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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...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Severe ARDS - Consider ECMO

    P/F <80 despite optimal conventional therapy

  2. 02Decision

    Optimal Conventional Therapy Attempted?

    ECMO is rescue, not replacement

    • Lung protective ventilation
    • Prone positioning attempted
    • Adequate sedation/paralysis
    • PEEP optimization
  3. 03Action

    Optimize Conventional Therapy First

    ECMO is not indicated yet

    • Prone positioning if not done
    • Trial of NMBA
    • PEEP titration
    • Treat underlying cause
  4. 04Decision

    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
  5. 05Decision

    Check Contraindications

    Absolute and relative

  6. 06Warning

    ⚠️ Absolute Contraindications

    ECMO not appropriate

    • Irreversible underlying disease
    • Unrecoverable neurologic injury
    • Uncontrolled bleeding
    • Contraindication to anticoagulation
    • Advanced malignancy/end-stage organ failure
  7. 07Outcome

    Continue Without ECMO

    Supportive care, reassess prognosis

  8. 08Action

    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)
  9. 09Action

    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
  10. 10Action

    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
  11. 11Decision

    ECMO Center Decision

    Accept for ECMO?

  12. 12Action

    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
  13. 13Outcome

    On VV-ECMO

    Continue at ECMO center

  14. 14Action

    Not ECMO Candidate

    Continue aggressive conventional care

    • Maximize conventional therapies
    • Goals of care discussion
    • Palliative care consultation if appropriate
  15. Path rejoins step 07Shared downstream outcome
  16. Path rejoins step 03Shared downstream outcome
  17. Path rejoins step 04Shared downstream outcome

Guideline Source

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline

DOI: 10.1164/rccm.202311-2011STView 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

pediatric

Applicable Regions

USEUGlobal

Global: ELSO guidelines + ATS 2024

Version 1Next review: 2028-01-01

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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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