Extracorporeal membrane oxygenation (ECMO) for infectious causes of refractory cardiopulmonary failure is established as appropriate therapy in high-income countries. Its use in low- and middle-income nations for tropical infections is not well-studied, however, perhaps because most of these countries have not been historically able to offer ECMO support. Tropical infections remain an important cause of global morbidity and mortality, but the role of ECMO is poorly described. We identified a list of viral, bacterial, fungal, and parasitic infections that qualified as tropical infectious diseases. These included infections that were either a World Health Organization (WHO) designated Neglected Tropical Disease (NTD) or an infectious disease with a higher prevalence in the Tropics than elsewhere. We conducted a comprehensive review of existing literature regarding ECMO use to support these infections. Multiple viral, bacterial, fungal, and parasitic tropical infections have been supported by ECMO with varying success. leptospirosis, melioidosis, and tuberculosis are conditions suitable for venovenous ECMO support with frequent use in the literature and reported survival as high as 84

OBJECTIVES:To evaluate the cost-effectiveness of implementing an extracorporeal cardiopulmonary resuscitation (ECPR) strategy for refractory out-of-hospital cardiac arrest (OHCA) compared with current practice in Singapore, where it is not routinely used. DESIGN:We performed a simulation-based cost-effectiveness analysis using a decision tree to model acute phase and a Markov model for long-term outcomes over a lifetime horizon, from a healthcare provider perspective. SETTING:Singapore healthcare system. PATIENTS:Nontraumatic adult OHCA patients from Singapore with initial shockable rhythm and no prehospital return of spontaneous circulation were analyzed. INTERVENTIONS:We modeled the implementation of an ECPR strategy and compared it with current practice using only conventional cardiopulmonary resuscitation. Transition probabilities of existing practice were derived from the nationwide Singapore OHCA registry (Pan-Asian Resuscitation Outcomes Study: PAROS), (2010-2016), while ECPR outcomes were based on the Comprehensive Registry of Intensive Care for OHCA Survival in Osaka (Osaka CRITICAL study) (2012-2019). Costs and quality-adjusted life-years (QALYs) were compared between strategies, with scenario analyses conducted to assess the impact of lower age eligibility thresholds and increased transport time to extracorporeal membrane oxygenation-capable hospitals. Incremental cost-effectiveness ratios (ICERs) were estimated using a willingness-to-pay threshold of S$45,000 per QALY. MEASUREMENTS AND MAIN RESULTS:A total of 1462 OHCA cases from Singapore were analyzed; the mean age of patients was 57 years (sd, 11 yr), and 87% were male. In base-case analysis, ICER was estimated at $34,320/QALY, with a positive net monetary benefit of $8,532. Scenario analyses demonstrated that an age-restricted ECPR strategy (< 65 yr) yielded a similar ICER ($33,469/QALY) to the base case. In contrast, incorporating a 10-minute transport extension slightly exceeded the willingness-to-pay threshold ($47,158/QALY). CONCLUSIONS:In this modeling study, adopting an ECPR strategy for OHCA in Singapore was likely to be cost-effective across different age-based eligibility thresholds; however, it was sensitive to delays in transport time. Further implementation research is important to guide scale-up and policy decisions.

BACKGROUND:Snakebite is a neglected tropical disease of major public health importance in India, contributing to significant morbidity and mortality. Acute kidney injury (AKI) is among the most serious complications of envenomation, particularly with viperid and some elapid species, and is associated with long-term chronic kidney disease (CKD) risk. OBJECTIVE:This article aims to provide evidence-based recommendations for the recognition, evaluation, and management of snakebite-envenomation-associated AKI (SAKI), integrating global best practices with national treatment protocols and resource realities. MATERIALS AND METHODS:The authors reviewed available literature through PubMed and international recommendations, including the Government of India's Standard Treatment Guidelines (STG), World Health Organization (WHO) guidance, and Kidney Disease Improving Global Outcomes (KDIGO) AKI guidelines. As per the available evidence, the recommendations were formulated through expert panel deliberations. RESULTS:Key recommendations include early recognition of envenomation syndromes, prompt administration of polyvalent antisnake venom (ASV), protocolized monitoring of coagulation and renal parameters, and standardized use of kidney replacement therapy (KRT) according to KDIGO indications. Supportive management of venom-induced consumption coagulopathy (VICC), rhabdomyolysis, and thrombotic microangiopathy (TMA) is emphasized. Special considerations have been outlined for children, pregnant women, patients with preexisting kidney disease, and those bitten by non-"Big Four" snakes. CONCLUSION:SAKI is preventable and treatable with timely intervention, but survivors remain at risk of CKD. With these recommendations, the authors have tried to standardize the diagnostic and therapeutic approach across general medicine, nephrology, and critical care medicine teams in India, aiming to reduce mortality and improve renal outcomes.

Frailty is increasingly recognised as a prognostic marker in cardiovascular disease, but its role in cardiogenic shock is less defined. In this retrospective cohort study across 188 intensive care units (ICUs), we analysed data from the Australia and New Zealand Intensive Care Society Adult Patient Database on adults (≥ 16 years) with admitted with cardiogenic shock between 2017–2023, and a documented Clinical Frailty Scale (CFS). The primary outcome was death at up to four years using an adjusted Cox proportional hazards model, which we also assessed using a time-varying model. We conducted subgroup analyses based on age, sex, aetiology of cardiogenic shock, and a landmark survival analysis at ICU discharge. We included 71,359 patients (median age 68.6 years, 70.0

Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings. We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70

OBJECTIVE:To determine the optimal PaO2:FiO2 threshold in the first 24 hours of intensive care unit admission, and its associated discriminatory capacity, for prognostication of mortality among critically ill patients. METHODS:This bi-national registry included adult patients admitted to intensive care units in Australia and New Zealand from January-2018 to December-2022. The primary outcome was hospital mortality. Acute hypoxic respiratory failure was defined as PaO2:FiO2 of < 300 using the worst PaO2:FiO2 within the first 24 hours of intensive care unit admission. The unadjusted association between PaO2:FiO2 and hospital mortality was evaluated using restricted cubic splines with four knots to allow for continuous, non-linear associations. To determine the optimal threshold of the PaO2:FiO2 for predicting hospital mortality, Youden's method was used to identify the maximum sum of sensitivity and specificity. The area under the receiver operating characteristic curve and Youden's J-index were calculated to compare pre-specified subgroups. RESULTS:Among the 662,612 included patients, acute hypoxic respiratory failure was not present in 324,761 (49%) patients, mild in 181,499 (27%) patients, moderate in 128,277 (19%) patients, and severe in 28,125 (4%) patients. The hospital mortality rates, respectively, were 4.9% (15,797/324,761), 7.9% (14,291/181,499), 14% (18,247/128,277), and 31% (8,717/28,125). The association between PaO2:FiO2 and hospital mortality was non-linear with an inflection point at PaO2:FiO2 = 200. The area under the ROC curve was 0.677 (95%CI 0.675 - 0.679) with an optimum PaO2:FiO2 threshold of 230. (Youden's J-index of 0.267, sensitivity 56.1% and specificity 70.6%). The area under the ROC curve was 0.627 for patients who required invasive ventilation during their intensive care unit stay, compared with 0.698 for those who did not. CONCLUSION:The optimal PaO2:FiO2 threshold for predicting hospital mortality was 230. PaO2:FiO2 has low discriminatory capacity in predicting hospital mortality among intensive care unit patients.

BACKGROUND:Post-cardiotomy acute right ventricular failure (aRVF) constitutes a complex clinical challenge that might necessitate escalating interventions, including extracorporeal life support (ECLS). This study evaluated outcomes of adults requiring ECLS for post-cardiotomy aRVF compared with other post-cardiotomy indications. METHODS:In this multicenter, international, retrospective study, we analyzed patients undergoing post-cardiotomy ECLS from January 2000 to December 2020 and compared patients' characteristics and in-hospital mortality between aRVF and other indications. RESULTS:Of 2010 patients, 240 (12%) had aRVF and 1770 (88%) had other indications for ECLS. Demographics were similar between groups; median age was 65 (55-72) years (P = .217), and 60% were male (P = .675). The aRVF group showed higher preoperative right-sided cardiac dysfunction, including preexisting right ventricular failure (aRVF, 22%; other indications, 8%; P < .001) and biventricular failure (aRVF, 12%; other indications, 7%; P = .013). Patients with aRVF more frequently underwent tricuspid valve surgery (aRVF, 20%; other indications, 13%; P = .003) and aortic root procedures (aRVF, 24%; other indications, 13%). They also required longer ECLS support (aRVF, 135 [70-221] hours; other indications, 116 [58-192] hours; P = .025) and longer intensive care unit stay (aRVF, 15 [7-29] days; other indications, 13 [6-25] days; P = .042). Despite more complications, including nonsurgical bleeding (aRVF, 31%; other indications, 25%; P = .042) and persistent right-sided heart failure (aRVF, 50%; other indications, 17%; P < .001), both in-hospital survival (aRVF, 59%; other indications, 61%; P = .526) and long-term survival were comparable (log-rank P = .17). CONCLUSIONS:Patients requiring ECLS for post-cardiotomy aRVF, despite higher preoperative risks and complex clinical courses, achieve survival rates comparable to those of patients with other indications.

Ultrasound has become indispensable in the management of patients supported with extracorporeal membrane oxygenation (ECMO), enabling rapid diagnosis, procedural guidance, physiologic monitoring, and informed decision-making across the entire ECMO continuum. This review, conducted under the auspices of the Extracorporeal Life Support Organization (ELSO), provides evidence-based recommendations for the use of ultrasound in adult, pediatric, and neonatal ECMO patients. An international, multidisciplinary panel of experts with dual expertise in ECMO and ultrasound, representing all ELSO chapters, convened to define the scope and structure of the review. A comprehensive literature review identified 133 relevant publications informing recommendations. The review addresses training and competency requirements, choice of ultrasound modalities, and the role of ultrasound before ECMO initiation, during cannulation, throughout ECMO support, for troubleshooting complications, and during ECMO weaning and post-decannulation care. Pre-ECMO ultrasound is emphasized for assessment of cardiopulmonary function, vascular anatomy, and identification of contraindications or reversible conditions. Real-time ultrasound guidance is recommended for cannulation to reduce complications and confirm optimal cannula positioning. During ECMO, echocardiography and extracardiac ultrasound are central to monitoring cardiac function, cannula position, ventricular loading conditions, pulmonary pathology, neurological complications, and vascular integrity. Ultrasound-based strategies for diagnosing hypoxemia, recirculation, tamponade, ventricular distension, and limb ischemia are detailed. Finally, ultrasound plays a critical role in assessing readiness for ECMO liberation and identifying post-ECMO complications. This review highlights the pervasive role of ultrasound as a core competency in ECMO care and provides a practical framework to support safe, effective, and standardized ultrasound use across diverse ECMO programs worldwide.

Abstract:Extracorporeal membrane oxygenation (ECMO) has increasingly been used in patients with refractory severe cardiorespiratory failure in recent years. The use of ECMO necessitates anticoagulation as blood passes through an extracorporeal circuit that has a membrane lung and a centrifugal pump. Although heparin is the most common anticoagulant used during ECMO runs, other anticoagulants like direct thrombin inhibitors and Factor X inhibitors have also been implemented in special circumstances. Bleeding is a well-known and severe complication while receiving ECMO, and balancing this against circuit thrombosis is a clinical challenge. While standard laboratory tests, such as activated partial thromboplastin time and point-of-care tests such as activated clotting time, help monitor anticoagulation on ECMO, they have their drawbacks. The use of viscoelastic assays (VEAs) in aiding anticoagulation management on ECMO has shown some benefits in reducing bleeding and thrombotic complications, though these assays are not widely used at present. This article explores the challenges of monitoring anticoagulation on ECMO and reviews the available evidence regarding VEAs in adult and pediatric ECMO.

Cardiac arrest in the intensive care unit (ICU-CA) is distinct from other in-hospital cardiac arrests, involving critically ill patients in monitored settings. Its prevalence and outcomes remain unclear. This systematic review and meta-analysis aimed to fill this evidence gap and identify areas for future research to improve outcomes in this patient population. We searched MEDLINE, Embase and Scopus databases from inception until 26 November 2025 for studies reporting on ICU-CA in adults. We performed random effects meta-analyses with the generalised linear mixed model. We used the Joanna Briggs Institute Checklist to assess risk of bias and the GRADE approach to assess the certainty of evidence. The primary outcome was the prevalence of patients with ICU-CA; secondary outcomes included ICU and in-hospital mortality. We performed subgroup analyses based on geographical region (continent), study source (registry vs. non-registry), and COVID-19 status (infected vs. non-infected). We included 35 observational studies including 36 cohorts in the meta-analysis. The pooled proportion of ICU-CA was 3.23

We aim to provide evidence-based clinical practice guidelines for the use of VV ECMO in adult patients across Australia and New Zealand. Developed by a multidisciplinary panel of clinicians from both countries, alongside a methodologist and patient representatives, these guidelines were produced in accordance with the National Health and Medical Research Council (NHMRC) 2016 standards for guidelines. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess the certainty of evidence and inform the development of recommendations. These guidelines are intended to support, not replace, clinical judgement and should be applied in the context of individual patient circumstances, values and preferences. In this part one of a three-part series, the Guideline Development Group (GDG) addressed four core clinical questions regarding the indications for and management of VV ECMO in adults. In addition to evidence-based recommendations, this guideline incorporates expert consensus through a well-established process and highlights important gaps in current evidence to guide future research priorities.

OBJECTIVES:Establishing an effective "chain of survival" for out-of-hospital cardiac arrest (OHCA) requires addressing gender disparities, which have been reported in both prehospital and in-hospital treatments. However, evidence of gender disparity in extracorporeal cardiopulmonary resuscitation (ECPR), which might contribute to differences in outcomes between sexes, remains limited. We aimed to investigate gender disparities in the administration of ECPR for OHCA. DESIGN:A secondary analysis of a prospective nationwide database. SETTING:The Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry, a multicenter database from 164 hospitals with emergency departments in Japan, collected data between June 2014 and December 2022. PATIENTS:Adult patients (≥ 18 yr) with OHCA from nonexternal causes who did not achieve return of spontaneous circulation before or upon hospital arrival and were transported to facilities with 24-hour ECPR availability within 60 minutes of emergency call. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary outcome was receiving ECPR, defined as emergent venoarterial extracorporeal membrane oxygenation implementation before return of spontaneous circulation within 60 minutes after hospital arrival. Multilevel logistic regression analysis was used to estimate the probability of receiving ECPR, adjusting for center-level and patient-level variables. Among 47,965 eligible patients, 28,754 (60.0%) were male and 19,211 (40.0%) were female. The median age was 78.0 years. ECPR was performed in 1713 male patients (6.0%) compared with 344 female patients (1.8%). After adjusting for potential confounders, male sex was associated with significantly higher odds of receiving ECPR (odds ratio, 1.68; 95% CI, 1.46-1.93). This male predominance was consistent across most subgroups but was not observed in patients with unequivocally eligible or ineligible for ECPR. CONCLUSIONS:ECPR was significantly more frequently performed in male patients with OHCA. Subgroup analyses suggest that gender disparity is particularly evident in cases where indications for ECPR are not clearly defined. Further research is needed to explore the underlying causes of this disparity.

Disclaimer:These guidelines are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

BACKGROUND:Acute respiratory failure after cardiac surgery is an uncommon complication, affecting morbidity and mortality. In these patients, respiratory extracorporeal membrane oxygenation (ECMO) support may be beneficial, as it may help reduce pulmonary vasoconstriction and the impact of respiratory pressures on the heart. Nevertheless, literature reports of postcardiotomy veno-venous (V-V) ECMO use are sporadic. METHODS:This retrospective, multicenter cohort study analyzes data from the PELS-1 registry, focusing on adult patients who required V-V ECMO following cardiac surgery. PELS-1 was conducted across 34 cardiac surgery centers in 16 countries from 2000 to 2020. RESULTS:The study included 24 patients who received V-V ECMO over a total of 2163 patients requiring postocardiotomy extracorporeal support (1.1%). The median age was 64[50-69] years, and 16/24 (67%) were male. Median Euroscore II was 6.2[3.1-19.6]. Most patients required prolonged cardiopulmonary bypass (CPB) time (208[110-350] min). V-V ECMO was initiated in the ICU in 21 patients (87.5%) after a median of 5 [2-12] days postoperatively. ECMO support rapidly normalized gas exchange and lactate levels. However, complications were frequent: bleeding (10/22, 45.5%), acute kidney injury (10/24, 41.7%), pneumonia (10/24, 41.7%), and arrhythmias (7/24, 29.2%) were the most frequent ones. In-hospital mortality was high, with only 21.7% discharged alive. One-year survival was 12.5%. CONCLUSIONS:Reported outcomes of patients receiving V-V ECMO after cardiac surgery are poor, despite effective correction of gas exchange. Early recognition of isolated respiratory failure and careful patient selection should be promoted. Further research is needed to optimize management in this high-risk population.

OBJECTIVES:Delayed awakening in resuscitated out-of-hospital cardiac arrest (OHCA) patients complicates neuroprognostication and exposes to inappropriate and premature withdrawal of life-sustaining therapy (WLST) decisions. We synthesised evidence on definitions, determinants and outcomes of delayed awakening after OHCA. METHODS:We searched Medline via PubMed, Embase, and Scopus, from inception to 22 February 2026. We included studies describing delayed awakening in resuscitated adult OHCAs, assessed risk of bias, and performed descriptive synthesis organised by definitions, determinants and outcomes. RESULTS:Nineteen studies (17 observational, 2 randomised trials; 5441 patients; all high-income countries) reported delayed awakening in 11-52% of patients. Eighteen of 19 studies predated the recommendations of International Liaison Committee on Resuscitation (ILCOR), and only two were conducted in settings without WLST. Nine distinct definitions varied in time threshold (48 h-7 days), reference point (post-resuscitation, post-rewarming, post-sedation withdrawal) and awakening criterion (Glasgow Coma Score, ability to follow commands, orientation, and Richmond Agitation-Sedation Scale). Therapeutic hypothermia, longer-acting sedatives, and prolonged sedation were the most consistent treatment-related determinants. Although delayed awakeners had worse outcomes, 51-94% achieved good neurological recovery at discharge across 4 cohorts, albeit with worse long-term quality of life. CONCLUSION:Delayed awakening after OHCA was predominantly influenced by treatment-associated variables and did not preclude meaningful neurological recovery. Nearly all existing evidence reflected outdated temperature management practices and was confounded by WLST-driven self-fulfilling prophecy bias, limiting conclusions regarding true outcomes. Standardised definitions and studies free of WLST-driven bias are urgently needed.

Purpose: This study aimed to analyze data from the Extracorporeal Life Support Organization (ELSO) registry to elucidate the epidemiology and outcomes of patients with tuberculosis necessitating extracorporeal membrane oxygenation (ECMO), an intervention typically employed in treating severe acute respiratory distress syndrome (ARDS), but infrequently reported in tuberculosis contexts. Methods: A retrospective analysis was conducted utilizing the ELSO registry data spanning from 2003 to 2022, specifically targeting patients with tuberculosis who underwent ECMO. Primary outcomes included survival to hospital discharge, while secondary outcomes encompassed pre-ECMO support, ECMO duration, complications, and discharge destinations. Univariate and multivariate Cox proportional hazard regression analyses were employed to identify factors influencing survival rates. Results: The analysis included 169 patients with tuberculosis, with a median ECMO support duration of 233 h. The weaning success rate was recorded at 62.7 %, and 55 % of patients achieved survival to hospital discharge. Complications arose in 69.8 % of cases, predominantly mechanical complications (46.6 %). Multivariate Cox regression analysis identified complications (HR: 0.448, 95 % CI: 0.222-0.748, P=0.001), =0.001), infections (HR: 0.483, 95 % CI: 0.241-0.808, P=0.001), =0.001), and prolonged intervals from admission to ECMO initiation (HR: 0.698, 95 % CI: 0.396-0.901, P=0.018) =0.018) as significant factors correlated with decreased survival likelihood. Conclusion: ECMO presents as a viable treatment option for patients with tuberculosis; however, timely initiation and meticulous management are critical to mitigate complications and enhance patient outcomes. Implication for clinical practice: Accurate identification of optimal ECMO initiation timing for eligible patients with tuberculosis can significantly enhance clinical outcomes in critical care settings, such as intensive care units.