V-V ECMO: Indications and Contraindications:
Indications
V-V ECMO should only be considered in patients with preserved cardiac function, who have one or more of the following:
- Hypoxemic respiratory failure associated with a high mortality rate:
- Persistently low PF ratio (< 80) despite optimal management with a mechanical ventilator.
- Hypercapnic respiratory failure:
- Refractory hypercapnia causing acidosis despite optimal management with a mechanical ventilator.
- Persistently elevated end-inspiratory plateau pressures despite optimal management with a mechanical ventilator.
Contraindications
Strictly speaking, there are no absolute contraindications to ECMO. Each patient should be considered on a case-by-case basis. However, relative contraindications to V-V ECMO include:
- Shock resulting from a low cardiac output state:
- V-V ECMO does not provide hemodynamic support.
- Severe pulmonary hypertension:
- Despite improvement in oxygenation and CO2 clearance, V-V ECMO may not be able to support right-sided heart dysfunction.
- Prolonged high ventilatory pressures (i.e. end inspiratory plateau pressures > 30 cmH2O for longer than 7 days):
- In this case, the lung parenchyma will probably have sustained such a great deal of injury during this time that it will be unlikely to regain any function.
- Prolonged elevated oxygen requirements (i.e. FiO2 > 80% for longer than 7 days):
- Prolonged exposure to oxygen is likely to produce irreversible lung toxicity to the extent that they will be unlikely to recover any function.
- Recent or expanding haemorrhage:
- The degree of systemic anticoagulation required will likely exacerbate the haemorrhage.
- Lack of vascular access.
- Advanced age:
- Although there is no strict age cutoff criteria, the older a patient is the worse they will do and this must be factored into the decision.
Common examples of V-V ECMO use at TGH include:
- ARDS refractory to lung protective ventilation strategies, neuromuscular blockade, and proning.
- Refractory hypoxemia or hypercarbia in a pre-lung transplant patient.
- Primary graft dysfunction post lung transplant.
- Severe asthma or COPD exacerbation.
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