The illness due to severe acute respiratory syndrome-related coronavirus-2 commenced in December 2019 and is now a worldwide crisis. [1] [2] Although patients with this infection may have mild-to-moderate disease with clinical recovery, some may develop severe respiratory failure with or without cardiovascular collapse. [3] [4] The high risks of infection have mandated rigorous infectious precautions and adjusted workflows for patient care, including airway management, echocardiography, cardiothoracic and vascular procedures as well as extracorporeal membrane oxygenation (ECMO). [5] [6] [7] [8] [9] [10] [11] The purpose of this freestanding editorial is to highlight the considerations in ECMO for critically ill patients with this important disease. The Extracorporeal Life Support Organization has recently released a guideline to outline strategies for this mechanical therapy in this setting. 5 This clinical focus will include best practices to disseminate the highest standards for care of both our patients and ourselves during this crisis. The provided references can also serve as a guide for healthcare teams as they manage the demands of the pandemic at their respective institutions.
The key components for the planning and provision of ECMO services in this pandemic include the following considerations: personnel, equipment, facilities, and support systems. [11] [12] [13] [14] [15] [16] Although ECMO has been recommended by the World Health Organization in settings with access to this expertise at experienced centers, current guidelines from the Extracorporeal Life Support
Organization further emphasize that ECMO should primarily be considered as a supportive modality in experienced centers. [12] [13] [14] [15] [16] 3 Furthermore, an additional key consideration is that ECMO is a rescue strategy for severe adult respiratory distress syndrome. 5 The initial management priorities in this challenging scenario include treating the underlying cause, securing the airway, optimizing protective lowstretch lung ventilation, as well as judicious fluid therapy and titrated diuresis. 5;14 In the setting of these management approaches, oxygenation may still deteriorate as measured by decreases in the blood oxygen tension/inspired oxygen ratio. [14] [15] When this ration falls below 150 mmHg, further recommended interventions include recruitment maneuvers, prone positioning, neuromuscular blockade, titration of positive end-expiratory pressure, and inhaled pulmonary vasodilators such as nitric oxide and epoprostenol. 5 If this ratio falls below 80 mmHg for 6 hours, or below 50 mmHg for 3 hours, then ECMO should be considered in the absence of institution-specific contraindications. 12-14 A third recognized indication for ECMO in this setting has also been based on a deteriorating arterial blood gas, namely a pH below 7.25 with a blood carbon dioxide tension greater than 60 mmHg for at least 6 hours. 5 Although ECMO is the primary strategy for management of refractory hypercarbia in this clinical setting, extracorporeal carbon dioxide removal may have a role in highly selected patients. [16] [17] The contraindications for ECMO in patients with coronavirus virus infection must be hospital-specific, taking into account factors such as experience with ECMO and availability of resources in real-time during the pandemic. [12] [13] [14] Furthermore, patient comorbidities such as advanced age, frailty, chronic lung disease, diabetes, heart failure, and prolonged mechanical ventilation significantly increase mortality risk in severe coronavirus infection and may consequently be contraindications to ECMO. [14] [15] [16] The indications and contraindications to ECMO during the coronavirus crisis should be adjusted in real-time to local factors. 4 
The assignment and management of personnel in the delivery of ECMO services at an experienced center should be centralized. [18] [19] There should be a clear chain of command that can dynamically lead the ECMO service line through the pandemic landscape. [20] [21] It is important to have flexible staffing models that maintain both the institutional standards and adequate reserves that can accommodate staff attrition. [12] [13] [14] Experienced centers may have to augment their relationships with referring centers with respect to advice, support, and transport protocols to accommodate the full impact of this pandemic, including the highly infectious nature of the coronavirus infection. 1-4; 22 The ECMO personnel will all require site-specific intensive training for the unique considerations of active coronavirus infection. These unique considerations cover indications and contraindications for ECMO, infectious hygiene, full barrier precautions including personal protective equipment, as well as control of aerosolization during airway management, echocardiography and transport. [5] [6] [7] [8] [9] [10] [11] [12] Patients may have to be grouped into cohorts for ECMO support in clearly designated hospital areas that are equipped and managed appropriately for maximal precautions. 12-14
The management of the ECMO equipment is essential to facilitate a smooth hardware process during the surge phase of the pandemic. 23 There should be a record of all equipment that can track hardware movement throughout the health system in real-time. This tracking and managing of hardware is best managed centrally with attention to reserves, changes in demand, control of waste, and avoiding of regional hoarding. [12] [13] [14] In the setting of a mobile lung rescue service, this hardware should be added to the central registry, including mobile 5 echocardiography. [22] [23] [24] The availability of all hardware supplies could also be a combination of regular supplies and additional supplies specific for a patient with suspected or known coronavirus infection. The titration of clinical simulation can greatly enhance best practices for appropriate utilization of all these supplies across all team members and member institutions. [12] [13] [14] 
The preparations and management of the ECMO service line during the coronavirus crisis should ideally be part of the coordinated response from the health system in question. [25] [26] A flexible strategy to accommodate infected patients requiring ECMO support may require thoughtful development of bed capacity across the health system, including regional coalition with neighboring hospitals as needed. 25 These plans for bed capacity should also include resilient and synergistic approaches within and across centers to address clustering of cases, infection control, patient transport, and waste management. [12] [13] [14] The ECMO teams should be protected and supported through the crisis with a dedicated leadership team, a focus on infection prevention, and an emphasis on high-quality open and transparent communication, [25] [26] 
The support systems for the delivery of high-quality ECMO services should focus on the dynamics of the personnel, hardware quality and supply, and the clinical space. [25] [26] Key processes in this arena include communication, coordination, resource allocation, contingency planning and management, information tracking, quality assurance and focused research opportunities. [12] [13] [14] Critical information should be transmitted in a timely and agile fashion to all team members via multiple platforms including team meetings, a telephone hotline, text-based messages, and e-mail groups. 25 
The support of the health care team members and their families is an important component for successful navigation through the coronavirus crisis. [25] [26] [27] [28] The negative psychological impact of quarantine can be considerable, including confusion, anger, and posttraumatic stress disorder. [27] [28] The factors that can significantly increase the impact of quarantine on psychological wellbeing include stressors such as quarantine duration, levels of frustration and fear, boredom, perceived risks of infection, deficiencies in supplies and information, financial loss, and stigma. 28 The management of these stressors can mitigate to a large extent the negative psychological effects of quarantine for team members and their families who are navigating this process.
The current coronavirus crisis has challenged the delivery of high-acuity care worldwide, including the planning and provision of ECMO services. The delivery of the best care in ECMO for patients with coronavirus infection should ideally include consideration of the following factors in this challenging setting: indications, contraindications, personnel, equipment; health care facilities, and support systems. A sustained focus on infection control to prevent transmission of coronavirus remains essential during the conduct of ECMO in this pandemic.