Referring Patients for ECMO

Deciding when to transfer a patient for ECMO is often a very difficult one. This decision can be facilitated by early consultation with an ECMO team physician, thereby allowing both teams to cooperatively decide when to transport a patient. However, when a patient is at high risk for failing maximal therapy the referring physician should decide to transfer before the patient is too unstable or moribund for safe transport. For this reason, it may be safer to transfer earlier in the course of illness rather than waiting and missing the transport window.

There are no standard or consistent criteria for transfer. The referring physician should begin to consider the need for ECMO when a patient has received appropriate medical management and continues to have a Pa02 of 50-70 mm Hg when the PIP is >30 cmH20 and the FI02 is over 70% for conventional ventilation, and in neonates after 6 hours of high frequency ventilation without improvement in oxygenation. After consultation with an ECMO physician the time of transfer can be determined through a team approach taking into account such items as transport time, type of transport needed, and availability of ECMO beds. Below are referral guidelines and how to reach us.

Neonatal Referrals

Gestational age > 32 weeks
Birthweight > 2,500 grams
No significant coagulopathy
No major intracranial hemorrhage
Mechanical ventilation < 10 days
Reversible lung injury
No lethal malformations
No major cardiac malformations

AaDO2 = [Patm-47-(PaCO2+PaO2)]/FiO2

> 600 torr for 4 to 12 hours

OI = [MAP x FiO2 x 100] / PaO2

25-40 for 1 to 6 hours

PaO2 35-50mmHg for 2-12 hours

Acute Deterioration:

PaO2 < 30-40 torr

pH < 7.25 for 2 hours

intractable hypotension

Pediatric Referrals

Respiratory Failure:
   PEEP > 8 cm H2O x 12 hours
   FiO2 > .8 x 12 hours
   PaO2/FiO2 < 150
   P(A-a) O2 > 450 mm Hg
Respiratory Acidosis:
pH < 7.28 with
PIP > 40 cm H2O or severe airleak

Duration of Ventilation:
   < 2 years <7 days
   2 - 8 years < 6 days
   > 8 years < 5 days
Reasonable certainty of quality of life

Adult Referrals

Hypoxemic respiratory failure

Failure of mechanical ventilation (PC-IRV) to reverse hypoxemia and improve lung compliance
Diffusely abnormal chest radiograph
Transpulmonary shunt > 30% on FiO2 > 0.6
Total static lung compliance < 0.5 ml/cm H2O/kg(or < 30 ml/cm H2O at Vt 10 ml/kg)
Lack of PEEP recruitment response (PEEP 5-->15 cm H2O)

Hypercarbic respiratory failure

Uncorrectable hypercarbia with pH < 7 and PIP > 45, or
PaCO2 > 45 despite Ve > 200 ml/kg/min

Exclusions

Contraindication to systemic anticoagulation (except surface-coated systems)
Terminal disease with short expected survival
Underlying moderate to severe chronic lung disease
Advanced multiple organ failure syndrome
Severe immunosuppression
Mechanical ventilation > 5 days
Severe pulmonary hypertension (MPAP > 45 or > 75% systemic)

How to reach us

ECMO Coordinator

Sheree Jordan, RN, BSN, MSN
   Office: 318-675-7610
   Mobile: 318-518-7289
   mjorda@lsuhsc.edu

ECLS Program Director

Steven Conrad, MD PhD
   MICU: 318-675-7215
   Pager: 1-877-772-8543
   sconrad@lsuhsc.edu