Letter to the Editor| Volume 153, P6-7, August 2020

Extracorporeal cardiopulmonary resuscitation should not be performed on confirmed or suspected COVID-19 patients


      ECMO (extracorporeal membrane oxygenation), E-CPR (extracorporeal cardiopulmonary resuscitation), ELSO (Extracorporeal Life Support Organization), PPE (personal protective equipment)
      The Extracorporeal Life Support Organization (ELSO) has issued interim guidelines for extracorporeal membrane oxygenation (ECMO) of COVID-19 patients.
      • The ELSO COVID-19 Working Group
      Extracorporeal Life Support Organization COVID-19 Interim Guidelines: a Consensus Document from an International Group of Interdisciplinary ECMO Providers.
      However, the guidelines make no mention of whether extracorporeal cardiopulmonary resuscitation (E-CPR) should be implemented for individuals with suspected infection and awaiting diagnostic PCR test results. Herein, we share our recent experience of resuscitating a suspected COVID-19 patient after out-of-hospital cardiac arrest particularly, our consideration of E-CPR, and the various challenges created by this decision.
      A 24-year-old male presented with a history of close contact with confirmed COVID-19 patients. Several days before admission, he started to develop fever and respiratory symptoms. Nasal swab for PCR test were taken in his home. The same day, he complained of respiratory distress and called an ambulance. He went into cardiac arrest and was transported to our hospital. During transferring, paramedics notified us about his suspected infection status. In response, we prepared an isolation zone, personal protective equipment (PPE) and E-CPR equipment. We performed resuscitation, anticipating the potential need for ECMO. Fortunately, his heartbeat resumed; thus, he was admitted to ICU without E-CPR. Cardiac arrest lasted for 54 min. Chest X-ray and CT scan revealed no infiltration shadow. PCR in nasal swabs and bronchoalveolar lavage tested negative for SARS-CoV-2. Four days after hospitalization, he regained consciousness and was extubated. The final diagnosis was acute pulmonary thromboembolism. He was currently undergoing rehabilitation.
      The patient, who had suspected COVID-19 status, confronted the resuscitation team with several obstacles in implementing CPR and ECMO, including the wearing PPE and the specialized environment of the negative-pressure isolation room. E-CPR for patient suspected infection should be performed in a limited number of staff. Staff was unaccustomed to perform CPR or intravenous cannulation while wearing the PPE. The N95 masks made communication within the isolation room difficult, and the physical isolation prevented communication with the outside of the room. Even once all critical-care procedures were completed, fears of infection among staff remained, in addition to immeasurable physical and emotional fatigue. Our experience illustrates that even routine medical procedures, which would be uncomplicated under normal circumstances, can become inordinately complicated by COVID-19 suspicion.
      Our experience suggests us to not perform E-CPR for patients suspected SARS-CoV-2 infection. E-CPR might be indicated for some of them who are non-COVID-19 with other cardiac arrest causes, but the drawbacks of doing so in the current pandemic outweigh the benefits. This puts resuscitation teams under enormous physical and emotional strain, all while trying to guarantee their safety. Conserving PPE, ECMO equipment, and other limited resources during the pandemic is another important consideration. Providing healthcare at the same quality as that under normal conditions will continue to be challenging amidst the increasing COVID-19 patients. We believe that E-CPR is unrealistic in suspected cases, given the need to maintain the emergency care for other, uninfected patients simultaneously. Our highest priority during COVID-19 should be the continued provision of healthcare services. To facilitate clinical decision-making in emergency departments, we believe authorities need to discourage E-CPR for both confirmed and suspected COVID-19 patients.

      Authors’ contributions

      Dr. Kenji Kandori: major decision-maker during the treatment, writing the paper
      Dr. Hiromichi Narumiya: major decision-maker during the treatment
      Dr. Ryoji Iizuka: major decision-maker during the treatment
      All authors have read and approved the final manuscript.



      Availability of data and materials

      No data is available.

      Ethics approval and consent to participate

      Ethical approval was exempted for letter to editor by our institution.

      Informed consent

      Written informed consent was obtained from the patient for publication of this letter.

      Competing interest

      The authors declare that they have no competing interest.


      We really appreciate all members of resuscitation team members.


        • The ELSO COVID-19 Working Group
        Extracorporeal Life Support Organization COVID-19 Interim Guidelines: a Consensus Document from an International Group of Interdisciplinary ECMO Providers.

      Linked Article

      • Coronavirus disease 2019 and ethical considerations for extracorporeal cardiopulmonary resuscitation
        ResuscitationVol. 154
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          In their recent letter to the Editor, Drs. Kandori and colleagues suggest against using extracorporeal cardiopulmonary resuscitation (E-CPR) in cardiac arrest patients with confirmed or suspected coronavirus disease 2019 (COVID-19).1 They argue: (1) potential technical difficulties with E-CPR interventions during resuscitation (e.g. vessel cannulation) while wearing personal protective equipment (PPE); (2) communication problems associated with wearing N95 mask in a negative-pressure isolation room; (3) resuscitation team fears of contracting the disease and “immeasurable physical and emotional fatigue”; and (4) conservation of valuable disposables during the pandemic.
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