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

Jonah Rubin; Alison S Witkin; Jerome C Crowley; Eriberto Michel; David M Furfaro; Ricardo Teijeiro-Paradis; Annette Ilg; Raghu Seethala; Sophia Zhao; Eddy Fan

doi:10.1016/j.chest.2024.02.042

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

Chest. 2024 Feb 27:S0012-3692(24)00278-2. doi: 10.1016/j.chest.2024.02.042. Online ahead of print.

Authors

Affiliations

¹ Division of Pulmonary & Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Corrigan Minehan Heart Center ICU, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address: jrubin@mgh.harvard.edu.
² Division of Pulmonary & Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
³ Division of Cardiac Anesthesia, Massachusetts General Hospital, Boston, MA; Corrigan Minehan Heart Center ICU, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
⁴ Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA; Corrigan Minehan Heart Center ICU, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
⁵ Harvard Medical School, Boston, MA; Division of Pulmonary & Critical Care, Beth Israel Deaconess Medical Center, Boston, MA.
⁶ Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
⁷ Harvard Medical School, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
⁸ Division of Pulmonary & Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Analytica Now LLC, Brookline, MA.
⁹ Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.

PMID: 38423278
DOI: 10.1016/j.chest.2024.02.042

Abstract

Background: Use of venovenous extracorporeal membrane oxygenation (ECMO) is increasing, but candidacy selection processes are variable and subject to bias.

Research question: What are the reasons behind venovenous ECMO candidacy decisions, and are decisions made consistently across patients?

Study design and methods: Prospective observational study of all patients, admitted or outside hospital referrals, considered for venovenous ECMO at a tertiary referral center. Relevant clinical data and reasons for candidacy determination were cross-referenced with other noncandidates and candidates and were assessed qualitatively.

Results: Eighty-one consultations resulted in 44 noncandidates (54%), 29 candidates (36%; nine of whom subsequently underwent cannulation), and eight deferred decisions (10%). Fifteen unique contraindications were identified, variably present across all patients. Five contraindications were invoked as the sole reason to deny ECMO to a patient. In patients with three or more contraindications, additional contraindications were cited even if the severity was relatively minor. All but four contraindications invoked to deny ECMO to a patient were nonprohibitive for at least one other candidate. Contraindications documented in noncandidates were present but not mentioned in 21 other noncandidates (47%). Twenty-six candidates (90%) had at least one contraindication that was prohibitive in a noncandidate, including a contraindication that was the sole reason to deny ECMO. Contraindications were proposed as informing three prognostic domains, through which patterns of inconsistency could be understood better: (1) irreversible underlying pulmonary process, (2) unsurvivable critical illness, and (3) clinical condition too compromised for meaningful recovery.

Interpretation: ECMO 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 guide practice more definitively.

Keywords: bioethics; clinical decision-making; disparities; equity; extracorporeal membrane oxygenation (ECMO).