See: [ECMO inclusion criteria](https://ecmo.icu/ecpr-inclusion-criteria/?parent=menuautoanchor-27&def=true) ; [bear](bear://x-callback-url/open-note?id=BB73838E-9800-40A4-A206-6DF000D94086) [bear RMH ECMO](bear://x-callback-url/open-note?id=F203B45B-A699-4EA0-B39B-F27BFACFF1BC-498-0000024B16671D71) - [RMH ECMO Criteria PDF](https://publish-01.obsidian.md/access/c7a2dec118c099030cde82ebda685acb/attachments/ECMO_case_selection_2.pdf) [Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in Australia: a narrative review.](bookends://sonnysoftware.com/ref/DL/246179), [ECPR - alfred ICU 2018](https://intensiveblog.com/everything-ecmo-025/) Trials: [[INCEPTION]], [[ARREST]], [CHEER3 pre-hospital study (Alfred)](bookends://sonnysoftware.com/ref/DL/200448) > This article is in large part regarding **E-CPR**, rather than the entire quagmire that is ECMO. Keep in mind there are other times ECMO should be considered, for example: > > ***Toxicology:*** > - cardioplegia from [[Calcium channel blocker overdose]] or [[beta blocker overdose]] > - [[Sodium channel blocker|sodium channel blocker toxicity]] (eg [[lamotrigine overdose]]) > - [Hydroxychloroquine/chloroqine tox](x-devonthink-item://7F1E7492-F8F3-4191-A3F4-35AEC761F4A6) > - [[Funnel-web spider]] > - others > > ***Non-tox:*** > - [[Hypothermia]] > - severe resp emergencies (VV ECMO) > - [[Asthma]] > - [[ARDS]] > - obstructive shock from [[Pulmonary Embolism]] > - other cardiac emergencies leading to cardiogenic shock like [[Myocarditis]] or refractory [[Ventricular Tachycardia|VT]] # general inclusion criteria ![[Pasted image 20240428011522.png]] Does not apply to accidental hypothermia ROSC <20min is considered continuous cardiac arrest; ROSC >20min is considered as separate arrests, the longer cardiac arrest time is taken # Indications - refractory VF - cardiogenic shock post MI - hypothermia and hyperthermia - toxicology (eg TCA, CCB OD) - passive PE - myocarditis - cardiomyopathy bridging to VAD or transplant # survival stats | Number of criteria outside inclusion | Associated survival \* | | ------------------------------------ | ---------------------- | | All criteria fulfilled | ~ 46% | | Only one | ~ 12% | | Two or more | NO survivor recorded | ![[Pasted image 20240428012249.png]] \* Only OHCA Factors at the bedside that almost certainly _favour exclusion_ - Age >65 - End-tidal CO2 less than 10 mmHg - Femoral cannulation impossible (e.g. iliacofemoral occlusion / occluded IVC filter / severe peripheral vascular disease) - Known aortic regurgitation > mild - Presence of pericardial effusion or tamponade with suspected aortic dissection # Factors when considering ECMO appropriateness **patient factors:** | factor | justification | | --------------------- | ---------------------------------------------------------------------------------------------------------------------- | | age | mortality ↑ with age; physiological reserve ↓ <br>Alfred ECMO suggests age 65 relative contraindication, > 75 absolute | | co-morbidities | advanced chronic organ failure | | underlying malignancy | non-responsive malignancy represents absolute contraindication | | patient anatomy | unfavorable anatomy may preclude some vascular access required for ECMO | | patient wishes | GoC, advanced health directive | **Clinical factors** | factor | justification | | --------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | reversibility of disease | ECMO not offered to pts who do not have a reversible condition where appropriate organ support leads to recovery of the patient.<br>eg: end-stage lung or heart failure without acceptance by a transplant service | | diagnosis | myocarditis, refractory VT/VF, post-transplant, pneumonia, asthma, burns/trauma, overdose have better outcomes | | number of failing organ systems | established multi-organ failure represents contraindication to ECMO. <br>early acute renal failure in cardiogenic shock doesn't represent a contraindication. severe hypoxic brain injury IS an absolute contraindication | | acute physiology and shock status | profound and established shock may represent an irreversible state despite ECMO, as flow rates may not be high enough to manage the cardiac demand | ## Patients who are not suitable for E-CPR >[!warning] ECMO STOP Criteria RMH > not suitable for E-CPR if any of these > - age > 65 > - treatment limitations > - life-limiting comorbidities (eg organ failure/malignancy) > - \> 40 min since arrest (hypothermia < 32 deg and drug intoxication exceptions) > - need to start cannulation within 40 min to be on ECMO within 60 min of arrest > - unwitnessed arrest > - asystole as initial rhythm > - greater than 5 min without CPR > - no realistic prospect of reversal ![[Pasted image 20241023172424.png]] # Related questions ## ecmo - [ ] 76Q: [OHCA with Long Downtime](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=8) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=7) - [ ] 77Q: [OHCA with Long Downtime](x-devonthink-item://EB2A381E-D8D3-4236-B51F-2DF81CE08885?page=15) -- [Answer](x-devonthink-item://8455B512-D9BD-4314-927B-D3208619EE2A?page=14)