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Quick Tip for Families in Intensive Care: When Should ECMO (Extracorporeal Membrane Oxygenation) Be Initiated in Intensive Care?

When should ECMO be initiated in intensive care? That’s what I’m going to answer today.

My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

Extracorporeal membrane oxygenation is a lifesaving support system used in ICU for patients with severe cardiac or respiratory failure when conventional treatments are failing. It’s essentially used as a last resort to give the heart and/or lungs time to rest and recover. When to initiate ECMO in intensive care?

Refractory respiratory failure. Veno-venous ECMO, also known as VV ECMO, is used for severe lung failure. Initiation is considered when ARDS, also known as acute respiratory distress syndrome, also known as lung failure, is severe and unresponsive to optimal ventilator support, including high PEEP (Positive End-Expiratory Pressure), prone positioning, neuromuscular blockade, etc. PaO2/FiO2 ratio, less than 80 millimeter per mercury for greater 6 hours, despite optimization.

What that means is if PO2 in an arterial blood gas is less than 80 millimeter per mercury, but FiO2 (Fraction of Inspired Oxygen), which is the oxygen that’s delivered from the ventilator, is going up and up for more than 6 hours, that’s another indication to initiate ECMO. And just to keep in mind, the air that you and I are breathing is room air, it’s 21% of oxygen, whereas if someone needs ECMO, it’s usually at 100% of oxygen from the ventilator. Also, in an arterial blood gas, PaO2 or oxygen levels in the arteries, if it’s less than 80, 70 millimeter per mercury, that’s really when it’s getting concerning and dangerous.

Next, severe hypercapnia with pH less than 7.2, despite maximal ventilator settings. What’s hypercapnia? Hypercapnia is high CO2 or high carbon dioxide. And with high carbon dioxide levels comes a lower ph. And if pH just keeps dropping below 7.2, again, that is when it’s really getting, getting dangerous and it’s a sign of severe, or can be a sign of severe lung failure, and then ECMO needs to be initiated to bypass the mechanisms of the lungs, so that oxygenation and removal of carbon dioxide can happen outside of the body, which is the ECMO machine, so that the body can continue to function. Murray scores greater than 3 or oxygenation index greater than 40.

What’s the Murray scores? It’s a tool used to assess the severity of acute lung injury or acute respiratory distress syndrome in patients. It’s a scoring system designed to evaluate the severity of lung injury in patients with acute lung injury, and ARDS. It considers four key parameters, hypoxemia measured by the PaO2/FiO2 ratio that I just explained.

Positive end expiratory pressure (PEEP), the amount of pressure maintained in the lungs at the end of exhalation, lung compliance, the ease with which the lungs can be inflated, and radiographic findings, assessment of the chest X-ray for signs of lung injury such as infiltrates. And each of these criteria is given a score from 0 to 4, with higher scores indicating more severe impairment. The individual scores are summed, and the total is divided by the number of components to get the final Murray score. A score of 0 indicates no lung injury. Scores between 1 and 2.5 generally indicate mild to moderate lung injury, and the scores greater than 2.5 is typically considered severe lung injury.

Next, let’s look at refractory cardiac failure or cardiogenic shock, which is basically veno-arterial ECMO, which is VA ECMO, supports both heart and lungs. Consider ECMO initiation for VA ECMO when persistent hypotension, systolic blood pressure is less than 90 millimeter per mercury, or MAP is less than 65 millimeter per mercury despite high dose inotropes and vasopressors. Evidence of end organ dysfunction, i.e., rising lactate, lower urine output, altered mental status.

Ejection fraction is less than 20 to 25% with signs of shock. What is ejection fraction? Ejection fraction is referring to the contractility or the pump function of the heart. If it’s only 20 to 25%, that means the heart is coming close to stopping to beat. That’s when ECMO needs to be initiated so the heart can recover. Can start a recovery process. Cardiac arrest, where high-quality CPR is ongoing and reversible cause is suspected. Cardiac arrest or ECPR, extracorporeal CPR. ECMO may be used during or after cardiac arrest if witness arrest with immediate CPR. Short, no flow, and low flow times less than 60 minutes. Potentially irreversible cause, i.e., myocardial infarct, which is also known as a heart attack, PE, known as pulmonary embolism, myocarditis, or drug overdose. And this can be a bridge to recovery, heart transplant or long-term support. Severe myocarditis, pulmonary embolism or post cardiotomy shock. As a bridge to LVAD or heart or lung transplant in selected patient.

What’s LVAD? LVAD is the left ventricular assist device. And it’s a mechanical pump implanted in the chest to help a failing heart pump blood to the rest of the body. It’s a type of ventricular assist device specifically for the left ventricle, the heart’s main pumping chamber and LVADs are used when the heart is too weak to circulate blood effectively, often in case. In cases of end-stage heart failure or as a bridge to a heart transplant.

What are contraindications for ECMO? And I’m referring here to relative or absolute. ECMO is usually not initiated when there is irreversible organ failure, i.e., severe brain damage, multi-organ failure, prolonged mechanical ventilation, 7 to 10 days, or greater with high ventilation settings, uncontrolled bleeding or contraindications to anticoagulation. The reason that might be an exclusion for ECMO is when someone is going on ECMO, they need to go on a heparin infusion as a blood thinner, otherwise, the blood will clot running through the ECMO filter. If there’s uncontrolled bleeding or contraindications to anticoagulation such as heparin, that’s when ECMO often can’t be initiated.

Next, advanced age or poor baseline functional status. Here’s the bottom line. Initiate ECMO when the underlying condition is potentially reversible for heart or for lung failure. The patient is failing maximal conventional therapy. The benefits outweigh the risks, and ECMO can serve as a bridge to recovery, other decisions, or to a heart or lung transplant. I hope that answers that question today.

I have worked in critical care nursing for over 25 years in 3 different countries where I worked as a nurse unit manager for over 5 years in intensive care. And I’ve been consulting and advocating for families in intensive care since 2013, here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care, including for clients on ECMO. I mean, when I worked in intensive care, I’ve looked after many patients on ECMO in intensive care.
You can verify that we have saved many lives for our clients in intensive care by going to our on testimonial section  at intensivecarehotline.com or you can go to our intensivecarehotline.com podcast section  where we have done client interviews.

Because our advice is absolutely life changing, that’s why we have saved so many lives for our clients in intensive care. We improve the lives of families in intensive care instantly by making sure they make informed decisions, have peace of mind, control, power and influence, making sure their loved ones get the best care and treatment, always.  And that’s why you can join a growing number of members and clients that we have helped over the years. You can join the growing number of clients and members by joining us here at intensivecarehotline.com.

That’s why I do one on one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you, and I talk to you and your families directly. I hand hold you through this once in a lifetime situation. That you simply can’t afford to get wrong. I also talk to doctors and nurses directly. And when I talk to doctors and nurses directly with you on your behalf, or I set you up with the right questions to ask, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. I also represent you in family meetings with intensive care teams. We also do medical record reviews in real time, so that you can get a second opinion in real time.

We also do medical record reviews after intensive care. If you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly.  In the membership, you have access to me and my team 24 hours a day in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded that are exclusively accessible to our members only.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to support at intensivecareholine.com with your questions.

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Thank you so much for watching.

This is Patrick Hutzel from intensivecarehotline.com, and I will talk to you in a few days.
Take care

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