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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.