Extracorporeal Membrane Oxygenation (ECMO) is a vital tool for healthcare providers in critical care medicine. When a person’s heart and lungs are compromised, ECMO is the process by which un-oxygenated blood is pumped to a heart and lung machine, reoxygenated and returned to the body (known as the ECMO “circuit”). This bypasses the heart and lungs and allows them to heal from a critical injury or illness. In addition to the risks of hospital acquired infection (HAI) associated with being inpatient, ECMO patients face an increased risk to the cannulation process used to create the circuit. Approximately 10-12% of those who receive ECMO experience a HAI and among those, the risk of mortality is 38-63%.

Patients Who are at Greater Risks

•    Older Adults
•    Pre-morbid disease of the immune system
•    Longer ECMO treatment
• Central instead of peripheral cannulation
• Surgical instead of percutaneous cannulation

Prevention:

• Follow standard guidelines for prevention of ventilator associated pneumonia by elevating the head of the bed and proper pulmonary toilet, consider early extubation if appropriate
•  Appropriate oral and GI decontamination protocols
•   Early and complete enteral nutrition
• Removal of unnecessary and unessential lines/devices
• Discourage placement of indwelling older term IV access
• Avoid maintaining ECMO treatment for longer than necessary
• Routinely monitor cannula insertion sites for evidence of infection
• Maintain a low threshold to obtain cultures

Treatment:

•  No specific antibiotic recommendations, prophylactic antibiotics are discouraged
• If antibiotics are used, ensure therapeutic levels
• The choice of antibiotics for infections are unrelated to ECMO, unless a silicone membrane is in use
• Complete the treatment of pre-ECMO infections
• For presumed sepsis in patients on ECMO, refer to the ELSO database
•  Persistently positive blood cultures should encourage investigation of “hidden” abscesses and raise consideration of changing the ECMO circuit

Resources

Abrams, D., Grasselli, G., Schmidt, M., Mueller, T., & Brodie, D. (2020). ECLS-associated infections in adults: what we know and what we don’t yet know. Intensive Care Medicine, 46(2), 182–191. https://doi.org/10.1007/s00134-019-05847-z

Biffi, S., Di Bella, S., Scaravilli, V., Peri, A. M., Grasselli, G., Alagna, L., Pesenti, A., & Gori, A. (2017). Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. International Journal of Antimicrobial Agents, 50(1), 9–16. https://doi.org/https://doi.org/10.1016/j.ijantimicag.2017.02.025

Extracorporeal Life Support Organization. (2008). Infection Control and Extracorporeal Life Support. 

A     Jason Johnson is a doctoral student and graduate assistant in the School of Public and Population Health.

     B