Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

Abstract

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Keywords: ARDS; ECMO; acute respiratory distress syndrome; contraindication; extracorporeal membrane oxygenation; indication.

Figure 1

Algorithm to indicate ECMO initiation; adapted from [19], modified from [1,5,20]. Abbreviations: ARDS = acute respiratory distress syndrome, paO₂ = partial arterial pressure of oxygen, FiO₂ = inspiratory oxygen fraction, paCO₂ = partial arterial pressure of carbon dioxide, PEEP = positive end-expiratory pressure, VILI = ventilator-induced lung injury, P-SILI = patient self-inflicted lung injury.

Figure 2

Sliding scales of relative contraindications. This figure is intended to illustrate the interplay between the continuous relative contraindications. A value in a red section in one or two categories can be countered by values in the green or at times yellow sections in another category.

Figure 3

Algorithm to include contraindications in the process of initiation of ECMO treatment after the indication has been confirmed according to Figure 1. Abbreviations: DN(A)R = do not attempt resuscitation, SAPS II = Simplified Acute Physiology Score first revision, SOFA = Sepsis-Related/Sequential Organ Failure Assessment, PRESERVE = Predicting Death of Severe ARDS on vvECMO, RESP = Respiratory Extracorporeal Membrane Oxygenation Survival Prediction, PRESET = Prediction of Survival on ECMO Therapy, BMT = bone marrow transplantation, HSCT = human stem-cell transplantation, GvHD = graft-versus-host disease, ICH = intracranial hemorrhage, ECMO = extracorporeal membrane oxygenation.