Interactive Case Discussion: Proning vs ECMO

Richard Jee presents a case: severe ARDS with CT, CXR, and blood chemistry to match. The P/F is 12.6.

A quick show of hands… “should this patient receive ECMO?” Not many hands go up, but even few when asked “should this patient not receive ECMO?”. Conclusion, most of us are siting on the fence.

ECMO (Pro debate)

Nick Barrett, head of ECMO at GSTT, takes the podium to advocate ECMO.

Key issues

  • Age – should not be a factor
  • Pathology – meets the criteria

Nick demonstrates how ECMO allows time to find the correct diagnosis. In a similar case, the addition of corticosteroids rapidly resolved the continuous inflammatory process and corrected the lung damage.

Proning (Con debate)

Ben Creagh-Brown, consultant at Guildford, presents an argument against ECMO.

High rate of complications, including intracranial haemorrhage as presented earlier. Thrombosis and leg amputation are another concern. Additionally, patients need to be transferred, which is not without risk.

Ben discusses the CESAR trial. If 3 patients hadn’t had the good outcome then the CESAR trial would not have been “significant” – known as a fragility index of 3.

Concerns:

  • Current oxygenation is acceptable
  • Patient is old
  • Patient is immunosuppressed
  • Is this pathology reversibility?

And a final vote

It appears there’s been a swing and more hands go up for this patient should not have ECMO.

Well done Ben and Nick for an excellent session.

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