I will consider this question in two parts;
- Should ECMO be considered for all patients?
- Should ECMO services be provided in all ICUs?
From a patient perspective, ECMO is a highly invasive intervention and like every other intervention that we consider, the benefits it provides must outweigh its risks for it to be worthwhile.
Clearly, veno-venous and veno-arterial ECMO supports are very different beasts – the patient profile, physiology, complications and outcomes differ considerably. At the extreme of the VA-ECMO spectrum is ECMO-CPR (e-CPR).
Whilst ECMO centres nationally and internationally have published indications and contraindications (which will be discussed), to make decisions around an individual case it is helpful to understand the burden that ECMO support imposes.
For patients this is the physiological burden of being placed on ECMO. This includes frequently the need for ongoing sedation and lack of mobility, the non-physiological cardiorespiratory effects conferred by ECMO, the complications at insertion and during support that patients are exposed to and the uncertain long-term outcomes. These will be discussed further.
The next question is whether all ICUs should be providing this service. The demand for this technology appears to be growing steadily, as is the expectation by other specialties within the hospital for an in-house ECMO service.
Again considering burdens imposed, housing an ECMO programme impacts workload and flow by utilising significant bed-days at the expense of other services that need to be provided, education and credentialing requirements for staff and a financial cost for these resource-intensive patients. These will be discussed individually.
Lastly, the patient outcome implications of centre volume for this highly specialised service will be debated.