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\begin{document}

\title{Outcomes of Extracorporeal Membrane Oxygenation in Acute Respiratory
Distress Syndrome due to COVID-19, lessons learned from the first wave
of COVID 19}



\author[1]{Cameron Blazoski}%
\author[1]{Michael Baram}%
\author[1]{Hitoshi Hirose}%
\affil[1]{Thomas Jefferson University Hospital}%


\vspace{-1em}



  
  \date{May 07, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Introduction: Extracorporeal membrane oxygenation (ECMO) has been used
as a refractory treatment for acute respiratory distress syndrome (ARDS)
due to COVID-19, but there has been little evidence of its efficacy. We
conducted this study to share our experience using ECMO as a bridge to
recovery for ARDS due to COVID-19. Methods: All adult patients who were
placed on ECMO for ARDS due to COVID -19 between April 2020 and June
2020 (during the first wave of COVID-19) were identified. The clinical
characteristics and outcomes of these patients were analyzed with a
specific focus on the differences between patients who survived to
hospital discharge and those who did not. Results: 20 COVID-19 patients
were included in this study. All patients were placed on veno-veno ECMO.
Comparing between survivors and non-survivors, older age was associated
with hospital mortality (p=0.02). The following complications were
observed: renal failure requiring renal replacement therapy (35\%, n=7),
bacteremia during ECMO (20\%, n=4),coinfection with bacterial pneumonia
(15\%, n=3), cannula site bleeding (15\%, n=3), stroke (10\%, n=2),
gastrointestinal bleeding (10\%, n=2), and liver failure (5\%, n=1). The
complications associated with patient mortality were culture positive
septic shock (p=0.01), culture-negative systemic inflammatory response
syndrome (p=0.01), and renal failure (p=0.01). The causes of death were
septic shock (44\%, n=4), culture-negative systemic inflammatory
response syndrome (44\%, n=4), and stroke (11\%, n=1). Conclusions:
Based on our experience, ECMO can improve refractory ARDS due to
COVID-19 in select patients. Proper control of bacterial infections
during COVID-19 immunomodulation therapy may be critical to improving
survival.%
\end{abstract}%



\sloppy


\textbf{Outcomes of Extracorporeal Membrane Oxygenation in Acute
Respiratory Distress Syndrome due to COVID-19, lessons learned from the
first wave of COVID 19.}

Cameron Blazoski, BA \textsuperscript{1}, Michael Bram,
MD\textsuperscript{2}, Hitoshi Hirose MD \textsuperscript{1}.

Department of Surgery, Thomas Jefferson University, Philadelphia, PA

Department of Medicine, Pulmonary and Critical Care, Thomas Jefferson
University, Philadelphia, PA

Corresponding author: Hitoshi Hirose, MD, PhD.

Department of Surgery, Thomas Jefferson University, Philadelphia, PA.

1025 Walnut St, Ste 605, Philadelphia, PA 19107

Tel: 215-955-6996; Fax: 215-955-6010; E-mail: genex@nifty.com

Conflict of Interests: None declared

Financial support: None

\textbf{Word count :1896}

\textbf{Abstract}

\textbf{Introduction:} Extracorporeal membrane oxygenation (ECMO) has
been used as a refractory treatment for acute respiratory distress
syndrome (ARDS) due to COVID-19, but there has been little evidence of
its efficacy. We conducted this study to share our experience using ECMO
as a bridge to recovery for ARDS due to COVID-19.

\textbf{Methods:} All adult patients who were placed on ECMO for ARDS
due to COVID -19 between April 2020 and June 2020 (during the first wave
of COVID-19) were identified. The clinical characteristics and outcomes
of these patients were analyzed with a specific focus on the differences
between patients who survived to hospital discharge and those who did
not.

\textbf{Results:} 20 COVID-19 patients were included in this study. All
patients were placed on veno-veno ECMO. Comparing between survivors and
non-survivors, older age was associated with hospital mortality
(p=0.02). The following complications were observed: renal failure
requiring renal replacement therapy (35\%, n=7), bacteremia during ECMO
(20\%, n=4),coinfection with bacterial pneumonia (15\%, n=3), cannula
site bleeding (15\%, n=3), stroke (10\%, n=2), gastrointestinal bleeding
(10\%, n=2), and liver failure (5\%, n=1). The complications associated
with patient mortality were culture positive septic shock (p=0.01),
culture-negative systemic inflammatory response syndrome (p=0.01), and
renal failure (p=0.01). The causes of death were septic shock (44\%,
n=4), culture-negative systemic inflammatory response syndrome (44\%,
n=4), and stroke (11\%, n=1).

\textbf{Conclusions:} Based on our experience, ECMO can improve
refractory ARDS due to COVID-19 in select patients. Proper control of
bacterial infections during COVID-19 immunomodulation therapy may be
critical to improving survival.

\textbf{(Word count of abstract: 250)}

\textbf{Introduction}

Since its outbreak in 2019, there have been over 50 million cases of
coronavirus disease 2019 (COVID-19) and 1.25 million recorded deaths.(1)
While most patients experience mild to moderate symptoms, COVID-19 can
progress to acute respiratory distress syndrome (ARDS), a rapidly
progressive inflammatory syndrome that impairs oxygen transport in the
lungs.(2,3) The pulmonary injury in ARDS due to COVID-19 has been shown
to resemble ARDS unrelated to COVID-19, and even with mechanical
support, ARDS is associated with a significant mortality among COVID-19
patients.(2,4,5)

The high mortality rate of ARDS due to COVID-19 increased the demand for
other treatment options, and the use of extracorporeal membrane
oxygenation (ECMO) was encouraged for select cases of refractory ARDS
with severe hypoxemia.(5--8) ECMO is a temporary form of mechanical
cardiopulmonary support for patients with severe cardiac and/or
respiratory shock. First clinically used in 1972, ECMO's use has
exponentially increased in the past two decades.(9--11) While its
efficacy in lowering mortality rates is still debated, ECMO is now a
common treatment for patients with refractory ARDS.(11--14)

Despite some recent publications,(15--17) there remains a lack of
evidence documenting the overall efficacy of ECMO in treating ARDS due
to COVID-19. The purpose of this paper is to share our experience using
ECMO as a bridge to recovery for patients with ARDS due to COVID-19
during the first wave of the COVID-19 pandemic in our area.

\textbf{Methods}

Adult patients positive for COVID-19 who underwent ECMO at our
institution from April 1, 2020 to June 11, 2020 were included in this
study. Patients were identified by an IRB-approved, prospectively
maintained ECMO database (IRB approval \# 11D.185). The data from these
patients was retrospectively extracted and details were further studied
by reviewing medical records. Inclusion criteria included a positive
COVID-19 test and a diagnosis of ARDS. ECMO placement was determined by
a multidisciplinary team that included a cardiac surgeon, a pulmonary
critical care physician, and a cardiovascular intensivist.

The indications for ECMO placement were the same as our previous
paper,(18) and contraindications for ECMO placement in treating COVID-19
patients are listed in Table 1. The exclusion criteria may be more
restricted than in non-COVID-19 patients, due to the limitations of
resources during this pandemic.

The primary mode of ECMO in COVID-19 ARDS was veno-venous ECMO (VV-ECMO)
using the femoral and internal jugular veins (Figure 1). All cannulation
was performed in the ICU without transport to either the operating room
or catheterization lab unless an issue occurred during bedside
cannulation. Since Avalon dual lumen ECMO cannula placement always
requires fluoroscopy and echocardiography, which requires additional
personnel including radiology technicians and an echocardiography
technician, the utilization of the Avalon cannula was discouraged.(18)
Veno-arterial ECMO (VA-ECMO) should be reserved for only those who had
severe but reversible cardiac dysfunction, such as COVID-19 related
myocarditis. ECMO assisted cardiopulmonary resuscitation (ECPR) for
patients with COVID-19 was discouraged due to its known poor outcomes.

Due to the COVID-19 pandemic, we no longer offer a mobile ECMO program
outside of our institutional network due to the concern of exposure of
required personnel including the ECMO surgeon, perfusionist, and
transfer nurses at the local site. Instead of activating mobile ECMO
cannulation teams, we encouraged local cardiac surgeons to place ECMO at
their institutions and then transport the patient to our facility.

The general management of ECMO has been described in one of our prior
papers.(19) Briefly, after placement of ECMO, the ventilator was set to
the ARDSnet protocol. The typical setting was pressure controlled
ventilation, rate 15, PEEP 15, delta P 15 until recovery of the
respiratory function. Paralytics were discontinued within 24 hours of
ECMO initiation, unless respiratory function was deetiolated. Sedatives
were used if a RAS score was negative 1-2. Blood pressure was maintained
at least mean arterial pressure of 60 mm Hg with vasopressors and/or
fluid as appropriate. A heparin drip was started once PTT fell below 50
seconds after cannulation and maintained at an anti-Xa level of 0.3-0.5.
If bleeding complications were observed, the anticoagulation was held
and then restarted at a lower anti-Xa goal of 0.1-0.3.

Timing of the decannulation was determined by chest x-ray findings and
lung mechanics. Before decannulation, the sweep gas was discontinued for
at least 24 hours to ensure the lungs were able to exchange oxygen and
carbon dioxide appropriately. For COVID-19 cases, we encourage bed-side
decannulation rather than transporting to operating room to limit
exposure to COVID-19.

The primary endpoints of this study were ECMO survival and hospital
survival. ECMO survival was defined by withdrawal of care or death
within 24 hours of decannulation. All patients who survived to hospital
discharge were classified as ``Survivors'' and all patients who did not
survive to hospital discharge were classified as ``Non-Survivors.'' The
baseline characteristics, clinical characteristics, and outcomes were
calculated and compared between the two groups.

Data was expressed as the number with percentage, mean +/- standard
deviation, or median (quantile) as appropriate. Two groups were compared
using chi-squared tests for categorical variables and standard t-tests
for continuous variables as appropriate. Significance was accepted at a
P-value less than 0.05.

\textbf{Results}

During this study period, 20 patients with ARDS positive for COVID-19
underwent ECMO placement. All patients were placed on veno-veno ECMO,
and the mean length of ECMO placement was 14.0 days. The average length
of symptoms prior to ECMO placement was 11.4 days, with the average
patient spending 10.3 days in the hospital prior to ECMO placement. The
average time spent on a ventilator prior to ECMO placement was 147
hours. 75\% of patients (n=15) were transferred from another institution
to our hospital, and 60\% of patients (n=12) had ECMO initiated at
another institution prior to transfer. Pre-ECMO characteristics and
patient demographics are displayed in Table 2. Patients were also
treated with different therapies prior to starting ECMO placement.
Therapy was administered in the form of steroids (65\%, n=13),
interleukin-6 inhibitors (55\%, n=11), remdesivir (20\%, n=4), and
plasma (15\%, n=3). None of the treatment therapies were associated with
better or worse mortality rates. The types of treatment and their
statistics are displayed in Table 3.

The ECMO survival rate was (15/20), and the survival rate to hospital
discharge was 55\% (11/20). 11 patients were labeled as Survivors and 9
as Non-Survivors based on their survival to hospital discharge. The only
baseline characteristic that was statistically different between the two
groups was age, as Non-Survivors were significantly older than Survivors
(58.4 vs. 49.6, p=0.02).

The causes of death were septic shock (44\%, n=4), culture-negative
systemic inflammatory response syndrome (SIRS) (44\%, n=4), and stroke
(11\%, n=1). The most common complication observed was renal failure
requiring renal replacement therapy (35\%, n=7). Complications that were
associated with patient mortality between the two groups were blood
culture positive sepsis (p=0.01), culture-negative systemic inflammatory
response syndrome (SIRS) (p=0.01), cannula site bleeding (p=0.04), and
renal failure (p=0.01). The complications are displayed in Table 4.

\textbf{Discussion}

The primary finding of this study is that among the 20 COVID-positive
patients that we treated with ECMO, the survival rate to hospital
discharge was 55\%. Also, our results suggest that proper patient
selection and control of bacterial infections prior to and/or during
ECMO placement may be key to improving survival, as culture-positive
septic shock and culture-negative SIRS were the main causes of death and
were only observed in patients who failed to survive to hospital
discharge.

The treatment of ARDS with ECMO remains disputed, even though its use in
treating ARDS has increased in the past decade.(11,12) While the exact
mortality rate of treating ARDS with ECMO varies by research study, it
is generally accepted to range between 34-39\%.(11,13,14) Thus, it is
generally recognized that ECMO should be primarily used for refractory
cases of ARDS, in which a patient remains severely hypoxic despite
aggressive treatment.(12)

Interestingly, our study and others on COVID-19 have found that the
mortality rates of treating ARDS due to COVID-19 with ECMO are similar
to the previously reported mortality rates of treating non-COVID ARDS.
Recently, there have been a few articles published that specifically
investigated the use of ECMO in treating ARDS due to COVID-19. The
largest of these studies was conducted by Barbaro et al., who drew from
an Extracorporeal Life Support Organization (ELSO) registry to analyze
the outcomes of 1035 COVID-positive patients who were treated with
ECMO.(15) The researchers found that among these patients, the 90-day
post-ECMO mortality rate was 37.4\%. The study included data from 213
different hospitals and included patients treated from January
16\textsuperscript{th} to May 1\textsuperscript{st} of 2020. Another
study that more closely resembles our own is from Schmidt et al, who
documented the outcomes of 83 COVID-positive patients who were treated
at their hospital.(16) They discovered that the 60-day mortality of
these patients was 31\%. Compared to these studies, our patients had a
slightly higher mortality rate of 45\%; however, it should be noted that
our sample size was significantly smaller than either of these two
articles.

Based on this current research on the use of ECMO in ARDS due to
COVID-19, the mortality rate appears to be anywhere between 31-45\%.
This mortality rate is similar to the 34-39\% mortality rate in treating
non-COVID ARDS with ECMO in select patients. Therefore, it is possible
that ECMO is just as effective at treating ARDS due to COVID-19 as it is
at treating ARDS due to non-COVID-19 etiologies if appropriate patient
selection was applied. For example, none of the patients in our study
had cardiac dysfunction. This is because our selection committee
considered COVID-19 patients with cardiac dysfunction and ARDS to have
multiorgan failure, which was a contraindication for ECMO placement.
While there needs to be far more research done on this topic to
definitively state that ECMO is effective in treating COVID-19, it is
possible that it is an effective treatment option for refractory cases
of ARDS due to COVID-19.

Sepsis and SIRS were the causes of death in all but one patient in our
study, suggesting that bacterial infections during ECMO placement may be
a significant factor in mortality rates. While immunomodulation therapy
has been shown to decrease the mortality rate of COVID-19,(20,21) it has
also been associated with an increased infection rate. For example, one
study demonstrated that 13\% of patients treated with tocilizumab were
diagnosed with new infections, compared to only 4\% of patients treated
solely with the standard of care.(21) There should be particular
attention to preventing, monitoring for, and responding early to
bacterial infections in COVID-19 patients placed on ECMO.

During the first wave of COVID-19 in Pennsylvania, the highest number of
daily COVID-19 cases occurred on April 8\textsuperscript{th} with 2,059
cases. By the end of our study period on June 11\textsuperscript{th},
the daily number of cases fell to 680, which was one of the lowest
number of daily cases in Pennsylvania since the beginning of the
pandemic. Our study beings on April 1\textsuperscript{st} and ends on
June 11\textsuperscript{th}, which fairly accurately represents the
beginning and end of the first wave of COVID-19 in Pennsylvania.
Beginning in late October, Pennsylvania entered a second wave, with
daily cases greatly exceeding those of the first wave. Future studies of
the second wave of COVID-19 will differ from this study, for multiple
reasons, including changes in pre-ECMO immunomodulation treatment.
During the second wave, interleukin inhibitors are no longer recommended
and steroids are more widely used.

Our study is limited by its small sample size and being based in one
hospital center. It is also possible that there was selection bias in
this study, even though ECMO placement was determined by a
multidisciplinary team of physicians.

Despite its limitations, this study provides extensive data on 20
patients with ARDS due to COVID-19 who were treated with ECMO. While we
cannot extrapolate from a sample size of 20 patients, we hope our
evidence can complement other studies and contribute to meaningful
meta-analyses and statistical analyses. Cases of ARDS due to COVID-19
will continue in the coming months and years, and we hope that our
analysis contributes to the growing research on how to treat this deadly
disease.

\textbf{Conclusion}

Based on our results, we conclude that ECMO placement can improve
refractory cases of ARDS due to COVID-19. More research is needed to
better understand the true efficacy of ECMO in treating COVID-19 and the
mortality rate associated with it.

\textbf{Table 1} : Contraindications for ECMO in COVID 19.\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\textbf{Standard contraindications}\tabularnewline
\midrule
\endhead
Age \textgreater{}70\tabularnewline
Body mass index \textgreater{}45 with high risk of vascular
access\tabularnewline
Mechanical ventilation \textgreater{}7 days\tabularnewline
Multiorgan failure\tabularnewline
End stage liver disease\tabularnewline
Irreversible neurological damage\tabularnewline
Contraindications of anticoagulation\tabularnewline
Cardiac arrest without ROSC\tabularnewline
\textbf{Relative contraindications}\tabularnewline
Age \textgreater{}65\tabularnewline
Body mass index \textgreater{}35\tabularnewline
Mechanical ventilation \textgreater{}5 days\tabularnewline
Active bacterial blood stream infection\tabularnewline
Severe COPD Cirrhosis Chronic heart failure\tabularnewline
Inability of access neuro status\tabularnewline
High lactate related to low perfusion status\tabularnewline
Limited activity at home\tabularnewline
No family or appropriate power of attorney Outside of institutional
network\tabularnewline
\textbf{Considering Veno-arterial cannulation}\tabularnewline
Cardiac arrest with ROSC\tabularnewline
Poor left or right ventricular function\tabularnewline
Known pulmonary hypertension\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2} : Demographics and baseline characteristics of studied
patients. Data is expressed with number (percentage) or mean \selectlanguage{ngerman}± standard
deviation.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
~Category & All patients & Survivors & Non-Survivors &\tabularnewline
\midrule
\endhead
~Number of patients & n = 20 & n = 11 & n = 9 & P-value\tabularnewline
Characteristics & & & &\tabularnewline
Age (years) & 54 \selectlanguage{ngerman}± 8.7 & 50 \selectlanguage{ngerman}± 8.5 & 58 \selectlanguage{ngerman}± 6.4 &
\textbf{0.020}\tabularnewline
Male & 12 (60\%) & 7 (64\%) & 5 (56\%) & 0.713\tabularnewline
Body surface area (cm\textsuperscript{2}) & 2.1 \selectlanguage{ngerman}± 0.3 & 2.1 \selectlanguage{ngerman}± 0.3 & 2.0
\selectlanguage{ngerman}± 0.3 & 0.259\tabularnewline
Body mass index & 35 \selectlanguage{ngerman}± 7 & 38 \selectlanguage{ngerman}± 7 & 32 \selectlanguage{ngerman}± 7 & 0.057\tabularnewline
Underlying Conditions & & & &\tabularnewline
Pre-ECMO positive blood culture & 5 (25\%) & 3 (27\%) & 2 (22\%) &
0.795\tabularnewline
Pre-ECMO time on ventilator (hrs) & 148 \selectlanguage{ngerman}± 255 & 206 \selectlanguage{ngerman}± 344 & 76 \selectlanguage{ngerman}± 68 &
0.280\tabularnewline
Smoking & 4 (20\%) & 3 (27\%) & 1 (11\%) & 0.369\tabularnewline
Chronic lung disease & 2 (10\%) & 0 (0\%) & 2 (22\%) &
0.099\tabularnewline
Diabetes & 6 (30\%) & 2 (18\%) & 4 (44\%) & 0.202\tabularnewline
Liver failure & 1 (5\%) & 0 (0\%) & 1 (11\%) & 0.257\tabularnewline
Chronic immunosuppression & 1 (5\%) & 0 (0\%) & 1 (11\%) &
0.257\tabularnewline
Pre-ECMO acute renal injury & 6 (30\%) & 2 (18\%) & 4 (44\%) &
0.202\tabularnewline
Pre-ECMO Vital signs & & & &\tabularnewline
Length of symptoms (days) & 11.4 \selectlanguage{ngerman}± 6.5 & 9.9 \selectlanguage{ngerman}± 4.6 & 13.5 \selectlanguage{ngerman}± 8.4 &
0.237\tabularnewline
Temperature (\selectlanguage{ngerman}°F) & 99.4 \selectlanguage{ngerman}± 1.4 & 99.7 \selectlanguage{ngerman}± 1.6 & 99.0 \selectlanguage{ngerman}± 1.1 &
~0.281\tabularnewline
Heart Rate & 102 \selectlanguage{ngerman}± 24 & 111 \selectlanguage{ngerman}± 23 & 91 \selectlanguage{ngerman}± 21 & ~0.064\tabularnewline
Respiratory rate & 28 \selectlanguage{ngerman}± 5.3 & 27 \selectlanguage{ngerman}± 3.9 & 29 \selectlanguage{ngerman}± 6.7 &
~0.330\tabularnewline
Mean arterial pressure (mm Hg) & 85 \selectlanguage{ngerman}± 17 & 87 \selectlanguage{ngerman}± 16 & 84 \selectlanguage{ngerman}± 20 &
~0.759\tabularnewline
FiO2 (\%) & 93 \selectlanguage{ngerman}± 14 & 90 \selectlanguage{ngerman}± 15 & 96 \selectlanguage{ngerman}± 13 & ~0.390\tabularnewline
PEEP (cm) & 16 \selectlanguage{ngerman}± 4.8 & 17 \selectlanguage{ngerman}± 5.6 & 15 \selectlanguage{ngerman}± 3.6 & ~0.345\tabularnewline
Other & & & &\tabularnewline
Pre-ECMO days in hospital (days) & 10 \selectlanguage{ngerman}± 13 & 12 \selectlanguage{ngerman}± 16 & 8.8 \selectlanguage{ngerman}± 7.7 &
0.654\tabularnewline
Transfer from outside hospital & 15 (75\%) & 8 (73\%) & 7 (78\%) &
~0.795\tabularnewline
ECMO initiated outside hospital & 12 (60\%) & 6 (55\%) & 6 (67\%) &
~0.582\tabularnewline
Length on ECMO (days) & 14 \selectlanguage{ngerman}± 9.6 & 11 \selectlanguage{ngerman}± 6.2 & 17 \selectlanguage{ngerman}± 12 &
0.183\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3} : Treatment modalities provided pre-ECMO placement.
Data is expressed with number (percentage).\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
~Category & All patients & Survivors & Non-Survivors &\tabularnewline
\midrule
\endhead
~Number of patients & n = 20 & n = 11 & n = 9 & P-values\tabularnewline
Pre-ECMO Treatment & & & &\tabularnewline
Steroids & 8 (40\%) & 5 (45\%) & 3 (33\%) & 0.582\tabularnewline
Interleukin inhibitor & 11 (55\%) & 7 (64\%) & 4 (44\%) &
0.391\tabularnewline
Remdesivir & 4 (20\%) & 3 (27\%) & 1 (11\%) & 0.369\tabularnewline
Plasma & 3 (15\%) & 2 (18\%) & 1 (11\%) & 0.660\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4} : Rates of ECMO complications. Data is expressed with
number (percentage)\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
~Category & All patients & Survivors & Non-Survivors &\tabularnewline
\midrule
\endhead
~Number of patients & n = 20 & n = 11 & n = 9 & P-values\tabularnewline
Complications & & & &\tabularnewline
Renal failure & 7 (35\%) & 1 (9.1\%) & 6 (67\%) &
\textbf{0.007}\tabularnewline
Liver failure & 1 (5\%) & 0 (0\%) & 1 (11\%) & 0.257\tabularnewline
Stroke & 2 (10\%) & 0 (0\%) & 2 (22\%) & 0.099\tabularnewline
Intracranial bleed & 1 (5\%) & 0 (0\%) & 1 (11\%) & 0.257\tabularnewline
Bacterial pneumonia & 3 (15\%) & 2 (18\%) & 1 (11\%) &
0.660\tabularnewline
Cannula site bleed & 3 (15\%) & 0 (0\%) & 3 (33\%) &
\textbf{0.037}\tabularnewline
Gastrointestinal bleed & 2 (10\%) & 0 (0\%) & 2 (22\%) &
0.099\tabularnewline
New infection during ECMO & 9 (45\%) & 3 (27\%) & 6 (67\%) &
0.078\tabularnewline
Culture-positive sepsis & 5 (25\%) & 1 (9.1\%) & 4 (44\%) &
0.069\tabularnewline
Septic shock & 4 (20\%) & 0 (0\%) & 4 (44\%) &
\textbf{0.013}\tabularnewline
Systemic inflammatory response & 4 (20\%) & 0 (0\%) & 4 (44\%) &
\textbf{0.013}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Legends of Figure}

\textbf{Figure 1} : Typical veno-venous cannulation in COVID 19 case.

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