ECMO year in review: transports, infections & sepsis, bleeding and hemostasis on ECLS

ECMO transports

Interhospital ECMO transport: safe & effective with minimal complications and favourable outcomes when performed at an experienced referral center using stringently applied protocols according to the experience of adult patients transported while on extracorporeal support to Columbia University Medical Center; findings might not be applicable to new programs with low ECLS volume/limited referral base.

Tipograf Y, Liou P, Oommen R, Agerstrand C, Abrams D, Brodie D, Bacchetta M. A decade of interfacility extracorporeal membrane oxygenation transport. J Thorac Cardiovasc Surg. 2019 Apr;157(4):1696-1706. link

PS full talk open access here link

Salvage VA ECMO retrieval service for patients with cardiogenic shock: learning from severe respiratory failure service organization? this experience describes the institution of extracorporeal support in the referring hospital, patient management and outcomes, demonstrating feasibility and survival benefit of transferring carefully selected patients with refractory cardiogenic shock on veno-arterial ECLS, even for long distances and with an open chest.

Ali JM, Vuylsteke A, Fowles JA, Pettit S, Salaunkey K, Bhagra S, Lewis C, Parameshwar J, Kydd A, Patvardhan C, Jones N, Rubino A, Abu-Omar Y, Sudarshan C, Tsui S, Catarino P, Jenkins DP, Berman M. Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. 2019 May 16. link

ECMO transport, results of an international survey: regulatory oversight is lacking about the validation, structure & quality assurance; the establishment of a dedicated international body to develop platforms for uniform education, training, quality, and equipment standards for ECLS transport is advocated.

Broman LM, Dirnberger DR, Malfertheiner MV, Aokage T, Morberg P, Næsheim T, Pappalardo F, Di Nardo M, Preston T, Burrell AJC, Daly I, Harvey C, Mason P, Philipp A, Bartlett RH, Lynch W, Belliato M, Taccone FS. International Survey on Extracorporeal Membrane Oxygenation Transport. ASAIO J. 2019 Apr 2. link

Interhospital transfer on ECMO support of brain‐dead small weight infant as bridge to procurement: protracting ECLS post BD diagnosis to expand pediatric donors pool vs organ shortage, realizing parents’ donation goal.

Leblanc C, Genuini M, Deho A, Lodé N, Philippe-Chomette P, Hervieux E, Amblard A, Pracros N, Léger PL, Jean S. Successful extracorporeal membrane oxygenation transport of a 4-month-old brain-dead infant for organ donation: A case report. Pediatr Transplant. 2019 Nov;23(7):e13515. link

Interhospital transports of newborns on ECMO, where are we now? basic requirements for education, training & experience are needed to increase performance, with wet-labs mimicking narrow spaces scenario, and high-fidelity simulations for the whole team. Preparing for transport, focusing on safe management, timeouts, checklists & ECLS A-B-C (pump, sweep gas, heater, tubings) are mandatory to increase safety. Where will we go? The introduction of new strategies to support the (extremely) premature, as artificial placenta and prem-ECMO, could increase mobile ECMO volume in the future. Neonatal ECMO transport services should include an out-reach service provided by ELSO centers, reporting data to the Registry for transport quality follow-up and research.

Broman LM. Interhospital Transport on Extracorporeal Membrane Oxygenation of Neonates-Perspective for the Future. Front Pediatr. 2019;7:329. Published 2019 Aug 6. Open access link

Infections, sepsis, septic shock and/on ECLS

Infections & extracorporeal support: commonly precede & frequently identified during the run. Here, a review of current knowledge regarding ECLS-associated infections, focusing on potential risk factors & challenges in the detection, treatment, prevention of infections on ECMO. The review also highlights the need for standardized definitions, consistent detection strategies, and comprehensive descriptions of patient characteristics & outcomes to drawn conclusions about the clinical significance of these infections, and suggest best practices for both prevention and management.
PS: Potential strategies to reduce infections during ECLS??
avoid maintaining ECMO support longer than necessary
use a percutaneous approach for cannulation whenever possible & routinely monitor insertion sites for evidence of infections
consider extubation for those at high risk of VAP, when appropriate
maintain a low threshold to obtain cultures
access the circuit only when absolutely necessary, and with proper sterile technique
sensure therapeutic levels of antimicrobials, when feasible.

Abrams D, Grasselli G, Schmidt M, Mueller T, Brodie D. ECLS-associated infections in adults: what we know and what we don’t yet know. Intensive Care Med. 2019 Nov 25. link

Nosocomial infections on ECMO in neonatal, pediatric, & adult patients: common, appearing to more frequently affect older children and adults, associated with longer duration of the ECLS run and (strongly) associated with adverse outcomes. Risk factors for nosocomial infection other than the duration of extracorporeal support include mechanical/bleeding complications and veno-arterial & central configurations. These the result of a narrative review, reporting a low overall quality of studies in the field, and heterogeneity in study design, case definitions, outcomes (so limited generalizability of findings). Diagnosis of infection appears challenging in this population, with lack of evidence to support the routine screenings (ie cultures or biomarkers); effects of anti-infective preventive measures implementation in ECMO patients scarcely studied, with the epidemiology of infections considerably variable (this, in the authors’ opinion, may be due to changes in clinical practice over the last decades, heterogeneity of the populations, differences in the defining nosocomial infection).

MacLaren G, Schlapbach LJ, Aiken AM. Nosocomial Infections During Extracorporeal Membrane Oxygenation in Neonatal, Pediatric, and Adult Patients: A Comprehensive Narrative Review. Pediatr Crit Care Med. 2019 Oct 31. link

There is a critical need for preventing, early detecting, & treating infections during the ECMO run, as mortality for patients developing these complications on extracorporeal support is two times higher than those without: here results from a survey administered to ECMO centers worldwide, reporting lack of consensus and considerable variability among region/center surrounding prevention, diagnosis & management of infections on ECLS, and emphasizing the need for specific research.

Farrell D, MacLaren G, Schlapbach LJ. Infections on Extracorporeal Life Support in Adults and Children-A Survey of International Practice on Prevention, Diagnosis, and Treatment. Pediatr Crit Care Med. 2019 Jul;20(7):667-671. link

with its accompanying editorial, advocating evidence-based dedicated guidelines to improve outcomes of ECMO patients.

Thiagarajan RR. No Consensus, Wide Variability: State of Infection Management During Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2019 Jul;20(7):684-685. link

Candida BSI rare & occurs late during the course of ECMO support? according to these authors early septic shock is frequent but largely due to bacteria: antifungal therapy should not be part of the first-line empiric antimicrobial therapy in septic shock occurring within first 2 weeks of the run, unless indicated for other comorbilities; consider systemic candidiasis in sepsis under prolonged MCS.

de Roux Q, Botterel F, Lepeule R, Taccone FS, Langeron O, Mongardon N. Candida bloodstream infection under veno-arterial ECMO therapy. Crit Care. 2019;23(1):314. Open access link

in reply Cavayas YA, Yusuff H, Porter R. Fungal infections in adult patients on extracorporeal life support. Crit Care. 2018;22(1):98. link

ECMO in septic shock? Results of this single (ECLS experienced) center analysis of both distributive septic shock and septic shock with cytotoxic cardiac failure, suggests that peripheral cannulation extracorporeal support may be beneficial for hospital & long-term survival, provided that ECLS should be initiated by and/or at least continued at a high-volume center with experience in both veno-venous & veno-arterial configuration, in order to provide proper support, adapted to to patient need.

Falk L, Hultman J, Broman LM. Extracorporeal Membrane Oxygenation for Septic Shock. Crit Care Med. 2019 Aug;47(8):1097-1105. link

Antimicrobials on ECMO? dosing on ECLS run can be challenging, as antibiotics cannot be titrated to clinical effect in real time, and challenges are may further increase if TDM is not readily available: apply the existing knowledge of critical illness-related PK changes and the emerging knowledge of altered PK on extracorporeal support to provide (or strive to provide) optimal pharmacotherapy!

Abdul-Aziz MH, Shekar K, Roberts JA. Antimicrobial therapy during ECMO – customised dosing with therapeutic drug monitoring: The way to go? Anaesth Crit Care Pain Med. 2019 Oct;38(5):451-453. link

Blood on ECLS: bleeding & hemostasis, anticoagulation (and no anticoagulation) & its monitoring, transfusion practices, hemolysis

Bleeding & thrombosis in pediatric ECLS: reviewing knowledge and current & novel medications, and proposing recommendations for future research directions to establish “best practice” for anticoagulation management on ECMO. All centers should report data on patients receiving extracorporeal support to a registry: the ELSO registry remains the primary and most successful data repository.

Penk JS, Reddy S, Polito A, Cisco MJ, Allan CK, Bembea MM, Giglia TM, Cheng HH, Thiagarajan RR, Dalton HJ. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 1. Pediatr Crit Care Med. 2019 Nov;20(11):1027-1033. link
Penk JS, Reddy S, Polito A, Cisco MJ, Allan CK, Bembea M, Giglia TM, Cheng HH, Thiagarajan RR, Dalton HJ. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 2. Pediatr Crit Care Med. 2019 Nov;20(11):1034-1039. link

Should patients on veno-arterial ECLS without other indications for anticoagulation be treated without systemic anticoagulation during extracorporeal support to prevent complications?? In this single center retrospective observation, no routine systemic anticoagulation during the ECMO run is not associated with higher mortality, pump failure, or thrombotic complications; patients required lower blood product transfusions, with no incidence of HIT.

Wood KL, Ayers B, Gosev I, Kumar N, Melvin AL, Barrus B, Prasad S. Venoarterial ECMO Without Routine Systemic Anticoagulation Decreases Adverse Events. Ann Thorac Surg. 2019 Sep 26. link

ECMO without anticoagulation: a series of immunocompromised patients with hemorrhagic tendency due to severe disease-related thrombocytopenia. No fatal clotting reported, with one patient receiving uninterrupted heparin‐free ECMO for really long‐term run (317 days! with only two extracorporeal circuit replacement – over a total of 6 – related to suspected ML thrombosis). Withdrawing systemic anticoagulation could be an appropriate and safe strategy in these population, as clotting events rarely occur, but indication for respiratory ECLS should be critically discussed, as prognosis appears poor.

Hermann A, Schellongowski P, Bojic A, Robak O, Buchtele N, Staudinger T. ECMO without anticoagulation in patients with disease-related severe thrombocytopenia: Feasible but futile? Artif Organs. 2019 Nov;43(11):1077-1084. link

Posterior fossa hemorrhage on VA ECMO support for postcardiotomy refractory cardiogenic shock: report of successful hematoma evacuation in semi-lateral position, avoiding risks of sitting or prone position with femoro-femoral cannulation, and protracted anticoagulant suspension without thrombotic events during ECLS.

Papin G, Sonneville R, Nataf P, Bouadma L. Emergency craniotomy in semi-lateral position for posterior fossa hemorrhage evacuation under venoarterial extracorporeal membrane oxygenation. Intensive Care Med. 2019 Aug;45(8):1152-1153. link

HEparin in critically iLl Patients undergoing ECMO); in this pilot two-center, randomized trial, the allocation to a low-dose or therapeutic dose heparin protocol resulted in a difference in the mean daily dose of UFH & in a significant difference in mean aPTT/anti-Xa; these results, even if not providing evidence on the optimal anticoagulation protocol for extracorporeal support, seem supporting the feasibility of a larger study to evaluate the safety/efficacy of low-dose anticoagulation on VV ECLS.

Aubron C, McQuilten Z, Bailey M, Board J, Buhr H, Cartwright B, Dennis M, Hodgson C, Forrest P, McIlroy D, Murphy D, Murray L, Pellegrino V, Pilcher D, Sheldrake J, Tran H, Vallance S, Cooper DJ; endorsed by the International ECMO Network (ECMONet). Low-Dose Versus Therapeutic Anticoagulation in Patients on Extracorporeal Membrane Oxygenation: A Pilot Randomized Trial. Crit Care Med. 2019 Jul;47(7):e563-e571. link

Good practice statements & supporting literature for red blood cell transfusions in critically ill children on ECMO, Ventricular Assist Devices or renal replacement therapy RRT from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

Bembea MM, Cheifetz IM, Fortenberry JD, Bunchman T, Valentine S, Bateman S, Steiner M, and for the Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI) *, in collaboration with the Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Recommendations on the Indications for RBC Transfusion for the Critically Ill Child Receiving Support From Extracorporeal Membrane Oxygenation, Ventricular Assist, and Renal Replacement Therapy Devices From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018;19(9S Suppl 1):S157–S162. link

Here, the consensus conference methodology, open access link

A standardized thrombo-elastography & aPTT driven anticoagulation-monitoring protocol on ECMO support: appears safe and feasible in this observation. Rate of major bleeding as defined by ELSO parameters did not differ between the treatment groups, but a significant difference in mortality and retroperitoneal bleeds was observed, potentially suggesting, in the authors’ opinion, an advantage and supporting protocol driven care to avoid over/under anticoagulation in this population.

Colman E, Yin EB, Laine G, et al. Evaluation of a heparin monitoring protocol for extracorporeal membrane oxygenation and review of the literature. J Thorac Dis. 2019;11(8):3325–3335. Open access link

Anti-Xa & aPTT monitoring of heparin in adults on ECMO support: in this retrospective evaluation, anti-Xa assay better correlated with weight based dose vs aPTT; as low anti-Xa values predictive of thrombosis & high aPTT predictive of bleeding, a balanced anti-Xa/aPTT therapeutic drug monitoring approach may be warranted.

Arnouk S, Altshuler D, Lewis TC, Merchan C, Smith DE 3rd, Toy B, Zakhary B, Papadopoulos J. Evaluation of Anti-Xa and Activated Partial Thromboplastin Time Monitoring of Heparin in Adult Patients Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J. 2019 May 10. link

Monitoring hemostasis on ECMO support: comparing different hemostatic assays, PT, PTT, ACT, antifactor Xa, to determine their sensitivity to changes in the levels of coagulation factors, ATIII, UFH, PLTs, Ht analyzing vitro/in vivo data. aXa seems the most specific for heparin levels vs PT for coagulation factor levels, making these assays well suited to monitor patients on extracorporeal support; PTT highly variable as multiple parameters are changing, but may be useful when aXa cannot be used because of interference; ACT too insensitive to UFH and sensitive to too many other factors & too imprecise to be useful.

Saifee NH, Brogan TV, McMullan DM, Yalon L, Matthews DC, Burke CR, Chandler WL. Monitoring Hemostasis During Extracorporeal Life Support. ASAIO J. 2019 Mar 21. link

High Hb & ECLS: report of a case of acute normovolemic hemodilution to improve impaired extracorporeal blood flow with drainage failure possibly linked to severe polycythemia and hyperviscosity in an ARDS patient on veno-venous ECMO support.

Ursulet L, Pierrakos C, Cudia A, Velissaris D, Janssenswillen E, Devriendt J, De Bels. High Hemoglobin Level As a Limiting Factor for Extracorporeal Membrane Oxygenation. D. ASAIO J. 2019 Nov/Dec;65(8):e97-e99. Open access link

Hemolysis on ECMO support: pathophysiology, prevalence (how/when), clinical consequences, clinical & biologic diagnosis, limits to prevent & manage hemolytic events. Despite of major technological improvements ECLS-associated hemolysis still occurs with various intensity, from a nonalarming/tolerable to a highly toxic one.

Dufour N, Radjou A, Thuong M. Hemolysis and Plasma Free Hemoglobin During Extracorporeal Membrane Oxygenation Support: From Clinical Implications to Laboratory Details. A Review. ASAIO J. 2019 Feb 26. link

Membrane Lung induced hyperfibrinolysis as cause of bleeding on ECMO support detected by comparing thromboelastometry results from blood samples obtained before & after oxygenator and successfully treated merely by ML exchange: a case report.

Durila M, Smetak T, Hedvicak P, Berousek J. Perfusion. 2019 May;34(4):330-333. Extracorporeal membrane oxygenation-induced fibrinolysis detected by rotational thromboelastometry and treated by oxygenator exchange. Open access link

Roller vs centrifugal pump in infants on ECMO?? results from a large propensity score–matched cohort study in ECLS recipients weighing less than 10kg within the ELSO registry. Centrifugal pump use, expanding with technological advances & ease of handling, reported as associated with increased inpatient mortality, and increased rates of extracorporeal support related complications (cardiovascular, neurologic, renal, pulmonary, mechanical, hemolytic, infectious, limb). Authors suggest hemolysis may mediate these observations, and that their results may support an ongoing role for rollers in small children needing for ECMO.

O’Halloran CP, Thiagarajan RR, Yarlagadda VV, Barbaro RP, Nasr VG, Rycus P, Anders M, Alexander PMA. Outcomes of Infants Supported With Extracorporeal Membrane Oxygenation Using Centrifugal Versus Roller Pumps: An Analysis From the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med. 2019 Dec;20(12):1177-1184. link

… and a related comment: how then should we interpret these data? enough to recommend roller pumps for children less than 10 kg? likely no, they state, considering the significant role of hemolysis in mediating observed results, lack of timing of events and potential confounders.

Dalton HJ, Hoskote A. There and Back Again: Roller Pumps Versus Centrifugal Technology in Infants on Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2019 Dec;20(12):1195-1196. link

ECMO year in review: ethics & end-of-life

Ethics of ECLS

ECMO, lifesaving but associated with several complications that may contribute to reduced survival: the equipe caring for neonates on extracorporeal support, at high mortality risk, must be deeply prepared to deal with complex clinical scenarios, but also with complex ethical issues associated with ECLS. The team must be trained to handle unsuccessful runs, focusing on high quality end of life care. In this open access paper, authors compare & contrast two ethical frameworks, principlism & personalism to enhance a broader understanding of cultural differences in applied ethics, potentially useful to healthcare professionals practicing in an increasingly multicultural & diverse patient mix.

Di Nardo M, Dalle Ore A, Testa G, Annich G, Piervincenzi E, Zampini G, Bottari G, Cecchetti C, Amodeo A, Lorusso R, Del Sorbo L, Kirsch R. Principlism and Personalism. Comparing Two Ethical Models Applied Clinically in Neonates Undergoing Extracorporeal Membrane Oxygenation Support. Front Pediatr. 2019 Jul 30;7:312. link

Practice & ethics in managing adult patients on VV ECMO: a survey to characterize the ethical attitudes & opinions of 539 physicians across 39 countries and 6 continents. The study highlights important findings including key factors (age, coexisting organ failures, prolonged mechanical ventilation) limiting ECLS initiation in severe ARDS, and key considerations influencing withdrawal decision (comorbidities, patient wishes, etiology of respiratory failure). The study also identifies factors associated with both increased/decreased odds of withdrawal. Although the decision to implement veno-venous ECMO was reported as influenced by factors associated with poor prognosis, the decision whether to continue or discontinue extracorporeal support was strongly influenced by known/unknown patient’s or surrogate’s wishes, level of consciousness, perceived “futility”. Low rates of incorporating shared decision-making, including involvement of ECMO patients and family, was reported.

Abrams D, Pham T, Burns KEA, Combes A, Curtis JR, Mueller T, Prager KM, Serra A, Slutsky A, Brodie D, Schmidt M; International ECMO Network (ECMONet). Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients: An International Survey. Crit Care Med. 2019 Oct;47(10):1346-1355. link

ECMO, more is more? a complex, costly & resource-intensive but promising intervention, effective in supporting critical patients with severe cardiac and/or pulmonary failure. Advancements have made ECLS safer & easier, and its use has exponentially grown, with economic/technical challenges to health system. Choosing & spending wisely is mandatory to to ensure that the best possible outcomes are being obtained, continually evaluating data from providers of high-cost/resource-intensive procedures, and developing evidence-based decision: high-quality registries, such the ELSO Registry may be helpful. Given the potential related risks it is critical engaging patients and their families in shared-decision making. A profound editorial.

Fan E, Karagiannidis C. Less is More: not (always) simple-the case of extracorporeal devices in critical care. Intensive Care Med. 2019 Oct;45(10):1451-1453. link

It is likely only a matter of time before data will be collected that incontrovertibly show ECPR to be superior to conventional CPR in select patients; physicians need to make evaluate who would likely benefit from extracorporeal CPR and decide with patients and families if this is something they would want; history of CPR suggests the importance of defining the limits of any kind of resuscitation: ECPR also pushes us to better define these limits.

Brauner DJ, Zimmermann CJ. AMA J Ethics. 2019 May 1;21(5):E443-449. Will We Code for Default ECMO? link

with this reply: Clarifying the scope of a Do-Not ECMO order and predicting some of the challenges likely to arise when incorporating DNE orders into hospital code status systems.

Blythe JA, Wieten SE, Batten JN. Response to “Will We Code for Default ECMO?”: Clarifying the Scope of Do-Not-ECMO Orders. AMA J Ethics. 2019 Oct 1;21(10):E926-929. link

ECMO support: unquestionably is saving lives but sometimes is a bridge to nowhere, raising ethical questions and legal constraints about our traditional definitions of life & death, medical futility and right/duty to withdraw extracorporeal life support to preserve dignity patients deserve at the end of life.

Mulaikal TA, Nakagawa S, Prager KM. Extracorporeal Membrane Oxygenation Bridge to No Recovery. Circulation. 2019 Jan 22;139(4):428-430. Open access link

Achieving value in highly complex acute care: applying a value (outcomes & cost) analysis to extracorporeal life support to define guidelines for ECLS delivery, exploring opportunities for more efficient care, based on the ELSO Registry data, peer reviewed literature, opinions from experienced clinicians; some of the key points:
reducing ECLS demands on ICU resources
discuss in advance/early about end of life care: outcomes need to be consistent with patient goals & preferences
properly select candidates
high ECMO volume could improve outcomes and also allows center to take advantage from economies of scale & other efficiencies.

A case study Nurok M, Warsh J, Dong E, Lopez J, Kharabi M, Kaplan RS. Achieving Value in Highly Complex Acute Care: Lessons from the Delivery of Extra Corporeal Life Support. NEJM Catalyst (October 31, 2019) link

Ethics and etracorporeal life support, some reflections about “bridge to nowhere” situation, withdrawal of sustaining treatments, challenges of neurological and cardio-circulatory determination of death on ECLS.

Abrams D, Curtis JR, Prager KM, Garan AR, Hastie J, Brodie D. Ethical Considerations for Mechanical Support. Anesthesiol Clin. 2019 Dec;37(4):661-673. link

Long-term survival, post-traumatic stress disorder, quality of life after ECMO support: a large single-centre retrospective cohort study surveying post ECLS patients, reporting good longterm survival rates, but a high occurrence of reduced QoL & PTSD, and reaffirming the need for long-term follow-up & rehabilitation in this population. The observed cohort experienced a decrease in QoL in all domains, appearing as significantly associated with a high risk for PTSD. RRT & duration of extracorporeal support significantly associated with increased mortality but not with QoL; no difference in QoL reported between different underlying conditions, despite different mortality.

Harley O, Reynolds C, Nair P, Buscher H. Long-Term Survival, Posttraumatic Stress, and Quality of Life post Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Nov 20. link

Neurocritical care & neuro-outcomes

Neurocritical care for ECMO patients: management of neurologic injuries potentially related to extracorporeal support is imperative: global hypoxic-ischemic brain injury, ischemic stroke, intracranial hemorrhage, cerebral air embolism, cerebral edema & acute elevation of ICP, seizures, brain death. Here, a review on these complications and on current science & best practices for guiding neuro-assessment/neuro-management in this population: NIRS, TCD, neuroimaging, plasma biomarkers, EEG and ICP monitoring.

Cho SM, Farrokh S, Whitman G1, Bleck TP2, Geocadin RG. Neurocritical Care for Extracorporeal Membrane Oxygenation Patients. Crit Care Med. 2019 Dec;47(12):1773-1781. link

Neuro-outcomes in neonatal & pediatric ECMO patients: according to the result of this pilot study, long-term developmental delay is common; the younger the age at the time of extracorporeal support, the higher the chances of impaired outcome; significant abnormalities on brain MRIs correlated with delay on follow-up. Authors suggest, for ECMO survivors, standardized neuro-psychologic testing & post ECLS imaging as standard of care.

Dhar AV, Scott S, Anton-Martin P, Tweed J, Morris MA, Modem V, Raman L, Golla S. Neurodevelopmental Outcomes in Extracorporeal Membrane Oxygenation Patients: A Pilot Study. ASAIO J. 2019 Aug 6. link

Longtime neuro-outcome of ECMO supported & non ECMO ARDS survivors: besides well-known complications like cerebral bleeding and ischemic stroke, more subtle injuries, not so severe, but potentially impacting on quality of life & psychological health, as impairing activities of daily living and work. These lesions have been detected by a thorough clinical exam, some seems directly related to ECLS, and, according to the authors, need to be considered when implementing extracorporeal support.

Harnisch LO, Riech S, Mueller M, Gramueller V, Quintel M, Moerer O. Longtime Neurologic Outcome of Extracorporeal Membrane Oxygenation and Non Extracorporeal Membrane Oxygenation Acute Respiratory Distress Syndrome Survivors. J Clin Med. 2019 Jul 12;8(7). pii: E1020. Open access link

Confirming Brain Death on extracorporeal support

Confirming Brain Death on veno-arterial ECMO: development & implementation of a protocol for permorming a safe & reliable apnea test on ECLS incorporating regular blood sampling of both righ radial & post-membrane lung, with a gradual reduction in fresh gas flow to ensure oxygenation. Authors also report their preliminary experience.

Ihle JF, Burrell AJC, Philpot SJ, Pilcher DV1, Murphy DA, Pellegrino VA. A Protocol that Mandates Postoxygenator and Arterial Blood Gases to Confirm Brain Death on Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Oct 11. link

How dow you confirm brain death on veno-arterial ECMO support? here a summary about specific challenges of BD determination on ECLS.

Bein T, Müller T, Citerio G. Determination of brain death under extracorporeal life support. Intensive Care Med. 2019 Mar;45(3):364-366. Open access link

…& some related considerations about simultaneous distal arterial & post-Membrane Lung blood sampling (same group of previous ASAIO study).

Ihle J, Burrell A. Confirmation of brain death on VA-ECMO should mandate simultaneous distal arterial and post-oxygenator blood gas sampling. Intensive Care Med. 2019 Aug;45(8):1165-1166. link

How to perform apnea test, a key component of the declaration of brain death, on ECMO support? In this case report, an alternative strategy, the addition of a controlled volume of CO2 into the gas inflow line of the membrane lung, to increase PaCO2 in patients on ECLS, avoiding the need to decrease sweep gas flow, potentially compromizing O2 delivery.

Beam WB, Scott P, Wijdicks EFM. The Physiology of the Apnea Test for Brain Death Determination in ECMO: Arguments for Blending Carbon Dioxide. Neurocrit Care. 2019 Dec;31(3):567-572. link

Diagnosis of death according to neurological criteria in adults on #ECMO support: why is ECLS a special circumstance? impact upon brainstem & apnea testing, and background & process of development of a UK nationally accepted guideline.

Meadows CIS, Toolan M, Slack A, Newman S, Ostermann M, Camporota L, Gardiner D, Webb S, Barker J, Vuylsteke A, Harvey C, Ledot S, Scott I, Barrett NA on behalf of the NHS England ‘‘ECMO in adults with severe respiratory failure’’ commissioned service. Diagnosis of Death Using Neurological Criteria in Adult Patients on Extracorporeal Membrane Oxygenation: Development of UK Guidance. JICS 2019 March 0(0) 1–5. Open access link

Neurological determination of death & challenges of apnea testing in patients dependent on ECMO support maintaining hemodynamic stability & maximizing oxygenation while adjusting gas flow to reduce excessive CO2 removal, a review.

Lie SA, Hwang NC. Challenges of Brain Death and Apnea Testing in Adult Patients on Extracorporeal Membrane Oxygenation-A Review. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2266-2272. link

Transcranial doppler on veno-arterial ECMO support, feasible/reliable to diagnose/confirm brain death? open access discussion…
TCD waveform patterns: interpretable even in patients on VA ECMO with no pulsatile arterial tracings?? If pulsatility is preserved, reverse flow can be a powerful finding to help confirm BD, while in the case of nonpulsatile blood flow, developing a loss of spectral Doppler signal in the MCA territory is indicative of BD: a comment

Berthoud V, Ellouze O, Constandache T, Martin A, Bouhemad B, Guinot PG. Transcranial Doppler Waveform Patterns in Nonpulsatile Blood Flow Under Venoarterial Extracorporeal Membrane Oxygenation for Brain Death Diagnosis. ASAIO J. 2019 Jun 6. link

referring to the (2018) retrospective single-center study aiming to investigate the feasibility of TCD in cerebral circulatory arrest diagnosis on VA #ECMO; findings suggest that TransCranial Doppler seems a reliable instrumental test regarding BD confirmation on extracorporeal support, provided that a pulsatile flow is maintained (native cardiac function, as properly assessed, or IABP), but do not allow to conclude whether TCD retains its validity if continuous, nonpulsatile arterial flow.

Marinoni M, Cianchi G, Trapani S, Migliaccio ML, Bonizzoli M, Gucci L, Cramaro A, Gallerini A, Picciafuochi F, Valente S, Peris A. Retrospective Analysis of Transcranial Doppler Patterns in Veno-Arterial Extracorporeal Membrane Oxygenation Patients: Feasibility of Cerebral Circulatory Arrest Diagnosis. ASAIO J. 2018 Mar/Apr;64(2):175-182. link

and here the authors’ reply, stating signal disappearance during a TCD continuous monitoring strongly suggests evolution to a condition of BD and prompts for further evaluations, but also recommending considerations about the wide international variability in diagnosing brain death.

Marinoni M1, Trapani S, Cianchi G. Transcranial Doppler Confirming of Brain Death in Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Jun 6. link

Determination of the cause of death is mandatory in ECLS patients, considering the high incidence of unrecognized events, several leading to death, often not diagnosed ante-mortem. The ECMO team need to be aware of the high rate of major complications/likely presence of hidden adverse events, remaining continuously alert for patient evaluation, particularly with advanced imaging modalities of the brain. Autopsy, and modernization of post-mortem investigations, may enhance & clarify effects of extracorporeal support in critically ills.

What you do not know, you do not recognize…and you do not improve future patient care…particularly in extracorporeal life support (ECLS) patients. J Thorac Dis. 2019 Sep;11(Suppl 15):S1930-S1934. Lorusso R, Corradi D. Open access link

The editorial is a comment to this analysis, reporting major discrepancies between pre & postmortem diagnoses in patients who underwent ECMO support, underscoring difficulties in clinically diagnosing events on ECLS and the need for enhanced surveillance/better diagnostic techniques.

Jia D, Neo R, Lim E, Seng TC, MacLaren G, Ramanathan K. Autopsy and clinical discrepancies in patients undergoing extracorporeal membrane oxygenation: a case series. Cardiovasc Pathol. 2019 Jul – Aug;41:24-28. link

ECMO year in review: Veno-Arterial ECLS

A two part review of post-cardiotomy ECMO in adults & pediatrics:
In the adult patients, PC represent PV most frequent indication for temporary MCS; considerable variability about surgical access/cannulation still exists, with no apparent major differences in outcomes. Veno-arterial ECMO can be life-saving, and survivors have favorable early outcomes, but mortality & morbidity remain high, reflecting underlying disease severity and an imperfect solution. When needed, avoid any delay, worsening outcomes as extended duration of hypoperfusion & hypoxia. ECMO-specific educational training programs focusing on patient selection, cannulation techniques, patient management, ethics, along with circuit technology evolution, mandatory to improve effectiveness.

Lorusso R, Raffa GM, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Kowalewski M, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, D’Alessandro DA, Boeken U, Whitman GJR. Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients. J Heart Lung Transplant. 2019 Nov;38(11):1125-1143. link

In pediatric patients represents an optimal support technique in CHD & post-cardiotomy shock, optimizing pre/postop metabolic status, and potentially improving survival of this high risk population, even if mortality/morbidity remain high. Neuro-injury & neurodevelopmental impairment are common post ECLS, reflecting severity of illness, complexity of cardiac surgery, ECMO complications. If no recovery, bridge to cardiac Tx can be successful, but organs availability/waiting list duration impact on survival.

Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R1, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D’Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant. 2019 Nov;38(11):1144-1161. link

Cardiac ECMO in neonates: invaluable tool to support therapy resistant circulatory failure; patient selection & timing for implementing ECLS remain very difficult and not yet evidence based. Mortality is very much dependent on underlying diagnosis, the ability to provide adequate systemic blood flow, duration of ECMO run, adverse events and complications: therefore, after initiation, attempts should be made to early identify and address concomitant conditions as residual lesions following cardiac surgery or arrhythmias, and to limit ECLS duration, resting the heart as much as possible, to reduce mortality. In this interesting and complete review, timing & indications for ECMO support in congenital heart disease, myocarditis/cardiomyopathy, arrhythmias, PH; contraindications, cannulation & neonatal extracorporeal circuit considerations, supportive care, #ultrasound and mechanical ventilation, predictors of survival, weaning, mid/long term outcomes (neuro-developmental) outcomes, future & research.

Roeleveld PP, Mendonca M. Neonatal Cardiac ECMO in 2019 and Beyond. Front Pediatr. 2019 Aug 21;7:327. Open access link

MCS & cardiogenic shock: initial assessment, optimization & stabilization, titrating therapies, specific management according to the etiology, veno-arterial ECMO and other mechanical circulatory supports, role of a MCS team, future perspectives.

Hajjar LA, Teboul JL. Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art. Crit Care. 2019 Mar 9;23(1):76. Open access link

VA ECMO, allowing rapid improvement in oxygenation, suitable in severe biventricular failure, and less expensive compared with other devices, has emerged as the first-line temporary circulatory support to manage patients with severe or refractory cardiogenic shock. In this review, VA ECLS principles, growing and emerging accepted indications, mode of operation, patient management, complications, with a discussion about current evidence: results of recent case series & trials.

Pineton de Chambrun M, Bréchot N, Combes A. Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence. Curr Opin Crit Care. 2019 Aug;25(4):397-402. link

Veno-arterial ECMO support in severe or refractory cardiogenic shock,

Despite technological advancements & improvements in ECMO devices, allowing for a better risk/benefit profile, extracorporeal support remains an invasive procedure associated with potentially severe complications that could strongly impact on outcome: this open access review provides a comprehensive outline on veno-arterial ECLS complications in adult patients, analyzing risk factors and strategies of management.

Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille’s heel. J Thorac Dis. 2018 Dec;10(12):6993-7004. link

VA ECMO for CS: an introduction for the busy clinician…epidemiology of cardiogenic shock & extracorporeal supportIndications/contraindications and short-term outcomes by indication, circuit & cannulation management & main complications, left heart venting, prognosis and weaning, conversion to durable MCS/heart Tx option, or withdrawal of support, models of care for patients on ECLS, futility, ethics and cost considerations.

Eckman PM, Katz JN, El Banayosy A, Bohula EA, Sun B, van Diepen S. Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock: An Introduction for the Busy Clinician. Circulation. 2019 Dec 10;140(24):2019-2037. Open access link

Predicting (& trying to improve) outcome

Scores for veno-arterial ECMO patients could help at bedside by providing information on outcome prediction as well as be of interest for research purposes; should they be used be used as a decision tool to indicate or limit access to ECLS? Never, according to this editorial.

Kimmoun A, Levy B. Predicting clinical outcome in patients undergoing VA-ECMO. Crit Care. 2019 Feb 14;23(1):47. Open access link

PS here links to the original papers presenting the cited scores:
SAVE-score, Schmidt et al. 2015, for refractory cardiogenic shock open access link

ENCOURAGE score, Muller et al. 2016, for acute myocardial infarction with CS link

REMEMBER to predict in-hospital mortality for patients receiving veno-arterial #ECMO for cardiogenic shock after isolated CABG: proposal of a new score, appearing better than others for the selected population, in this study identifying four risk classes with their corresponding mortality (13%, 55%, 70%, and 94%, respectively).

Wang L, Yang F, Wang X, Xie H, Fan E, Ogino M, Brodie D, Wang H, Hou X. Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score. Crit Care. 2019 Jan 11;23(1):11. Open access link

May regional cerebral oxygen saturation be used as a monitoring parameter for mortality in patients on VA ECMO support? this retrospective study reports higher rScO2 values & lower lactate levels in the survivor vs nonsurvivor group during the first 7 days; the risks of 28 day mortality seems higher among patients with a right rScO2 of <58% and a left rScO2 of <57%.

Kim HS, Ha SO, Yu KH, Oh MS, Park S, Lee SH, Han SJ, Kim HS, Chang IB, Ahn JH. Cerebral Oxygenation as a Monitoring Parameter for Mortality During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 May/Jun;65(4):342-348. link

Association of early fibrinogen/albumin ratio & ischemic stroke on veno-arterial ECMO support: according to this single center, retrospective study on adult patients, the level of FAR seems associated with an incrementally higher likelihood of subsequent ischemic stroke. May FAR evaluation, calculated in the first 24 hours, assist with early stratification of patients at risk for development of ischemic neurologic complications on ECLS?

Acharya P, Jakobleff WA, Forest SJ, Chinnadurai T, Mellas N, Patel SR, Kizer JR, Billett HH, Goldstein DJ, Jorde UP, Saeed O. Fibrinogen Albumin Ratio and Ischemic Stroke During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Mar 27. link

Development of the PEP Pediatric ECMO Prediction model for predicting in-hospital mortality among children receiving ECLS for any indication.

Bailly DK, Reeder RW, Winder M, Barbaro RP, Pollack MM, Moler FW, Meert KL, Berg RA, Carcillo J, Zuppa AF, Newth C, Berger J, Bell MJ, Dean MJ, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Bratton SL, Dalton H; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN).Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality. Pediatr Crit Care Med. 2019 May;20(5):426-434. link

… with related editorial: MacLaren G, Cho HJ, Schlapbach LJ. Transforming Data Into a Crystal Ball-Predicting Outcomes After Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2019 May;20(5):490-491. link

Calculator available at link

It is unlikely that low-volume centers will be efficient or facile in managing complex ECLS cases. How to achieve greater efficiency improving outcomes? developing regional networks and consolidating cooperation to share costs & direct resources to centers with better outcomes. Fast, early cannulation (as lactates at time of ECMO implementation is a strong predictor of mortality) at smaller hospitals by outside physicians, with transfer to an experienced ECMO referral center, could be an effective approach to increase survival in cardiogenic shock. These patients can be safely transported on extracorporeal support, as long as the transfer team is well experienced. Alternatively, mobile VA ECMO teams could be developed, based out of the ECMO referral center.

Mazzeffi M, Del Rio JM, Gutsche J. Give Me Your Tired, Your Poor, Your Extracorporeal Membrane Oxygenation Patients. J Cardiothorac Vasc Anesth. 2019 Nov;33(11):3054-3055. Open access editorial link

And its related paper: an high-volume single-center large experience with veno-arterial ECMO, comparing outcomes for patients cannulated in-house vs those transferred from a referral hospital after cannulation, reporting no difference in survival to ECLS or to discharge.

Dalia AA, Axtel A, Villavicencio M, D’Allesandro D, Shelton K, Cudemus G, Ortoleva J. A 266 Patient Experience of a Quaternary Care Referral Center for Extracorporeal Membrane Oxygenation with Assessment of Outcomes for Transferred Versus In-House Patients. J Cardiothorac Vasc Anesth. 2019 Nov;33(11):3048-3053. link

ECMO? Is a team Sport!! The implementation of a multidisciplinary ECLS team establishing a set of protocols & guidelines to care for patients on extracorporeal support played an integral role in the improvement in survival to discharge at the authors’ institution.

Dalia AA, Ortoleva J, Fiedler A, Villavicencio M, Shelton K, Cudemus GD. Extracorporeal Membrane Oxygenation Is a Team Sport: Institutional Survival Benefits of a Formalized ECMO Team. J Cardiothorac Vasc Anesth. 2019 Apr;33(4):902-907. link

Early vs delayed ECMO support in cardiogenic failure refractory to medical management for cardiovascular surgery patients? the implementation of an aggressive strategy, early initiating post-cardiotomy extracorporeal support, lead to increased survival in this single center experience, improving cardiac output, promoting lactate clearance, decreasing complications and shortening ECLS run, MV time & ICU stay.

Ge M, Pan T, Wang JX, Chen ZJ, Wang DJ. Outcomes of early versus delayed initiation of extracorporeal life support in cardiac surgery. J Cardiothorac Surg. 2019 Jul 4;14(1):129. Open access link

Mortality & risk profiles in infants with CDH supported with ECMO over the years: although the overall mortality rate near 50% remained approximately constant over time, individual likelihood of death has declined over time in the moderate-risk cohort, remained unchanged in the high-risk cohort, increased in the low-risk cohort. About last group, there was a decreasing frequency of low-risk infants placed on ECMO in later years but with an increasing mortality risk profile among those who were cannulated.

Guner YS, Delaplain PT, Zhang L, Di Nardo M, Brogan TV, Chen Y, Cleary JP, Yu PT, Harting MT, Ford HR, Nguyen DV. Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Jul;65(5):509-515. Open access link

PS also check this (2018) paper about the development & validation of ECMO mortality-risk models for Congenital Diaphragmatic Hernia.

Guner YS, Nguyen DV, Zhang L, Chen Y, Harting MT, Rycus P, Barbaro R, Di Nardo M, Brogan TV, Cleary JP, Yu PT. Development and Validation of Extracorporeal Membrane Oxygenation Mortality-Risk Models for Congenital Diaphragmatic Hernia. ASAIO J. 2018 Nov/Dec;64(6):785-794. Open access link

here the online calculators for both pre/on-#ECLS mortality-risk models for CDH, freely accessible link

Hyperlactatemia as readily available, valid biomarker indicating very poor tissue perfusion on veno-arterial ECMO (due to inappropriate extracorporeal blood flow or peripheral conditions or local obstruction), facilitating prediction of early outcome & improving prognosis these critically ills, a comment.

Formica F, D’Alessandro S, Sangalli F. Arterial lactate level. A simple and effective tool during extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg. 2019 May;157(5):e265-e266. link

referring to this (2018) study: Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. J Thorac Cardiovasc Surg. 2018 Nov;156(5):1894-1902.e3. link
… & take a look at this open access cited (2010) paper too! Formica F, Avalli L, Colagrande L, Ferro O, Greco G, Maggioni E, Paolini G. Extracorporeal membrane oxygenation to support adult patients with cardiac failure: predictive factors of 30-day mortality. Interact Cardiovasc Thorac Surg. 2010 May;10(5):721-6. link

Epinephrine, inodilator, or no inotrope on VA ECMO?? after cannulation, vasoplegia & cardiac depression are frequent; in this large single-center experience, patients on continuous epinephrine infusion within the first day of ECLS performed significantly worse compared to patients with or without inodilator therapy.

Zotzmann V, Rilinger J, Lang CN, Kaier K, Benk C, Duerschmied D, Biever PM, Bode C, Wengenmayer T, Staudacher DL. Epinephrine, inodilator, or no inotrope in venoarterial extracorporeal membrane oxygenation implantation: a single-center experience. Crit Care 23, 320 (2019). Open access link

Pediatric ECLS, an integral part of modern PedsICU care, rapidly growing world-wide… even if still associated costly/complex, and potentially associated to severe complications. What’s new and what the priorities for both mechanical circulatory/respiratory support? patient selection and timing, extracorporeal cardiopulmonary resuscitation ECPR, longterm neurodevelopmental outcomes and volume–outcome relationships, anticoagulation management prevention/rescue from bleeding & thrombotic complications. Read this experts’ opinion…

MacLaren G, Brown KL, Thiagarajan RR. What’s new in paediatric extracorporeal life support? Intensive Care Med. 2019 Nov 25. link

Hemodynamics & hemodynamic monitoring

Hemodynamics on Veno-Arterial ECMO for Cardiac Support, an international (worldwide) survey among ELSO Centers, collecting data related to the center characteristics and hemodynamic goals & management strategies (echomonitoring & echocardiographic parameters at weaning, LV venting, pulsatility, inotropes, fluid balance) to identify which areas could provide further investigation in a hypothesis-generating manner. PS also check the supplemental pics with interesting data related to geographical differences in approaching the patient ie echomonitoring (timing/parameters) LV venting strategies, weaning…

Siriwardena M, Dozois M, Fan E, Billia F. Hemodynamic Aspects of Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiac Support: A Worldwide Survey. ASAIO J. 2019 Jun 5. link

Challenging case presented in this report, highlighting diagnostic dilemmas of cardiac tamponade on veno-arterial ECMO support & potential effects of drainage pressure.

Adams AJ, Guck AN, Shillcutt SK. Right Atrial Inversion Mimicking Right Atrial Mass in the Setting of Cardiac Tamponade. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2351-2355. link

… with some considerations about echocardiography & ECLS in the related open access editorial

Gutsche JT, Ortoleva J. Echocardiography: Do We Need New Standards for ECMO Patients? J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2356-2357. link

Markedly collapsed right atrium on veno-arterial ECMO with drainage cannula at RA/IVC junction: is this echo finding a consistent early ( = before lowering of drainage pressure, chattering, flow drop) sign of (even small degree) hypovolaemia?

Au SY, Fong KM, Wu HLH, Ng WYG. Collapsed right atrium as an early sign of hypovolemia in VA ECMO. J Echocardiogr. 2019 Mar 27. link

Hemodynamic monitoring in the ECMO patient, a review: understanding the unique physiology of extracorporeal support is mandatory; multiple threats to perfusion due to ECLS induced circulation perturbations, and not so easy to judge perfusion adequacy as validity of many monitoring tools impaired on extracorporeal support; POCUS and NIRS can play a significant role in monitoring adequacy of global/regional perfusion; consider checking LV overload/distention, RV failure, cannula malposition & cannulated limb ischemia.

Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care. 2019 Jun;25(3):285-291. link

Microcirculation monitoring: promising tool to be integrated in clinical practice, to predict outcome/guide treatments of patients with refractory cardiogenic shock requiring veno-arterial ECMO support? in this prospective study, authors report severely impaired microcirculation parameters in this population; furthermore, inability to early/quickly normalize microcirculation in the first 24 hours, despite normal global/macrocirculatory hemodynamics, was associated with increased risk of death on ECLS.

Chommeloux J, Montero S, Franchineau G, Bréchot N, Hékimian G, Lebreton G, Le Guennec L, Bourcier S, Nieszkowska A, Leprince P, Luyt CE, Combes A, Schmidt M. Microcirculation Evolution in Patients on Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock. Crit Care Med. 2020 Jan;48(1):e9-e17. link

Intracardiac (not only) thrombosis & SEC on ECMO support

SEC or thrombus?? Spontaneous echo contrast is an echogenic swirling pattern of blood as flow velocity is markedly decreased, and could result in increased risk of intracardiac thrombus & stroke; take a look at these TEE transesophageal echo images of a patient on ECMO support: here, SEC mimics a thrombotic lesion in the aortic root.

De Bono JA, McGiffin DC, Waldron BJF, Leet AS, Doi A.Spontaneous echo contrast mimicking aortic root thrombus in a patient supported with extracorporeal membrane oxygenation. Echocardiography. 2019 Feb;36(2):419-421. link

A case of massive pulmonary embolism evolved in sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on veno-arterial ECMO and related review of the literature describing pathophysiology, risk stratification, prevention, & management of this rare entity.

Bhat AG, Golchin A, Pasupula DK, Hernandez-Montfort JA. Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review. Case Rep Crit Care. 2019 Jan 6;2019:8594681. Open access link

Prosthetic valves and veno-arterial ECMO?? maintain a high index of clinical suspicion for potential thrombosis & reassess valvular function to early detect, decompressing the left ventricle and allowing valves to open/close to avoid stasis, carefully managing anticoagulation; eventually consider reconfiguration if indicated. Here, a couple of cases of this “unfriendly” combination…

bioprosthetic mitral valve thrombosis on extracorporeal support:
Dahl AB, Gregory SH, Ursprung E, Kawabori M, Couper GS, Hueneke R. Acute Presentation of Bioprosthetic Mitral Valve Thrombosis in a Patient on Venoarterial Extracorporeal Membranous Oxygenation. J Cardiothorac Vasc Anesth. 2019 Mar;33(3):844-849. link

… and mechanical mitral valve thrombosis on ECLS: Sandoval E, Ascaso M, Pereda D, Quintana E. Extracorporeal membrane oxygenation and mechanical valves: An unfriendly relationship. J Thorac Cardiovasc Surg. 2018 Aug;156(2):e103-e105. link

Spontaneous echo-contrast in the aortic root in a pt on veno-arterial support & severe LV hypokinesis + no AV opening pattern despite inotropes/IABP: try to maintain pulsatility to avoid thrombosis. Dilemma: is a thrombus already there? look for evidence of reversibility of SEC. A case rep with nice scans.

Duncan K, Thorleifson M, Ghorpade N, Grocott H. A Concerning Finding in the Aortic Root of a Patient on Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. 2019 Dec;33(12):3517-3518. link

Acute coronary syndrome on veno-arterial ECMO? take a look at aortic valve… is it opening or not?? open access case rep about complication of blood stasis on VA ECLS with TEE scans.

Au S, Fong K, Yuen HJ, Shek KJ, Ng WG. A special cause of acute coronary syndrome in patients supported with VA ECMO. J Emerg Crit Care Med 2019;3:58 link

Left (& right) ventricular distention and unload

Reviewing the pathophysiology underlying Left Ventricular distension on veno-arterial ECMO & constructing a systematic diagnostic and therapeutic approach: if IABP or direct left vent already in place at the time of ECLS initiation, these should be continued; as this severe complication occurs, treatment is required. However, whether venting should be performed prophylactically versus selectively in high risk patients, or only post hoc to treat distension, remains unclear.

Rajagopal K. Left Ventricular Distension in Veno-arterial Extracorporeal Membrane Oxygenation: From Mechanics to Therapies. ASAIO J. 2019 Jan;65(1):1-10. link

Unloading LV on veno-arterial ECMO, narrative review: implications of left ventricular distension, monitoring cardiac ejection & echocardiographic detection of LV distention/assessment of decompression, spontaneous echo contrast, aortic regurgitation, identifying patients with minimal or no ejection during ECLS, who may benefit from left ventricular decompression strategies. Managing extracorporeal blood flow, mean arterial pressure, differential hypoxemia, pharmacological approach to ventricular dysfunction; IABP, atrial septostomy & percutaneous right & left ventricular assist devices. An early evaluation of cardiac, neurological, systemic recovery is recommended, with eventual switch to percutaneous LVAD &/or RVAD, decision regarding transplantation, or long term ventricular assist device implantation for destination therapy.

Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation – A Narrative Review. J Cardiothorac Vasc Anesth. 2020 Jan;34(1):208-218. link

Approaches & timing of left ventricular venting on central and peripheral VA ECLS in cardiogenic shock: a systematic review with one of the largest meta-analysis (to date). Authors report more successful weaning & lower 30-day mortality among patients who received concomitant LV venting; moreover, early (within 12 hours) initiation of LV venting seems associated with better outcomes; a nonsignificant trend towards improved in-hospital and long-term mortality has been observed.

Al-Fares AA, Randhawa VK, Englesakis M, McDonald MA, Nagpal AD, Estep JD, Soltesz EG, Fan E. Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Circ Heart Fail. 2019 Nov;12(11):e006486. link

and the related editorial highlighting that veno-arterial ECMO may provide circulatory support but requires concomitant strategies to provide cardiac support & to protect LV from injury mediated by (ECMO) increased afterload, and advocating more data to improve risk prediction and MCS management in cardiogenic shock.

Kapur NK, Davila CD, Chweich H. Protecting the Vulnerable Left Ventricle: The Art of Unloading With VA-ECMO. Circ Heart Fail. 2019 Nov;12(11):e006581. link

Left Ventricular unloading during VA ECMO support in adult patients with cardiogenic shock, a meta-analysis examining the efficacy & safety of unloading strategies in adult patients with cardiogenic shock on veno-arterial ECLS: unloading on ECLS is associated with decreased mortality in observational studies; in the absence of prospective randomized data, may be considered for selected patients.

Russo JJ, Aleksova N, Pitcher I, Couture E, Parlow S, Faraz M, Visintini S, Simard T, Di Santo P, Mathew R, So DY, Takeda K, Garan AR, Karmpaliotis D, Takayama H, Kirtane AJ, Hibbert B. Left Ventricular Unloading During Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. J Am Coll Cardiol. 2019 Feb 19;73(6):654-662. Open access link

And here a couple of comments
Meuwese CL, Koudstaal S, Braithwaite S, Hermens JAJ, Donker DW. Left Ventricular Unloading During Extracorporeal Membrane Oxygenation: Insights From Meta-Analyzed Observational Data Corrected for Confounders. J Am Coll Cardiol. 2019 Jun 18;73(23):3034-3035. link
Li Y, Gao S, Cai L, Zhang Q. Left Ventricle Unloading Strategy: Which One Is More Effective in Venoarterial Extracorporeal Membrane Oxygenation Patients? J Am Coll Cardiol. 2019 Jun 18;73(23):3035-3036. link

and the authors’ reply
Russo JJ, Di Santo P, Kirtane AJ, Hibbert B. Reply: Left Ventricle Unloading Strategy: Which One Is More Effective in Venoarterial Extracorporeal Membrane Oxygenation Patients? J Am Coll Cardiol. 2019 Jun. link 18;73(23):3036.

Consequences of failing to prevent, diagnose, & treat LV distension on VA ECMO are severe, and may worsen left ventricular function, impairing cardiac recovery, contributing to blood stasis and LV/aortic root thrombus formation, worsening pulmonary edema. Physiologic basis and clinical manifestations of left ventricular distension on veno-arterial ECMO support, indications for venting, management strategies, a review.

Cevasco M, Takayama H, Ando M, Garan AR, Naka Y, Takeda K. Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation. J Thorac Dis. 2019 Apr;11(4):1676-1683. Open access link

ECMO + IABP?? a study examining the effect of the simultaneous use of IABP during ECLS with central cannulation, providing insights into IABP-mediated LV unloading: Intra-Aortic Balloon Pump has the ability to reduce pulmonary artery pressure in these patients; however, this did not translate into improved survival or clinical outcomes.

Tepper S, Garcia MB, Fischer I, Ahmed A, Khan A, Balsara KR, Masood MF, Itoh A. Clinical Outcomes and Reduced Pulmonary Artery Pressure With Intra-Aortic Balloon Pump During Central Extracorporeal Life Support. ASAIO J. 2019 Feb;65(2):173-179. link

Timing & approach for left atrial decompression on VA ECLS: in this multicenter study on a large cohort of pediatric patients receiving venoarterial #ECMO, late (≥ 18 hr) LA unload associated with longer duration of run & mechanical ventilation; authors suggest, taking into account complications associated with prolonged extracorporeal support, this may justify a recommendation for early decompression, even if no survival benefit demonstrated.

Zampi JD, Alghanem F, Yu S, Callahan R, Curzon CL, Delaney JW, Gray RG, Herbert CE, Leahy RA, Lowery R, Pasquali SK, Patel PM, Porras D, Shahanavaz S, Thiagarajan RR, Trucco SM, Turner ME, Veeram Reddy SR, West SC, Whiteside W, Goldstein BH. Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med. 2019 Aug;20(8):728-736. link

… here related editorial Coleman RD, Chartan C, Qureshi AM, Shekerdemian LS. Left Atrial Decompression on Venoarterial Extracorporeal Membrane Oxygenation: Getting to the Heart of the Matter.Pediatr Crit Care Med. 2019 Aug;20(8):780-781. link

ECPELLA? concomitant Impella device in patients on venoarterial extracorporeal support: an increasingly applied strategy to manage patients with cardiogenic shock requiring VA ECMO, according to the results of this review. Use of the LVAD seems associated with higher weaning from ECLS in most of the included studies. In the two (over 5) studies adjusting for potential confounders (baseline characteristics between groups) 30 day mortality reported as lower in the ECPELLA group versus VA ECMO alone.

Vallabhajosyula S, O’Horo JC, Antharam P, Ananthaneni S, Vallabhajosyula S, Stulak JM, Dunlay SM, Holmes DR Jr, Barsness GW1. Venoarterial Extracorporeal Membrane Oxygenation With Concomitant Impella Versus Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. ASAIO J. 2019 Jul 17. link

ECMO support and Impella ventricular unload… be aware of the lot of potential interactions and regularly check with #ultrasound to early detect eventual complications, displacement or hemodynamic effects of extracorporeal blood & LVAD flows adjustment during the run, a case rep with interesting pics/video of POCUS scans.

Au SY, Fong KM, Ng WYG, So SO, Leung KHA. Interaction between VA-ECMO and Impella. J Echocardiogr. 2019 Oct 11. link

Percutaneous cannula insertion through IJV on peripheral veno-arterial ECMO to reach & vent main PA, allowing additional RV drainage & satisfactory LV unloading, to manage ECLS with biventricular dysfunction.

Loforte A, Baiocchi M, Dal Checco E, Gliozzi G, Fiorentino M, Lo Coco V, Martin Suarez S, Marrozzini C, Biffi M, Marinelli G, Pacini D. Percutaneous Pulmonary Artery Venting via Jugular Vein While on Peripheral Extracorporeal Life Support. ASAIO J. 2019 Mar 19. Open access link

Time to LA decompression & outcomes on VA ECMO: in this multicenter study on pediatrics, late LA decompression (≥ 18hr) associated with longer duration of ECLS, mechanical ventilation, ICU stay, independently of severity of illness & comorbidities; although no survival benefit noticed, authors suggest that earlier left atrial unload may be beneficial.

Zampi JD, Alghanem F, Yu S, Callahan R, Curzon CL, Delaney JW, Gray RG, Herbert CE, Leahy RA, Lowery R, Pasquali SK, Patel PM, Porras D, Shahanavaz S, Thiagarajan RR, Trucco SM, Turner ME, Veeram Reddy SR, West SC, Whiteside W, Goldstein BH. Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study. Pediatr Crit Care Med. 2019 Aug;20(8):728-736. link

A case demonstrating the hemodynamics of a “trapped ventricle” in a patient on extracorporeal CPR ECPR with profound ventricular dysfunction: despite the end-organ perfusion benefits associated with ECMO support, the increased afterload calls for LV unloading to allow for cardiac recovery, take a look at the videos/pictures in this paper!

Alam A, Mody K, Iyer D, Ikegami H, Hakeem A. “The Trapped Ventricle”: Importance of Left Ventricular Unloading in Resuscitated Patients on VA-ECMO. JACC Cardiovasc Interv. 2019 Feb 25;12(4):e33-e34. link

other complications of (or on) veno-arterial ECMO

Differential Hypoxemia: part of the physiology of veno-arterial ECMO support… in this open access paper from the Karolinska Hospital ECMO Center: O2 delivery on ECLS, physiology, assessment & management of fulminant DH & proposal of a solution, to drain venous blood from SVC, appearing superior vs veno-arterovenous configuration in terms of rationale, efficiency, safety, & simplicity in clinical circuit design.

Falk L, Sallisalmi M, Lindholm JA, Lindfors M, Frenckner B, Broomé M, Broman LM. Differential hypoxemia during venoarterial extracorporeal membrane oxygenation. Perfusion. 2019 Apr;34(1_suppl):22-29. Open access link

Successful mechanical thrombectomy in acute ischemic stroke occurring on veno-arterial ECMO support, report of two adult cases with good long term neuro-outcome; in both cases, femoral access opposite to the arterial return cannula has been chosen to perform the procedure, even if authors suggest eventually to consider transradial access ie if IABP in use (avoiding ipsilateral radial artery if axillary ECLS outflow cannula). All arterial accesses can be considered in veno-arterial ECMO configuration.

Le Guennec L, Schmidt M, Clarençon F, Elhfnawy AM, Baronnet F, Kalamarides M, Lebreton G, Luyt CE. Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation. J Neurointerv Surg. 2019 Nov 19. link

Shunt of bacterial vegetation from tricuspid valve to aorta in a pt on veno-arterial ECMO support + Impella (ECPELLA or ECMELLA) with no intra-cardiac shunt & no lesions on other valves, likely drained from right & returned to left from ECLS.

Au SY, Fong KM, Ng GWY, So SO. Vegetation shunted from right to left by VA-ECMO. Intensive Care Med. 2019 Oct;45(10):1474-1475. link

Veno-arterial ECMO support as successfull bridge to recovery in pericardial decompression syndrome: report of a case & discussion about potential pathophysiology mechanisms of PDS, a rare & still to be fully understood dysfunction, occurring immediately or early after pericardial drainage, associated with very high morbidity and mortality rates. MCS could be considered as full & rapid recovery is possible.

Ricarte Bratti JP, Brunette V, Lebon JS, Pellerin M, Lamarche Y. Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report. Crit Care Med. 2020 Jan;48(1):e74-e75. link

PS about ECPR check the dedicated section! link

ECMO year in review: Cannulation & cannulae/cannulation related complications

Cannulation strategies for veno-arterial ECMO: each one with distinct benefits & drawbacks! In this paper various techniques and their indications are discussed, from the easier/most conventional ones to more sophisticated and highly demanding strategies, as triple or quadruple cannulation, in cases of combined respiratory/cardiac failure requiring dual organ support, in cases of left ventricular stasis with the need for unloading LV, or to facilitate mobilization and physical conditioning.

Camboni D, Philip A, Schmid C, Loforte A. Double, triple and quadruple cannulation for veno-arterial extracorporeal membrane oxygenation support: is there a limit? Ann Cardiothorac Surg. 2019 Jan;8(1):151-159. Open access link

Choosing ECMO catheters…

Pressure & flow properties of ECMO cannulae: do available informations correspond to in-vivo clinical performance? could testing catheters with whole blood flows be recommended to properly guide clinicians?

part I, return cannulae:
Broman LM, Prahl Wittberg L, Westlund CJ, Gilbers M, Perry da Câmara L, Swol J, Taccone FS, Malfertheiner MV, Di Nardo M, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Müller T, Belliato M, Lorusso R. Pressure and flow properties of cannulae for extracorporeal membrane oxygenation I: return (arterial) cannulae. Perfusion. 2019 Apr;34(1_suppl):58-64. link
& part II, drainage cannulae:

Broman LM, Prahl Wittberg L, Westlund CJ, Gilbers M, Perry da Câmara L, Westin J, Taccone FS, Malfertheiner MV, Di Nardo M, Swol J, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Müller T, Belliato M, Lorusso R. Pressure and flow properties of cannulae for extracorporeal membrane oxygenation II: drainage (venous) cannulae. Perfusion. 2019 Apr;34(1_suppl):65-73. link

& here a letter referring to previous 2 papers, suggesting some “in vivo” considerations when selecting catheters for extracorporeal support: do available informations correspond to in-vivo clinical performance? could testing catheters with whole blood flows be recommended to properly guide clinicians?

Giani M, Lucchini A, Rona R, Capalbi S, Grasselli G, Foti G. Pressure-flow relationship of cannulae for extracorporeal membrane oxygenation. Perfusion. 2019 Aug 13:267659119867182. link

Cannulating the ECMO patient

Bedside percutaneous bicaval-double lumen ECMO cannulation performed by experienced intensivists under exclusive transthoracic echo guidance seems feasible, effective, & safe even in newborns/small children according to this retrospective analysis, and could be a valid alternative to surgical cutdown and semi-Seldinger technique. IJV diameter not the only factor influencing choice of cannula size give priority to the one potentially more effective in providing proper blood flow; consider LIJV approach if RIJV not practicable.

Moscatelli A, Febbo F, Buratti S, Pezzato S, Bagnasco F, Lampugnani E, Nuri H, Buffelli F, Grasso C, Castagnola E. Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis. Pediatr Crit Care Med. 2019 Jun;20(6):551-559. link

Ultrasound & vascular access in the critically ill: prevalence & evidence supporting echo guided CVC insertion, proposal of an algorithmic approach, specific central line insertion technique and US guidance for cannulation at other sites: peripheral veins, arteries, IO access & ECMO cannulae, training. An open access review addressing the state of ultrasound-guided vascular access in the ICU, including current practice & future directions.

Schmidt GA, Blaivas M, Conrad SA, Corradi F, Koenig S, Lamperti M, Saugel B, Schummer W, Slama M. Ultrasound-guided vascular access in critical illness. Intensive Care Med. 2019 Apr;45(4) access link

Cannulation strategies

Are patients on veno-arterial extracorporeal life support with carotid artery cannulation at higher risk for ischemic neuro-injuries? Maybe, or maybe not: ASAIO Journal editorial suggesting, until more definitive longer-term follow-up data will reccomend otherwise, to maintain a position of equipoise, selecting vessels for ECMO cannulation not based on fear of stroke risk; regardless of cannulation sites, employ strategies providing both effective support & minimizing severe morbidity, be it brain or limb.

Woods RK. Extracorporeal Life Support and Increased Risk of Stroke with CarotidCannulation: Maybe, Maybe Not. ASAIO J. 2019 Sep/Oct;65(7):635. link

Here the study author refers to, reporting increased likelihood of stroke with cannulation of the carotid artery in patients 6–40 years old vs femoral cannulation for VA ECLS, but also suggesting to consider many other factors when selecting arterial cannulation site.

Di Gennaro JL, Chan T, Farris RWD, Weiss NS, McMullan DM. Increased Stroke Risk in Children and Young Adults on Extracorporeal Life Support with Carotid Cannulation. ASAIO J. 2019 Sep/Oct;65(7):718-724. link

Unconventional approaches

Adjunctive pulmonary artery cannulation on ECMO to provide additional RV drainage or support & LV unload supporting hemodynamic needs as preoperative or intraoperative biventricular or right ventricular dysfunction occurs, allowing for better patient management. Read about this multicenter experience, with detailed description of the technique and results.

Lorusso R, Raffa GM, Heuts S, Lo Coco V, Meani P, Natour E, Bidar E, Delnoij T, Loforte A. Pulmonary artery cannulation to enhance extracorporeal membrane oxygenation management in acute cardiac failure. Interact Cardiovasc Thorac Surg. 2019 Oct 26. open access link

Novel use of a dual-lumen single cannula bypassing RV in a VA ECMO configuration for intraoperative hemodynamic support of a patient with severe pulmonary hypertension & right ventricular dysfunction undergoing bilateral LTx, avoiding risks of CPB & postoperative switch to RVAD configuration &/or VV ECMO allowing for pulmonary support & RV unload.

Budd AN, Kozarek K, Kurihara C, Bharat A, Reynolds A, Kretzer AUse of ProtekDuo as Veno-arterial and Veno-venous Extracorporeal Membrane Oxygenation During Bilateral Lung Transplantation. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2250-2254. link

Additional venous return on VA ECMO support in patients undergoing lung transplantation: results of this study demonstrate that conventional femoral-femoral ECLS may produce suboptimal coronary oxygenation in subjects unable to tolerate one-lung ventilation. Authors suggest the creation of a small left-to-right shunt flow, using veno-arterio-venous hybrid ECLS configuration, may improve coronary & cerebral oxygenation, preventing intraoperative differential hypoxemia, and supporting both hemodynamics & gas exchange function during LTx.

Lee JG, Kim N, Narm KS, Suh JW, Hwang J, Paik HC, Yoo YC. The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Oct 23. link

Peripheral VVA ECMO draining from both cephalad jugular vein/right atrium & reinfusing in right carotid artery: effective and feasible approach to pediatric refractory septic shock? here a case series from Sabará Hospital Infantil, Brazil!

van Leeuwen Bichara GC, Furlanetto B, Gondim Teixeira L, Di Nardo M. Is peripheral venovenous-arterial ECMO a feasible alternative to central cannulation for pediatric refractory septic shock? Intensive Care Med. 2019 Nov;45(11):1658-1660. link

Cannula related complications: limb ischemia

Limb ischemia in peripheral VA ECMO: a still frequent complication, when preventive strategies are not adopted, potentially impacting on survival and long-term functional outcome, as can lead to compartment syndrome, requiring fasciotomy or even limb amputation. Peripheral cannulation can be quickly, percutaneously established, and is less likely to cause bleeding or infections than central cannulation, but is characterized by a higher rate of vascular complications. In this paper, a comprehensive narrative review with a proposed flow chart for managing lower limb ischemia. Pathophysiology and risk factors: a multifactorial genesis that can act at any stage of the run; how to early detect: clinical signs & diagnostic/monitoring tools; preventive strategies: cannula size/side selection, cannulation technique, bidirectional cannula & distal perfusion; ECLS weaning and decannulation; treatment: threatened vs nonviable extremity? could be rather subjective (appearance of soft tissue/amount of necrotic tissue), but longer the symptoms, less likely limb salvage.

Bonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Coco VL, Arcadipane A, Pilato M, Lorusso R. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care. 2019 Jul 30;23(1):266. Open access link

Not to miss complication on peripheral veno-arterial ECMO support: clot formation between arterial femoral cannula & reperfusion SF artery catheter detected by ultrasound in a patient with no full anticoagulation due to high bleeding risk… remember to scan all vessels with ultrasound before decannulation to prevent embolism and acute lower limb ischemia.

Au SY, Chan KS, Fong KM, Ng GWY. Clot formation between the ECMO catheter and the reperfusion catheter in a patient supported by peripheral VA-ECMO. Intensive Care Med. 2019 Nov;45(11):1657. Open access link

Percutaneous VA ECMO: cannula size & indication setting are most important factors for development of ischemic vascular complications a frequent phenomenon on ECLS with ECPR & smaller catheter associated with decreased risk in this retrospective analysis.

Lunz D, Philipp A, Müller T, Pfister K, Foltan M, Rupprecht L, Schmid C, Lubnow M, Graf B, Sinner B. Ischemia-related vascular complications of percutaneously initiated venoarterial extracorporeal membrane oxygenation: Indication setting, risk factors, manifestation and outcome. J Crit Care. 2019 Aug;52:58-62. link

Should a distal perfusion cannula must always be positioned during peripheral veno-arterial ECMO support? or not?? & what about the timing? at ECLS implantation or delayed? here an interesting correspondence including a comment and the reply by the authors of the paper referred to.

Formica F, Avalli L, Sangalli F, Danial P, Combes A, Lebreton G. Should we always use the peripheral cannula for distal leg reperfusion in femoro-femoral ECMO patients? Intensive Care Med. 2019 Apr;45(4):559-560. link

PS this the link to the original article, a propensity score framework analysis comparing outcomes of percutaneous vs surgical approach for femoro-femoral VA-ECMO (published in 2018).

Danial P, Hajage D, Nguyen LS, Mastroianni C, Demondion P, Schmidt M3, Bouglé A, Amour J, Leprince P, Combes A, Lebreton G. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive Care Med. 2018 Dec;44(12):2153-2161. link

Critical limb ischemia & VA extracorporeal support with femoral cannulation: the absence of distal limb perfusion identified as an independent risk factor in this evaluation involving more than 300 cases. The application of DLP during peripheral veno-arterial ECMO, regardless of the implantation technique, should be considered as a mandatory approach to minimize the ischemia-induced complications and to avoid the additional morbidity in these critically ills.

Kaufeld T, Beckmann E, Ius F1, Koigeldiev N, Sommer W, Mashaqi B, Fleissner FN, Siemeni T, Puntigam JO, Kaufeld J, Haverich A, Kuehn C.
Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach? Perfusion. 2019 Feb 8:267659119827231. Open access link

Cannula related complications: infections

Cannula-related infection in patients on peripheral ECMO support happens! and not rarely, according to this cohort study (17.2 CRI per 1,000 ECMO days). CRI are associated with longer hospital stay; risk factors: longer ECLS run & higher SAPS2 score; concomitant bacteremia frequent (strongly suspect & investigate in cases of positive blood culture); management of could require exploration of the surgical site.

Allou N, Lo Pinto H, Persichini R, Bouchet B, Braunberger E, Lugagne N, Belmonte O, Martinet O, Delmas B, Dangers L, Allyn J. Cannula-Related Infection in Patients Supported by Peripheral ECMO: Clinical and Microbiological Characteristics. ASAIO J. 2019 Feb;65(2):180-186. link

Cannula related complications: thrombosis

High incidence of cannula-related thrombosis post VV ECMO reported in this observational study from the University Hospital of Regensburg ICU; reduced systemic anticoagulation may enhance the risk, sustained elevation of D-dimer after decannulation may arise the suspect; routinely screen previously cannulated vessel after ECLS with doppler ultrasound to detect this complication!

Fisser C, Reichenbächer C, Müller T, Schneckenpointner R, Malfertheiner MV1, Philipp A, Foltan M, Lunz D, Zeman F, Lubnow M. Incidence and Risk Factors for Cannula-Related Venous Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Adult Patients With Acute Respiratory Failure. Crit Care Med. 2019 Apr;47(4):e332-e339. link

Cannula-associated thrombotic complications after VV ECMO support: frequency & risk factors investigated in this study, reporting data from a large cohort of patients who underwent a thoraco-abdominopelvic CT CE scan with iodinated contrast injection within 4 days after decannulation. Cannula-associated deep vein thrombosis reported as common event (71.4% of survivors), with anticoagulation recommendations seeming to have a moderate impact on thrombotic risk, & thrombocytopenia a protective effect on CaDVT. The interest in the systematic imaging of all previously cannulated vessels following veno-venous ECLS run is advocated by authors.

Parzy G, Daviet F, Persico N, Rambaud R, Scemama U, Adda M, Guervilly C, Hraiech S, Chaumoitre K, Roch A, Papazian L, Forel JM. Prevalence and Risk Factors for Thrombotic Complications Following Venovenous Extracorporeal Membrane Oxygenation: A CT Scan Study. Crit Care Med. 2019 Nov 25. link

Cannula related complications: malposition

Echo-guided bicaval dual-lumen VV ECMO cannula placement in ICU; persistent hypoxemia/low EC flow may suggest malposition: need to reposition the during the run is common. TEE could be useful to support a stepwise approach to troubleshooting persistent hypoxemia on VV ECLS, detecting cannula malposition (ie problems with depth of cannula, tip location, orientation) and to guide repositioning.

Griffee MJ, Zimmerman JM, McKellar SH, Tonna JE. Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review. J Cardiothorac Vasc Anesth. 2019 Oct 18. link

Malposition of dual lumen cannula, frequent & challenging complication in neonates on extracorporeal support: in this study, a detailed performance evaluation of the malpositioned DLC using computational fluid dynamics methodology. Considerations about atrial hemodynamics and DLC performance (drainage efficiency, blood residence time, and oxygenated blood delivery) related to patient-specific configurations with interesting graphic elements explaining different scenarios.

Jamil M, Rezaeimoghaddam M, Cakmak B, Yildiz Y, Rasooli R, Pekkan K, Salihoglu E. Hemodynamics of neonatal double lumen cannula malposition. Perfusion. 2019 Oct 3:267659119874697. link

How to prevent displacement? providing proper securement… what works in securing bicaval dual-lumen ECMO cannula? Optimal methods to provide stabilization allowing ambulation and patient comfort suggested here.

Tignanelli CJ, Weinberg A, Napolitano LM. Optimal Methods to Secure Extracorporeal Membrane Oxygenation Bicaval Dual-Lumen Cannulae: What Works? ASAIO J. 2019 Aug;65(6):628-630. open access link

Interesting case reports & series

Hazardous complication related to ECMO cannulation for EISOR, extracorporeal interval support for organ retrieval in DCD… be cautious & carefully check wire/cannula position before implementing reperfusion!

Brogi E, Circelli A, Gamberini E, Russo E, Benni M, Pizzilli G, Agnoletti V. Normothermic Regional Perfusion for Controlled Donation After Circulatory Death: A Technical Complication During Normothermic Regional Perfusion. ASAIO J. 2020 Jan;66(1):e19-e21. open access link

Novel mother-and-child fluoroscopy guided technique, assembling catheters & guidewire, to assist double-lumen bicaval VV ECMO cannula repositioning with a retrograde approach through femoral vein, maintaining extracorporeal circuit integrity. A case rep with interesting images/video content.

Kahloon R, Mangi MA, Moukarbel GV. Migrated Avalon Elite Venovenous ECMO Cannula: Novel Technique to Reposition Without Disrupting the Circuit. JACC Cardiovasc Interv. 2019 Sep 23;12(18):e161-e162. link

Repositioning a misplaced dual-lumen bicaval cannula in a 20-week-old infant on veno-venous extracorporeal support by interventional catheter technique with trans-femoral approach, using a goose neck snare & guiding the tip back into IVC, without interrupting ECMO support.

Houmesa RJ, Krasemannb T, Keyzer-Dekkerc CMG. Reposition of a Bi-caval Dual Lumen ECMO cannula using a trans-femoral lasso. Journal of Pediatric Surgery Case Reports Volume 52, January 2020. open access link

Bilateral cerebral infarction during veno-arterial #ECMO support with right carotid artery cannulation, due to rare anomaly of the circle of Willis in 6-month-old infant.

Sonobe A, Kato H, Mathis BJ, Hiramatsu Y.Catastrophic cerebral infarction during extracorporeal life support due to a rare anomaly in the circle of Willis. Interact Cardiovasc Thorac Surg. 2019 Nov 1;29(5):816-817. open access link

Novel surgical technique for minimally invasive central veno-arterial ECLS avoiding resternotomy or ventricular compression, while maintaining antegrade blood flow and permitting sternal closure following ascending aortic surgery: description & two cases of patients undergoing elective aortic arch replacement, with no short/long-term related complication.

Lorusso R, Bidar E, Natour E, Heuts S. Minimally invasive management of central ECMO after ascending aortic surgery. J Card Surg. 2019 Mar;34(3):131-133. link

Off-label use of carotid ECLS return cannula in neonates & infants < 5 kg on veno-arterial ECMO for angiography & interventions (through Y-connector with hemostatic valve) avoiding need for additional access, interesting case reports with circuit pics/clip.

Kang SL, Lee KJ, Stanisic A, Chaturvedi RR. Using the arterial cannula for cardiac catheterization in neonates and small infants supported by extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg. 2019 Apr 25. link

A case of azygous vein cannulation & drainage insufficiency at VA ECMO support implementation in a neonate, missed on chest radiography but promptly recognized & corrected with TTE: a case rep suggesting to routinely use echocardiography to guide cervical ECLS cannulation.

Runkel BG, Fraser JD, Daniel JM, Carlson KM. Identification of Inadvertent Azygous Vein Cannulation Using Transthoracic Echocardiography During Venoarterial Extracorporeal Membrane Oxygenation Initiation. CASE (Phila). 2019 Apr; 3(2): 67–70. open access link

ECMO year in review: ECPR

Let’s start with the American Heart Association focused update on Advanced Cardiac Life Support – ACLS, with recommendations on the use of advanced airways, vasopressors, extracorporeal during cardiac arrest; about ECMO assisted cardio-pulmonary resuscitation: there is insufficient evidence to recommend routine use of ECPR, but may be considered for selected patients as rescue therapy when conventional CPR is failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD). Read full recommendations, open access! Also available the Update on Pediatric Advanced Life Support & the Focused update on neonatal resuscitation!

Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabañas JG, Link MS, Kurz MC, Chan PS, Morley PT, Hazinski MF, Donnino MW.
Abstract. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e881-e894. link

Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e904-e914. link

Escobedo MB, Aziz K, Kapadia VS, Lee HC, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin JG. 2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e922-e930. link

Extracorporeal cardiopulmonary resuscitation: editorial with example of ECPR protocol for intra-hospital cardiac arrest to streamline the decision-making process leading to the involvement of #ECLS team, efficiently & consistently gather relevant info needed arrive at a consensus, prepare for initiating ECMO support.

Han JJ, Hoenisch K, Bermudez C. Designing an Extracorporeal Cardiopulmonary Resuscitation Protocol: It Is Time to Address Quality. ASAIO J. 2019 Aug;65(6):533-534. open access (with full algorithm access) link

The INCEPTION trial: early INitiation of extraCorporeal lifE suPporT in refractory Ohca, aiming to determine the clinical benefit for the use of #ECPR in patients with refractory out-of-hospital cardiac arrest presenting with VF/VT, and evaluating the feasibility & cost-effectiveness of #ECMO assisted cardio-pulmonary resuscitation. Read details about the trial design & current status.

Bol ME, Suverein MM, Lorusso R, Delnoij TSR, Brandon Bravo Bruinsma GJ, Otterspoor L6, Kuijpers M, Lam KY, Vlaar APJ, Elzo Kraemer CV, van der Heijden JJ, Scholten E, Driessen AHG, Montero Cabezas JM, Rittersma SZH, Heijnen BG, Taccone FS, Essers B, Delhaas T, Weerwind PW, Roekaerts PMHJ, Maessen JG, van de Poll MCG. Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial. Am Heart J. 2019 Apr;210:58-68. open access link

2CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion), multi-centre, prospective cohort study enrolled 12–70 years patients with refractory cardiac arrest, and reporting ECMO support in refractory cardiac arrest as feasible and associated with very good neurologically intact survival.

Dennis M, Forrest P, Bannon P, Scott S, Lowe D, Reynolds C, Burns B, Habig K, Nair P, Gattas D, Buscher H. The 2CHEER Study: (Mechanical CPR, Hypothermia, ECMO and Early Re-Perfusion) for Refractory Cardiac arrest. Heart, Lung & Circulation 2019 28:S322 link

High fidelity ECPR simulation training enables emergency teams to acquire/retain skills to rapidly & safely initiate ECMO support: this strategy could be valuable for institutions initiating ED-based ECPR programs or planning to participate in ECPR trials for Out-of-Hospital cardiac arrest.

Whitmore SP, Gunnerson KJ, Haft JW, Lynch WR, VanDyck T, Hebert C, Waldvogel J, Havey R, Weinberg A, Cranford JA, Rooney DM, Neumar RW.
Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario. Resuscitation. 2019 May;138:68-73.

Outcomes, outcome prediction & neuroprognostication

Impact of medical management on prognostication after cardiac arrest, review focusing on target temperature management & extracorporeal life support. indications & implications of TTM, with shivering as most common complication, particularly during induction, attenuating benefits by increasing metabolism, and TTM induced sedatives/analgesics PK changes, potentially impacting on late awakening/prognostication. ECMO support… a therapeutic agent after cardiac arrest? suggested neuromonitoring tools for ECPR patients at key time-points, pre cannulation, to identify the salvageable cases, post-cannulation, to detect neuro-complications included brain death, & post-awakening. Withdrawal of life-sustaining treatments due to perceived poor neurological outcome remains most common cause of hospital death: a valuable multimodal prognostication scheme including novel biomarkers, quantitative measures of brain stem reflexes, POC cerebral perfusion monitoring tool after ROSC still needed!

Agarwal S, Morris N, Der-Nigoghossian C, May T, Brodie D. The Influence of Therapeutics on Prognostication After Cardiac Arrest. link

Cardiac arrest before VA ECMO support: initial (nonshockable) rhythm, metabolic state expressed as level of lactate just before venoarterial ECLS, and ischemic heart disease identified as independent risk factors of 90-day mortality by this observation at Karolinska University Hospital, and may be more important than rigid low-flow (CPR) time/age limits and absence of ROSC (not significant risk factors) when considering ECPR or ECMO in post-arrest cardiogenic shock.

Fux T, Holm M, Corbascio M, van der Linden J. Cardiac Arrest Prior to Venoarterial Extracorporeal Membrane Oxygenation: Risk Factors for Mortality. Crit Care Med. 2019 Jul;47(7):926-933. link

Extracorporeal CPR in refractory OHCA: 4% of out-of-hospital cardiac arrest supported with ECPR in this population-based prospective registry study of the Paris region. comparing survival at hospital discharge with and without ECPR and identifying factors associated with survival in ECMO CPR group. In the latter, factors reported as associated with hospital survival: initial shockable rhythm, transient ROSC before ECPR, and prehospital ECMO implementation. These may help in selecting patients.

Bougouin W, Dumas F, Lamhaut L, Marijon E, Carli P, Combes A, Pirracchio R, Aissaoui N, Karam N, Deye N, Sideris G, Beganton F, Jost D, Cariou A, Jouven X; Sudden Death Expertise Center investigators. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J. 2019 Oct 31. link

Outcomes after ECMO assisted CPR ECPR in pediatric in-hospital cardiac arrest reported by linking two national registries, the American Heart Association Get With the Guidelines—Resuscitation and the ELSO – registries: encouraging results! Noncardiac diagnoses, preexisting renal failure, longer time from onset of the CPR event to ECLS initiation, and adverse events during the ECMO run are associated with worse outcomes.

Bembea MM, Ng DK3, Rizkalla N, Rycus P, Lasa JJ, Dalton H, Topjian AA, Thiagarajan RR, Nadkarni VM, Hunt EA; American Heart Association’s Get With The Guidelines – Resuscitation Investigators. Outcomes After Extracorporeal Cardiopulmonary Resuscitation of Pediatric In-Hospital Cardiac Arrest: A Report From the Get With the Guidelines-Resuscitation and the Extracorporeal Life Support Organization Registries. Crit Care Med. 2019 Apr;47(4):e278-e285. link

ECMO assisted vs conventional CPR in Cardiac Arrest: significantly higher occurrence of long-term favorable neurological outcome with ECPR (almost 50% relative increase of good neuro-recovery).

Patricio D, Peluso L, Brasseur A, Lheureux O, Belliato M, Vincent JL, Creteur J, Taccone FS. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Crit Care. 2019 Jan 28;23(1):27. open access link

ECMO assisted cardiopulmonary resuscitation for patients presenting with VF or pulseless VT found to be highly cost-effective (providing higher survival rate) vs ECPR if presenting rhythm asystole or PEA, borderline cost-effective (costing about twice as much), a retrospective observation.

Kawashima T, Uehara H, Miyagi N, Shimajiri M, Nakamura K, Chinen T, Hatano S, Nago C, Chiba S, Nakane H, Gima Y. Impact of first documented rhythm on cost-effectiveness of extracorporeal cardiopulmonary resuscitation. Resuscitation. 2019 Jul;140:74-80. link

Neurobehavioral outcomes & factors associated with survival 1 year after in-hospital cardiac arrest for children who received ECPR, secondary analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital THAPCA-IH trial: findings support American Heart Association & ILCOR recommendations to consider ECMO assisted CPR in children with cardiac disease.

Meert KL, Guerguerian AM, Barbaro R, Slomine BS, Christensen JR, Berger J, Topjian A, Bembea M7, Tabbutt S, Fink EL, Schwartz SM, Nadkarni VM, Telford R, Dean JM, Moler FW; Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Extracorporeal Cardiopulmonary Resuscitation: One-Year Survival and Neurobehavioral Outcome Among Infants and Children With In-Hospital Cardiac Arrest. Crit Care Med. 2019 Mar;47(3):393-402. open access link

& related editorial MacLaren G, Hoskote. Resuscitating Hearts and Minds: 1-Year Outcomes Following Extracorporeal Membrane Oxygenation for Cardiac Arrest. Crit Care Med. 2019 Mar;47(3):476-477. link

TTM on ECLS after OHCA: does this combination poses an excessive risk on pts? an Euro ELSO annual conference survey, supporting the statement that the use of outcome-enhancing targeted temperature management strategies is considerably variable; therefore, further studies weighting the risk of hypothermia-mediated relevant bleeding vs potential neuroprotective benefits of TTM on ECPR are needed.

Rolfes C, Muellenbach RM, Lepper PM, Spangenberg T, Swol J, Lorusso R, Weber K, Foerstner S, Lotz C, Belohlavek J. Targeted temperature management in patients undergoing extracorporeal life support after out-of-hospital cardiac arrest: an EURO-ELSO 2018 annual conference survey. Perfusion. 2019 Nov;34(8):714-716. link

Hyperoxemia & mortality in extracorporeal cardiopulmonary resuscitation ECPR after OHCA: additional data from this retrospective study underline the potential toxicity of high O2 dose, suggesting an optimal management of oxygenation, strictly controlling O2 administration after the initiation of ECMO assisted CPR in refractory out-of-hospital cardiac arrest is crucial.

Halter M, Jouffroy R, Saade A, Philippe P, Carli P, Vivien B. Association between hyperoxemia and mortality in patients treated by eCPR after out-of-hospital cardiac arrest. Am J Emerg Med. 2019 Jul 8. link

Which partial pressure of CO2 during ECMO CPR? Rapid PaCO2 drop may occur soon after ECPR initiation, & as relationship between Pre/Post ML PCO2 is not consistent/predictable, sweep gas flow should be adjusted based on PaCO2 avoiding sudden CO2 removal.

Morris KP, Brincat E, Sanz I, Scholefield BR. Which partial pressure of carbon dioxide during extracorporeal cardiopulmonary resuscitation (ECPR)? Resuscitation. 2019 May;138:42-43. link

According to this registry study, reporting strong correlation between hospital survival and arterial pH (no such correlation with paCO2), it might be reasonable to correct both respiratory and metabolic acidosis in ECPR patients.

Bemtgen X, Schroth F, Wengenmayer T, Biever PM, Duerschmied D, Benk C, Bode C, Staudacher DL.How to treat combined respiratory and metabolic acidosis after extracorporeal cardiopulmonary resuscitation? Crit Care. 2019 May 21;23(1):183. open access link

Early and 24h post-ROSC oxygenation status & Pao2/Fio2 ratio in pts treated with #ECMO assisted CPR #ECPR post CA is associated with both neuro-outcome & survival: closely monitor both during the early postcardiac arrest care. According to the results of this study optimal Pao2 range 77-220mmHg.

Chang WT, Wang CH, Lai CH, Yu HY, Chou NK, Wang CH, Huang SC, Tsai PR, Chou FJ, Tsai MS, Huang CH, Ko WJ, Chen WJ, Chen YS. Optimal Arterial Blood Oxygen Tension in the Early Postresuscitation Phase of Extracorporeal Cardiopulmonary Resuscitation: A 15-Year Retrospective Observational Study. Crit Care Med. 2019 Nov;47(11):1549-1556. link

Coagulation in refractory cardiac arrest treated with ECMO assisted CPR: derangements are frequent & may have important consequences for ECPR management of anticoagulation and blood product transfusion; presence of DIC diagnostic criteria should be considered among prognostic factors in this population, results from a single high-volume center experience.

Ruggeri L, Franco A, Alba AC, Lembo R, Frassoni S, Scandroglio AM, Calabrò MG, Zangrillo A, Pappalardo F. Coagulation Derangements in Patients With Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. J Cardiothorac Vasc Anesth. 2019 Jul;33(7):1877-1882. link

Development of a new a risk prediction score for early neuro-prognosis of ECPR patients (nECPR) using independent predictors and interaction between age & low-flow time (model based on a retrospective analysis).

Ryu JA, Chung CR, Cho YH, Sung K, Jeon K, Suh GY, Park TK, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon H5, Carriere KC, Ahn J, Yang JH. Neurologic Outcomes in Patients Who Undergo Extracorporeal Cardiopulmonary Resuscitation. Ann Thorac Surg. 2019 Sep;108(3):749-755. link

Routinely perform a full-body CT scan in all ECPR patients?? may be reasonable… in this observation, a relevant number of clinically significant CT findings is reported after ECMO assisted cardiopulmonary resuscitation. Early detection of intracranial pathologies or iatrogenic complications by full-body CT scans, reported as associated with poor prognosis, could potentially influence further management, and eventually early limitation of care. In the study, multiple rib fractures (common, 65% of cases, supposedly related to vigorous conventional CPR efforts) appears not associated with poor outcome. PS: ECMO cannula malposition detected in 6% of patients!

Zotzmann V, Rilinger J, Lang CN, Duerschmied D, Benk C, Bode C, Wengenmayer T, Staudacher DL. Early full-body computed tomography in patients after extracorporeal cardiopulmonary resuscitation (eCPR). Resuscitation. 2019 Dec 4. link

ECMO support in cardiac arrest: early initiation of ECLS (within 46′) found to be associated with favourable neurological outcome in patients suffering from CA caused by cardiac events in this single center experience ECPR.

Komeyama S, Takagi K, Tsuboi H, Tsuboi S, Morita Y, Yoshida R, Kanzaki Y, Nagai H, Ikai Y, Furui K, Tsuzuki, Shibata N, Yoshioka N, Yamauchi R, Sugiyama H, Morishima I.The Early Initiation of Extracorporeal Life Support May Improve the Neurological Outcome in Adults with Cardiac Arrest due to Cardiac Events. Intern Med. 2019 May 15;58(10):1391-1397. open access link

Evaluating predictive value of NSE in patients on ECMO implemented for cardiogenic shock post cardio-pulmonary resuscitation or to support ECPR: neuron-specific-enolase is a still valuable tool after even on ECLS; serial measurements provided the highest specificity in this observation.

Schrage B, Rübsamen N, Becher PM, Roedl K, Söffker G, Schwarzl M, Dreher A, Schewel J, Ghanem A, Grahn H, Lubos E, Bernhardt A, Kluge S, Reichenspurner H, Blankenberg S, Spangenberg T, Westermann D. Neuron-specific-enolase as a predictor of the neurologic outcome after cardiopulmonary resuscitation in patients on ECMO. Resuscitation. 2019 Mar;136:14-20. link

Emergency physician-initiated & managed resuscitative ECMO: in this single-center experience, EPs implemented & managed ED #ECPR demonstrates promising clinical outcomes with limited downstream inpatient resource utilization.

Shinar Z, Plantmason L, Reynolds J, Dembitsky W, Bellezzo J, Ho C, Glaser D, Adamson R. Emergency Physician-Initiated Resuscitative Extracorporeal Membrane Oxygenation. J Emerg Med. 2019 Jun;56(6):666-673. open access link

Most promising candidates for ECMO assisted CPR among patients with refractory OHCA might be those with sustained VF/ pVT before extracorporeal support; patients with conversion from VF/pVT to PEA/asystole before ECPR might be unlikely to experience favorable neurological outcomes.

Nakashima T, Noguchi T, Tahara Y, Nishimura K, Ogata S, Yasuda S, Onozuka D, Morimura N, Nagao K, Gaieski DF, Asai Y, Yokota H, Nara S, Hase M, Atsumi T, Sakamoto T; SAVE-J Group. Patients With Refractory Out-of-Cardiac Arrest and Sustained Ventricular Fibrillation as Candidates for Extracorporeal Cardiopulmonary Resuscitation - Prospective Multi-Center Observational Study. Circ J. 2019 Apr 25;83(5):1011-1018. open access link

Effectiveness (& cost-effectiveness) of ECPR

Extracorporeal cardiopulmonary resuscitation: effective vs conventional CPR for adults in cardiac arrest?? Data presented in this open access systematic literature review & meta-analysis suggest that, in selected patients, ECPR could increase rate of survival to discharge & number of neurologically intact survivors; factors associated with improved outcome: initial shockable rhythm & short low-flow time. We still need high-quality evidence to support ECMO assisted resuscitation, but lot clinical trials are ongoing, which will hopefully provide some answers.

Twohig CJ, Singer B, Grier G, Finney SJ. A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest. J Intensive Care Soc. 2019 Nov;20(4):347-357. link

Extracorporeal Cardio-Pulmonary Resuscitation in IHCA: a study aiming to estimate cost-effectiveness of this strategy to support in-hospital cardiac arrest management. Authors apply a decision tree & Markov model constructed based on current literature, and report evaluation according to the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines for this population. ECPR appears cost-effective from a healthcare perspective, considering conventional WTP thresholds between 50-100,000 €/$; authors suggest identifying patients who could benefit most, and long-term effects of ECPR, as goals for future investigations… Waiting for the results of the (at least) 5 ongoing RCTs!

Gravesteijn BY, Schluep M, Voormolen DC, van der Burgh AC, Dos Reis Miranda D, Hoeks SE, Endeman H. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model. Resuscitation. 2019 Oct;143:150-157. Open access  link 

A cost analysis with modelling of cost effectiveness and quality of life outcomes of patients who have undergone ECPR, reporting ECMO support in refractory cardiac arrests as cost effective and favourably comparing to accepted cost effectiveness thresholds. Over 10 years ECPR was estimated to add a mean gain of 3.0 Quality Adjusted Life Years (QALYs) per patient. Mean cost per QALY did not differ significantly by OHCA or IHCA.

Dennis M, Zmudzki F, Burns B, Scott S, Gattas D, Reynolds C, Buscher H, Forrest P; Sydney ECMO Research Interest Group. Cost effectiveness and quality of life analysis of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Resuscitation. 2019 Jun;139:49-56. link

Cost-Utility of extracorporeal cardiopulmonary resuscitation ECPR in the setting of refractory cardiac arrest: according to this evaluation, calculated cost-utility is largely within the threshold considered cost-effective in the United States; results appears comparable to the cost-effectiveness of heart Tx for end-stage heart failure.

Bharmal MI, Venturini JM, Chua RFM, Sharp WW, Beiser DG, Tabit CE, Hirai T, Rosenberg JR, Friant J, Blair JEA, Paul JD, Nathan S, Shah AP. Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest. Resuscitation. 2019 Mar;136:126-130. link

Pulmonary embolism

ECPR important rescue strategy in fulminant PE as intraarrest thrombolysis fails: although bleeding concern, potential life-saving benefits of ECMO assisted CPR overcome hemorrhagic risks. Here a case rep; what the best approach? preparing for ECLS during early administration of thrombolytics to be prepared for eventual failure or implementing ECMO as primary intervention?

Thind GS, Hanane T, Bribriesco A, Yun J, Anandamurthy B, Latifi M, Unai S, Krishnan S. Extracorporeal cardiopulmonary resuscitation in a patient with fulminant pulmonary embolism refractory to intraarrest thrombolysis. Perfusion. 2019 Jul 21:267659119862932. link

2019 European Society of Cardiology Guidelines for the diagnosis & management of acute pulmonary embolism developed in collaboration with the European Respiratory Society. Temporary use of mechanical cardiopulmonary support, mostly veno-arterial ECMO may be considered, and may be helpful in combination with surgical embolectomy or catheter-directed treatment, in patients with high-risk PE and refractory circulatory collapse or cardiac arrest. Survival of critically ill patients has been described in a number of case series, but no RCTs in the setting of high-risk PE have been conducted to date.

Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory. Eur Respir J. 2019 Oct 9;54(3). Open access link

Extracorporeal support or ECPR in massive pulmonary embolism: veno-arterial ECMO able to save lives and extend time for definitive treatment if implemented in a timely manner, as reported in this series of patients suffering form circulatory collapse or cardiac arrest due to PE; a trained ECMO team need to be involved & alerted in all cases suspected for massive PE.

Kjaergaard B, Kristensen JH, Sindby JE, de Neergaard S, Rasmussen BS. Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism. Perfusion. 2019 Feb 17:267659119830014. link

May Extracorporeal Cardiopulmonary Resuscitation improve the outcomes of patients who suffer from CA due to massive PE? yes, according to this before-after study! ECPR seems promising treatment to support patients with refractory cardiac arrest due to (suspected) massive pulmonary embolism compared to conventional CPR (26 vs 5%, with no favourable neurological outcome in CCPR patients compared to 21% of the ECMO patients, p < 0.05), even if outcomes remain poor.

Mandigers L, Scholten E, Rietdijk WJR, den Uil CA, van Thiel RJ, Rigter S, Heijnen BGADH, Gommers D, Dos Reis Miranda D. Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study. Resuscitation. 2019 Mar;136:8-13. link

Accidental hypothermia

Looking for reliable cut-off values for identification of hypothermic avalanche victims with reversible OHCA at admission for extracorporeal assisted rewarming to allocate ECLS resources increasing survivors: serum potassium accurately predicted survival, combined serum K+ 7 mmol/L & core temperature 30°C achieved lowest overtriage rate/highest PPV; presence of vital signs at the time of extrication strongly associated with survival open access.

Brugger H, Bouzat P, Pasquier M, Mair P, Fieler J, Darocha T, Blancher M, de Riedmatten M, Falk M, Paal P, Strapazzon G, Zafren K, Brodmann Maeder M. Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective multi-centre study. Resuscitation. 2019 Jun;139:222-229. open access link

Hypothermia outcome prediction after ECLS for hypothermic cardiac arrest: may the HOPE score replace serum K+ as triage tool when considering ECMO assisted rewarming of a hypothermic CA victim? first external validation.

Pasquier M, Rousson V, Darocha T, Bouzat P, Kosiński S, Sawamoto K, Champigneulle B, Wiberg S, Wanscher MCJ, Brodmann Maeder M, Paal P, Hugli O. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation. 2019 Jun;139:321-328. link

ECMO support to improve outcomes in accidental hypothermia with no vital signs? veno-arterial ECLS associated with higher survival & favourable neurological outcomes compared with conventional CPR alone in this cohort, according to the results of this large nationwide observation.

Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. Resuscitation. 2019 Nov;144:27-32. link

Severe hypothermia? Promising outcomes (hospital survival = 89% with excellent neuro-recovery) for veno-arterial ECMO in this case series from an established high-volume ECMO & #CPR European center, comparing severely hypothermic patients rewarmed on VA-ECLS with hypothermic patients rewarmed conservatively. Except for mildly lower temperature in the ECMO group and presence of refractory cardiac arrest, previously published prognostic indicators (arterial lactate level, pH, plasmatic K) did not differ between the two groups.

Balik M, Porizka M, Matousek V, Brestovansky P, Svobodova E, Flaksa M, Rulisek J, Mlejnsky F, Hodkova G, Grus T, Vobruba V, Belohlavek J. Management of accidental hypothermia: an established extracorporeal membrane oxygenation centre experience. Perfusion. 2019 Apr;34(1_suppl):74-81. link

Interesting ECPR case reports

Prolonged cardiopulmonary resuscitation & low flow… contraindications for #ECLS?? here longest (to date!) duration for conventional CPR (>2h) followed by successful ECMO support in pediatric out-of-hospital, witnessed cardiac arrest OCHA, demonstrating unpredictability of outcomes, especially in a previously healthy children: ECPR can provide the chance of recovery even in the setting of an extremely long resuscitation. Patient has been discharged home with no impairment of cognitive abilities.

Deshpande SR, Vaiyani D, Cuadrado AR, McKenzie ED, Maher KO. Prolonged cardiopulmonary resuscitation and low flow state are not contraindications for extracorporeal support. Int J Artif Organs. 2019 Sep 23:391398819876940. link

ECPR & prolonged use of mechanical compression device to provide LV unloading in the setting of peripheral veno-arterial #ECMO: a combined support while correcting hypothermia, coagulopathy, acid-base abnormalities allowing for return of spontaneous circulation & successful neurologic outcome after hypothermic cardiac arrest, despite downtime greater than 100′: case rep… Hint! TEE guidance critical to optimize LUCAS position!

Trethowan B, Michaud C, Kumar A, Strotbaum A, Berjaoui W, Spurlock D. Veno-arterial extracorporeal membrane oxygenation and prolonged use of mechanical compression device combine for good outcome after hypothermic cardiac arrest: a case report. Journal Of Emergency And Critical Care Medicine, 3, jan. 2019. link

ECPR in prolonged refractory cardiac arrest + switch from veno-arterial to veno-venous configuration of ECMO as cardiogenic shock improved to support impaired lung function and weaning with full neuro-recovery, an interesting open access case from Japan!

Ichinohashi K, Natsukawa T, Ueda T, Sawano H, Hayashi Y, Shigeoka H, Kitazawa Y, Hiraide A. Unexpectedly Good Neurological Outcome after Prolonged Cardiac Arrest. OJEM Vol.7 No.1 , March 2019 link

Report of 2 cases of refractory cardiac arrest presenting with agonal breathing, both successfully resuscitated with favourable neurological outcome at discharge through ECLS, despite initial non-shockable rhythms (asystole & PEA)… look at the signs of life when considering criteria for ECPR!

Bunya N, Wada K, Yamaoka A, Kakizaki R, Katayama Y, Kasai T, Kyan R1, Murakami N, Kokubu N, Uemura S, Narimatsu E. The prognostic value of agonal respiration in refractory cardiac arrest: a case series of non-shockable cardiac arrest successfully resuscitated through extracorporeal cardiopulmonary resuscitation. Acute Med Surg. 2019 Feb 20;6(2):197-200. open access link

Would you consider ECPR in acute aortic dissection?? here, concerns about stopping veno-arterial ECMO support implementation upon identification of Type A AAD & case report triggering the discussion.

Kelly C, Ockerse P, Glotzbach JP, Jedick R, Carlberg M, Skaggs J, Morgan DE. Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation. Am J Emerg Med. 2019 Jun;37(6):1214.e5-1214.e6. link

Rescue TEE for monitoring mechanical chest compressions, improving cCPR quality & guiding ECPR cannulation in refractory cardiac arrest, increasing efficiency in implementing #ECMO. In pulseless patients, POCUS allows for vessel identification, decreasing complications of blind attempts & reducing time needed to obtain accesses, confirming sites prior to dilation cannulation, and may improve survival.

Giorgetti R, Chiricolo G, Melniker L, Calaf C, Gaeta T. RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest. J Clin Ultrasound. 2019 Dec 10. link

ECMO year in review: education & standardization

Fist obliged citation: the ECMOed Taskforce position paper, to describe the state of ECMO education worldwide, noting current limitations and challenges, & to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.

Zakhary B, Shekar K, Diaz R, Badulak J, Johnston L, Roeleveld PP, Alinier G, Lai PCK, Ramanathan K, Moore E, Hassan I, Agerstrand C, Ngai WC, Salazar L, Raman L, Bembea MM, Davidson M, Gomez-Gutierrez RD, Mateo-Sidrón JAR, Kukutschka J, Antonini MV, Dickstein ML, Schmidt M, Abrams D, Ogino MT; ELSO ECMOed Taskforce.Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce. Crit Care Med. 2019 Dec 11. link

ECMO education, in particular with regards to emergencies during a veno-arterial ECLS run, is challenging due to its intrinsic characteristics: a complex, high risk, often relatively low volume activity requiring dynamic decision making, multidisciplinary teamwork & communication, and rapid response. A simulation training focusing on CRM – Crisis Resource management and interprofessional communication could effectively address these educational needs. Institutional commitment to provide resources (both capital & human) is mandatory to the success of ECMO training programs. Read this full open access paper, Wallace Ngai of the ECMOed Workshops WG & Peter Lai of the Curriculum WG named among authors, congratulations! 

Sin SWC, Ng PY, Ngai WCW, Lai PCK, Mok AYT, Chan RWK. Simulation training for crises during venoarterial extracorporeal membrane oxygenation. J Thorac Dis. 2019 May; 11(5): 2144–2152.
open access link

ECMO simulation-based training: a safe venue to practice complex interventions & learn how troubleshooting at best ECLS related complications through a well-coordinated teamwork. In this paper, Professor Guillaume Alinier, member of the ECMOed Curriculum & Research workgroups, and his colleagues of Qatar University & Hamad Medical Corporation in Doha, propose a novel SBT solution not based on real ECMO equipment but trying recreating problematic situations & emergencies scenarios with realism/high-fidelity and remote control, while avoiding costs related to extracorporeal support machine/circuits, enjoy!

Al Disi M, Alsalemi A, Alhomsi Y, Bensaali F, Amira A, Alinier G. Extracorporeal membrane oxygenation simulation-based training: methods, drawbacks and a novel solution. Perfusion. 2019 Apr;34(3):183-194. link

Screen-based simulators as affordable & realistic alternative to replace conventional ECLS education?? Here, an evaluation of the efficacy of an open-source interactive & low-cost screen-based ECMO simulator, showing no significant dissimilarities between training through this simulator and didactic classroom-based teaching, in terms of learning outcomes, self-efficacy, learner performance (& both could be considered complementary to mannequin-based immersive #simulation training). ECMOed members Mark Ogino, President of the ELSO, and Guillaume Alinier cited between the authors.

Alsalemi A, Tanaka L, Ogino M, Disi MA, Alhomsi Y, Bensaali F, Amira A, Alinier G. A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation. Perfusion. 2019 Jul 13:267659119859120. link

ps here the link to ECMOjo simulator

A mandatory reading, with referral to standardization: another ELSO position paper, a consensus about nomenclature & abbreviations for extracorporeal life support to ensure accurate, concise communication.

Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Bembea MM, Barbaro RP, Diaz R, Grazioli L, Pellegrino V, Mendonca MH, Brodie D1, Fan E, Bartlett RH, McMullan MM, Conrad SA. The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support – a position paper of the Extracorporeal Life Support Organization. Crit Care. 2019 Feb 8;23(1):36. open access link

(& to get clear about ExtraCorporeal Life Support, do not forget previous one… even if it was published in 2018: extensive, consistent & unambiguous nomenclature for the description of the practice of ECLS & ECMO.

Conrad S, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Grazioli L, Barbaro RP, McMullan DM, Pellegrino V, Brodie D, Bembea MM, Fan E, Mendonca M, Diaz R, Bartlett RH. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med. 2018 Aug 15;198(4):447-451. link

And to conclude this first part of the year in review, let’s talk about the ELSO Registry: here, update and perspectives, with acknowledgement for the contribution of all centers & professionals who make up the ELSO community, for supporting this scientific initiative in the challenging ECLS field, and a thought to all the patients who were treated with ECMO support against critical illnesses and pending death.

Lorusso R, Alexander P, Rycus P, Barbaro R. The Extracorporeal Life Support Organization Registry: update and perspectives. Ann Cardiothorac Surg. 2019 Jan; 8(1): 93–98. open access link

ECMOed Survey

Are you an ECMO practitioner?? Help us standardise worldwide #ECMO education!
The ELSO – Extracorporeal Life Support Organization is an international non-profit consortium of health care institutions dedicated to improving extracorporeal life support through continuing education, guidelines development, research, and maintenance of a comprehensive registry of patient data. The ECMOed Taskforce is working on a collaborative approach toward standardisation of global ECMO education. Please complete this form if your centre is interested in helping with this initiative and helping outline the current state of ECMO education worldwide: follow the link to #ECMOedsurvey, just few minutes needed to fill!

ECMOed faculty

Let’s introduce the faculty of ECMOed, the ECMO Education Taskforce of the ELSO – Extracorporeal Life Support Organization, an an international consortium of Health Care Professionals dedicated to the development and delivery of high-quality education & training in the field extracorporeal support, ECLS. To start, the creators and pillars: Mark Ogino, Elso President, Bishoy Zakhary, ELSO Chair of Logistics and Education, & Rodrigo Diaz, former president of the Latin America Chapter of the Extracorporeal Life Support Organization, ELSO LATAM!

First ECMOed meeting in Santiago, Chile in 2018.
Second ECMOed meeting in Doha, Qatar in 2018

ECMOed Position Paper

Visual abstract of the position paper to describe the state of ECMO education worldwide, noting current limitations and challenges, & to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization: a statement from the ELSO – Extracorporeal Life Support Organization ECMOed Taskforce online first on Critical Care Medicine at
A dedicated twitter chat under the hashtag #ECMOedPP will be held in January, do not miss the opportunity to discuss the topic with the ECMOed Workgroups representatives, read the paper & stay tuned for updates!!

Zakhary B, et al. Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce. Crit Care Med. 2019.

ELSO Endorsement

Planning or running an ECMO course, a simulation-based course or an ECMO workshop/symposium?? The endorsement process will ensure that your event achieves an educational quality as defined by The Extracorporeal Life Support Organization! Any ELSO or non-ELSO center or scientific Society may submit application. How? in 4 easy steps, summarised in the infographic!

1. Application submission: the course or workshop/symposium director will send the initial checklist, to verify that all the preliminary criteria are met. If any hurdles is identified, recommendations will be offered to support proper adjustment before resubmitting.

2. Visit preparation: once materials are submitted and reviewed, a site survey will be scheduled. At this stage, the educational activity can be branded as ELSO-compliant.

3. Site survey: a surveyor appointed by the ECMOed Endorsement WG, not involved in the event will visit the venue while the educational activity is carried out, for a comprehensive  review . At least 1 month in advance,  lecture slide sets & simulation scenarios will be evaluated too.  The Endorsement WG  will discuss findings, to provide a final recommendation

4. Endorsement agreement: once endorsement is achieved, the ELSO Name and Logo should be used in accordance with the ‘Agreement for Use of ELSO’s Name and Materials for Training Courses’. For Comprehensive Simulation-Based ECMO Courses and ECMO courses, an ELSO standardized online pre/post-course survey and evaluation form must be administered. For workshops & symposia, an evaluation form should be administered and submitted to ELSO for review.

Brought to you by ECMOed Endorsement Workgroup