensive resources required to provide this therapy. In less well-resourced countries, many more lives will be saved by ensuring oxygen and pulse oximetry are widely available, they stated. Mitigation efforts to slow the outbreak are critical so that healthcare systems are not overwhelmed and all patients receive the correct management, whether simply confirmation of the diagnosis, an appropriate quarantine, oxygen therapy alone, mechanical ventilation, or for those most likely to benefit, perhaps ECMO. Even at this stage of the global pandemic, the authors recognized that information is power in any response and advocated for mobilization of existing registries and clinical networks to facilitate the systematic collection of data. This was a call to action. The COVID-19 pandemic has resulted in unprecedented data availability and visualization, much of it open access and front-facing to healthcare workers, policy makers, and the wider public. In addition to the earliest available case numbers and mortality in aggregate, interactive data visualization to target countries and regions has been available. This is the interface that many of you will recognize from John Hopkins coronavirus resource centers, but there are many others, but there are many others, including some provided through the World Health Organization, CDC, NIH, and beyond. The ECMO community response to the pandemic also included changes to how data was collected, shared, and presented. For example, this is a representation from the Extracorporeal Life Support Organization, the ELSO Registry, which has collated data from more than 170,000 patients supported with ECMO since the mid-1980s. In response to the COVID-19 pandemic, the registry added a real-time COVID addendum and asked centers to change the way data was collected, to enter data at the point they recognized the patient had COVID, and then complete the record once the patient had achieved any potential outcomes. Collated, de-identified patient characteristics and outcomes are available at the reference website and updated daily. In addition to primary COVID addenda, the ELSO Registry, with input from PDECMO Research Collaborative, added some specific questions for the pediatric community. Since the beginning of the pandemic, some 386 neonates and children have received ECMO for SARS-CoV-2, but with the overwhelming population supported with ECMO during the pandemic presenting as adults with respiratory or cardiorespiratory failure, this population will form the rest of this presentation. EURO-ELSO, the collaborator of the European ECMO centers, also moved quickly to capture ECMO utilization, patient characteristics and outcomes data as the COVID-19 moved through contributing countries. While Australia and New Zealand took advantage of their geographic isolation and were protected from the early waves of the pandemic, a group of researchers established ECMOCARD and the COVID-19 Critical Care Consortium to collect data. Through extensive collaboration with interprofessional organizations, including ASARIC, the International Severe Acute Respiratory Emerging Infection Consortium. And these are just examples of the largest international registries collecting ECMO data and outcomes during the pandemic. Local, regional and national collaboratives evolved to share protocols, processes, regional capacity and ECMO equipment management. These continue to inform the field and have changed the way ECMO is delivered around the world. Leveraging that available data and resulting publications, let's take a look at the use of ECMO during the COVID-19 pandemic. With so much unknown early in the pandemic, the safety of ECMO provision to the critically ill needed to be established. While many patients supported on ECMO do undergo other aerosol generating procedures as part of their care, the ECMO circuit and oxygenator did not appear to be a source of the spread of SARS-CoV-2 in this very early study out of Paris. They looked at 25 patients from three ICUs in Paris, including two different oxygenators in the ECMO circuit and demonstrated that although the 25 patients receiving ECMO had positive SARS-CoV-2 respiratory samples, 13 had positive plasma samples. All samples tested negative from scavenging the ECMO membrane. As a healthcare community, we focused on appropriate utilisation of PPE, sharing protocols for escalation and education and simulation to ensure provider safety during procedural and bedside aspects of care. It was thus recognised early that ECMO was safe to the healthcare workers, but was it of benefit to the patients? In these early reports of critically ill populations with COVID-19 in China, it was revealed that a total of 17 patients who received ECMO who had outcome data, 14 died. Despite the early poor outcomes reported, initial guidance documents included reference to the provision of ECMO cannulation. This from the first affiliated hospital for the Zhejiang School of Medicine in China. ECMO was also referenced as a suggestion in the surviving sepsis campaign guidelines on the management of critically ill adults with coronavirus disease 2019 and clinical experts in the provision of ECMO were paired with Dr. Bartlett to compile the initial ELSO guidance document for ECMO for COVID-19 patients with severe cardiopulmonary failure. This document included an algorithm modelled on the suggested utilisation for ECMO for ARDS in adults, which remained relevant for the updated ELSO guidelines in 2021. Without paediatric or congenital heart disease specific guidelines, it was amongst many who derived equivalent algorithms for care, identifying those particularly at high risk for deterioration and early consideration of ECMO in order to avoid cardiopulmonary arrest. We're very happy to share these if you'd like to see. Leveraging the available data, let's have a look at the use of ECMO during the COVID-19 pandemic. This retrospective single region five ICU hospital network study reported the results of 83 patients who received ECMO for severe ARDS associated with COVID-19. The centres leveraged the AOLIO trial inclusion criteria and patients received standardised ECMO and ICU care. Compared to the earlier reports with 84 to 100% mortality following ECMO for this disease, the authors reported an estimated 31% probability of 60 day post cannulation mortality, which is consistent with the previous AOLIO trial results, 35% and the larger prospective lifeguard registry, 39% at 180 days. In this report of ECMO use in the greater Paris region, including 17 ECMO centres serviced by six mobile ECMO transport teams, the authors provide much detail about the local network organisation, patient selection and provision of ECMO care starting in these graphs with the sourcing of additional ECMO pumps from other centres and industry, along with the timeline of the first wave of COVID-19 in the region. The authors provide their detailed network planning, agreed upon indication criteria for ECMO support in this disease, as well as proportion of patients approved for ECMO transport. This hub and spoke model of ECMO provision is a sophisticated example of something which evolved in many regions over the course of the pandemic. The outcomes of the 302 ECMO patients were also shared in this publication. The authors noticed that despite guideline managed ECMO anticoagulation, circuit thrombosis occurred in 10% of the patients and pulmonary emboli were diagnosed in 18%. At 90 days after ECMO initiation, 46% of the cohort were alive. In a multivariable time to mortality analysis, increasing age, pre-ECMO renal dysfunction, time between intubation and ECMO cannulation and centre volume less than 30 in the previous year were associated with worse outcome. The implications that the authors considered important were that with central regulation and pooling of resources on a regional level, VV-ECMO was an effective ECMO technique for managing patients with refractory COVID-19 related odds in greater Paris. As a strong volume outcome effect was observed, VV-ECMO should preferably be performed in high volume expert centres, potentially with mobile ECMO teams capable of cannulating patients in remote intensive care units and transferring them to ECMO centres. In this study with data from the ELSO registry submitted by 213 experienced ECMO centres from 36 countries, 1,035 patients with COVID-19 received ECMO support. The patient characteristics and pre-ECMO treatment listed here were similar to those in the EOLIA trial. The estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was also similar to that reported in ECMO-supported patients of the EOLIA trial, 37.5%. Not surprisingly, many of these patients survived the critical illness ARDS and ECMO-supported study, and many patients were transferred to either rehabilitation or long-term acute care facilities for recovery. In this early large multicenter study, increasing patient age, circulatory support for cardiovascular dysfunction were associated with the patient outcome of mortality. In this report from the ECMO Viber Study, a regional collaboration of ECMO programs on the Iberian Peninsula, the authors report on 319 consecutive patients supported with the ECMO for COVID-19 associated ARDS from 24 ECMO centers during the study period of March to December 2020. Of the patients, 180 were successfully decannulated with a median duration of ECMO run of 17 days. More than a quarter of whom were managed on ECMO for greater than 30 days. Survival to hospital discharge was 49% and was found to be higher. Mortality was found to be higher in the second wave of COVID-19 in the region. Patient factors of advancing age, some comorbidities, second wave of COVID-19 infection, and hospital center volume were associated with ARDS. Hospital center volume were associated with the outcome of patient survival to hospital discharge. So the early findings of patient outcomes following ECMO support for COVID-19 associated ARDS were reassuringly similar to pre-COVID reports, with the particular findings of overall mortality for well-selected patients was consistent with what had previously been reported. Improved mortality and mortality outcome was present for those with lower age, less cardiovascular dysfunction, and improved mortality outcome appeared to be associated with larger volume centers. These were true in reports from smaller regional studies in single centers as well as in the large international registries. In this updated report from the ELSO registry, including 4,812 patients with COVID-19 who received ECMO across 349 global centers within 41 countries, the authors describe patient population and time to in-hospital mortality outcome according to defined patient groups. Group A1 include those patients supported in established centers with ECMO commenced before the 1st of May 2020. Group A2 represents patients supported in established centers from May till December 2020, and Group B is patients supported in centers that were late adopters of ECMO. There were few differences in patient or care characteristics, but there was an important difference in cumulative incidence of in-hospital mortality over 90 days after ECMO initiation. This was lower in patients who received ECMO prior to the 1st of May, those in the blue line, compared to those in the second wave, 52% of whom died even when they were treated in the same sorts of centers as the first wave population. Mortality was even higher at 59% for patients who were supported in centers who were late adopters of ECMO as therapy for this disease. This report from the Euro-ELSO, Euro-ECMO survey confirmed the previously reported findings of increased mortality when ECMO was used to support patients with COVID-19 related to ARDS in the second wave of the pandemic. They also demonstrate the increased duration of ECMO support during the second wave, which has major implications for ICU and ECMO capacity. You can see that while the first wave in 2020, the second wave in 2020, while the first wave in 2020 peaked with ECMO support and then declined, the second wave seems to just carry on with lots of ECMO supported patients for many days. So the evolving nature of ECMO support of COVID-19 pandemic, including reported increased mortality over the course of the pandemic, and increased duration of ECMO runs over time, warrants ongoing monitoring and may inform making for strategies of support during times of ECMO constraint, of resource constraint. The other important features of ECMO, which were clear after the first wave of the COVID-19 pandemic is that there were more thrombotic complications in these patients with an increased anticoagulation requirement. And in the setting of therapeutic immunosuppression, there was more infection. A higher proportion of these patients had right heart failure than was typically recognized in ARDS. Despite the concerning findings of increased mortality in the second wave and beyond, there's still many studies which show a perceived benefit of ECMO therapy. This is one of them. In this study from the UK, including 111 referral centers to two specialized ECMO centers, the authors promote a survival benefit of ECMO in severe COVID-19. Using a multi-center propensity match cohort study. In this propensity score match analysis, there were 1,363 patients, including 263 who received ECMO and 209 propensity match controls. The authors report a marginal odds ratio for mortality of 0.44, with confidence intervals of 0.29 to 0.68, and an absolute mortality reduction of 0.48. And an absolute mortality reduction of 18.2% for treatment with ECMO in a specialized center. In this single center study out of the Vanderbilt ECMO program, they used granular local data to review all patient referrals to the single center between January 1, 2021 and August 31, 2021. The authors considered patients eligible for ECMO if they met the inclusion criteria for severe ARDS according to AOLIA criteria, with none of the exclusion criteria of age greater than 60 days, BMI greater than 55, prolonged duration of mechanical ventilation, or irreversible end-organ injuries. As medical eligibility was determined, there was a systematic assessment of the health system's resources to provide ECMO, that is equipment, personnel, ICU bed availability. When health system's resources were available, the patient was transferred to an ECMO center, but with no availability they were not transferred, there was no wait list. The two groups of patients who met criteria for ECMO support were compared for primary outcome. Of died before hospital discharge using Cox proportional hazard regression analysis, adjusting for patient age, acute kidney injury, and receipt of vasopressors. The characteristics of patients in each group were similar at the time of decision making as shown on the table. There was also no difference between the groups according to mechanical ventilation strategy or arterial blood gas results. But patient survival to hospital discharge, however, was impressively different between the groups as shown in the graph depicting cumulative proportion of patients who died compared to days since ECMO referral. There was no interaction between ECMO health system capacity or hospital strain measured by two week average hospitalizations or deaths in the state over the study period. The authors proposed that the benefits of life support therapy can be difficult to estimate because there may no longer be equipoise for providing or withholding a life support therapy. That trials assessing potential benefits of ECMO support have been confounded by concerns of equipoise selection bias and crossover from the control group. While this natural experiment shows that among patients who are eligible for ECMO in one referral region, the health system capacity to provide ECMO was available for less than half the patients and mortality was 90% when the health system capacity to provide ECMO was not available compared to 43% when capacity was available. So, while ECMO has not been evaluated in the important and ongoing clinical trials of therapies during the pandemic, there are accumulating causal inference observational studies which suggest a survival benefit for well-selected patients in whom this invasive care is goal concordant. This adds to the challenges of conducting RCTs during the pandemic. There's a perceived lack of clinical equipoise to add to the lack of pre-existing organization, infrastructure and funding, while the clinical care team was overwhelmed by the burden of critically ill patients. As the total ICU deaths from COVID-19 in the USA approaches 1 million patients, our ICU and ECMO teams still feel it's far from normal. As a brief aside, I'd considered sharing the YouTube video of this parody of a public service announcement produced by the Australian Broadcasting Commission during the COVID-19 pandemic. A number of comedians and public personalities contributed and the message was that mates don't let mates start podcasts. Despite this excellent and considered advice, we started a podcast. Much more conversational and with a side of medicine than many of the journal and professional organization webinars, we heard direct from Drs Giovanna Colombo and Lorenzo Grazioli about life inside the COVID-19 first wave in Bergamo, Italy, and later from Dr. Sam Parnia in New York City. While I was aware of some of the resource limitations during the H1N1 pandemic in 2009 and beyond, I didn't have a construct to think about the inundation of the critically ill population that was occurring in their region. I asked Dr. Grazioli to help me understand why all these people are dying. Why would some form of ECMO not help them? He said, currently, a 70-year-old with COVID-19 and no comorbidities is too old to be admitted to ICU in our hospital. We have an age limit of 60 for ECMO. Unfortunately, if we were in peacetime, half these patients would be on ECMO. And with his response, it's clear that crisis standards of care with daily resource limitation were in place. Since early in the pandemic, debate, discussion, and enunciation of the ethical principles and associated processes which should guide the allocation of scarce resources, as these become limited in the pandemic, have become available. The guiding principles of maximizing benefits, equity, priority for healthcare workers who may benefit others during the pandemic, have all been proposed. This is only one of the summary articles, but there are many. The principles and processes to guide resource allocation were an important update to the 2021 ELSO guidelines for COVID-19. Before ECMO capacity becomes saturated within a given region, they recommended that these ECMO networks adapt unified patient exclusion criteria at a regional level to promote equitable access to ECMO and avoid the need for transferring centers to make referrals to multiple ECMO centers. They provided this algorithm, which documents that even after ECMO indications are met, that there's a second patient selection strategy step. And after that step, a further step assessing ECMO capacity. Conventional capacity is available, the patient moves straight through to ECMO, but they offer multiple capacity tiers through to crisis capacity, where additional ECMO cannulations are simply not feasible and ECMO resources needed to be repurposed. It's no wonder then that the healthcare workforce, and particularly the ECMO workforce, is feeling overwhelmed by the ongoing pandemic. In this national cross-sectional survey of healthcare workers in Qatar, the authors aim to assess the development of burnout in the ICU and any relationship as to whether the clinician worked in a unit which offered ECMO. They used an online questionnaire, the Maslach Burnout Inventory Human Services Survey for medical personnel, to assess intensive care practitioners across five tertiary hospitals, including eight ICUs. They found that the overall prevalence of burnout is high in ICUs, with almost two-thirds of practitioners meeting criteria for diagnosis. Burnout was not less prevalent in ICUs with ECMO provided, and indeed the personal accomplishment scales were lower in those who provided ECMO. When the authors looked at specific healthcare worker factors associated with the diagnosis of burnout, they did find a higher association when the worker had personally been infected with COVID-19 or knew someone who had. Of note, providers satisfied with their compensation appeared less prone to burnout, which may be a message to administrators everywhere. Healthcare worker grief is associated with burnout and distress, as bereaved healthcare workers strive to balance caring professional identities and evolving work responsibilities. In this review paper, the authors can suggest that burnout itself may be the direct result of an inability to integrate inevitable mounting losses into an ongoing career in life. As busy clinicians move on to the next, grief compounds and the consequences of unprocessed grief accumulate. The authors highlight eight ways that the COVID-19 pandemic has impacted professional grief. Obviously, there's a large absolute number of deaths. Individuals may be deployed to different work environments. Understaffing may result in long hours without adequate breaks to refill the tank. Uncertainty about the pandemic course and when life will return to normal has affected us all. Moral distress is particularly prevalent. The lack of usual engagement with patients and families is compounded by patients who are dying alone at the bedside. And the extremes of death and the potential impact on the number of deaths with the broader use of vaccines. They also mentioned family member restricted access at the end of life, which puts healthcare workers in a new and vulnerable place in the context of dying. The authors include a list of resources for reference for those coping with grief and loss. By the numbers presented in prior studies, many of us may benefit from engaging with some of those services. Please review the full list in the published paper if you think it might be of benefit to you. The authors also discussed the equivalent of emotional PPE. They suggest that healthcare workers recognize their responsibility to report the bereaved loved ones to patients, but also must attend to our own grief. To promote healthy grieving, both individual and system interventions are key to helping healthcare workers prepare for loss and supporting healthcare workers in their grief over the COVID-19 deaths of patients, colleagues, and families. In this paper, the author suggests coping strategies in order to protect ourselves and our organizations during the ongoing pandemic. They break down the factors into individual, organizational, and leadership structures. Individual interventions obviously include adequate rest and exercise, but some of the organizational structures may include factoring in a moment's silence, rest in peace, or a prayer, something with which you find comfort. Debriefing as part of your team if it can be supportive and moderated. Healthcare center leadership must be communicative, responsive, and express gratitude for their workers. Remember that we're all ECMO leaders in our spaces, and that means that we should be engaging in that mindset as well. Some centers have deliberately brought professional psychologists, ethicists, counselors into their ICUs to support the team. In my center, we have frequent access to a clinical ethicist who sometimes joins clinical rounds, but always joins bereavement meetings. We found this very helpful. So ECMO for COVID-19 then. At the end of the day, ECMO is a support strategy for the sickest patients with respiratory and cardiorespiratory failure. While inpatient care and early reports are focused on patient survival to hospital discharge, what does survival actually look like after an episode of care which includes ECMO? This small single center study of post-hospitalization outcomes after ECMO for COVID-19 in 24 survivors offers some reassuring findings. The patient population is reflective of those reported in other studies with essentially the same inclusion criteria for ECMO. At the time of hospital discharge, supplemental oxygen was common, and some patients were discharged with tracheostomy and ventilation. Only 29% of patients were discharged directly home with almost half discharged to a rehabilitation center. At the time of follow-up, however, at two months to one year post-ECMO decannulation, only two patients remained on supplemental oxygen. All of the other patients with tracheostomy had been decannulated, and no patients required tube feeds. Using the patient-reported outcomes measures information system, patient-reported outcomes were assessed at medium eight months post-ECMO cannulation. You can see that patients reported relatively high levels of global physical function, and though there were reported high incidents of fatigue, overall pain scores were low. From this small study, it appears that long-term outcomes in survivors of COVID-19 ARDS who received ECMO support are really promising with a very low rate of technological dependence and high levels of global physical function. So what has COVID-19 taught us about ECMO? The pandemic has really brought ECMO to prime time. From a systems perspective, accurate real-time data and analytic capability has facilitated recognition of the changing outcomes of COVID-19 patients who were supported on ECMO during the course of the pandemic, and they've informed educational quality and academic webinars and publications. Communication and collaboration are essential to the global response to the pandemic and the potential for flattening the curve, sharing anecdotes before guidelines and guidelines before patient-level data was available. Ongoing collaboration is facilitating high-quality causal inference studies of the outcomes of ECMO utilization in this population and beyond. The evolution and strengthening of local networks and referral pathways, sharing capacity, availability, and ECMO equipment has allowed maximum benefits to benefit from this care. In a more ECMO-specific way, COVID-19 has helped us realize that ECMO for well-selected patient population is moving beyond a rescue therapy with a number of causal inference observational studies suggesting benefit of ECMO support. Care protocols should continue to be personalized, multidisciplinary, and goal-concordant. An example specific to the use of ECMO during the COVID-19 pandemic relates to anticoagulation utilization and the recognition that increased thrombosis was occurring in circuits, prompting increases in therapeutic targets for heparinization to meet the new demand. And finally, the early release of ECMO consensus-based guidelines highlighting the potential benefit of ECMO in this disease and some key recommendations for indications and clinical care of the ARDS patient on ECMO provided a sound strategy for centers, particularly inexperienced or new centers to approach this resource-intensive support strategy. And finally, COVID-19 has brought the ECMO workforce into the limelight. ECMO has always been a team sport, but the stresses associated with the pandemic, whatever the circumstances at home, busy clinical work, isolated patients, fear, have added a burden to our teams. Burnout in our workforce is common and worsened by the complexity of care in the pandemic, but there are individual, organizational, and leadership actions which can impact the mental health and resilience of our workforce. Strategic implementation and investment will ensure that we have ECMO teams through the rest of the COVID-19 pandemic and beyond. In my mind, the impact of ECMO center volume on outcomes in this population is a direct reflection of the system's ECMO-specific protocols and ECMO and ICU workforce expertise at the bedside that's reflected by the silos on this slide. Through the experiences of the COVID-19 pandemic, we've learned a lot about supporting patients with ECMO, optimizing ECMO delivery, and monitoring trends and outcomes which will form a powerful new baseline in the provision of ECMO support through the pandemic and beyond. And now, we continue the conversation with Dr. Alexander. Good morning. It is my pleasure to introduce Dr. Vita Alexander. She has been, this year, awardee for the Max Harriwell Award within the SCCM. And her lecture, What Has COVID-19 Taught Us About ECMO? is bringing us now to this conversation with Dr. Alexander. I have high respect for all what Dr. Alexander has done for our ECMO patients, not only in the United States, I think around the globe. So, it is important for me starting this conversation with a question regarding the availability of resources regarding ECMO. So, Dr. Alexander, ECMO is an expensive resource. That appears to provide better outcomes than conventional organ support for selected patients in respiratory and cardiac failure. How we should decide to allocate ECMO during a national health emergency when it consumes many more resources than conventional support? Dr. Diaz-Gomez, thank you very much for inviting me to present today and the SCCM selecting me for this award is an absolute honor. I think that your question is the key question that we've been asking ourselves for much of the last two years. And I presume it's a question that we're going to keep asking ourselves into the future as health resource expenditure is outstripping what many countries and what many individuals can afford. I think that during the pandemic, this has been highlighted in a number of opinion pieces and constructs have been formed about how we do manage scarce resources at times of overwhelming healthcare need. As somebody who's involved with the Extracorporeal Life Support Organization, the ELSO group, I thought that they balanced very effectively how to consider escalating restriction of ECMO to the point where sometimes it simply can't be offered even to those who are currently receiving it in times of real resource crisis crunch. But there've also been articles such as the one I referenced in the New England Journal of Medicine that puts forward other constructs looking to improve the health outcomes of many in times of resource limitation. I don't have a more formed opinion than the many consensus documents that are around, but I think that the question you've asked is the critical one for us as we move forward both through this pandemic as well as through the ongoing issues that many countries are going to face with healthcare expenditure continuing to increase at times where overall revenue is not going to be available to continue to increase for marginal gains. Thank you, Dr. Alexander. I really appreciate your answer because I know how difficult that question is, not only for us, but the hospital's administrators. I think a proper follow-up on that question is the fact that pre-COVID palliative medicine was something that intensive we're practicing. So I would like to ask you, how has COVID-19 and ECMO experience impacted the field of palliative medicine? Oh, I wish I was informed enough on how it's impacted the field of palliative care medicine. I can only imagine that they are overwhelmed by the requirement and the need for their resources as are the critical care community. My interest and experience with the palliative care community has evolved over the last few years, before the pandemic and through the COVID-19 pandemic, as intensivists have actually embraced the expertise that palliative care physicians and palliative care interdisciplinary teams bring to the bedside of the most critically ill patients. I'm confident that palliative care physicians and teams have helped in these socially isolating times. And I've certainly seen and been involved in some palliative care communication tool discussions. One that I reference often, and I recognize wasn't in my talk today, is one that Dr. Moynihan published in the Pediatric Critical Care Medicine, looking at different conversations that should inform the patient course over an ECMO run, how actually people are cannulated to ECMO and may not recognize that 30 or 40 or 50% of patients receiving that invasive care go on to die before hospital discharge. That's not something that's implicit in many of our consent discussions with patients and families. And so having those discussions iteratively is something that's very much been informed by palliative care teams in my institution, and I'm sure across the world. I can only imagine what the increased burden on their resources has been in the past couple of years, but I'm confident I'm not knowledgeable enough to answer that direct question. Thank you. You're very humble, but certainly that reference from Pediatric Critical Care Medicine, we should read it. I do agree with you. And still, I'm pretty sure you, as a leader in the ECMO field, you probably can share with us, what has been the biggest surprise evolution of ECMO using COVID-19 over the past two years? Anything that really you identify as a real evolution on the field? I think that my concept of this has evolved in the past 10 months or so, since I guess I was invited to give this talk. And the references that I clipped in the notes that I made early after being invited evolved very much over the course of the next six or 12 months. And I will expand on that a little bit if we've got time. I think that early on, after I was first nominated for this, the news on the street about ECMO was that actually mortality was rising in the patients that were being cannulated to ECMO with this disease. And that felt like a really big deal at the time. It was a big deal at the time. The patient populations were suddenly changing, the therapeutics that were available to really treat the disease before patients were cannulated to ECMO, probably changed the population in terms of they'd already had the potential to respond to therapy before they were cannulated to ECMO, as well as the new variants that looked to be a little bit more virulent, as well as the new centers that were using ECMO. All of these things felt like they were going to be the big story as I was approaching this talk. But the closer we've come to today, the more I recognize that the big story in ECMO over the course of the pandemic has been the communication and the teams and the networks that have really become established and become essential to the ongoing utilization of ECMO moving forward. And I'll give you some examples, but these are no means exclusive. They're just the ones that I'm most aware of. There have been many, many well-published networks of ECMO utilization and the agreed-upon criteria for which ECMO would be considered for patients, particularly in the UK and the Greater Paris Network. They've certainly published very effectively out of their cohorts. And that hub-and-spoke model of a central ECMO tertiary center that's going to focus resources, training, and capabilities on the delivery of ECMO and other referring centers that then focus on delivery of other care to different patient populations and being networked together either by mobile ECMO or early referral systems has really been key to the successful deployment and utilization of ECMO in those regions where that was established. But over the course of the pandemic, regions and countries that didn't necessarily have that established network and framework of referring centers and sharing ECMO resource capacity that's available has become much more common. ELSO, as an organization, certainly was involved in starting to build those discussions and build some of the networks. We looked at a capacity map very early on in the ECMO, sorry, in the COVID pandemic, where we tried to encourage centers to daily update whether or not they had ECMO resources available. And that way centers could look at the map and know who to call. Groups of centers in the Northwest and certainly in the Northeast region, which I'm a part of the US, actually established communication lines and referral lines that previously had not been established. And those sorts of shared resource decision-making through shared capacity and network evolution that hadn't existed before is a massive change in the way ECMO is being utilized and distributed in certainly in the US. I think that the other thing that's become a much more relevant fourth or fifth wave of the pandemic, so to speak, is the burden on healthcare workers and our ECMO teams that has become so prevalent in the past six months. I think that our teams have been amazing at digging in and getting the job done and being here for the patients and for each other for what felt like a sprint at the start and what's just become a never-ending marathon. I can remember, and you must've felt this too, very early in the pandemic when we could see it coming, but it wasn't yet at our doors. We had the most amazing team-building simulation sessions where we worked out how we were going to manage ECMO accumulation for these patients that were an infectious risk for the whole team and where we're going to put different equipment and where the doors were going to be open and where they were going to be closed and who was watching who get dressed to keep our team safe. And that time, in retrospect, was a really fantastic team commitment to each other time. And over the course of the pandemic, what we found instead is a lot more isolation and a lot more of the burden of moral distress. Those decisions that you started asking me about at the very beginning, who is treated with ECMO for how long and who misses out on other care, ECMO is a support strategy for this patient to have it. And the burden of the cognitive load of moral distress and the isolation of our teams, which have always functioned, ECMO is a team sport. It's why so many of us enjoy it so much. And part of the pandemic, as it runs on, has taken away so much of that socialization of the healthcare that we provide. And I think that as your question was, what have we really learned about ECMO over the pandemic? And I fear that what we've learned isn't what we thought we were going to learn. It's much less about the membrane and the pressures. And I'm sure that the size cannula makes a difference to the overall support of the patient. But if there's no workforce there to effectively deliver this care, there is no care. And that's, I think, what we all need to be focusing on as we move forward through the next stage of whatever the coronavirus or other emerging issues bring. Thank you so much. And that answer gives me the possibility to have a follow-up questions, specifically after reading that article by Gannon published in February, 2022, as you presented in your lecture. And I can see that interest in smaller facilities that want to start an ECMO program. And when you show that data, having ECMO capacity versus not having ECMO capacity, and you are showing that publication from the UK and greater Paris, the question for you is now, what we should do? Really be more focused on strengthening those referral networks or giving that support to a community hospital that have wonderful people, they are team players, and they just want to start an ECMO program. What would be your thoughts on that? And more specifically, of course, for the entire planet, but in the United States, it might be different than in Asia or Europe. What would be your thoughts on that, Dr. Alexander? Look, I think you're asking a really important question that the ECMO community within the critical care community, within the overall health networks of each country, really do need to give some genuine consideration to, as we all debrief our systems as we come through this pandemic. And the reason, I don't need to hedge my bets. Most people who know me know that I wouldn't normally sit on the fence, so to speak, when asked a question, but I think that the results of different programs across the pandemic have informed me being much less committed to one side or another of this discussion. So for example, I work in a large ECMO center. I see a lot of ECMO. I think about ECMO a lot. My teams see a lot of ECMO. And what that means is that we have had enough discussions over enough patients, months, years, that our teams know what we're really interested in knowing about right now versus what they can let me know next time they see me versus what goes in an email. For example, just as a starting point for dialogue, whereas in a new ECMO program, I think that the ECMO leadership and the invested group of interprofessionals that are going to start this care need to be much more hands-on. And so that means they have to be much more available. I think that over the pandemic, the ELSO community took a couple of different strategies from the beginning. One was that very first paper that was published in JAMA that was an opinion piece saying, this is really a global pandemic and resources are going to be limited. Let's not all look at ECMO when appropriate testing, tracing, PPE, supplemental oxygen, and general intensive care is going to save many, many more patients than ECMO. So let's just be a bit pragmatic. And when resources are really restricted, it's probably not the time to have all eyes on a new process and new procedures and new support strategies that are unfamiliar to the team as a baseline. And then the next kind of ELSO initiative was to get guidelines for ECMO care of the acute respiratory distress patient out to the community early, before we knew very much about this particular disease. It clearly presented with mainly respiratory symptoms at the beginning. And so let's get out some guidelines so that if people are managing something that's unfamiliar to them, they've got the potential to lean on something that comes from a group of experts who've done a lot of it. And then over time that evolved into, when we cannulate somebody to ECMO for this disease, it's not a short run. And so patients are supported for a long time, support runs have extended in duration as we've seen longer runs end in successful patient outcomes. And so we know that just stacking one centre in a region with ECMO patients over the course of the pandemic doesn't really maximise resources either. And so using, leveraging experience from a large centre to support a smaller centre in addition to guidelines, shared processes, shared management plans may actually be a feasible way. And there are some publications that I didn't quote in my talk showing that actually smaller centres emerging through the pandemic have been able to achieve very successful outcomes for selected patient populations by using all of those strategies. And so I think that the bigger picture question is the health resource utilisation question. And where do we as societies and communities, how do we want our health budget spent and where does that go? And that you and I both have accents that don't belong to the United States of America. I try very hard not to make political statements while my accent doesn't match my home. Thank you so much Dr. Alexander. I will 100% agree with what you just said. And perhaps I would like to use the last couple of minutes on can you really tell us what do you think would be the most important outstanding ECMO research priorities and see how we can be better prepared for the future with or without another pandemic? Oh, you are asking my favourite questions. I think that the research priorities as we move forward on ECMO can start to be focused more to the actual timing, the indication for when a patient meets the threshold of having been sick enough to benefit from ECMO and enough that the risk of complications or the ECMO support itself that the risk benefit ratio is in the right direction. Do you know what I mean? And so that's not is ECMO a benefit? It's more when would this patient benefit from ECMO? And then I think that the other strategies, the other research priorities in my mind relate to more how we actually manage patients on ECMO. There are a lot of observational studies now that show that we can manipulate, that not we can. There's a lot of association between rapid changes in for example, PAO2, PACO2 and outcomes of patients after they go on ECMO. I think that post-resuscitated care including ECMO specifically should be a research priority because otherwise we're applying principles that may not actually be relevant to this patient population and may have consequences that we aren't looking for and we're not seeing. I think that part of the core of research for ECMO is being undertaken as people like Dr. Hodgson from Australia and the ECMO network have started to define core outcomes, started to actually define ECMO. And so that when we're talking about different constructs we're actually using a familiar language. So I think that there's a lot to be done in ECMO research moving forward. But in my personal opinion, the question as to whether ECMO is of benefit to well-selected patient populations is probably not the one that we need to continue to focus on, but rather how will ECMO best benefit this patient and how do I manage it best to benefit this patient? And that's certainly where my research in the next few years is going to be directed. I also think that patients receiving ECMO as a mode of support for their critical illness all bring different substrates, different pathophysiologies and different potential for the consequences of the care. And it's entirely possible, I'm gonna say something a little bit heretical right now. It's entirely possible that randomized control trials won't be the answer to all of our research questions here. I love the adaptive platform trials that are being used in the community-acquired pneumonia population at the moment. And I'm really interested in whether more complex strategies for resource such as those could be applied to ECMO populations. And I also genuinely believe that there will be a path forward to a learning healthcare model where individual patient data informs the way we manage the next series of patients as we move forward with this invasive care. Because I think that the technology is moving quickly enough that by the time we fund a randomized control trial, move through a randomized control trial, the technology that we're applying the results to won't necessarily be the same. And the COVID pandemic has only made that clearer because even the therapeutics that we're using today as standard in these patients are very different from what they were two years ago. Thank you very much. As we just came to our conclusion for this question and answer session, I just want to really, really share with you that I really enjoy your approach, which is actually focused on personalized care, multidisciplinary care, and well-concordant. I always think about those principles you enlighten us about because I think it really makes difference in a day-to-day basis, you know, practice of ECMO support in the ICU. Thank you so much, Dr. Alexander, and congratulations again on the Mass Harry Weld Award in 2022 with the SCCM. Thank you. Thank you so much. That's really very much appreciated.

COVID-19

ECMO

Extracorporeal Membrane Oxygenation

respiratory failure

cardiac failure

interdisciplinary care

communication

collaboration

severe cases

lessons learned