Further information is available

• Safer Care Victoria’s Implementing the Victorian ECMO Service recommendations, appendix 3.3 and 3.4
• ECMO.icu

The five tenets of case selection are give below to provide insight into case selection process.

1. ECMO is a broad term that covers multiple forms of physiological support for cardiac and respiratory failure. In cases of severe respiratory or cardiac failure, ECMO can provide physiological stability and prolong life where less invasive forms of support cannot.

2. ECMO can provide an enduring benefit to the patient when its use results in patient survival with a level of function consistent with the patient’s preferences and values.

3. ECMO may benefit the patient by providing physiological support, preventing additional organ damage, and prolonging immediate survival. It can assist patient care by:

• Supporting recovery and return to health
• Bridging to long term mechanical support or organ transplantation 
• Providing time and physiological stability to allow additional investigation and establish informed prognostication
• Facilitating disease specific treatment

4. ECMO should only be offered where there is a realistic possibility of achieving one of the above treatment goals.

5. ECMO may harm the patient through improper patient selection, the burden of general intensive care and support, and ECMO specific complications, such as:

• discomfort, pain and loss of dignity and privacy  
• prolonged sedation and immobility
• extending the dying process without realistic prospect of recovery to quality of life acceptable to the patient
• delayed delivery of palliation
• ECMO specific complications, including bleeding, leg ischaemia and worsened left ventricular failure
• post ECMO complications including muscle weakness, chronic pain, pressure injury and neuro-psychiatric disorder.

The balance between benefit and harm depends on patient specific factors such as presenting illness, age, and chronic health problems as well as ECMO related factors such as timing, method and duration of ECMO.

When a patient presents with severe life-threatening cardiac or respiratory failure, timely initiation of ECMO may occur in the absence of specific disease diagnosis or prognosis, knowledge of patient’s chronic health and functional ability, and understanding of the patient’s preferences and values. The decision to continue ECMO should be guided by this information as it becomes available. ECMO should not be provided where the sole anticipated benefit is to extend the dying process for family or medico-legal reasons.

The criteria for initiating ECMO is complex and needs to cover multiple components at the time of decision making. These include patient specific factors (age, comorbidities, and acute physiological derangements) and diagnostic category of the cause of the acute illness. Each of these factors will influence the likely benefit and success of ECMO for the patient.