Manuel Celedon, MD
Use of Extracorporeal Membrane Oxygenation in the Emergency Department
Utilization of Extracorporeal Membrane Oxygenation (ECMO) has increased dramatically in recent years. Its utilization is no longer isolated to the use as a support device in the operating room. It is now seen as a viable intervention option for patients who present with acute cardiac and/or pulmonary failure, refractory to conventional medication and/or mechanical ventilatory support. Studies have shown that patients have better outcomes when ECMO is initiated early.
Utilization of ECMO in the Emergency Department (ED) can be divided into pulmonary vs cardiac support. Venovenous ECMO provides an alternative treatment of patients in acute respiratory failure, secondary to reversible causes such as acute respiratory distress syndrome (ARDS). A meta-analysis looked at 28 randomized controlled trials, comparing outcomes based on intervention modalities for the treatment of moderate to severe ARDS. It was found that patients treated with prone positioning and Venovenous ECMO had a lower 28-day mortality compared to conventional mechanical ventilation alone. Other implementations of ECMO include extracorporeal life support (ECLS). ECLS is primarily used in patients who may not stable enough to undergo other forms of cardiac support. An observational study found that patients who survived the ECLS bridge to left ventricular assist device placement had an 80% 1-year survival. Other observational studies in the use of Venoarterial ECMO in the treatment of refractory cardiogenic shock found that early support can rescue up to 40% of otherwise fatal cases.
All physicians should be aware of the capabilities and limitations of ECMO. Recognizing candidates early in the hospital course will minimize delays in initiating ECMO, or at the very least, initiating the transfer process to an ECMO-equipped facility. The procedure is not free of risks and should not be done without through assessment, but earlier utilization of this intervention is key when conventional treatments have failed.