Suspected Acute Heart Failure — Considerations for ECMO/Other Mechanical Support — Clinical Pathway: Emergency, ICU and Inpatient

Suspected Acute Heart Failure Clinical Pathway — Emergency Department, ICU and Inpatient

Considerations for ECMO/Mechanical Support

Activation
  • Decision to use mechanical circulatory support is a complex issue
  • Requires input from attending physicians from:
    • Heart failure team
    • Cardiac surgery
    • CICU
    • Anesthesia
  • Ideally, instituted before arrest or irreversible end-organ damage
  • Consider having ECMO readily available for intubation or cardiac catheterization
Guidance for Initiation
  • ECMO and other mechanical circulatory support, such as ventricular assist device, may be considered if, despite optimizing preload inotropic support (e.g., epinephrine > 0.1 mcg/kg/min or dopamine > 10 mcg/kg/min), and ventilatory assistance, any of the following are present:
    • Ejection fraction < 20%
    • Cardiac index < 2L/M2/min
    • Mixed venous saturation < 40%
    • Persistent lactic acidosis
    • Recalcitrant arrhythmias
    • End organ dysfunction (renal, hepatic, intestinal)
    • Cardiac arrest
Location for ECMO Cannulation
  • Highly preferable, more efficient to occur in Cardiac ICU due to resource allocation and other logistical considerations
  • In emergent circumstances where ECMO is being considered, all reasonable attempts should be made to transfer patient to the CICU (or other appropriate destination in the cardiac center)
  • The CICU Team will make final decision