Are contraindications to extracorporeal membrane oxygenation slowly vanishing?

In the mid-1980s, the application of extracorporeal membrane oxygenation (ECMO) in newborns with severe respiratory failure gained a footing when fewer than a dozen ECMO centers became established. What followed was the emergence of nearly 100 ECMO centers in the United States and very successful outcomes for neonates who would have probably died without ECMO. Inclusion and exclusion criteria were established, and ECMO became an important option in the care of newborns with severe respiratory failure unresponsive to conventional measures, which at the time was good old fashioned timecycled pressure-limited ventilation.1 In the early 1990s the use of ECMO in newborns began to decline with the introduction of high-frequency oscillatory ventilation, and continued to decline with the availability of surfactant replacement therapy and inhaled nitric oxide.2 As a result of these advancements the treatment algorithm for respiratory failure in newborns was recalibrated, with ECMO used more in a rescue manner. As centers gained more experience and ECMO systems improved, so did expanded applications, including pediatric and adult patients with respiratory and cardiac failure. Cardiac applications continue to increase, particularly in areas such as congenital heart disease and ECMO to aid resuscitation, known as ECMO-CPR.3 The hospital survival rates with these applications have not been as favorable as were those with the early neonatal experience, but the populations are more heterogeneous and include a wide range of diagnoses and comorbidities. Nonetheless, survival rates such as 50–60% for pediatric and adult respiratory failure and 30–40% in ECMO-CPR support the use of ECMO beyond its proven niche.3-5