EDECMO 103: HIV and ECMO

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 Historically, HIV and severe immunosuppression were considered relative contraindications for ECMO. With modern antiretroviral therapy (ART), outcomes have dramatically improved. Patients with HIV who receive effective ART can recover immune function and achieve near-normal life expectancy. Therefore, HIV alone should not exclude patients from ECMO candidacy. 2. Immune Reconstitution Makes Recovery Possible ART can rapidly suppress viral load and restore immune function. Patients with very low CD4 counts (even <10) can recover to normal CD4 counts (>800) over time. This means even severely immunocompromised patients may recover if given time and support. ECMO can act as a bridge to immune recovery. 3. ECMO Functions as a “Pause Button” ECMO stabilizes respiratory or cardiac failure while clinicians: Treat infections Start ART Manage complications This buys time for reversible disease processes to recover. 4. 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. 5. 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. 6. 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. 7. 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. 8. 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. 9. 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). 10. 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. 11. 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. 12. 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.