Variability in Venovenous Extracorporeal Membrane Oxygenation Candidacy Decision-Making: An International Survey

To characterize the variability in venovenous extracorporeal membrane oxygenation (VV-ECMO) candidacy decision-making processes across international Extracorporeal Life Support Organization (ELSO) member institutions.

An international survey study of ELSO centers performing adult VV-ECMO.

Internet-based survey conducted between February 2024 and April 2024.

ECMO clinicians representing ELSO member institutions, including ECMO directors, physicians, coordinators, and others listed in the ELSO institutional directory as of January 2024.

None.

Measurements included center characteristics, decision-making processes, contraindications used, and clinician perceptions of consistency in candidacy determinations. Most centers (82%) reported having formal inclusion and exclusion criteria, with 95% having absolute contraindications to initiating VV-ECMO as a bridge to recovery. However, very few centers shared identical sets of contraindications. The most common absolute contraindications were severe neurologic injury (77%) and disseminated malignancy (75%). Clinician judgment was perceived as equally or more important than institutional guidelines in 93% of centers. Representatives from 54% of centers believed that candidacy decisions were not always consistent between clinically identical patients, and less than half of centers routinely reviewed all prior candidacy decisions.

This study reveals significant variability in VV-ECMO candidacy decision-making processes across international ELSO centers. The observed inconsistencies in contraindications, reliance on clinical judgment, and perceived variability in decisions suggest a need for more standardized, evidence-based approaches to ECMO candidacy determination. Implementing routine review processes and developing more robust guidelines could improve consistency and equity in ECMO allocation.