In the absence of significant cardiac disease, patients with refractory hypoxic respiratory failure should be considered for venovenous extracorporeal membrane oxygenation (VV-ECMO).
Though indications vary slightly among organizations, the Extracorporeal Life Support Organization states that ECMO is indicated when the PaO2/FiO2 is < 80 mm Hg on FiO2 > 90% or safe plateau pressures (< 30 cm H2O) cannot be maintained.
A few pearls when initiating VV-ECMO:
Fluids are often needed in the first few hours after initiation of ECMO
Reduce tidal volumes to maintain plateau pressures < 25 cm H2O
Decrease FiO2 to maintain oxygen saturations > 88%
Use a hemoglobin threshold of 7-8 g/dL for blood transfusion
Combes A, et al. What is the niche for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome? Curr Opin Crit Care 2012; 18:527-32.