The widespread havoc brought on by the Covid-19 pandemic has led the medical fraternity, policymakers, and most of the people to scramble for an efficient remedy. A number of drugs and therapy modalities have been launched over the previous 18 months for Covid-19 therapy. Whereas many of those had been launched amidst a lot enthusiasm and confirmed promise initially, most turned out to be damp squibs later. The most recent youngsters on the block seem like extracorporeal membrane oxygenation (ECMO) and lung transplantation. Nevertheless, the precise on-ground profit afforded by these modalities, and feasibility with respect to expense and sources, stay unclear.
ECMO is a way by which the affected person’s blood is drawn out right into a machine, oxygen added, carbon dioxide eliminated, after which returned to the affected person’s physique. Very similar to a cardiopulmonary bypass machine that takes over the perform of the guts and lungs for a brief interval, ECMO successfully takes over the perform of the lungs. In Covid-19, it has been hypothesized to behave by permitting a interval of relaxation to the lungs, lowering irritation, and permitting a rise in oxygen content material of the blood. Nevertheless, not like cardiopulmonary bypass, which is required just for a number of hours, ECMO is normally utilized for days to weeks relying on the affected person’s situation. Actually, an ECMO run over 300 days has been reported in literature!
This has led to the assumption that ECMO is a ‘savior’ in extreme Covid-19 sufferers when all different therapies have failed. Latest instances have seen determined households working pillar to publish for ECMO services in hospitals, within the misguided perception that ECMO could cause a dramatic turnaround within the medical course of their family members and probably save dying sufferers. Nevertheless, these beliefs are usually not supported by the out there literature or suggestions of worldwide regulatory our bodies. Extracorporeal Life Assist Group (ELSO), the worldwide registry of ECMO facilities worldwide, clearly recommends ECMO for Covid-19 sufferers to be provided solely in established ECMO facilities already accustomed to excessive volumes of ECMO procedures.
The physique emphatically recommends towards the organising of recent ECMO facilities for Covid therapy. Additional, the physique recommends prioritizing non-Covid qaECMO sufferers over Covid sufferers, and younger sufferers with a brief anticipated ECMO run over older, sicker sufferers. Equally, the USA-based Society for Crucial Care Medication recommends towards trying ECMO in sufferers on extended mechanical air flow. That is additionally supported by pointers from the Nationwide Institutes of Well being (NIH), USA which state that there’s inadequate information to suggest the usage of ECMO in Covid-19. If thought of, it might be considered solely as short-term rescue remedy in a specific affected person subset. A latest assessment of the literature on ECMO in Covid-19 sufferers discovered stories of mortality charges as excessive as 83-100% in some instances. Profit, if seen, is probably going in younger sufferers with remoted respiratory failure, with poor oxygenation regardless of efficient use of standard methods of mechanical air flow and susceptible positioning. ECMO should even be used inside every week of initiation of mechanical air flow, to be of any use. The best candidate for ECMO, i.e. younger, in any other case wholesome, and with no different failing organs additionally represents the affected person group with the most effective probability of survival in Covid. anyway. In different phrases, would these sufferers survive anyway even with out the usage of ECMO? It’s troublesome to take a position.
An necessary a part of any dialogue on ECMO is the fee and logistics. One wants to think about the judiciousness of pouring cash and sources into organising and working an ECMO unit in a creating nation like India, the place the overwhelming majority of the inhabitants is unable to entry or afford even primary healthcare services. The price of a single ECMO machine might be over ₹35 lakh. After factoring in the price of the single-use parts like circuits, the process can price ₹1.5 lakh-₹3 lakh per day. That is other than fees for the educated personnel wanted for this skill- and labor-intensive process, who’re additionally in brief provide. In response to a worldwide rating of common wages ready by Picodi.com, in 2020, the common month-to-month wage in India is Rs 32,800. Thus, the monetary implications of ECMO for the affected person’s household are immense. Coming instances may even see households exhausting their monetary financial savings or being pushed into extreme debt whereas chasing the thought of a miraculous remedy for his or her family members. Medical practitioners have reported receiving a number of inquiries every day, concerning ECMO services from anxious relations determined for therapy for his or her dying kin. It is a worrisome development. The implications for the medical fraternity are immense as properly. We reside in a time when the belief divide between sufferers and relations is excessive, and in a rustic the place docs routinely face violence by the hands of affected person’s relations. On this scenario, it’s straightforward to think about that docs can be blamed and even crushed up for advising what could also be deemed costly remedies with doubtful outcomes if the affected person dies later.
ECMO is in its infancy in India, and the idea of lung transplantation for Covid-19 sufferers continues to be within the womb! Lung transplantation in Covid-19 sufferers consists of surgical removing of each diseased lungs and changing them with lungs from a cadaver. Because of the nature of the process, the lungs should be transplanted into the sufferers inside six hours of harvesting them from an acceptable deceased donor. Lung transplantation has been steered in sufferers with extreme post-Covid lung fibrosis, which interferes with oxygenation and carbon dioxide elimination from the blood. It’s important to emphasise right here that lung transplantation will not be thought of a remedy for Covid-19 sickness, however a approach to cope with its sequelae, after the an infection settles. Certainly, present pointers mandate 2 adverse RTPCR exams 24 hours aside earlier than the surgical procedure. There are only a few reported instances worldwide of lung transplantation in post-Covid sufferers throughout the previous 18 months of the Covid pandemic.
The conclusion is that each ECMO and lung transplantation are removed from being the pillars of mainstream Covid-19 administration. ECMO might supply some profit in a small subset of sufferers, however the infrastructure necessities, price, and stringent affected person choice imply that it shouldn’t be portrayed as a routine a part of Covid-19 care, like mechanical air flow. Its portrayal as a last-ditch rescue remedy able to salvaging dying sufferers should even be discouraged as scientifically inaccurate and socially irresponsible. Failure to take action might have far-reaching penalties for the medical fraternity, the general public, and policymakers. In the case of the long run evolution of those methods and their effectiveness in COVID -19, the jury continues to be out.
Prof Anjan Trikha, Division of Anesthesiology, Ache Medication and Crucial Care
Chairperson, Medical Managerial Group, JPNTC Designated COVID Hospital, AIIMS New Delhi