Evidence-based guidelines for the use of extracorporeal membrane oxygenation in Australia and New Zealand using GRADE methodology (part 1): Venovenous extracorporeal membrane oxygenation (V-V ECMO) indications and management

The ANZ V-V ECMO Guideline is the first in a series of nationally developed, evidence-based recommendations for extracorporeal life support, using a rigorous GRADE methodology. It provides practical guidance on patient selection, timing, and management of V-V ECMO in adult respiratory failure, with a focus on severe ARDS. The guideline supports the use of V-V ECMO as a conditional recommendation in carefully selected patients after failure of optimal conventional therapy, while highlighting important uncertainties around long-term outcomes, ventilation strategies, and patient subgroups. It also emphasises the complexity, resource implications, and need for system-level coordination in delivering high-quality ECMO care.

Key Points

• Purpose and scope
  • Provides national, evidence-based recommendations for adult VV ECMO in severe respiratory failure.
  • Designed to support (not replace) clinical judgement, reduce practice variability, and improve consistency of care across centres. 
• Methodology
  • Developed using GRADE methodology with transparent assessment of evidence certainty and strength of recommendations. 
  • Combines systematic review evidence with structured expert consensus.

1. Indications – Severe Hypoxic Respiratory Failure (ARDS)

• Conditional recommendation FOR V-V ECMO in severe ARDS after failure of optimal conventional therapy (e.g. lung-protective ventilation, proning, paralysis). 
• Evidence suggests:
  • Short-term mortality benefit (moderate certainty)
  • Uncertain long-term outcomes and disability burden
• Typical criteria (adapted from EOLIA):
  • Severe hypoxaemia (e.g. PaO₂/FiO₂ <80–50 despite optimisation)
  • <7 days mechanical ventilation
• Benefit less clear in multi-organ failure (>2 organs)

2. Hypercapnic Respiratory Failure

• No recommendation (insufficient evidence)
• May be considered case-by-case (e.g. near-fatal asthma), but data are limited and largely observational

3. Prone Positioning on V-V ECMO

• Conditional recommendation AGAINST routine use
• Rationale:
  • Observational data suggest possible benefit
  • RCT data (PRONECMO) negative
  • Significant logistical complexity and risk (cannula issues, bleeding)

4. Mechanical Ventilation Strategy on ECMO

• Good practice statement (no high-quality comparative evidence)
• Core principle: maximise lung protection (“lung rest”)
  • Reduce driving pressure, tidal volume, mechanical power
• ECMO should be used to facilitate ultra-protective ventilation
• No single optimal strategy defined

5. Outcomes and Trade-offs of V-V ECMO in these conditions

• Benefits:
  • Improved survival in selected severe ARDS
• Risks:
  • High resource intensity
  • Complications: bleeding, neurological injury, long-term disability
  • Prolonged ICU/hospital stay
• Cost-effectiveness likely acceptable but context-dependent (service model, retrieval systems)

6. Key Uncertainties / Research Gaps

• Optimal patient selection and timing
• Role of ECMO in moderate ARDS or earlier use
• Best ventilation strategy on ECMO
• Long-term outcomes (functional, cognitive, quality of life)
• Use in hypercapnic failure and specific subgroups

Summary

• V-V ECMO should be viewed as a selective, resource-intensive rescue therapy for severe ARDS, with evidence supporting short-term survival benefit but ongoing uncertainty around long-term outcomes and optimal management strategies.
• As part of a review of evidence informing bi-national ECMO guidelines in Australia and New Zealand Aoetaroa, this is an important read.