From the Guidelines
ECMO should be initiated in the emergency department for patients with severe cardiopulmonary failure who are unresponsive to conventional therapy but have potentially reversible conditions, such as refractory cardiac arrest, severe respiratory failure with PaO2/FiO2 ratio <80, refractory cardiogenic shock, or massive pulmonary embolism with hemodynamic collapse, as supported by the most recent guidelines 1. When considering ECMO initiation, it is crucial to rapidly assess eligibility criteria, including age, absence of severe comorbidities, no irreversible brain injury, and no contraindications like uncontrolled bleeding.
- Key considerations for ECMO initiation include:
- Refractory cardiac arrest with ongoing CPR beyond 10 minutes
- Severe respiratory failure with PaO2/FiO2 ratio <80 despite optimal ventilator management
- Refractory cardiogenic shock with evidence of end-organ hypoperfusion despite vasopressors and inotropes
- Massive pulmonary embolism with hemodynamic collapse Early consultation with the ECMO team is vital while continuing resuscitative efforts, and preparation should include establishing large-bore vascular access, administering heparin, ensuring blood product availability, and preparing for cannulation, as outlined in recent position papers 1. The decision to initiate ECMO should be made on a case-by-case basis, taking into account the patient's individual circumstances and the availability of specialized teams and equipment, with the goal of improving morbidity, mortality, and quality of life outcomes 1.
From the Research
Initiation of Extracorporeal Membrane Oxygenation (ECMO) in the Emergency Department
The decision to initiate ECMO in the emergency department is based on several factors, including the severity of respiratory failure and the patient's response to conventional therapy.
- ECMO is used for acute severe respiratory failure in advanced ICUs, with a current survival rate of 60-70% 2.
- The Extracorporeal Life Support Organization (ELSO) Guidelines provide inclusion criteria for ECMO, including PaO2 / FiO2 < 80 for at least 3 hours or pH < 7.25 for at least 3 hours 3.
- ECMO can be used as a respiratory support (venovenous ECMO) or as a cardiac and/or respiratory support (venoarterial ECMO) 3, 4.
- The initiation of ECMO has emerged as a salvage intervention in patients with cardiogenic shock or cardiac arrest refractory to standard therapies 4.
Patient Selection
The selection of patients for ECMO is critical, as it is a very invasive therapy that should only be used in patients with extremely severe respiratory failure who have failed to respond to conventional therapies.
- Patients with severe ARDS (acute respiratory distress syndrome) may benefit from ECMO, as it reduces or eliminates the risk of lung damage associated with invasive mechanical ventilation 3.
- Age and pH at 48 h after onset of ECMO are independent predictors of survival in patients with respiratory failure 5.
Clinical Considerations
The management of ECMO requires advanced medical care, and the emergency department should be prepared to provide this level of care.
- ECMO does not cure the heart and/or lungs, but it gives the patient a chance to survive a period when these organs are inefficient 3.
- The use of ECMO in the emergency department requires careful consideration of the patient's underlying condition, the potential benefits and risks of ECMO, and the availability of advanced medical care 6, 4.