Variability in Venovenous Extracorporeal Membrane Oxygenation Candidacy Decision-Making: An International Survey
James C. Henderson, Annette Ilg, Melissa Meeker, Jacqueline M. Kruser, Alison S. Witkin, Eddy Fan, Jonah Rubin
Abstract
OBJECTIVE: To characterize the variability in venovenous extracorporeal membrane oxygenation (VV-ECMO) candidacy decision-making processes across international Extracorporeal Life Support Organization (ELSO) member institutions. DESIGN: An international survey study of ELSO centers performing adult VV-ECMO. SETTING: Internet-based survey conducted between February 2024 and April 2024. PARTICIPANTS: ECMO clinicians representing ELSO member institutions, including ECMO directors, physicians, coordinators, and others listed in the ELSO institutional directory as of January 2024. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 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. CONCLUSIONS: 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.