The criteria of eligibility to the extracorporeal treatment.

RESPONSE

Dear colleagues,

We agree with your analysis and believe that a higher circulation of the criteria of eligibility to the extracorporeal treatment, both for the treatment of severe cases of ARDS and for refractory shock, could lead to a greater number of patients treated and therefore saved.

However we cannot forget the  serious economic crisis that part of Europe is suffering, and the remarkable cut of the financial resources that seriously limits the possibility to carry out programs of widespread awareness campaign. Despite these hard limitations, other initiatives continue. A web-based interface for information (www.ecmonet.org) is continuously updated. A 24/24 hours and 7/7 days telephone Help-line ( 800 - 82 12 29 ) is always active in Italy for any kind of information and assistance. In engaging ourselves to keep alive the interest of the scientific community and looking forward to a “consensus conference” that will establish guidelines, we propose, as follows, the criteria of inclusion to the extracorporeal therapy.

Pathological Processes Suitable for

Severe pneumonia

ARDS

Acute lung (graft) failure following transplant

Pulmonary contusion

Others:

- Alveolar proteinosis

- Smoke inhalation

- Status asthmaticus

- Airway obstruction

- Aspiration syndromes

Respiratory Indications to V-V ECMO (after considering recruitment maneuvers, conventional or HFO protective lung ventilation, prone positioning, diuresis or renal replacement therapy for correction of volume overload, optimization of perfusion including restoration of oncotic pressure, intravascular volume, and inotropes). Identify acute reversible pulmonary injury and select patients early in the course.

Murray score >3

PaO2/FIO2 <100 (mm Hg) despite high PEEP (10 -20 cmH2O) on FiO2 >80%

Others:

- Intrapulmonary right-to-left shunt (Qs/QT) >30%

- Total thoracopulmonary compliance (CTstat) <30 ml/cmH2O

- Severe hypercapnia with PaCO2 >80 on FiO2 >90% or pH <7.20

- Maximal medical therapy >48 h

Contraindication to V-V ECMO

Absolute

Irreversible cardiac or pulmonary disease

Metastatic malignancy

Significant brain injury

Current intracranial hemorrhage

Major pharmacologic immunosuppression (absolute neutrophil count <400 )

Relative

Age >65-70 years, considering increasing risk with increasing age

Mechanical ventilation at high settings (FiO2 >90%, Plateau Pressure >30) >7-10 days

Multitrauma with high risk of bleeding

Pathological Processes Suitable for

Cardiogenic shock: Acute Myocardial Infarction and complications (including: wall rupture, papillary muscle rupture, refractory ventricular tachycardia or fibrillation) refractory to conventional therapy including intraaortic balloon pump

Post cardiac surgery: unable to wean safely from cardiopulmonary bypass using conventional supports

Drug overdose with severe cardiac depression

Myocarditis

Early graft failure: post heart/heart-lung transplant

Others:

- Pulmonary embolism

- Cardiac or major vessel trauma

- Massive hemoptysis/pulmonary hemorrhage

- Pulmonary trauma

- Acute anaphylaxis

- Peri-partum cardiomyopathy

- Sepsis with severe cardiac depression

- Bridge to transplant

Cardiac Indications to V-A ECMO (shock persist despite volume administration, maximal inotropic and vasoconstrictors support, mechanical ventilation and intra-aortic balloon counterpulsation - if appropriate -)

Cardiac index <2 L/min/m2

Lactate level >50 mg/dl or 5 mmol/L or Central Venous Oxygen Saturation - ScVO2 <65% with maximum medical management

Others:

- Systolic blood pressure less than 90 mmHg

- Low cardiac output

Contraindication to V-A ECMO

Absolute

Unrecoverable heart and not a candidate for transplant or Ventricular Assist Device (VAD)

Age >75 years

Chronic organ dysfunction (Emphysema, cirrhosis, renal failure)

Prolonged Cardiopulmonary Resuscitation without adequate tissue perfusion

Aortic dissection

Severe aortic valve regurgitation

Current intracranial hemorrhage

Extracorporeal Cardiac Life Support (ECLS) - Extracorporeal Cardiopulmonary Resuscitation (ECPR)

Indications to V-A ECMO include persistent cardiopulmonary arrest despite traditional resuscitative efforts.

ECLS-ECPR Contraindications to V-A ECMO

Initial rhythm asystole

Age >80 years

Chest compressions not initiated within 10 min of arrest (either bystanders or emergency medical team)

Cardiopulmonary Resuscitation >60 min before implanting ECMO

Pre-existing severe neurological disease (including traumatic brain injury, stroke, or severe dementia)

Current intracranial hemorrhage

Malignancy in the terminal stage

Cardiac arrest of traumatic origin with uncontrolled bleeding

Irreversible organ failure leading to cardiac arrest when no physiological benefit could be expected despite maximal therapy

Alberto Zangrillo

Professor of Anesthesiology and Intensive CareUniversità Vita-Salute San Raffaele, Milan