UMEM Educational Pearls

Title: VA ECMO in Pulmonary Embolism

Category: Critical Care

Keywords: ECMO, PE, hypotension (PubMed Search)

Posted: 10/18/2016 by Daniel Haase, MD (Updated: 4/10/2018)
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--Massive PE is defined as PE with obstructive shock (hypotension [SBP <90] or end-organ malperfusion)

--Consider venoarterial (VA) ECMO in massive PE for hemodynamic support, particularly prior to intubation

--VA ECMO may prevent intubation/mechanical ventilation, surgical intervention, systemic and local thrombolysis

Additional Information

--Patients on VA ECMO require systemic anti-coagulation to prevent arterial embolism. So, patients with relative and absolute contraindications to catheter-directed and systemic thrombolysis should be considered for VA ECMO for HD support while AC works.

--Intubating already hemodynamically tenuous patients is dangerous and increases in intra-thoracic pressure worsens RV failure and suppressing patient's catecholamine drive with sedation during RSI may also worsen hemodynamics.

--Frequently, patients who get VA ECMO will not require surgical embolectomy as the clot burden will resolve after a few days of heparin. And RV function with improve as demonstrated by serial echocardiography

--A recent review showed an overall survival of 70% in VA ECMO patients for massive PE. This included patients already in cardiac arrest. Review included case series, cohorts, but no RCTs.

References

1. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Yusuff HO, Zochios V, Vuylsteke A. Perfusion. 2015 Nov;30(8):611-6. doi: 10.1177/0267659115583377. Epub 2015 Apr 24. Review.