ECMO FOR SHOCK REFERRAL PROCESS

Shock is a life threatening condition that can result in death unless treated emergently. As one of the largest ECMO centers in the country, Washington University and Barnes-Jewish Hospital Shock Team are experts in the treatment of these patients using extracorporeal membrane oxygenation (ECMO).

If you believe your patient may benefit from our services, we request that you call the BJC Transfer Center immediately at 800.252.3627 and request ECMO. The BJC Transfer Center will connect you with the on-call ECMO surgeon to discuss the situation.

If you're unsure if your patient may benefit, please review the indications for extracorporeal life support (ECLS). If your patient meets any of these criteria, contact our team for consult or transfer.

GUIDELINES FOR REFERRAL

Cardiogenic Shock

• Non-improving hemodynamic status:

1. Cardiac index <2.0 L/min/m2
2. Vasoactive Inotropic Score >20
3. Escalating inotropic and vasoactive medication doses:

• Norepinephrine >.10 mcg/kg/min, or >15 mcg and/or
• Epinephrine >.15 mcg/kg/min, or >10 mcg and/or
• Vasopressin >.04 mcg/min, and/or
• Dopamine or dobutamine >7.5 mcg/min/kg

4. Patient who needs or is already placed on ECMO
5. Signs of leg malperfusion distal to the percutaneous device (pale, no pulse or no Doppler signals)

• Signs of end-organ malperfusion

1. Altered mental status due to brain hypoperfusion
2. Worsening lactic acidosis (Increased lactate >3.0)
3. Liver enzyme increase or signs of acute liver failure
4. Acute oliguria or anuria with acute creatinine increase

Respiratory Shock

• Severe hypoxemic (or mixed hypoxemic/hypercapnic) respiratory failure despite ventilator optimization and use of adjunctive ARDS therapies:

1. PF ratio of <100 for >3 hours
2. pH <7.25, PCO2 >60, PaO2 <60
3. Plateau pressure >25, PEEP >10, peak pressure >40

• Acute severe asthma with persistent pH <7.25 despite ventilator optimization, nebulization and steroids
• Advanced lung disease with active listing for lung transplantation, with input from lung transplant team

Contraindications to ECLS

1. Functional debility at baseline
2. Advanced chronic lung disease (other than asthma) on home O2 w/o active listing for lung transplantation
3. Prolonged period of mechanical ventilation (generally >7 days)
4. Terminal cancer
5. Bleeding diathesis/hypocoagulability
6. DNR status

Learn more about ECMO as bridge-to-transplant as a part of our heart transplant program.