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.

We need a major change in the way we think about the brains of ECPR patients.  We have been duped into thinking that they are the same as regular resuscitation patients, and the answer is that they are not.  On EDECMO 102, we learn about this idea from two wonderful people: Ingrid Magnet and Michael Poppe.  In addition to the inspirational ECPR program they have created in Vienna, they have published a paper showing just how different these two groups of patients are.  They show that ECPR patients improve their neurologic function tremendously over the six months following their event.  This really changes the way we need to think about these patients and how we discuss options with their families in the hospital.

How do we improve survival from cardiac arrest?  Does Head-Up CPR improve outcomes?  Paul Pepe, the premier expert in the field, gives us the data and reasons why head-up CPR can improve outcomes.  Dr. Pepe also discusses estrogen and it’s potential to improve resuscitation outcomes.

On this 100th episode of EDECMO, Sydney’s very own Nat Kruit tells us how they organized a prehospital system.   She and her crew have a wonderful job organizing a cadre of new cannulators to now have a functional system that can provide the residents of Sydney the opportunity to benefit from ECPR.  Take a listen, she’s fantastic.

EDECMO – Episode 99 is a gem.  Charles Bruen tells us how he has become an ECPR cannulator within the prestigious Minnesota Mobile Resuscitation Consortium.  He shares pearls about cannulation as well as the next steps for Minnesota’s innovative approach to bringing ECPR to largest population that is possible.

A couple of pearls from Dr. Bruen’s cannulation piece are holding pressure in the groin with the ultrasound probe, understanding that the inguinal fold does not represent the inguinal ligament, inserting the needle at a 45-degree angle, and insertion at the common femoral artery.

Who Really Gets VV ECMO? Numbers, Nuance, and the Human Factor

Is VV ECMO purely a numbers game? Or is there a softer, more human side to deciding who receives this life-saving therapy? In this candid and insightful interview, Jon Marinaro sits down with the legendary Dr. Eddy Fan—one of the most published and respected voices in the field of critical care.

Together, they unpack the hard data and the gray areas: prognostic scoring, patient selection, and the ethical dilemmas that come with scarce resources. They also dive into the “sticky” dynamics of ECMO programs, including the subtle (or not-so-subtle) influence that a cannulating specialist can have on who actually gets the therapy.

This is a must-listen for anyone working at the intersection of critical care, ethics, and real-world ECMO decision-making.

Rubin J, Witkin AS, Crowley JC, Michel E, Furfaro DM, Teijeiro-Paradis R, Ilg A, Seethala R, Zhao S, Fan E. Venovenous Extracorporeal Membrane Oxygenation Candidacy Decision-Making: Lessons and Hypotheses From a Single-Center Observational Analysis. Chest. 2024 Sep;166(3):491-501. doi: 10.1016/j.chest.2024.02.042. Epub 2024 Feb 27. PMID: 38423278.

Combes A, Schmidt M, Hodgson CL, Fan E, Ferguson ND, Fraser JF, Jaber S, Pesenti A, Ranieri M, Rowan K, Shekar K, Slutsky AS, Brodie D. Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med. 2020 Dec;46(12):2464-2476. doi: 10.1007/s00134-020-06290-1. Epub 2020 Nov 2. PMID: 33140180; PMCID: PMC7605473.

Jon interviews Dr. Stephen Wall from NYU on the podcast where they discuss the need for organs and how ECPR inclusion criteria can significantly impact the problem.

In our last episode, Trina Augustin discussed whether we should use a blender in ECPR patients citing the Blender Trial. This month we got the first author of the Blender Trial, Aidan Burrell, to give us insight into the use of blenders for not only ECPR patients but also thoughts on patients on VA for cardiogenic shock and VV patients. Jon Marinaro interviews Aidan for this wonderful addition to this complex decision.

Blender Trial – Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. Crit Care Resusc. 2023 Aug 4;25(3):118-125. doi: 10.1016/j.ccrj.2023.06.001. Erratum in: Crit Care Resusc. 2024 Feb 01;26(1):60. doi: 10.1016/j.ccrj.2024.01.003. PMID: 37876374; PMCID: PMC10581278.

Trina’s editorial – Augustin K, Shinar ZM, Dos Reis Miranda D. Correspondence by Augustin et al. regarding the article “Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation”. Intensive Care Med. 2025 Jan 21. doi: 10.1007/s00134-025-07791-7. Epub ahead of print. PMID: 39836262.