VV-ECMO Evaluation for Refractory ARDS
VV-ECMO Evaluation for Refractory ARDS: Severe ARDS - Consider ECMO → Optimal Conventional Therapy Attempted? → Optimize Conventional Therapy First → Me...
Interactive Decision Tree
Algorithm Steps
- ▶Start
Severe ARDS - Consider ECMO
P/F <80 despite optimal conventional therapy
- ◆Decision
Optimal Conventional Therapy Attempted?
ECMO is rescue, not replacement
- Lung protective ventilation
- Prone positioning attempted
- Adequate sedation/paralysis
- PEEP optimization
- ●Action
Optimize Conventional Therapy First
ECMO is not indicated yet
- Prone positioning if not done
- Trial of NMBA
- PEEP titration
- Treat underlying cause
- ◆Decision
Meets ECMO Indications?
ELSO/ATS criteria
- P/F <80 for >6h despite optimal care
- OR P/F <50 for >3h
- OR pH <7.25 with PaCO2 >60 for >6h
- Potentially reversible etiology
- ◆Decision
Check Contraindications
Absolute and relative
- ⚠Warning
⚠️ Absolute Contraindications
ECMO not appropriate
- Irreversible underlying disease
- Unrecoverable neurologic injury
- Uncontrolled bleeding
- Contraindication to anticoagulation
- Advanced malignancy/end-stage organ failure
- ✓Outcome
Continue Without ECMO
Supportive care, reassess prognosis
- ●Action
Relative Contraindications - Discuss
Case-by-case ECMO center decision
- Age >65 (relative, not absolute)
- BMI >40 (cannulation challenges)
- Prolonged mechanical ventilation >7 days
- Immunocompromised (consider)
- Prior CPR (assess neuro status)
- ●Action
Calculate RESP Score
Prognostic tool - not deterministic
- Age, immunocompromise, MV duration
- Diagnosis, CNS dysfunction
- Acute associated conditions
- Score correlates with survival
- Class I (≥6): ~92% survival
- Class V (≤-6): ~18% survival
- ●Action
Contact ECMO Center EARLY
Do not wait until patient is moribund
- Call before patient deteriorates further
- Discuss candidacy with ECMO team
- Prepare for potential transfer
- Mobile ECMO teams may cannulate remotely
- ◆Decision
ECMO Center Decision
Accept for ECMO?
- ●Action
Transfer/Cannulation for ECMO
Coordinate with ECMO team
- Mobile ECMO team may travel to patient
- Cannulate before transport if unstable
- Femoral or IJ cannulation (VV)
- Initial flows 3-4 L/min, titrate
- ✓Outcome
On VV-ECMO
Continue at ECMO center
- ●Action
Not ECMO Candidate
Continue aggressive conventional care
- Maximize conventional therapies
- Goals of care discussion
- Palliative care consultation if appropriate
Guideline Source
An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Requires ECMO center - early referral essential
- Resource-intensive, limited availability
- RESP score is prognostic, not diagnostic
- Does not replace clinical judgment
- Transport logistics may limit access
Contraindicated Populations
Applicable Regions
Global: ELSO guidelines + ATS 2024
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Related Resources
Frequently Asked Questions
What is the VV-ECMO Evaluation for Refractory ARDS?
The VV-ECMO Evaluation for Refractory ARDS is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline.
What guideline is the VV-ECMO Evaluation for Refractory ARDS based on?
This algorithm is based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline (DOI: 10.1164/rccm.202311-2011ST).
What are the limitations of the VV-ECMO Evaluation for Refractory ARDS?
Known limitations include: Requires ECMO center - early referral essential; Resource-intensive, limited availability; RESP score is prognostic, not diagnostic; Does not replace clinical judgment; Transport logistics may limit access. Individual patient factors may require deviation from these recommendations.
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