CLINICAL PATHWAY AND PROTOCOLS TO FOLLOW FOR ECMO
GUIDELINES FOR CARDIAC FAILURE
Indication for ECMO in adult cardiac failure is cardiogenic shock:
- Inadequate tissue perfusion manifested as hypotension and low cardiac output despite adequate intravascular volume.
- Shock persists despite volume administration, inotropes and vasoconstrictors, and intraaortic balloon counterpulsation if appropriate.
- Typical causes: Acute myocardial infarction, Myocarditis, Peripartum Cardiomyopathy, Decompensated chronic heart failure, Post cardiotomy shock.
- Septic Shock is an indication in some centers.
Guidelines on relative survival without ECMO:
IABP score postcardiotomy(Hausmann H Circ 2002)
Samuels score postcardiotomy (Samuels LE J Cardiac Surg 1999)
Options for temporary circulatory support Surgical temporary VAD: Abiomed, Levitronix Percutaneous VAD:TandemHeart, Impella
ECMO: Advantages: Biventricular support, bedside immediate application, oxygenation, Biventricular failure, Refractory malignant arrythmias, Heart failure with severe pulmonary failure
A. ECMO is a bridge to...
Recovery: Acute MI after revascularization, Myocarditis, Postcardiotomy Transplant: Unrevascularizable acute MI, Chronic heart failure Implantable circulatory support: VAD, TAH
B. Contraindications to ECMO
- Absolute: Unrecoverable heart and not a candidate for transplant or VAD, Advanced age, Chronic organ dysfunction (emphysema, cirrhosis, renal failure), Compliance (financial, cognitive, psychiatric, or social limitations), Prolonged CPR without adequate tissue perfusion.
- Relative: Contraindication for anticoagulation, Advanced age, Obesity.
GUIDELINES FOR RESPIRATORY FAILURE
- In hypoxic respiratory failure due to any cause (primary or secondary) ECLS should be considered when the risk of mortality is 50% or greater, and is indicated when the risk of mortality is 80% or greater.
- 50% mortality risk is associated with a PaO2/FiO2 < 150 on FiO2 > 90% and/or Murray score 2-3.
- 80% mortality risk is associated with a PaO2/FiO2 < 100 on FiO2> 90% and/or Murray score 3-4 despite optimal care for 6 hours or more.
- CO2 retention on mechanical ventilation despite high Pplat (>30 cm H2O)
- Severe air leak syndromes
- Need for intubation in a patient on lung transplant list
- Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)
There are no absolute contraindications to ECLS, as each patient is considered individually with respect to risks and benefits. There are conditions, however, that are associated with a poor outcome despite ECLS, and can be considered relative contraindications.
- Mechanical ventilation at high settings (FiO2 > .9, P-plat > 30) for7 days or more
- Major pharmacologic immunosuppression (absolute neutrophil count <400/mm3)
- CNS hemorrhage that is recent or expanding
- Non recoverable co morbidity such as major CNS damage or terminal malignancy
- Age: no specific age contraindication but consider increasing risk with increasing age
All guidelines are in reference to ELSO (Extrcorporeal life support organization) and international guidelines including American and European society of ECMO.