Kathleen
Place on VV ECMO
Place on VA ECMO
Place on VA-V ECMO
Decline for ECMO Support
While your initial response might be “Duh!”, given the collective list of potential problems and contraindications to ECMO, let’s look more closely at the primary reason to turn down Kathleen for ECMO support.
Kathleen is 70. Some centers do have strict age cut-offs, but in present day most experienced centers have successfully supported many older patients, even into the 80’s, based on “physiologic age” rather than “chronologic age”.
She had ovarian cancer. Given the remoteness of her diagnosis and treatment, most centers would not decline support for that reason.
She has been on the ventilator 12 days. Once a relatively strict number (two frequently cited paper proposed a 7-day limit, and a 10-day limit). But experience has shown us that different patients react differently to the “toxic” levels of oxygen and high pressures, and no one number fits all circumstances. There are many ECMO survivors who have been on high ventilator support for more than 10 days, even a few weeks, so that alone should not disqualify her.
Risk of bleeding and her H.I.T. diagnosis. With the availability of Direct Thrombin Inhibitors and viscoelastic testing to monitor bleeding and fibrinolysis after recent surgery or injury, both these conditions are manageable by experienced ECMO teams.
Fluid overload, capillary leak, anasarca, renal insufficiency and albumin of 1.6. These are all very common and usually manageable when supporting septic patients on ECMO.
Occluded right internal jugular. Patients have been successfully supported with left subclavian, left internal jugular and high femoral vein inflow cannulas when the RIJ is not an option.
Pancreatitis. This can be extremely challenging to manage on or even off ECMO. Almost universally the ARDS from pancreatitis will not resolve until the inflammation in the pancreas resolves. But it can be done.
If the above list made you run away, no one would fault you. But some larger centers with more adult ECMO experience might take her on even with those challenges. But, the absolute kicker for Kathleen is the Pancytopenia. Patients with pancytopenia from overwhelming sepsis (as well as from recent or ongoing chemotherapy or BMT), do very poorly with or without ECMO support. If you were still on the fence previously, that should quickly knock you off.
Not surprisingly, Kathleen was declined for ECMO and expired within days of her overwhelming sepsis.