• ECMO centers should be actively involved in the Extracorporeal Life Support Organization (ELSO) including participation in the ELSO Registry.
• An Annual Data Report, utilizing the center's collated data, or the collated report of data submitted to the ELSO ECMO Registry, should be available for quality assurance review.
ELSO Guidelines for ECMO Centers 2014
• An Annual Data Report summarizing the center’s collected data regarding ECMO indications and results should be available for quality assurance review.
• Staff responsible for data collection should maintain the appropriate databases.
• ECMO centers are strongly encouraged to submit their data to large national or
international databases, such as the ELSO registry, to cross-analyze their results with other national and international institutions.
Combes et al., 2014
• Each intensive care department must enter in a national register all patients treated for severe ARDS (CR).
• ECMO is indicated for selected neonatal, pediatric and adult patients with severe, acute cardiac and/or respiratory failure who have failed to respond to conventional medical management.
ELSO Guidelines for ECMO Centers 2014
• The primary indication for ECLS is acute severe heart or lung failure with high mortality risk despite optimal conventional therapy. ECLS is considered at 50 % mortality risk, ECLS is indicated in most circumstances at 80 % mortality risk. Severity of illness and mortality risk is measured as precisely as possible using measurements for the appropriate age group and organ failure [detailed in patient-specific protocols].
• Other elective indications are to support heart and or lung function during temporary nonfunction, such as extensive bronchoalveolar lavage, operations on the trachea or mediastinum, or coronary artery occlusion during procedures.
• Most contraindications [for ECLS] are relative, balancing the risks of the procedure (including the risk of using valuable resources which could be used for others) vs. the potential benefits. The relative contraindications are: 1) conditions incompatible with normal life if the patient recovers; 2) preexisting conditions which affect the quality of life (CNS status, end stage malignancy, risk of systemic bleeding with anticoagulation); 3) age and size of patient; 4) futility: patients who are too sick, have been on conventional therapy too long, or have a fatal diagnosis [detailed in patient-specific protocols].
ELSO General Guidelines – all ECLS 2017
• ECMO is indicated for life-threatening forms of respiratory and/or cardiac failure where the risks of less invasive support are considered greater than the risks of ECMO and there is a reasonable expectationof long-terme survival without severe disability.
[Annex 1 of Guideline specifies :]
o ECMO is indicated for potentially reversible, life-threatening forms of respiratory and/or cardiac failure which are unresponsive to conventional therapy OR
Alfred Health Guideline – ECMO 2015
INDICATIONS/CONTRE-INDICATIONS
RECOMMANDATIONS REFERENCE
o Irreversible forms of cardiac or respiratory failure with option of VAD or transplantation (age under 50)
• Conditions where ECMO should be considered and is commonly associated with favourable clinical outcomes:
1. Respiratory failure (age < 65)
a. ARDS with primary lung injury from infection, aspiration or direct trauma b. Primary graft dysfunction following lung transplantation (within 7 days) c. Pulmonray vasculitis (Goodpasture’s, ANCA-associated, Autoimmune) 2. Cardiac failure (age < 65)
a. Acute fulminant myocarditis b. Cardiomyopathy first presentation
c. Primary graft failure: post heart/heat-lung transplant d. AMI-cardiogenic shcock without multiple organ failure
e. Drug overdose with profound cardiac depression or arrhythmia f. Pulmonary embolism with cardiogenic shock
g. In-hospital cariac arrest (with ECMO commenced within 60 min) h. Post cardiac surgery (failure to wean from CPB)
• Conditions where ECMO is often considered, but outcome is variable. Acceptance o patinets for WCMO support with thses conditions depends on individual patient
circumstances and must include discussion with experienced ECMO clinical services staff.
1. Respiratory failure
a. ARDS from secondary lung injury (e.g. intra-abdominal sepsis or burns) b. Lung transplant recipients 7-30 days post transplant
c. Lung transplant recipients > 30 days and suitable for re-transplantation from eCMO
d. Age > 65 (any cause) 2. Cardiac failure
a. Chronic cardiomyopathy (suitable for VAD and heart transplant) with acute severe heart failure or sepsis
b. Ischaemic cardiogenic shock with multiple organ failure or sepsis
c. Heart transplant recipient with chronic rejection and end stage heart failure and suitable for VAD and re-transplantation
d. Age > 65 (any cause)
• Contraindications for all forms of ECMO
1. Presence of additional severe chronic organ failures (cirrhosis, COAD, end-stage renal or hepatic failure)
2. Severe brain injury 3. Malignancy 4. Age > 75
[Annex 2 specifies absolute and relative contraindications]
o All types of ECMO:
§ Absolute:
- major pre-existing comorbidity (e.g irreversible neurological disease, cirrhosis with varices or encephalopathy)
- malignancy with expected limited survival
§ Relative:
INDICATIONS/CONTRE-INDICATIONS
RECOMMANDATIONS REFERENCE
- age > 65
- multi trauma or multi organ failure o Veno-venous (for respiratory failure)
§ Absolute:
- pulmonary hypertension mPAP > 50 mmHg - severe cardiac failure (EF < 25 %)
- cardiac arrest
§ Relative:
- high pressure
- high FiO2 IPPV for > 1 week o Veno-arterial (for cardiac failure)
§ Absolute:
- severe aortic valve regurgitation - aortic dissection
§ Relative:
- severe peripheral vascular disease
• Conditions where ECMO should not be applied, as survival from ECMO is very low.
Compassionate use of ECMO in thses conditions would be associated with remarkable patient circumstances.
1. Respiratory failure
a. Interstitial lung diseases/Pulmonary fibrosis (“negative” biopsy is required to exclude thos process for patients referred for ECMO at high clinical risk, such as known SLE, RA, scleroderma, sarcoidosis, dermatomyositis, methotrexate toxicity, etc.)
b. Lung transplant chronic rejection
c. Cystic fibrosis (infrequent use as bridge to transplant)
d. Severe acute restrictive lung disease with relatively clear CXR (early) is suggestive of cryptogenic organizing pneumonia (bronchiolitis obliterans with organizing pneumonia) and biopsy should be performed prior to instituting ECMO if this condition is suspected
e. Long-term immuno-suppressed (heart, renal, bone marrow transplant recipients, HIV, graft versus host lung disease)
2. Cardiac failure
1. Un-repaired moderate-severe aortic or mitral valve regurgiation
• ECMO should not be applied in some conditions in the presence of multiple acute organ failures prior to the initiation of ECMO, as survival is very low.
1. Respiratory failure with septic shock and 3 or more of the folllowing features a. Lactate > 10
b. Noradrenaline > 1.5µg/Kg/min c. Severe myocardial depression
d. Advanced microcirculatory failure with severe mottling or established peripheral purpura
2. Cardiogenic shock and 3 or more of the following features a. Lactate > 15
b. Advanced microcirculatory failure with severe mottling or established peripheral purpura
INDICATIONS/CONTRE-INDICATIONS
RECOMMANDATIONS REFERENCE
c. AST or ALT > 2000, or, INR > 4.5 d. Anuria > 4 hours
SUPPORT RESPIRATOIRE