Oxigenación con membrana extracorpórea veno-venosa en el manejo de hipoxemia severa refractaria: indicaciones y propuesta de un protocolo de ingreso

The acute respiratory distress syndrome (ARDS) is an inflammatory disorder of the lung, causing impaired gas exchange, with hypoxemia and respiratory failure. ARDS mortality has not changed significantly a decade after its initial description (1994 -2006). This figure fluctuated around 40% in clinical trials and observational studies. In spite of new interventions with compelling evidence of improvements with protective ventilation, use of neuromuscular-blocking drugs, and the prone position, refractory hypoxemia is still a high mortality condition. Ventilatory management in ARDS patients is a critical determinant of outcome. Ventilator-associated lung injury is a major cause of perpetuation of the systemic inflammatory response, lung fibrosis, and multiple organ dysfunction (MOD). Patients with refractory hypoxemia, despite protective mechanical ventilation are in serious risk of death. extracorporeal membrane oxigenation (ECMO) has been proposed as a rescue therapy in this situation. The extracorporeal life support organization (ELSO) Guidelines recommend that ECMO should be considered in acute respiratory failure from any cause when the risk of mortality is 50% or higher. ELSO guidelines suggest that ECMO must be indicated when the risk death is 80% or greater. However, it is not clear which therapies should be indicated before ECMO, and for how long the patient must kept on these therapies before going on ECMO. In the following review, a protocol for early admission of patients to ECMO is proposed, based on the probability of death and the review of the current management of patients with ARDS.