Management of ECMO Complications
ECMO complications require immediate multidisciplinary intervention with protocolized neurological monitoring, aggressive hemodynamic optimization, and carefully balanced anticoagulation management to reduce the 2-3 fold increase in mortality associated with acute brain injury and hemorrhagic complications. 1
Neurological Complications Management
Immediate Detection and Monitoring
- Implement protocolized neurological monitoring immediately upon ECMO initiation, as acute brain injury (ABI) occurs in 16% of all ECMO patients, with significantly higher rates in VA-ECMO (19%) versus VV-ECMO (10%). 2
- Perform continuous cerebral oximetry to detect ABI early, particularly in peripheral VA-ECMO patients at risk for differential hypoxia. 3
- Conduct comprehensive neurological examinations assessing consciousness, cognition, brainstem function, and motor function at regular intervals. 2
- Utilize intermittent EEG and somatosensory evoked potentials (SSEP), especially in comatose patients. 3
Acute Stroke Management
- Obtain non-contrast head CT immediately to rule out intracranial hemorrhage in patients with suspected stroke during ECMO. 1
- Do NOT administer tPA for acute ischemic stroke in ECMO patients due to prohibitively high bleeding risk with systemic anticoagulation and platelet dysfunction. 1, 2
- Proceed with mechanical thrombectomy for acute large vessel occlusion, as this is the recommended intervention. 1, 2
- For acute ischemic stroke, allow permissive hypertension (BP ≤ 220/120 mmHg) to maintain cerebral perfusion if cardiac function tolerates the increased afterload. 3
Intracranial Hemorrhage Management
- For VV-ECMO with acute intracranial hemorrhage, cease systemic anticoagulation for >2 days. 1
- VA-ECMO can be maintained without anticoagulation but carries higher thromboembolism risk; carefully balance anticoagulation versus bleeding risk. 1
- VV-ECMO tolerates longer periods without anticoagulation than VA-ECMO given lower thromboembolism risk. 1
- Target lower blood pressure (systolic BP <140 mmHg and MAP <90 mmHg) for intracerebral hemorrhage due to anticoagulation-associated bleeding risk. 3
- Resume anticoagulation judiciously with repeated neuroimaging after ECMO-associated ischemic stroke or intracranial hemorrhage. 1
Surgical Neurological Interventions
- Consider decompressive craniectomy for stroke only after risk-benefit discussion between the multidisciplinary team and patient surrogate. 1
- Implement stepwise acute intracranial hypertension management protocols. 1
- Consider extra-ventricular drain placement cautiously in patients with limited options and high death risk from intraventricular hemorrhage and hydrocephalus. 1
- Exercise caution with intracranial pressure monitors or brain tissue oxygenation monitors, as no current data suggests outcome improvement in ECMO patients. 1
Hemodynamic Complications Management
Differential Hypoxemia (VA-ECMO Specific)
- Monitor for differential hypoxemia where poorly-oxygenated blood from the failing native heart perfuses the upper body. 3
- Obtain arterial blood gases from a right radial arterial line to best represent cerebral oxygenation. 3
- A wide pulse pressure on right radial arterial monitoring indicates significant left ventricular ejection reaching the upper body, suggesting a distal mixing point. 3
- When differential hypoxemia is detected, immediately increase ECMO flow to move the mixing point proximally toward the innominate artery. 3
Flow and Perfusion Targets
- Target initial ECMO flow of 3-4 L/min immediately post-cannulation, gradually increasing as tolerated. 3, 2
- Maintain arteriovenous oxygen difference between 3-5 cc O₂/100ml blood as the most reliable flow parameter. 3, 2
- Target mean arterial pressure >70 mmHg to ensure adequate cerebral and end-organ perfusion while minimizing left ventricular afterload. 3, 2
Oxygenation Management
- Maintain PaO₂ >70 mmHg to prevent hypoxemia-associated acute brain injury. 3, 2
- Avoid severe arterial hyperoxia (PaO₂ >300 mmHg), particularly in VA-ECMO where reperfusion injury risk is high. 3, 2
Hemorrhagic and Thrombotic Complications Management
Anticoagulation Strategy
- Anticoagulation is required for cannulation and circuit/oxygenator clot prevention but must be balanced against high bleeding risk. 3
- Recent data shows 42% of VV-ECMO patients experience thrombotic events, 37% experience bleeding events, and 21% experience both complications. 3
- Hemorrhagic complications occur in 28.3% of ECMO patients, with cannulation site hemorrhage being most common (13.6%). 4
- Hemorrhage is independently associated with increased in-hospital mortality (OR 2.97). 4
Monitoring Anticoagulation
- Carefully monitor systemic anticoagulation and plan resumption strategy after decompressive craniectomy. 1
- Recognize that hemocoagulation tests are not specific and results can be biased by many factors. 5
- Consider novel anticoagulants (argatroban, bivalirudin) which may offer better predictability, function independently of antithrombin, and eliminate heparin-induced thrombocytopenia risk. 5
Neurological Prognostication
Multimodality Assessment
- Use a multimodality, multidisciplinary approach combining clinical/neurological examination, electrophysiological tests, and neuroimaging for prognostication. 1, 2
- Never use any single factor/tool (e.g., brain imaging only) as the sole indicator for patient prognosis. 1
- Rule out confounding factors including sedatives, significant electrolyte disturbances, and hypothermia before making prognostic determinations. 1
Poor Outcome Indicators
- Poor neurological outcome is strongly suggested by ≥2 indicators of severe ABI including: 1, 2
- 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 levels exceeding 60 μg/L at 48-72 hours
- Status myoclonus ≤72 hours
- Extensive diffuse anoxic injury on brain CT/MRI
Avoiding Prognostic Pitfalls
- Exercise caution to mitigate "self-fulfilling prophecy" bias where poor prognostic test results inappropriately influence treatment withdrawal decisions. 1
- Conduct the most crucial evaluation after rewarming in patients undergoing targeted temperature management. 1
Post-ECMO Follow-up and Rehabilitation
Discharge Planning
- Establish comprehensive rehabilitation plans addressing physical therapy, occupational therapy, speech therapy, and management of chronic conditions. 1
- Provide comprehensive education and psychosocial support for patients, family members, and caretakers. 1
- Formulate nutritional plans for optimal recovery. 1
Post-Discharge Surveillance
- Conduct serial neurological assessments and quality of life assessments at standardized intervals. 1
- For patients with neurological complications, arrange clinical examination by a neurological specialist, neuroimaging (preferably MRI), and other tailored examinations. 1
- Coordinate follow-up with disease-specific specialists including pulmonologist, cardiologist, neurologist, nephrologist, gastroenterologist, and hematologist as needed. 1
- Ensure follow-up with primary care physician. 1
- Assess modified Rankin Scale at discharge and during each follow-up visit. 1
Data Management
- Establish a centralized and secure data repository to store patient data that can be shared with outpatient healthcare providers. 1
- Submit data to the ELSO registry or equivalent database for cross-institutional analysis. 3
System-Level Requirements
Staffing and Expertise
- Maintain nurse-to-patient ratio of 1:1 to 1:2 maximum. 3
- Ensure neurological consultation availability for acute neurological changes. 1
- Assemble multidisciplinary team including intensivists, perfusionists, neurologists, surgeons, and specialized nursing staff. 3