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Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak – Episode 103
Key Points: ECMO in HIV/AIDS Patients
1. HIV Is No Longer a Strong Contraindication to ECMO
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Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO.
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With modern antiretroviral therapy (ART), outcomes have dramatically improved.
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Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy.
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Therefore, HIV alone should not exclude patients from ECMO candidacy.
2. Immune Reconstitution Makes Recovery Possible
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ART can rapidly suppress viral load and restore immune function.
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Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time.
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This means even severely immunocompromised patients may recover if given time and support.
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ECMO can act as a bridge to immune recovery.
3. ECMO Functions as a “Pause Button”
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ECMO stabilizes respiratory or cardiac failure while clinicians:
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Treat infections
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Start ART
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Manage complications
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This buys time for reversible disease processes to recover.
4. Major Cause of Respiratory Failure: Pneumocystis Pneumonia
Common features in HIV patients requiring ECMO:
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Pneumocystis jirovecii pneumonia (PJP)
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Severe respiratory failure
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Cystic lung destruction
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Frequent bronchopleural fistulas and pneumothorax
Ventilation can worsen these conditions.
Thus ECMO is used to:
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Reduce ventilator pressure
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Prevent further lung damage
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Allow lung healing.
5. Ventilator Strategy: Minimize Positive Pressure
Typical strategy:
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Rapid ECMO initiation if ventilation causes lung injury
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Attempt early extubation
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If needed:
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tracheostomy
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minimal ventilator settings
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Example “rest settings” described:
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Driving pressure ≈ 10
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PEEP ≈ 10 (often reduced further)
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FiO₂ ≈ 50%
Goal: avoid further lung trauma.
6. ECMO Candidate Selection
Primary question:
Is the disease reversible?
If yes → ECMO should be considered.
Factors supporting ECMO:
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Young patient
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Treatable infection
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Potential immune recovery
Possible relative contraindications:
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Severe fungal infection
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Multiple uncontrolled opportunistic infections
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Extreme cachexia or severe systemic deterioration.
7. Early ART Should Be Started
Modern approach:
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Start antiretroviral therapy during acute illness
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Do not delay until after ICU discharge
Benefits:
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Rapid viral suppression
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Faster immune recovery
Risk:
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Immune Reconstitution Inflammatory Syndrome (IRIS)
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Temporary worsening of infection due to immune rebound.
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8. Circuit and Infection Complications
Important ECMO considerations in HIV patients:
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Increased risk of circuit thrombosis
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Possible fungemia
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If fungemia occurs:
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circuit replacement
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possible re-cannulation
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These complications require careful monitoring.
9. Cannulation Strategy
Example high-volume center approach:
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Bilateral femoral VV ECMO cannulation
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Fast
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Reliable flow
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Allows later neck access if needed
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Used especially during high-volume periods (e.g., COVID).
10. Outcomes and Indication Expansion
ECMO indications are evolving:
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Older age
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Longer ventilator times
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HIV/AIDS
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Cancer patients
All are examples of “indication creep” as experience grows.
The key principle remains:
ECMO should be used if there is a realistic chance of recovery.
11. Resource and Program Considerations
Decision-making must consider:
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Resource availability
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Program experience
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Institutional risk tolerance
High-volume ECMO centers can often accept higher-risk patients.
12. Broader Lesson
Medical contraindications often change with new technology and therapies.
Example given:
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HIV was once a contraindication for kidney transplantation
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Now it is accepted due to improved treatment.
The same evolution may be happening with ECMO indications.
