ECMO

Criteria for consulting ECMO service in patients with acute respiratory failure

The presence of escalating FiO₂ requirements and/or mechanical ventilator settings identifies the subset of patients with ARDS most prone to develop adverse effects of mechanical ventilation. At the bedside, ARDS progresses along a continuum, at times unpredictably. Our goal is to help in the management of acute lung injury. Early consultation, even if ECMO therapy is not needed immediately, is a welcome opportunity for discussing triggers for initiating ECMO for the specific patient in question. It also helps the service in planning for adequate equipment and manpower.

Our experience suggests that many contraindications mentioned in the literature derive from historical cohorts that may not reflect our practice and results. We would prefer to have a discussion with the referring service rather than have a set of rigid exclusion criteria.

The criteria listed below are general guidelines for an ECMO consult for acute respiratory failure.     

1)   Severe ARDS (PaO₂\FiO₂ ratio ≤ 100 with PEEP ≥ 5 cm H₂O)

2)   Moderate ARDS (PaO₂\FiO₂ ratio ≤ 200 mm Hg with PEEP ≥ 5 cm H₂O)

3)   Mild ARDS (PaO2\ FiO₂ ratio ≤ 300 with PEEP ≥ 5 cm H₂O) with steady worsening (2 or more ABG’s with declining PaO2 despite optimization of ventilator settings and hemodynamics)

4)   Patients with ARDS in whom adequate oxygenation is achievable only with ventilator settings that have a high likelihood of inducing ventilator induced lung injury (Tidal volumes > 6mL/kg, Plateau pressure ≥ 30 cm H₂O)

5)   Prone ventilation is being considered

Contraindications:

·      Age > 65yrs (relative contraindication)

Absolute Contraindications to all forms of ECMO include:

·      Non-recoverable cardiac disease

·      Non-recoverable respiratory disease

·      Non-recoverable neurological disease

·      Chronic severe pulmonary hypertension

·      Active malignancy, graft vs. host disease or significant immunosuppression

·      Weight > 140 kg

·      Advanced liver disease

·      AIDS with associated poor prognostic features:

Secondary malignancy, prior hepatic or renal failure (Crt > 250umol/l) or need for salvage anti-retroviral therapy

·      Unwitnessed cardiac arrest or CPR > 60min prior to commencement of ECMO (this includes set up - cannulation time)

Contacting the ECMO service –

Call the 'ECMO Specialist':

859-582-7448 (2-7488)

Office: 859-323-9914

Pager: 859-323-3000 *3311