Use of venovenous extracorporeal membrane oxygenation (ECMO) is increasing, but candidacy selection processes are variable and subject to bias. What are the reasons behind venovenous ECMO candidacy decisions, and are decisions made consistently across patients? Prospective observational study of all patients, admitted or outside hospital referrals, considered for venovenous ECMO at a tertiary referral center. Relevant clinical data and reasons for candidacy determination were cross-referenced with other noncandidates and candidates and were assessed qualitatively. Eighty-one consultations resulted in 44 noncandidates (54%), 29 candidates (36%; nine of whom subsequently underwent cannulation), and eight deferred decisions (10%). Fifteen unique contraindications were identified, variably present across all patients. Five contraindications were invoked as the sole reason to deny ECMO to a patient. In patients with three or more contraindications, additional contraindications were cited even if the severity was relatively minor. All but four contraindications invoked to deny ECMO to a patient were nonprohibitive for at least one other candidate. Contraindications documented in noncandidates were present but not mentioned in 21 other noncandidates (47%). Twenty-six candidates (90%) had at least one contraindication that was prohibitive in a noncandidate, including a contraindication that was the sole reason to deny ECMO. Contraindications were proposed as informing three prognostic domains, through which patterns of inconsistency could be understood better: (1) irreversible underlying pulmonary process, (2) unsurvivable critical illness, and (3) clinical condition too compromised for meaningful recovery. ECMO candidacy decisions are inconsistent. We identified four patterns of inconsistency in our center and propose a three-domain model for understanding and categorizing contraindications, yielding five lessons that may improve candidacy decision processes until further research can guide practice more definitively.

中文翻译：

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静脉体外膜氧合候选决策：单中心观察分析的经验教训和假设

静脉-静脉体外膜肺氧合（ECMO）的使用正在增加，但候选资格选择过程是可变的并且容易受到偏见的影响。静脉 ECMO 候选决策背后的原因是什么？患者做出的决策是否一致？对所有入院或院外转诊的患者进行前瞻性观察研究，考虑在三级转诊中心接受静脉 ECMO。相关临床数据和候选资格确定的原因与其他非候选者和候选者交叉引用，并进行定性评估。 81 次咨询后，44 名候选人（54%）、29 名候选人（36%；其中 9 名随后接受了插管）和 8 名推迟决定（10%）。确定了 15 种独特的禁忌症，所有患者的情况各不相同。拒绝为患者提供 ECMO 的唯一理由是五项禁忌症。对于具有三个或更多禁忌症的患者，即使严重程度相对较小，也会引用其他禁忌症。除了四种拒绝对患者进行 ECMO 的禁忌症外，所有其他禁忌症对于至少一名其他候选者来说都是非禁止性的。其他 21 名非候选者 (47%) 存在记录在非候选者中的禁忌症，但未提及。 26 名候选人 (90%) 至少有一项禁止非候选人的禁忌症，包括拒绝 ECMO 的唯一原因的禁忌症。提出禁忌症作为三个预后领域的信息，通过这些领域可以更好地理解不一致的模式：(1) 不可逆的潜在肺部过程，(2) 无法生存的危重疾病，(3) 临床状况严重受损，无法进行有意义的恢复。 ECMO 候选决定不一致。我们确定了我们中心的四种不一致模式，并提出了一个用于理解和分类禁忌症的三领域模型，得出了五个教训，可以改善候选决策过程，直到进一步的研究可以更明确地指导实践。