ECMO is not usually the first line therapy. It needs to be considered when first line modalities start failing or start causing unwanted effects. A patient deteriorating even after best of mechanical ventilatory efforts for the lungs OR after highest possible doses of inotropes/vasopressors, needs to be considered for ECMO provided the organ failure has a reversible cause.
The choice for the type of ECMO is determined by the predominant failure: V-A ECMO if cardiac and V-V ECMO if respiratory.
The following principles need to be thought out before accepting a patient for ECMO:
• Is the pulmonary/cardiac disease life threatening?
• Is the disease likely reversible?
• Are other diseases relative to prognosis?
• Is ECMO more likely to help than hurt?
• VA or VV?
INDICATIONS OF V-V ECMO
Lung disease that is:
- Acute .
- Life threatening
- Unresponsive to conventional /alternative therapy
4. Status asthmaticus
5. Severe COPD exacerbations
6. Trauma/Drowning/lnhalational injuries
7. Auto immune diseases
8. Broncho-pleural fistulas/Post-operative
WHEN DOES A RESPIRATORY FAILURE BECOMES AN ECMO CANDIDATE
If 2 or more of the following criteria’s exist even after four-six hours of maximal conventional ventilation in a reversible disease.
1. Pa02/Fi02 ratio < 100 with Fi02 1.0
2. Murray score > 3
3. Respiratory acidosis pH < 7.2 or PaCO2 > 100
4. A-a gradient > 600mm Hg
5. Lung compliance < 0.5 ml/cm of H20/Kg
INDICATIONS OF V-A ECMO
Acute reversible cardiac failures like
1. Failure to wean from bypass
2. Myocarditis: toxic (aluminium phosphide, beta blockers, CCB) orviral
3. Cardiogenic Shock: Acute MI and its complications
4. Pulmonary embolism
5. Sepsis with profound cardiac depression
WHEN DOES A CARDIAC FAILURE BECOMES AN ECMO CANDIDATE?
If 2 or more of the following criteria’s exist even after four-six hours of maximal conventional support in a reversible disease
1. Cardiogenic shock on high vasopressors (>=0.2mcg/kg/min of noradrenaline or equivalent vasopressors)
2. Lactate> 5 mmol/L
3. ScV02 < 65%
4. Low cardiac output with Organ failure: AKI, Hepatic, pulmonary edema)
5. Life threatening arrhythmias unresponsive to medical therapy