Extracorporeal life support (ECLS) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic coronavirus disease 2019 (COVID-19) with ECLS have been restrained. In the meantime, ECLS has been shown to produce similar outcomes in patients with severe COVID-19 compared to existing data on ARDS mortality. We performed an international email survey to assess how ECLS providers worldwide have previously used ECLS during the treatment of critically ill patients with COVID-19. A questionnaire with 45 questions (covering, e.g., indication, technical aspects, benefit, and reasons for treatment discontinuation), mostly multiple choice, was distributed by email to ECLS centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO); 276 ECMO professionals from 98 centers in 30 different countries on four continents reported that they employed ECMO for very severe COVID-19 cases, mostly in veno-venous configuration (87%). The most common reason to establish ECLS was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno-arterial cannulation due to heart failure (3%). Time on ECLS varied between less than 2 and more than 4 weeks. The main reason to discontinue ECLS treatment prior to patient's recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators, were responsible for discontinuation of ECLS support. Most ECLS physicians (51%, IQR 30%) agreed that patients with COVID-19-induced ARDS (CARDS) benefitted from ECLS. Overall mortality of COVID-19 patients on ECLS was estimated to be about 55%. ECLS has been utilized successfully during the COVID-19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECLS. Triage situations were rarely a concern. ECLS providers stated that patients with severe COVID-19 benefitted from ECLS.

2nd Department of Internal Cardiovascular Medicine General University Hospital Prague Czech Republic

Cardio Thoracic Surgery Department Heart and Vascular Centre Maastricht University Medical Centre Maastricht The Netherlands

Department of Anaesthesiology and Critical Care Medicine Campus Kassel of the University of Southampton Kassel Germany

Department of Anaesthesiology and Critical Care Medicine University Hospital of Ulm Ulm Germany

Department of Anaesthesiology and Intensive Care Medicine District Hospital Bergstrasse University Hospital Heidelberg Heppenheim Germany

Department of Anaesthesiology Critical Care Medicine and Pain Medicine University Medical Centre Saarland University Homburg Germany

Department of Anaesthesiology University Hospital of Göttingen Göttingen Germany

Department of Intensive Care Erasme University Hospital Université Libre de Bruxelles Brussels Belgium

Department of Internal Medicine 5 Pneumology Allergology and Critical Care Medicine University Medical Centre Saarland University Homburg Germany

Department of Medicine 3 Medical Center University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany

Department of Pneumology Allergology and Sleep Medicine and Intensive Care Medicine Paracelsus Medical University General Hospital Nuremberg Nuremberg Germany

ECLS Centre Karolinska Department of Pediatric Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden

Interdisciplinary COVID 19 Center University Medical Centre Saarland University Homburg Germany

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Extracorporeal life support provision in COVID-19 patients - An international EuroELSO 2022 update survey