What are the next steps for a patient not improving on Extracorporeal Membrane Oxygenation (ECMO)?

Management of Patients Not Improving on ECMO

For patients not improving on Extracorporeal Membrane Oxygenation (ECMO), a comprehensive multidisciplinary approach is required, including neurological assessment, optimization of physiological parameters, consideration of surgical interventions, and appropriate prognostication to guide further management decisions.

Initial Assessment and Optimization

Neurological Evaluation

• Perform serial neurological examinations to detect acute brain injury (ABI), which increases in-hospital mortality by 2-3 times 1
• Consider neurological consultation for any acute neurological changes 1
• Obtain non-contrast head CT to rule out intracranial hemorrhage in patients with suspected neurological complications 1

Physiological Parameter Optimization

• Oxygenation targets:

  • For VV ECMO: Maintain PaO₂ > 70 mmHg to prevent hypoxemia-associated brain injury 1
  • For VA ECMO: Avoid hyperoxemia (PaO₂ > 300 mmHg) as it may contribute to oxidative stress 1

• Carbon dioxide management:

  • Avoid rapid PaCO₂ changes which can alter cerebral blood flow 1
  • Target normocapnia (PaCO₂ 35-45 mmHg) 1

• Blood pressure management:

  • Maintain mean arterial pressure > 70 mmHg 1
  • Consider individualized blood pressure goals based on patient comorbidities 1

• Temperature management:

  • Maintain normothermia and actively prevent fever (> 37.7°C) 1
  • For VA ECMO, especially ECPR cases, consider mild-moderate hypothermia (33-36°C) for 24-48 hours 1
  • Hypothermia is not recommended for VV ECMO 1

Sedation Management

• Implement standardized sedation protocols with validated scoring systems (e.g., Richmond Agitation Sedation Scale) 1
• Prefer intermittent (as-needed) analgo-sedation over continuous infusion 1
• Consider short-acting, non-benzodiazepine sedatives 1
• Perform daily reassessment of sedation goals and implement stepwise sedation weaning 1

Advanced Interventions for Non-Improving Patients

For Patients with Neurological Complications

Ischemic Stroke Management

• Tissue plasminogen activator (tPA) is generally not indicated due to high bleeding risk 1
• Consider mechanical thrombectomy for large vessel occlusion 1

Intracranial Hemorrhage Management

• Prevent hematoma expansion through BP control and discontinuing systemic anticoagulation 1
• For VV ECMO: Consider prolonged (>2 days) cessation of anticoagulation 1
• For VA ECMO: Balance the risk of anticoagulation cessation against thromboembolism risk 1
• Consider neurosurgical interventions in select cases after multidisciplinary discussion 1

Surgical Options

• Decompressive craniectomy may be considered for patients with space-occupying lesions causing acute intracranial hypertension 1
• External ventricular drainage may be considered in selected patients at risk of imminent death from intraventricular hemorrhage and hydrocephalus 1

Bridge to Definitive Treatment

• Consider ECMO as a bridge to conventional cardiac surgical procedures in critically ill patients 2
• For respiratory failure patients, ambulatory ECMO may serve as a bridge to lung transplantation 3

Prognostication and Decision-Making

Multimodal Prognostication Approach

• Use a multimodality, multidisciplinary approach including clinical examination, electrophysiological tests, and neuroimaging 1
• Never use a single factor/tool as the sole indicator for patient prognosis 1
• For ECPR patients, consider a combination of clinical, biomarker, electrophysiological, and neuroimaging assessment 1

Goals of Care Discussions

• Conduct frequent meetings with patient surrogates that reflect the patient's preferences 1
• Consider ethics consultation within 72 hours of cannulation to mitigate ethical conflicts 1
• Discuss withdrawal from ECMO as a structured process when appropriate 1

Long-term Follow-up Considerations

• Establish follow-up with disease-specific specialists tailored to underlying conditions 1
• Assess modified Rankin Scale at discharge and during follow-up 1
• Consider additional detailed assessments (e.g., Glasgow Outcome Scale Extended, Montreal Cognitive Assessment) 1

Common Pitfalls to Avoid

• Relying on a single parameter for prognostication
• Failing to recognize acute brain injury due to inadequate neurological monitoring
• Overlooking the importance of maintaining optimal physiological parameters
• Delaying multidisciplinary discussions about goals of care
• Neglecting to establish a long-term follow-up plan for survivors

Remember that early detection of complications and timely intervention are crucial for improving outcomes in patients on ECMO who are not showing improvement.