**9.10 Patient selection for ECMO**

In patients with sepsis, 13–65% develop SCM, but not all patients in septic shock will benefit from VA-ECMO [153, 156–158]. Patients with sepsis who are refractory to standard therapy, including adequate fluid resuscitation, antibiotics, and stress dose steroids, have increasing requirement of vasopressors and inotropes, and echocardiography findings are consistent with SCM, and they should be considered for prompt VA-ECMO support. A positive blood culture alone is not a contraindication for VA-ECMO, especially when source control and antibiotic therapy have already been initiated [159]. The early introduction of VA-ECMO and other types of MCS can prevent adverse effects of an escalating dose of inotropes and vasopressors and the mechanical ventilation, the effect termed as "metabolic rest" [160]. Any situation in which incremental escalation of standard therapies results in disproportionately lower hemodynamic improvement should warrant the use of ECMO and other AMCS devices. However, use of ECMO in patients with SCM who had CA remains controversial with poor outcomes [161, 162].
