Corona and Ecmo: Doctors suspect overtherapy at the end of life

by time news

DBlood flows out of the patient’s body through thick cannulas. Your lungs don’t have to work temporarily, a machine next to the bed takes over the function. This enriches the blood with oxygen before it is returned. In the winter of 2015/16, Sabine Weiß (name changed) first developed a severe cough as a result of a flu infection and finally suffered severe acute lung failure.

In a university hospital, doctors connected the then 50-year-old to a so-called Ecmo device: practically an artificial lung that is supposed to give the vital organ time to recover.

According to Weiss, he was in a coma for a total of around a month, 16 of which were on the Ecmo. She has very few memories of that time. “I was sort of between the spheres: once my mother, who had died a year earlier, appeared to me in a dream. She said she’s fine where she is.”

As Weiss is told afterwards, her husband visited her every day: He spoke to her, read to her, held her hand. And he put pictures from vacations together at the foot of the bed as an encouragement to recovery. Weiss thinks he felt his care. “I am grateful to him to this day.”

When Weiß was taken out of the coma at the end of January 2016, she was disoriented. Because she doesn’t know that she was transferred from another hospital by special transport. At the time, she didn’t find the many tubes on her body and the situation in general to be bad. “There was always confidence to get well.”

Life-saving therapy – but not for everyone

The therapy that saved Weiß’s life – extracorporeal membrane oxygenation (ECMO) – has also become better known outside of specialist circles in the Covid 19 pandemic. Because like many other respiratory pathogens, Sars-CoV-2 can trigger severe acute lung failure. The pictures of infected people struggling for their lives on Ecmo devices could be seen in photos in newspapers and in TV documentaries. Thousands of people in this country are likely to have been affected by spring 2022, but final data is not yet available. However, the numbers that are already known about the pandemic in Germany alarm experts.

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Because a much higher proportion of Ecmo patients died in hospital than was usual before the pandemic. Depending on the type of Ecmo therapy, 72 or around 66 percent of those suffering from Covid 19 did not survive, according to a group led by specialist Benjamin Friedrichson from the University Hospital Frankfurt in a study from the end of February in the “European Journal of Anaesthesiology”. To do this, they analyzed all 4279 Ecmo treatments in Covid 19 patients in German hospitals between January 2020 and the end of September 2021.

International publications with the results of mostly specialized centers therefore showed significantly better rates, depending on the study, only 37 or 53 percent died there.

Contrary to what might be expected given the initial lack of experience with Covid-19, the results did not improve over the course of the pandemic. “The doctors in this country don’t make bad medicine and Ecmo is a wonderful therapy that we don’t want to do without,” says Friedrichson. “The results are also very good for younger people.”

“Unacceptably high” death rate

In Germany, however, compared to other countries, many people over the age of 60 were treated at Ecmo. In this older group, more than three quarters died (77 percent – “unacceptably high” according to the study). That affects the overall result.

A previous study with similar results on the first three corona waves said the data should serve as a warning for clinicians. Co-author Thomas Bein, formerly an intensive care physician at the Regensburg University Hospital, says: “Overall, the Ecmo was used too uncritically and unregulated during the corona pandemic: as a last resort when nothing else helped.” He speaks of a “quality problem” and thinks stronger ones regulation as necessary.

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In Germany, a relatively large number of clinics offer Ecmo for acute lung failure: more than 270 according to the latest data from 2020, around 40 more than two years earlier, as Friedrichson says. “Even the swine flu pandemic of 2009 was a booster for the technology.” Today’s mobile devices are easy to use, like a smartphone. “Supposedly, that doesn’t require a great deal of expertise.” According to experts, Corona should have spread it further.

Steffen Weber-Carstens, intensive care doctor at the Charité, gives a comparative figure: “Across Great Britain, eight clinics are currently using Ecmo. Patients are transferred there.” So few houses each have many patients. It’s different in Germany: A study in the journal “Plos One” looked at almost 30,000 Ecmo treatments from the pre-pandemic period – with the result that a good 60 percent of the clinics that offered Ecmo only treated one case a year. Centers with more than 20 or 30 patients per year are considered experienced.

A therapy that requires a lot of experience

“Ecmo belongs in very experienced hands, there is a high potential for complications and side effects. However, many hospitals, especially smaller ones, do not have the expertise,” says Bein. It has also been shown in other medical fields that routine leads to better results. A group led by Bein and Weber-Carstens recently expressed the hypothesis in the “Deutsches Ärzteblatt” that misguided financial incentives in the healthcare system tempted smaller clinics to carry out such treatments. According to experts, the costs for the entire package of treatment run into a high five-digit number. If patients have to be cared for for 100 or 120 days, it can be even longer.

Other experts consulted see little or no such incentives. “Doctors want to help as much as possible,” says Friedrichson. Since rental devices are often used, it is not the case that the acquisition costs have to be amortized.

Specialist Oliver Milbradt from the Clemenshospital in Münster, where the number of annual Ecmo treatments has risen from one to two to six to seven since 2014, also reports that at the peak of the pandemic, overburdened Ecmo centers begged to take on patients . Despite the great results, an Ecmo is never used lightly: “We’re happy when the device doesn’t work.”

Too many providers on the market?

From Friedrichson’s point of view, 100 or fewer instead of more than 270 Ecmo providers would be completely sufficient for the supply in Germany.

Where exactly does expertise make the difference? As physicians report, it is not enough to just connect patients to the high-tech device. Rather, this is a piece of the puzzle in a treatment concept.

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According to experts, this includes, for example, the right medication against Covid-19, but also against other infections and often also dialysis, and vascular surgeons should also be available in case of complications. It is considered optimal to lay patients on their stomachs, even if this makes care more complex. “It also plays a role whether it is possible to let patients breathe spontaneously with support, whether they are trained, whether they are occasionally sat up for blood circulation or allowed to walk across the hall,” says Weber-Carstens.

The example shows: From an expert’s point of view, Ecmo treatment should no longer be imagined as a permanent, motionless deep sleep. After the acute phase, patients are no longer put under as deep anesthesia as they used to be. Although it is important to prevent stress and pain, they should be able to open their eyes when spoken to. All of this means more maintenance. The patients benefited, said Bein: The changed sedation has contributed significantly to higher survival rates since the turn of the millennium.

For Thomas Bein, however, all of this does not mean that every patient has a realistic chance of making it. Rather, doctors should also be careful not to cause unnecessary suffering. Even those who leave the hospital alive are often not the same person as before. Many former Ecmo patients died in the year after discharge. You shouldn’t give your family false hope. “I plead for more restraint in old age. To put it bluntly, you just delay death.”

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Sabine Weiß is still grateful that the therapy exists, as she says. It was bad to fail at supposedly simple activities in the first time afterwards: getting out of bed or stepping onto a curb, for example. It took her half a year to get physically fit again. And even today, years later, she gets sore muscles faster than before. But she considers herself lucky compared to some other former Ecmo patients who struggle with anxiety, depression and post-traumatic stress disorders.

Weiss describes the chapter of her serious illness as closed today. “I’ve learned I only have one life. I live more intensively, I am more grateful and I don’t get upset as quickly as I used to.”

Despite concerns about infection, she and her husband did not let the pandemic completely stop them from traveling, but they were careful. The longtime camper raves about the first joint flight recently. When White hears criticism of using Ecmo too generously, she becomes thoughtful. She says: “We all have a right to life.”

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