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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 5  |  Page : 2-6

New national centralized extracorporeal membrane oxygenation program during a pandemic: Reaping what we sow!

1 Critical Care Department, Dr. Suliman Alhabib Medical Group, King Saud Medical City, Riyadh, Saudi Arabia
2 Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
3 Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
4 Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR; Cardiac Surgery Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
5 Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR, Jeddah, Saudi Arabia
6 Critical Care Department, King Khaled University Hospital, Asser, Saudi Arabia
7 Critical Care Departments, Alhayat Medical Group, King Fahd Medical City, Riyadh, Saudi Arabia
8 Critical Care Department, King Fahd Medical City, Riyadh, Saudi Arabia

Date of Submission29-Oct-2022
Date of Decision23-Nov-2022
Date of Acceptance03-Dec-2022
Date of Web Publication04-Feb-2023

Correspondence Address:
Ahmed A Rabie
Department of Critical Care, King Saud Medical City, Ulaishah Discreet 12746, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2543-1854.369158

Rights and Permissions

Extracorporeal membrane oxygenation ECMO was widely utilized during the coronavirus disease COVID-19 pandemic. ECMO provision in Saudi Arabia has shown notable improvement; however, a considerable increase in the demand for the services regionally and globally. The national Ministry Of Health MOH ECMO program was started during the COVID-19 pandemic and aimed to organize and centralize the ECMO service all over Saudi Arabia to cope with the kingdom's vision. The program has different tasks, including lifesaving ECMO transportation during the time of surge to specialized ECMO centers through the ministry of health 1937 hotline life-saving call center. In this review article, we aimed to highlight the feasibility of launching a new national centralized ECMO program for proper control of resources during the pandemic and operational management challenges.

Keywords: Centralization, ECMO, new centers, New national ECMO program

How to cite this article:
Azzam MH, Rabie AA, Elhazmi A, Mufti H, Bahaudden HA, Al Bshabshe AA, Assiri AY, Al Maani M. New national centralized extracorporeal membrane oxygenation program during a pandemic: Reaping what we sow!. Saudi Crit Care J 2022;6, Suppl S1:2-6

How to cite this URL:
Azzam MH, Rabie AA, Elhazmi A, Mufti H, Bahaudden HA, Al Bshabshe AA, Assiri AY, Al Maani M. New national centralized extracorporeal membrane oxygenation program during a pandemic: Reaping what we sow!. Saudi Crit Care J [serial online] 2022 [cited 2023 Mar 21];6, Suppl S1:2-6. Available from: https://www.sccj-sa.org/text.asp?2022/6/5/2/369158

  Introduction Top

Extracorporeal membrane oxygenation (ECMO) was widely utilized during the coronavirus disease COVID-19 pandemic.[1],[2],[3] Giving lifesaving modality,[4],[5] transporting patients on ECMO found to be feasible, safe with favorable outcome,[6],[7],[8] particularly in countries utilizing centralization with hub and spoke model. ECMO provision in Saudi Arabia has shown notable improvement; however, a considerable increase in the demand of the services regionally and globally as well. Before the pandemic, ECMO transportation was provided institutionally through the Ministry of Health (MOH) hospitals; nevertheless, the Saudi Vision 2030 framework, released in 2017,[9] has paved the path for digital transformation that optimized the resources in preparedness during the COVID-19 pandemic. The national MOH ECMO program was started during the COVID-19 pandemic and aimed to organize and centralize the ECMO service all over Saudi Arabia to cope with the kingdom's vision. The program has different tasks, including lifesaving ECMO transportation during the time of surge to specialized ECMO centers through the MOH 1937 hotline life-saving call center.[10] To date and over 3 years, the program received more than 1000 ECMO consultations and responded to more than 250 life-threatening COVID-19 cases that probably improved the overall outcomes.

  Challenges Top

The kingdom's geographical nature poses many challenges to ECMO provision during the pandemic, most importantly panning the aviation services in the presence of peripheral areas lack ECMO service distributed in the north and south periphery of the country, which permits against delivery of ECMO service that necessitated launching new ECMO centers in well-established hospitals to cover the service in these areas.[10]

Three new ECMO programs were launched in selected hospitals with well-established infrastructure; the programs required extensive training, close observation, and conservative selection of ECMO candidacy.[1] At a time when services were started in 3 centers, ELSO published the 1st dynamic guidelines recommended against new centers. A few months later,[11] the national MOH ECMO program commissioned the King Saud Medical City KSMC ECMO research program to evaluate the outcome of these new centers. The observational analysis included 307 patients inside and outside SA, and 5 new ECMO centers in the region showed favorable outcomes of the patients treated in new centers comparable to established ones without significant differences in mortality.[1] In response to this unique experience, the updated ELSO guideline came less stringent and allowed starting of new centers in select cases during the pandemic.[12]

  Operational Management Top

The pandemic lasted for months, and the program took measures based on the best available evidence. In view of this, we have provided some pieces of advice from our experience that can be reliably passed on to the next generation in case of future pandemics.

Patient selection

The launch of the new national ECMO program as preparedness for the COVID-19 pandemic directed the Patient ECMO candidacy to be restricted mainly to confirmed COVID-19 severe ARDS patients with refractory hypoxia admitted to the MOH hospitals and private sector patients who are critically ill in ICUs not providing Extracorporeal Life Support (ECLS) services in Saudi Arabia. The protocols followed a tight bed capacity-based patient selection to ensure judicious allocation of resources,[13] yet EOLIA inclusion criteria were the main guidance in the process.[7],[8] The service availability and the targeted group of patients to be salvageable for ECMO were divided into 3 color-coded levels, red, green, and black, according to the occupancy rate of available resources. Cut off physiologic age and multiorgan failures were used to control patient candidacy under the clinical judgments of expert ECMO providers.[13]

Process of extracorporeal membrane oxygenation provision

During the COVID-19 pandemic, critically ill patients are referred to the national MOH ECMO program through hotline 1937. A dedicated group of ECMO experts discusses all cases to evaluate ECMO candidacy. ECMO was provided only after the final approval of at least two consultants. ECMO candidate patients are selected according to the permitted capacity level based on predefined policies and protocols prepared, especially at the time of the surge. For the patients who are candidates for ECMO, a designated highly expert team is deployed upon activating the ECMO service by the ECMO consultant on call[13],[14] [Figure 1].
Figure 1: MOH ECMO command center referral process. ECMO: Extracorporeal membrane oxygenation, MOH: Ministry of Health

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On the other hand, the patients who are not candidates continue their conservative management. All referrals are managed centrally and then redistributed to the teams according to the geographical distributions.[14] The deployed ECMO team remotely inserted ECMO cannula in the referring hospitals and started ECMO support, then transferred to a MOH-specialized ECMO center. The mission ends upon arrival and endorsement of the patient to the receiving hospital ECMO team [Figure 2]. Patients on ECMO are managed according to local institutional policies and protocols, written under the guidance of documents and guidelines released by the national MOH ECMO program and national societies.[15] All the specialized ECMO centers were in tertiary hospitals that are nationally and internationally accredited. The model of ECMO specialists who care for the ECMO machine are variables between the centers, mainly perfusionists, except in two or three centers, a well-trained ECMO nurse works as an ECMO specialist. Intensivists treat patients in the intensive care unit, including at least one ECMO expert who acts as the head of the program in his institution.[15]
Figure 2: The Saudi Ministry of Health ECMO referral from call to transfer pathway for COVID-19 patients. ECMO: Extracorporeal membrane oxygenation

Click here to view

Extracorporeal membrane oxygenation transportation

All ECMO experts and leaders providing ECMO transportation services in Saudi Arabia joined the national MOH ECMO program. Exceptional precautions were implemented to protect the mobile ECMO team, who have heightened exposure to the contagion with limited available workspace and prolonged exposure time during ground or aeromedical transportation. To provide maximum staff safety and successful transportation, we took the following precautions [Figure 3].
Figure 3: Mobile ECMO transport. ECMO: Extracorporeal membrane oxygenation

Click here to view

  • Minimize team members to the smallest effective team
  • Apply full personal protective equipment (PPE) for all the team members from deployment time until the end of the mission
  • Perform and document All ECMO team members' fit tests for N95 or equivalent respirators; if not feasible, consider using Powered Air Purified Respirator
  • Optimize the quality of protective equipment, including full body suits, eye protection (goggles or face shield), gloves, overshoes, head caps, and disposable gowns
  • The vehicle used for transportation should contain a venting source, to be checked before every mission. The transport platform requires deep cleaning after each mission as per local regulations
  • Consider all appropriate measures to reduce exposure time. A balance must be struck between the risk of staff exposure during lengthy transfers and the cost associated with transportation by air
  • Secure all ventilators and exhalation valves with a viral filter as appropriate and avoid unnecessary mechanical ventilation circuit breaks
  • Separate the cab/cockpit and the passenger compartment with different air sources; this may allow the driver/pilot to remove PPE, potentially improving visibility, and comfort, therefore, improving safety [Figure 2]
  • Whenever possible, conduct simulations wearing full PPE prior to the first transport in order to familiarize the team with the procedures and troubleshoot potential complications while donned. In addition, repeat simulation scenarios at regular intervals unless transports are frequent. Debriefing is required to review positive performances and required improvements.

Supply and equipment preparedness

There was no accurate estimate of global ECMO capacity or activity at the time of the surge. Expanding equipment capacities and maintaining supply chains for consumables could be a significant challenge. Centers maintain a log of equipment and their movement field. While hoarding should be avoided, it is prudent to maintain adequate stock. Liaison with different industries is essential to ensure supply chains are maintained and resources are allocated where these are most needed in the country. The central coordination of supplies across a jurisdiction provided better oversight and resource utilization. Country-specific resource organizations/agencies helped tide over the supply emergencies as restrictions were applied due to import liabilities. Sharing the ECMO disposables across the country makes the process smoother.[11],[15]

  Future Perspectives of Extracorporeal Membrane Oxygenation Services Top

The future plan should be directed towards:

  • Raising awareness about the potential role of ECMO and increasing the availability to access extracorporeal support services and wide use of ECLS applications all over the country
  • Starting a fellowship clinical education program and certificate on high-quality courses with high-fidelity simulation on ECMO for medical and paramedical personnel (perfusionist, staff nurse, respiratory therapist)
  • Establishing unified ECMO providers' credentialing, privileging, and ECMO centers' accreditation on a national basis; moreover, encourage all reputable scientific bodies and societies to take on their roles in education, release national guidelines, and give scientific advisory support
  • Increasing investment in scientific research, conducting high-quality research toward best ECMO management and avoiding wasting time proving ECMO favorable outcomes are paramount to improving outcomes
  • Expanding the service all over the country to include the private sector and supporting nongovernmental ECMO programs initiatives to keep team members more engaged with the national program and working on decreasing the service cost
  • Implementing an organized and structured extracorporeal cardiopulmonary resuscitation program on a national level to save more lives; will first require optimizing the standards of emergency and ambulance services as well as communications between the many stakeholders in emergency response and the emergency room.

  Conclusion Top

The availability of ECMO services in Saudi Arabia has grown and improved dramatically during the past 5 years. Better resource allocation and lower operating costs are possible through ECMO organization and centralization model in providing the service.


The MOH national ECMO team is a group of ECMO experts across Saudi Arabia led by Dr. Mohamed Azzam; the team members are the authors and Dr. Alaa Azhari, Dr. Hasan Massloom, Dr. Faisal Al-tatar, Dr. Ayman Kharabah, Dr. Mostafa Rajab, Dr. Asia Ragaan, Dr. Mahdy, Dr. Ahmed Rajab, Dr. Ahmed Al Ohali, Dr. Yasir Ameen, Dr. Marwa Ead, Dr. Haitham Alzahrani, Dr. Reham Alharbi, Dr. Wadiah AlFilfil, Dr. Sayed Yousef, Dr. Rayan Qutob, Dr. Islam Seada, Dr. Naser Nasim, Dr. Zohdi Farea, Dr. Saud AlDugaither, Dr. Moaayed Alshowaish, Dr. Medhat Elsherbiny, Dr. Faisal Rebahi, Dr. Mohamed Alsharani, Dr. Wael AlQassem, Mr. Ismael Al Enezi, Mr. Bashar Abu Judah, Mrs. Hamsah Rajab, Mr. Rawan Qashish, Mr. Prabhagaran G. Franklin. The group would like to express their gratitude to Mrs. Velia Marta Antonine for the designs she contributed to the figures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rabie AA, Azzam MH, Al-Fares AA, Abdelbary A, Mufti HN, Hassan IF, et al. Implementation of new ECMO Centers during the COVID-19 pandemic: Experience and results from the middle East and India. Intensive Care Med 2021;47:887-95.  Back to cited text no. 1
Lebreton G, Schmidt M, Ponnaiah M, Folliguet T, Para M, Guihaire J, et al. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: A multicentre cohort study. Lancet Respir Med 2021;9:851-62.  Back to cited text no. 2
Shaefi S, Brenner SK, Gupta S, O'Gara BP, Krajewski ML, Charytan DM, et al. Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19. Intensive Care Med 2021;47:208-21.  Back to cited text no. 3
Combes A, Peek GJ, Hajage D, Hardy P, Abrams D, Schmidt M, et al. ECMO for severe ARDS: Systematic review and individual patient data meta-analysis. Intensive Care Med 2020;46:2048-57.  Back to cited text no. 4
Rabie AA, Asiri A, Rajab M, Mufti HN, Alsherbiny M, Azzam MH, et al. Beyond frontiers: Feasibility and outcomes of prolonged veno-venous extracorporeal membrane oxygenation in severe acute respiratory distress syndrome. ASAIO J 2021;67:339-44.  Back to cited text no. 5
Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet 2009;374:1351-63.  Back to cited text no. 6
Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 2018;378:1965-75.  Back to cited text no. 7
Goligher EC, Tomlinson G, Hajage D, Wijeysundera DN, Fan E, Jüni P, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a post hoc Bayesian analysis of a randomized clinical trial. JAMA 2018;320:2251-9.  Back to cited text no. 8
National Transformation Program Delivery Plan 2018-2020. Kingdom of Saudi Arabia Vision 2030. 2018. [2020-08]. Available from: https://vision2030.gov.sa/sites/default/files/attachments/NTP%20English%20Public%20Document_2810.pdf. [Last accessed on 2023 Jan 15].  Back to cited text no. 9
Mufti H, Bahudden H, Al Aseri Z, Azzam M. Extracorporeal membrane oxygenation in COVID-19: The Saudi ECLS-Chapter perspective. Saudi Crit Care 2020;4:115-8.  Back to cited text no. 10
Shekar K, Badulak J, Peek G, Boeken U, Dalton HJ, Arora L, et al. Extracorporeal life support organization coronavirus disease 2019 interim guidelines: A consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers. ASAIO J 2020;66:707-21.  Back to cited text no. 11
Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, et al. Extracorporeal membrane oxygenation for COVID-19: Updated 2021 guidelines from the extracorporeal life support organization. ASAIO J 2021;67:485-95.  Back to cited text no. 12
Mufti HN, Rabie AA, Elhazmi AM, Bahaudden HA, Rajab MA, Al Enezi IS, et al. The Saudi critical care society extracorporeal life support chapter guidance on utilization of veno-venous extracorporeal membrane oxygenation in adults with acute respiratory distress syndrome and special considerations in the era of coronavirus disease 2019. Saudi Med J 2021;42:589-611.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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