Venovenous Extracorporeal Membrane Oxygenation Candidacy Decision-Making: Lessons and Hypotheses From a Single-Center Observational Analysis

Abstract

BackgroundUtilization of veno-venous extracorporeal membrane oxygenation (V-V ECMO) is increasing, but candidacy selection processes are variable and subject to bias. Research QuestionWhat are the reasons behind V-V ECMO candidacy decisions, and are decisions made consistently across patients? Study Design and MethodsProspective observational study of all patients, admitted or outside hospital referrals, considered for V-V ECMO at a tertiary referral center. Relevant clinical data and reasons for candidacy determination were cross-referenced with other non-candidates and candidates and qualitatively assessed. ResultsEighty-one consultations resulted in 44 (54%) non-candidates, 29 (36%) candidates (9 were subsequently cannulated), and 8 (10%) deferred decisions. Fifteen unique contraindications were identified, variably present across all patients. Five contraindications were invoked as the sole reason to decline a patient. In patients with three or more contraindications, additional contraindications were cited even if their severity was relatively minor. All but four contraindications invoked to decline a patient were non-prohibitive for at least one other candidate. Contraindications documented in non-candidates were present but not mentioned in 21 (47%) other non-candidates. Twenty-six (90%) candidates had at least one contraindication that was prohibitive in a non-candidate, including a contraindication that was the sole reason to decline. Contraindications were proposed as informing three prognostic domains, through which patterns of inconsistency could be better understood: (1) irreversible underlying pulmonary process, (2) unsurvivable critical illness, and (3) clinical condition too compromised for meaningful recovery. InterpretationECMO candidacy decisions are inconsistent. We identified four patterns of inconsistency in our center and propose a three-domain model for understanding and categorizing contraindications, yielding five lessons that may improve candidacy decision processes until further research can more definitively guide practice.