4, 5, 7, 8, 10
Primary reference for Chapter 4 selection. The single-absolute-contraindication framing is the most important practical point: age, obesity and immunosuppression are risk modifiers, not gates.
Consider VV ECMO at PaO2/FiO2 under 80 mmHg after optimal medical management including a prone positioning trial; or pH under 7.25 with PaCO2 at or above 60 mmHg despite maximal conventional ventilation; or as a bridge to lung transplantation or for post-transplant primary graft dysfunction. ONE absolute contraindication: anticipated non-recovery without a plan for viable decannulation, though bridge-to-decision initiation is permitted with multidisciplinary discussion and clear time limits. Relative contraindications: CNS haemorrhage or injury, systemic bleeding, contraindication to anticoagulation, immunosuppression, advanced age (no threshold established), and mechanical ventilation over 7 days at plateau pressure over 30 cmH2O with FiO2 over 90%. Increasing duration of mechanical ventilation before ECMO is associated with worsening mortality; no safe threshold is defined. Prone positioning is mandatory before ECMO consideration - ECMO should not be an alternative to proning - and the guideline notes only 11% of US ECMO patients were proned in 2017. Transfer decisions should use the RESP and Murray scores, and transfer should be early. Citation: Tonna JE, Abrams D, Brodie D, et al. ASAIO J 2021;67(6):601-610.
Adult VV ECMO indications, contraindications, timing and referral