New guidance has been released to help haematologists and intensive care specialists decide on which haematopoietic cell transplantation (HCT) patients in need of life-support interventions might be eligible for extracorporeal membrane oxygenation (ECMO).
Currently, there are no published guidelines on the use of ECMO in adults who have received HCT and are in refractory respiratory failure or refractory cardiac failure, but it has traditionally been viewed as controversial because these patients, particularly those with haematological malignancies, have a poor prognosis and high in-hospital mortality rate.
Now an international expert group has agreed that HCT should no longer be considered “an absolute contraindication” to ECMO as a life-supporting intervention, after concluding that a restricted subgroup of patients could be eligible for such therapy.
However, these patients would need to be carefully selected by an inter-professional team including haematologists, intensive care physicians and ECMO specialists, the authors said, in a consensus statement published in The Lancet Respiratory Medicine.
As such, the group developed a set of consensus statements which they said should help to “guide haematologists and intensive care providers during the difficult decision-making process to establish ECMO candidacy, and during the management of these complex patients at the bedside”.
There was strong agreement among the expert group (84%) that venovenous ECMO can be considered “on a selective case-by-case basis” in patients who have received HCT and have respiratory failure in the late post-transplant period, while venoarterial ECMO is potentially an option for managing reversible cardiac toxicities.
Similarly, use of ECMO in patients receiving immune effector cell (IEC) therapy should only be considered on a case-by-case basis in those with cardiac or respiratory failure due to cytokine release syndrome post IEC therapy, “on the basis of expected reversibility with specific treatment (eg, tocilizumab)”, according to the paper.
However, clinicians should only consider use of ECMO in HCT patients who have had non-malignant disease or for those with malignant diseases in remission and at low risk of recurrence, the authors stressed.
Clinical teams should also base ECMO decisions on a litany of other factors such as chance of recovery from the illness requiring the intervention, the number of organ failures, the type of HCT and condition regimen, co-morbidities and graft function, etc., for best chance of success, they added.
In an accompanying editorial, a group of Australian intensive care specialists noted that the incidence of acute respiratory distress syndrome (ARDS) in patients with allogeneic HCT is 15·6% and 2.7% in those with autologous HCT, with reported mortality varying from from 38% to 73%.
Identifying the cause of respiratory failure in such patients, and thus understanding its underlying pathophysiology and trajectory, “must be a focus of management” as “an improved understanding would allow a more nuanced approach to decision making for ECMO”, said Dr Priya Nair and colleagues from St Vincents Hospital, Sydney.
Also, “knowing the pre-transplant risk factors that predispose patients to the development of ARDS after HCT might assist haematologists in including discussions around ARDS and the potential consideration of ECMO during the HCT consenting process for patients who are considered high risk, to maximise shared decision making at a time when the patient is competent to do so”, they suggested.
Read the position paper here