What are the management strategies for Extracorporeal Membrane Oxygenation (ECMO) patients in the Intensive Care Unit (ICU)?

Management of ECMO Patients in the ICU

ECMO patients in the ICU require a standardized, multidisciplinary approach focused on five critical domains: neurological monitoring, hemodynamic optimization, prevention and management of acute brain injury, anticoagulation management, and systematic prognostication—all guided by the 2024 ELSO consensus guidelines. 1

Neurological Monitoring and Assessment

Protocolized neurological monitoring is essential as acute brain injury (ABI) occurs in 16% of all ECMO patients, with significantly higher rates in VA-ECMO (19%) compared to VV-ECMO (10%). 1, 2

Core Monitoring Components

• Perform comprehensive neurological examinations on all ECMO patients, assessing consciousness, cognition, brainstem function, and motor function at regular intervals 2
• Implement continuous cerebral oximetry to follow trends and detect ABI early, particularly in peripheral VA-ECMO patients at risk for differential hypoxia (Harlequin syndrome) 3
• Obtain neurological consultation immediately for any acute neurological change 1, 2
• Use pupillometry if available to objectively evaluate pupil size and reactivity 3
• Consider intermittent EEG and somatosensory evoked potential (SSEP) monitoring, especially in comatose patients 3

Neuroimaging Strategy

• Obtain non-contrast head CT to rule out intracranial hemorrhage when acute neurological changes are suspected, particularly in anticoagulated patients 1, 2
• Perform neurological assessment before and after weaning from ECMO support to evaluate for potential ABI 4

Hemodynamic Management

ECMO Flow Optimization

• Target ECMO flow of 3-4 L/min immediately after cannulation, gradually increasing as tolerated 1, 3
• Maintain arteriovenous oxygen difference between 3-5 cc O₂/100ml of blood as the most reliable parameter for setting ECMO flow goals (not influenced by hemoglobin levels) 1, 3
• Target mixed venous saturation (SvO₂) >66% and oxygen delivery to consumption ratio (DO₂:VO₂) >3, recognizing these are hemoglobin-dependent parameters 1

Blood Pressure Management

• Maintain mean arterial pressure (MAP) >70 mmHg to ensure adequate cerebral and end-organ perfusion while minimizing left ventricular afterload 1, 3
• Discontinue mechanical chest compressions upon cannulation and wean vasoactive support as tolerated 1

Arterial Blood Gas Monitoring

• Obtain arterial blood gases from a right radial arterial line as this best represents ascending aortic/innominate and cerebral perfusion 1
• Monitor for Harlequin (North-South) syndrome in peripherally cannulated patients, which occurs in ~10% of cases 1
• Recognize pulse pressure patterns: narrow pulse pressure from right radial line suggests mixing point proximal to innominate artery; wide pulse pressure indicates distal mixing point 1

Management of Differential Hypoxia

When Harlequin syndrome is identified:

• Increase ECMO flow to move the mixing point proximally 1
• Manipulate ventilator settings to improve native lung oxygenation 1
• Consider V-AV ECMO configuration (inserting oxygenated return cannula in jugular vein) 1

Oxygenation and Ventilation Targets

Oxygen Management

• Maintain PaO₂ >70 mmHg to prevent hypoxemia-associated ABI 3
• Avoid severe arterial hyperoxia (PaO₂ >300 mmHg), particularly in VA-ECMO where reperfusion injury risk is high 3
• Target arterial oxygen saturation of 92-97% by adjusting ECMO sweep gas oxygen percentage 3

Carbon Dioxide Management

• Avoid rapid changes in CO₂ levels within the first 24 hours of ECMO support to prevent cerebrovascular complications 3

Temperature Management

• Continuously monitor core temperature and actively prevent fever (>37.7°C) 3
• Consider mild-moderate hypothermia (33-36°C) for 24-48 hours in VA-ECMO patients, especially those undergoing ECPR 3

Fluid Management

• Strive for daily negative fluid balance after ECMO flows are optimized and hemodynamic stability is achieved 3
• Monitor for fluid overload, which is associated with increased mortality by the third day of ECMO 3

Management of Acute Brain Injury

Ischemic Stroke

• Tissue plasminogen activator (tPA) is NOT recommended for acute ischemic stroke in ECMO patients due to high bleeding risk with systemic anticoagulation and platelet dysfunction 1, 2
• Mechanical thrombectomy is recommended for acute large vessel occlusion 1, 2

Intracranial Hemorrhage

• For VV-ECMO patients with acute ICH, implement prolonged cessation of systemic anticoagulation (>2 days) 1
• VA-ECMO can be maintained without anticoagulation albeit at higher thromboembolism risk; balance bleeding risk against thromboembolism risk 1
• VV-ECMO can be maintained without anticoagulation for longer periods than VA-ECMO given lower thromboembolism risk 1
• Implement early cessation and judicious resumption of anticoagulation with repeated neuroimaging for ECMO-associated ischemic stroke and ICH 1, 2

Intracranial Hypertension Management

Use stepwise approach for acute intracranial hypertension: 1, 2

1. Raise head of bed
2. Hyperosmolar therapy
3. Sedation/analgesia

Neurosurgical Interventions

• Consider decompressive craniectomy for stroke based on risk-benefit discussion between multidisciplinary team and patient surrogate 1
• External ventricular drain placement may be considered in patients with intraventricular hemorrhage and hydrocephalus at high risk of death with limited management options 1, 2
• Carefully monitor and resume systemic anticoagulation after decompressive craniectomy 1
• Use caution with invasive ICP/brain tissue oxygenation monitors as no data suggests improved outcomes in ECMO patients 1, 2

Neurological Prognostication

Multimodal Approach

• Use multimodality, multidisciplinary approach combining clinical/neurological examination, electrophysiological tests, and neuroimaging—never rely on single factor/tool 1, 2
• For ECPR patients, poor neurological outcome is strongly suggested by ≥2 indicators of severe ABI: 1
  • Absence of pupillary and corneal reflexes at ≥72 hours
  • Bilateral absence of N20 cortical waves on SSEP at ≥24 hours
  • Highly malignant EEG patterns at >24 hours
  • Neuron-specific enolase >60 μg/L at 48-72 hours (note: values often elevated in ECMO due to hemolysis)
  • Status myoclonus ≤72 hours
  • Extensive diffuse anoxic injury on brain CT/MRI

Brain Death Determination

• Determine brain death based on devastating brain injury on imaging, neurological examination, and apnea test after excluding confounding factors and following country-specific guidelines 1
• When apnea test is challenging, use cerebral angiogram or radionuclide brain scan as preferred ancillary tests 1

Communication

• Hold frequent meetings and goals of care discussions with patient surrogates reflecting patient preferences 1

Organizational Considerations

Team Structure

• Establish multidisciplinary ECMO support team comprising physicians, nurses, perfusionists, neurologists, neurosurgeons, and specialized nursing staff 2, 5, 6
• Implement daily multidisciplinary rounds with ECMO team participation 5

Common Pitfalls to Avoid

• Avoid "self-fulfilling prophecy" bias where poor prognostic test results inappropriately influence treatment decisions 2
• Recognize that clinical diagnosis can be challenging due to non-specific symptoms (headache, seizure, encephalopathy) 2
• Balance thromboembolism risk against bleeding risk when managing anticoagulation in ECMO patients 2
• Recognize that acquired von Willebrand syndrome develops in almost all ECMO patients but resolves rapidly after weaning 4