Critical Care ECMO with Dr. Jon Marinaro, Dr. Gary Schwartz and Dr. Cedrick Spak – Episode 103Key Points: ECMO in HIV/AIDS Patients

1. HIV Is No Longer a Strong Contraindication to ECMO

2. Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO.

3. With modern antiretroviral therapy (ART), outcomes have dramatically improved.
4. Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy.
5. Therefore, HIV alone should not exclude patients from ECMO candidacy.

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1. Immune Reconstitution Makes Recovery Possible

2. ART can rapidly suppress viral load and restore immune function.

3. Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time.
4. This means even severely immunocompromised patients may recover if given time and support.
5. ECMO can act as a bridge to immune recovery.

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1. ECMO Functions as a “Pause Button”

2. ECMO stabilizes respiratory or cardiac failure while clinicians:

   • Treat infections
   • Start ART
   • Manage complications
   • This buys time for reversible disease processes to recover.

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1. Major Cause of Respiratory Failure: Pneumocystis Pneumonia

Common features in HIV patients requiring ECMO:

• Pneumocystis jirovecii pneumonia (PJP)
• Severe respiratory failure
• Cystic lung destruction
• Frequent bronchopleural fistulas and pneumothorax

Ventilation can worsen these conditions.

Thus ECMO is used to:

• Reduce ventilator pressure
• Prevent further lung damage
• Allow lung healing.

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1. Ventilator Strategy: Minimize Positive Pressure

Typical strategy:

• Rapid ECMO initiation if ventilation causes lung injury
• Attempt early extubation

• If needed:

  • tracheostomy
  • minimal ventilator settings

Example “rest settings” described:

• Driving pressure ≈ 10
• PEEP ≈ 10 (often reduced further)
• FiO₂ ≈ 50%

Goal: avoid further lung trauma.

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1. ECMO Candidate Selection

Primary question:

Is the disease reversible?

If yes → ECMO should be considered.

Factors supporting ECMO:

• Young patient
• Treatable infection
• Potential immune recovery

Possible relative contraindications:

• Severe fungal infection
• Multiple uncontrolled opportunistic infections
• Extreme cachexia or severe systemic deterioration.

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1. Early ART Should Be Started

Modern approach:

• Start antiretroviral therapy during acute illness
• Do not delay until after ICU discharge

Benefits:

• Rapid viral suppression
• Faster immune recovery

Risk:

• Immune Reconstitution Inflammatory Syndrome (IRIS)

  • Temporary worsening of infection due to immune rebound.

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1. Circuit and Infection Complications

Important ECMO considerations in HIV patients:

• Increased risk of circuit thrombosis
• Possible fungemia

• If fungemia occurs:

  • circuit replacement
  • possible re-cannulation

These complications require careful monitoring.

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1. Cannulation Strategy

Example high-volume center approach:

• Bilateral femoral VV ECMO cannulation

  • Fast
  • Reliable flow
  • Allows later neck access if needed

Used especially during high-volume periods (e.g., COVID).

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1. Outcomes and Indication Expansion

ECMO indications are evolving:

• Older age
• Longer ventilator times
• HIV/AIDS
• 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.

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1. Resource and Program Considerations

Decision-making must consider:

• Resource availability
• Program experience
• Institutional risk tolerance

High-volume ECMO centers can often accept higher-risk patients.

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1. Broader Lesson

Medical contraindications often change with new technology and therapies.

Example given:

• HIV was once a contraindication for kidney transplantation
• Now it is accepted due to improved treatment.

The same evolution may be happening with ECMO indications.