ECMO referrals and transfer pathway

How to refer a patient for ECMO

Step 1: Go to Signpost ECMO Services & make the referral; please read the instructions carefully.

If you have difficulty in making the referral on the pathway, you can:

  • Click here for instructions
  • Get help by clicking “Request Help” (24/7 service)
  • Call RBH ECMO Nurse on 07815 494 175

Step 2: RBH ECMO team will receive the notification of referral & review the details

Step 3: RBH ECMO Consultant on call will contact the referring doctor and discuss.

If your patient’s condition is time critical, please call the above number while filling the referral.
 

Referral criteria

During the coronavirus pandemic, patients who meet the following clinical criteria may be considered suitable for ECMO support.

Inclusion Criteria (revised in response to the COVID-19 pandemic)

  • Potentially reversible severe respiratory failure
  • Lung Injury Score ≥3 (see below)
  • Failed trial of ventilation in prone positioning ≥ 6 hrs (unless contraindicated)
  • Failed Airway Pressure Release Ventilation (ARPV) or “High PEEP ventilation strategy” ≥ 6 hrs (unless contraindicated)
  • Clinical Frailty Scale category ≤ 3 (see below)
  • If RESP score ≤ 3 ECMO should be considered only after agreement across at least 2 centres

Exclusion Criteria

  • Refractory multiorgan failure

Click here for detailed information on the clinical guide for ECMO for respiratory failure in adults during the coronavirus pandemic.


Outside the coronavirus pandemic, the general referring criteria are as follows:
  • Severe hypoxaemia (for example, PaO2/FiO2 <13.3kPa)
  • Severe hypercapnic acidosis (for example, pH <7.20)
  • Inability to achieve lung protective tidal volumes and pressures (tidal volume < 6ml/kg predicted body weight, plateau pressure <30cmH2O)
  • Failure to improve with rescue therapies such as high-frequencyoscillation and prone positioning
  • Significant air leak/bronchopleural fistula.
There are specific criteria for consideration of ECMO support based on the CESAR study and defined by NHS Specialised Services during the commissioning of ECMO capacity. 
Indications 
Contraindications (relative)
  • Age ≥16 years
  • Potentially reversible severe acute respiratory failure
  • No limitation to on-going life-sustaining treatment 
  • Murray score ≥3.0 (consider referral is ≥2.5 and rapid clinical deterioration) OR
  • Uncompensated hypercapnoea with pH <7.20
  • Age >65 years
  • Intracranial bleed (current or recent) 
  • Other contraindications to heparinisation 
  • High pressure (peak inspiratory pressure >30 H2O and/or high FiO2 (>0.8) ventilation for more than seven days


Murray Score (Lung Injury Score) 

  0 1 2 3 4
P/F ratio (kPa)* ≥40 30-39.9 23.3 – 29.9 13.3 – 23.2 <13.3
PEEP (cmH2O) ≤5 6-8 9-11 11-14 ≥15
Compliance (ml/cmH2O)* ≥80 60-79 40-59 20-39 ≤19
CXR quadrants infiltrated 0 1 2 3

4

Final Murray Score = Sum of all 4 individual scores divided by 4

* P/F ratio = PaO2/FiO2
* Compliance = Tidal volume (ml) / Driving pressure; Driving pressure = Pplateau – PEEP


Clinical Frailty Scale

RESP (Respiratory ECMO Survival Prediction) Score

Click here for more information and to calculate.


Predicted Body Weight & Target Tidal Volume

PBW in kg (males) = 50 + 0.91 x (Height in cm - 152.4)

PBW in kg (females) = 45.5 + 0.91 x (Height in cm - 152.4)

Target TV = 6ml/kg PBW

                     Male                                 Female                                   
Height PBW (KG) Target TV (ml) PBW (KG) Target TV (ml)
150 47.8 287 43.3 260
155 52.4 315 47.9 288
160 56.9 342 52.4 315
165 61.4 369 56.9 342
170 65.9 396 61.4 369
175 70.5 423 66.0 396
180 75.0 450 70.5 423
185 79.5 477 75.0 450
190 84.2 506 79.7 479

 

Transfer pathway for ECMO and severe respiratory failure service

The film below illustrates the process for transferring patients with severe acute respiratory failure who may be suitable for extracorporeal membrane oxygenation (ECMO). It is aimed at clinical staff including doctors, nurses, allied healthcare professionals, ambulance crews and managers who might be involved in caring for these critically ill patients pending transfer.

Any hospital considering referring a patient for ECMO should contact their local ECMO centre in the first instance.

This film was created by North West London Critical Care Network. 

 

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