Extracorporeal Membrane Oxygenation in Extreme Obesity: A Case Report and Review of the Literature.

The use of extracorporeal membrane oxygenation (ECMO) in the treatment of acute respiratory distress syndrome (ARDS) has been described as early as 1972 [Hill 1972]. Though a subsequent randomized trial showed no survival benefit over conventional mechanical ventilation [Zapol 1979], protective ventilation strategies and evolving extracorporeal technology improvements have led to a resurgence in the use of ECMO for patients with ARDS. The most recent randomized clinical trial, Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR), showed a significant mortality reduction in ARDS patients who were treated with ECMO [Peek 2009]. The results of the trial have led some to believe that the widespread adoption of ECMO as a feasible treatment for severe respiratory failure is forthcoming [MacLaren 2012; Del Sorbo 2014]. As the use of ECMO continues to increase, clinicians must be aware of the extremes in patient characteristics for which therapy might be considered reasonable. For example, many studies focus on the limited benefit of advanced therapies, such as ECMO, in the elderly [Salna 2014]. However, there is a paucity of literature on using veno-venous extracorporeal membrane oxygenation (VV ECMO) to treat ARDS in patients with extremity obesity [Ull 2015; Belliato 2016; Kadakia 2017]-a population that is often inherently discriminated against with regards to advanced medical and surgical therapies because of the practical challenges of treating someone of great size as well as the inherent social (and professional) biases against such patients. This case demonstrates application of ECMO in a patient with an extreme body mass index (BMI) and confirms the successful use of ECMO in this BMI patient population.