Introduction: The onset of COVID-19 pandemic overwhelmed hospital resources with a high admission rate to critical care units. In patients experiencing progressive respiratory failure despite conventional therapies such as mechanical ventilation and prone positioning, venovenous extracorporeal membrane oxygenation (VV-ECMO) offered the only hope for survival. The VV-ECMO duration for COVID-19 is often described as longer than other respiratory illnesses. The outcome of these cases varies from country to country. As the literature available on the outcome of prolonged ECMO in an Indian setting is sparse, we planned to study the same. Methods: This retrospective study included all adult patients who had undergone VV-ECMO of more than 30 days for COVID-19 illness at Medica Medica Superspecialty Hospital, Kolkata, West Bengal, India between 1 April 2020 and 31 March 2022. Patients who were still in the hospital at the end of the study period were excluded from the study. Data on total ECMO days, in-hospital mortality, age, sex, BMI, symptom onset to ECMO duration, intubation to ECMO duration, mechanical complications such as oxygenator failure or pump failure, patient complications such as major hemorrhage, ischemic stroke, liver/renal dysfunction, thrombocytopenia, culture-proven infection and use of prone position ventilation were collected from an electronic database. Patients who were discharged from the hospital were followed up at 6 months. The data were analyzed using the statistical package for the social sciences (SPSS) software, version 26 (IBM, Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and evaluated using Student's t-test. Categorical data were expressed as frequency (in %) and evaluated using the Chi-square test or Fischer's exact t-test as applicable. Observation: Twenty patients who had prolonged ECMO (>30 days) were found eligible for the study. The average ECMO days and in-hospital mortality were 54.75 ± 33.14 and 60%, respectively. An early decision to ECMO after symptom onset and prone positioning during ECMO were factors associated with a favorable outcome. The requirement of renal replacement therapy (RRT) for renal failure was a poor prognostic factor. Conclusion: Prolonged ECMO for COVID-19 poses many challenges in terms of thrombotic and bleeding complications, major organ dysfunction, and high mortality. However, this remains the only survival hope for sick COVID-19 acute respiratory distress syndrome (ARDS) patients.

ECMO (Extra Corporeal Membrane Oxygenation), synonymously known as ECLS (Extra Corporeal Life Assist) has been proven to be helpful in saving the lives of patients who have been critically unwell due to reversible, cardio-pulmonary failure. The knowledge and the scientific discoveries leading to the successful trials of ECMO happened over centuries. It is interesting to note how the beliefs and superstitions were replaced by proven, scientific data over millennia before we reached the latest era of working with bio-compatible materials. Medical History has always been interesting. In this review article, I will briefly summarise the evolution of Medicine in different periods as the foundations were laid in this period. I will narrate further concepts about the development of ECMO technology over a period of four centuries in part 2. Lastly, in Part 3, I will describe the birth and evolution of ECMO as a science and the perfection of the components of ECMO.

Sedation, analgesia, and muscle relaxants are an integral part of critical care unit, which works like a double-edge sword, and hence judicious use of each agent remains the matter of primary concern. These get more compounded, especially when the patient is on extracorporeal therapy. The patient who needs extracorporeal therapies besides being critically ill also has altered pharmacokinetics for varied reasons and usually has longer ICU stay. Recently, there is a paradigm shift in practice of sedation in critical care unit from deep and prolonged sedation to short and minimal sedation. The basic goal of sedation therapy in a critical care unit is to keep the patient comfortable with minimal possible sedation, avoid muscle relaxants as far as possible, and try to give sedation break. The commonly used drugs are opioids, benzodiazepines, major tranquilizers, and anesthetic agents like barbiturates, propofol, etc. Ideal sedative agents during ECLS should be short-acting as daily sedation break is mandatory to assess CNS status, should not be reacting to the circuit (like fentanyl and propofol), and cardiostable. Extracorporeal circuits alter the pharmacokinetics of sedative agents by increase in the volume of distribution, circuit adsorption, and hypoproteinemia secondary to systemic inflammatory response syndrome (SIRS). The need for sedation in cardiac ECMO is very limited, provided there is no associated lung pathology (like pulmonary edema). Cardiac patient can well be kept off the ventilator, or if already intubated, can be extubated at the earliest so that the sedation requirement is minimized. In respiratory ECMO, invariable sedation is required, especially in the first few days till the time the patient stabilizes. Sedation requirement after 48 hours of ECMO is mostly because of patient-ventilator asynchrony and the air hunger. This can be to some extent managed by maintaining low PCO₂ (less than 30), which can be achieved by keeping high-sweep gas. The different scoring systems that can be followed are modified motor activity assessment scale (MMAAS) and Richmond agitation-sedation scale and comfort score. The monitoring scale is as per the institutional protocol. In contrast to the sedated patient, the awake patient has multiple advantages on medical, psychological, and social front.

Septic shock with acute respiratory distress syndrome (ARDS) comes with extremely high mortality. In this case report, we are presenting a case of septic shock with biventricular dysfunction rescued by primary hybrid VAV ECMO and de-escalated the support as the organs started improving.

Acute airway obstruction poses a therapeutic challenge to treating physicians. There can situations where one is unable to secure the airway along with complete airway obstruction. In such conditions, ECMO can be considered as one of method that can protect from hypoxic damage simultaneously by giving time for adequate surgical access to airway. We present a case of complete airway obstruction where time for adequate surgical access was provided by use of VV-ECMO without any hypoxic damage.