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Published in final edited form as: Crit Care Med. 2020 Jun;48(6):838–846. doi: 10.1097/CCM.0000000000004330

Joint SCCM-ELSO Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation

Jeffrey DellaVolpe 1, Ryan P Barbaro 2, Jeremy W Cannon 3, Eddy Fan 4, Wendy R Greene 5, Kyle J Gunnerson 6, Lena M Napolitano 7, Ace Ovil 8, Jeremy C Pamplin 9, Matthieu Schmidt 10, Lauren R Sorce 11, Daniel Brodie 12
PMCID: PMC7422732  NIHMSID: NIHMS1612251  PMID: 32282350

Abstract

Objective:

To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation (ECMO).

Design:

Retrospective review of the literature and expert consensus

Setting:

Series of in-person meetings, conference calls, and emails from January 2018 until March 2019.

Subjects:

A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine (SCCM) and the Extracorporeal Life Support Organization (ELSO). Experts were identified by their respective societies based on reputation, experience, and contribution to the field.

Interventions:

A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9.

Measurements and Main Results:

The Task Force developed 18 strong and 5 weak recommendations in 5 topic areas of ECMO initiation and management. These recommendations were organized into five areas related to the care of patients on ECMO: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is ECMO is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead.

Conclusions:

The role of the intensivist in the care of patients on ECMO continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding ECMO selection, cannulation, and management are applied.

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a form of respiratory or cardiac life support consisting of a vascular access cannula, a blood pump, and an artificial lung, which removes carbon dioxide and adds oxygen [1]. While ECMO utilization has expanded rapidly since 2009 [2, 3], the majority of ECMO centers remain relatively low volume centers with a median of 15 [interquartile range 5-35] cases per year (4). The clinical implication is that intensive care clinicians are increasingly likely to be involved in the critical care of patients supported by ECMO, regardless of whether they are part of a large ECMO program. These patients are medically complex, at risk for complications, and resource intensive. Consequently, the Society of Critical Care Medicine (SCCM) established a task force to advance ECMO education and investigation.

The SCCM-ELSO Task Force was appointed as a joint collaboration between the SCCM and the Extracorporeal Life Support Organization (ELSO). The charge of the Task Force was to define the role of the intensivist in the initiation and management of patients on ECMO. We accomplished this charge by reviewing published literature and providing consensus statements written for the intensivist and multidisciplinary ECMO team.

METHODS

The Task Force organizing committee convened in January 2018 to define the methodology, select the topics for study, and identify experts in the field. Experts were identified by their respective societies based on reputation, experience, and contribution to the field.

Through a series of emails, conference calls, and in-person discussions, five topics related to the role of the intensivist in the care of adult patients on ECMO were identified. These were the role of the intensivist in patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. Experts were tasked with developing recommendations within each topic area for consideration by the entire Task Force.

A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. In the absence of high-quality evidence, Task Force recommendations were made based on the combination of low-quality evidence and consensus expert opinion among the Task Force. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9 (9). Each member of the committee had an equal vote with the highest and lowest scores discarded. Strong agreement required all members to agree with the recommendation with a score of 7 or higher. Weak agreement was achieved when one member ranked the recommendation below 7, but the median was at least a 7. When the committee reached strong agreement statements were characterized as Recommend when the committee reached weak agreement statements were characterized as Consider (Table 1).

Table 1.

Recommendations by the Joint SCCM-ELSO Task Force

Strength of recommendation The Role of the Intensivist in the Selection and Timing of ECMO Initiation
Recommend The decision to initiate ECMO and the timing of this decision are complex and should involve a multidisciplinary ECMO team. Intensivists should play a central role in the formation of this team and the discussion about patient selection.
Recommend Future research should seek to identify patient criteria that can identify ECMO candidacy and optimal timing for ECMO initiation.
Recommend The decision to withhold ECMO should be made by a multidisciplinary team that includes intensivists.
Recommend The decision to withhold ECMO should be based on an evaluation of the prognosis, assessing whether ECMO will improve or worsen the overall prognosis.
Recommend The multidisciplinary team assessing ECMO candidacy should be aware the factors associated with reduced and improved ECMO survival, consulting with an ECMO expert when possible.
Recommend Patients with respiratory failure should receive optimal mechanical ventilation and prone positioning where appropriate prior to consideration for ECMO.
Consider *ECMO can be considered for patients with ARDS from a reversible etiology who have received optimized care with P:F ratio < 50 mmHg for > 3 hours, P:F ratio < 80 mmHg for > 6 hours with FiO2>80% and PEEP >10, or arterial pH < 7.25 with paCO2 ≥ 60 mmHg for > 6 hours while trying to maintain Pplat < 32 despite a respiratory rate of 35 breaths per minute.
Recommend Patients with severe respiratory failure who are not responding to conventional management should undergo early transfer to a hospital with ECMO capabilities if clinically feasible.
Recommend cECMO can be considered for patients with cardiogenic shock, especially with signs of poor perfusion and failure of medical therapy, transferring to a specialty center capable of both long term and short-term support options when clinically appropriate.
Consider *ECPR requires emergent, time-sensitive deployment of invasive life support; therefore, we recommend centers offering ECPR establish a multidisciplinary ECMO team with explicit guidelines for patient selection, exclusion, and team member notification. Intensivists should play a central role in the formation of these guidelines and the delivery of subsequent intensive care needs.
The Role of the Intensivist in Cannulation for ECMO
Recommend Many specialists, including intensivists, can successfully perform cannulation for ECMO. For cases where the intensivist does not cannulate, the intensivist should remain involved in the decisions surrounding cannulation such as timing, configuration, and cannula size, all of which can impact ICU management.
Recommend Intensivists performing cannulation should use percutaneous access in lieu of open cannulation techniques.
Avoiding and Rescuing Patients from ECMO-related Complications
Recommend Intensivists should be familiar with complications specific to ECMO and should participate in developing institution-specific protocols for preventing and managing these complications.
Recommend Ultrasound, radiography, and/or fluoroscopy should be used to aid in the visualization of vessels, wire, and cannula during cannulation.
Recommend Post-cannulation plain radiographs should be obtained to document cannula positioning.
Consider *For bleeding patients on ECMO, the intensivist role is to evaluate if clinically significant bleeding is present, evaluate the patient’s ability to form and maintain clot, evaluate the ECMO circuit’s clot burden, and assimilate the information to decide if anticoagulation should be reduced or held and assess if bleeding will require further medical or procedural interventions.
Consider *Intracranial hemorrhage on ECMO can be life threatening. Potential options for the managing intensivist include holding/decreasing anticoagulation, evaluation for ECMO discontinuation, serial neurological examination, neuroimaging, and neurosurgical evaluation as appropriate.
Consider *The decision to perform any procedure on patients supported by ECMO should be carefully weighed against the risk of hemorrhage, and performed by clinicians with significant expertise after a plan has been developed for how anticoagulation will be adjusted.
Recommend Hospitals should have a ready and rapidly deployable plan for replacing failed ECMO equipment, as well as a protocol for monitoring equipment in order to diminish the risk of failure.
Recommend Intensive evaluation of the distal extremity is necessary with arterial cannulation with attention to any signs of ischemic injury which can be limb threatening.
Recommend Intensivists should be aware of the clinical manifestations of left ventricular distension and develop clinical thresholds and strategies for decompressing the left ventricle.
Leading a Multidisciplinary Team
Recommend The establishment of a multidisciplinary care team responsible for daily rounds to provide continuity of care, surveillance of quality metrics, and a mechanism to perform case review at regular intervals is essential.
Surrogate Decision-Maker Communication
Recommend Established processes should exist for ensuring family-centered communication. Other team members involved in surrogate communications (e.g., palliative care, case management) should be familiar with the unique challenges related to the care of patients receiving ECMO.

ECMO extracorporeal membrane oxygenation; ARDS acute respiratory distress syndrome; PEEP positive end expiratory pressure; Pplat plateau pressure; cECMO cardiac extracorporeal membrane oxygenation; ECPR extracorporeal cardiopulmonary resuscitation; ICU intensive care unit.

Recommend corresponds to strong agreement

*

Consider corresponds to weak agreement

For the purposes of this Task Force an intensivist is a practitioner who is eligible to sit for critical care medicine boards.

RESULTS

The 5 topics identified by the SCCM-ELSO Task Force are as follows, with recommendations as appropriate (Table 1).

Topic 1. The Role of the Intensivist in the Selection and Timing of ECMO Initiation

ECMO is neither a definitive treatment nor a destination therapy. ECMO can be deployed as a bridge to recovery, transplant, or destination therapy with mechanical circulatory support (MCS) [47]. Decisions regarding ECMO initiation are best made by a combination of an experienced multidisciplinary team and existing center guidelines [710]. Due to the many facets of involved in the care of patients on ECMO, a multidisciplinary team consisting of institutional key stakeholders is essential. This team may include intensivists, emergency medicine, anesthesiologists, cardiologists, surgeons, ECMO specialists, pharmacists, nursing, respiratory therapy, rehabilitation team, and palliative care. In emergent situations or circumstances where the entire multidisciplinary team cannot be assembled in an efficient manner, there is value in assembling key personnel.

The timing of ECMO initiation is also complex. ECMO carries substantial risk of complications and uses significant resources [2, 11], but delaying ECMO may risk progressive organ injury and increased risk of mortality [12].

Recommendation:

The decision to initiate ECMO and the timing of this decision are complex and should involve a multidisciplinary ECMO team. Intensivists should play a central role in the formation of this team and the discussion about patient selection.

Recommendation:

Future research should seek to identify patient criteria that can identify ECMO candidacy and optimal timing for ECMO initiation.

1.1. Contraindications for ECMO Support.

There are no universally accepted contraindications to ECMO support and we did not achieve consensus on specific contraindications. The American Heart Association, the International ECMO Network and an international group of experts each considered ECMO contraindications [79]. ELSO Guidelines have also identified relative contraindications such as end stage malignancy and unrecoverable CNS damage as well as conditions associated with a poor overall prognosis such as prolonged mechanical ventilation time and prolonged CPR without adequate tissue perfusion. These expert panels suggested that experienced multidisciplinary teams evaluate ECMO candidacy. Patients with chronic organ failure who are not candidates for transplant or a long-term device may be poor candidates for ECMO support.

Recommendation:

The decision to withhold ECMO should be made by a multidisciplinary team that includes intensivists.

Recommendation:

The decision to withhold ECMO should be based on an evaluation of the prognosis, assessing whether ECMO will improve or worsen the overall prognosis.

1.2. ECMO Outcomes and Risk Factors.

Hospital mortality for patients receiving ECMO support is approximately 40% for respiratory ECMO (rECMO), 60% for cardiac ECMO (cECMO) and 70% for extracorporeal cardiopulmonary resuscitation (ECPR) [2, 1215]. The mortality burden has motivated researchers to identify risk factors and prognostic scores that stratify risk within specific patient populations [1624].

Recommendation:

The multidisciplinary team assessing ECMO candidacy should be aware the factors associated with reduced and improved ECMO survival, consulting with an ECMO expert when possible.

1.3. Patient Selection and Timing for rECMO Support

Bridge to recovery.

Two randomized trials have evaluated the role of ECMO as a bridge to recovery in acute respiratory failure (14, 15). The inclusion criteria of both trials are summarized in Table 2. The CESAR trial randomized patients with acute respiratory failure to be transferred to an ECMO center for consideration of ECMO or to remain at a conventional treatment center, with the primary outcome of death or severe disability at 6 months. At 6 months, 33 of 90 (37%) patients cared for at an ECMO capable hospital and 46 of 87 (53%) patients cared for at a non-ECMO capable hospital died or had severe disability (relative risk [RR] 0.69; 95% confidence interval [CI] 0.05-0.97) [13]. Of note, the trial was not a comparison of ECMO versus no ECMO, with 22 of 90 (24%) patients randomized to transfer to an ECMO center not receiving ECMO. Also, adherence to standard of care lung-protective ventilation was lower at the non-ECMO capable centers [25].

Table 2.

Entry criteria for EOLIA and CESAR trials.

Entry Criteria EOLIA CESAR
Severity of lung disease ARDS + one of the following:
  1. Hypoxemia despite optimization of mechanical ventilation (Vt set at 6 ml/kg and trial of PEEP ≥ 10 cm H2O) and adjunctive therapies (NO, recruitment maneuvers, prone position, HFO ventilation, almitrine infusion)
   a. P/F < 50 mm Hg with FiO2 ≥ 80% for > 3 hours
   or
   b. P/F < 80 mm Hg with FiO2 ≥ 80% for > 6 hours
Uncompensated hypercapnia pH < 7.25 with PaCO2 ≥60 mm Hg for > 6 hours despite increasing the respiratory rate increased to 35 breaths per minute while maintain plateau pressure ≤ 32 cm H2O (first by reducing tidal volume by steps of 1 mL/kg to 4 mL/kg, and second by PEEP reduction to a minimum of 8 cm H2O)
Acute Respiratory Failure + one of the following:
 1. Murray Score ≥ 3 and FiO2 100% despite optimum conventional treatment.
 The Murray score is the sum of a-d.
  a. CXR: 0.25 points for each quadrant of CXR consolidation
  b. P/F: 0.25 points if P/F is 225-299; 0.5 points if P/F is 175-224; 0.75 points if PF is 100-174; 1 point if PF is < 100
  c. PEEP: 0.25 points if PEEP is 6-8; 0.5 points if PEEP is 9-11; 0.75 points if PEEP is 12-14; 1 point if PEEP is ≥15
  d. Compliance (tidal volume/ driving pressure): 0.25 points if compliance is 60-79; 0.5 points if compliance is 40-59; 0.75 points if compliance is 20-39; 1 point if compliance is ≤ 19
 2. Acidosis: pH <7.2
Duration of Mechanical Ventilation Receipt of mechanical ventilation for <7 days Peak Inspiratory Pressure > 30 cm H2O or FiO2 > 80% for more than 7 days
Age ≥18 18-65

Exclusions
Pregnancy;
BMI > 45;
Long term ventilatory insufficiency;
Cardiac failure resulting in VA ECMO;
HIT;
Cancer with life expectancy < 5 years;
Coma after cardiac arrest not due to medications;
Moribund (SAPS > 90);
unable to obtain vascular access for ECMO

Intracranial hemorrhage;
Contraindication to heparinization;
Contraindication to continued therapy

Abbreviations: BMI body mass index; CXR chest x-ray; HFO high frequency oscillation; HIT heparin induced thrombocytopenia; NO nitric oxide; P:F ratio of partial pressure of arterial oxygen to fraction of inspired oxygen; PEEP positive end expiratory pressure; SAPS simplified acute physiology score; Vt tidal volume

The EOLIA trial randomized adults with severe acute respiratory distress syndrome (ARDS) who had been intubated for < 7 days to receive ECMO or conventional ARDS management. The trial design ensured optimized low-volume, low-pressure ventilation with moderate positive end expiratory pressure (PEEP) and strongly encouraged the use of neuromuscular blockade and prone positioning. At 60 days, 44 of 124 (35%) ECMO patients and 57 of 125 (46%) patients in the control group died [RR 0.76; 95% CI 0.55-1.04]. Importantly, crossover to ECMO was allowed for pre-defined refractory hypoxemia, occurring in 35 of 125 (28%) patients. A post-hoc Bayesian analysis of EOLIA as well as a recent meta-analysis demonstrated a high likelihood of mortality benefit from ECMO in this setting [26, 27].

While specific recommendations for ECMO initiation are made based on available evidence, the ultimate decision to initiate ECMO is a clinical decision and should be weighed in the context of all available clinical data.

Recommendation:

Patients with respiratory failure should receive optimal mechanical ventilation and prone positioning where appropriate prior to consideration for ECMO.

Recommendation:

ECMO can be considered for patients with ARDS from a reversible etiology who have received optimized care with P:F ratio < 50 mmHg for > 3 hours, P:F ratio < 80 mmHg for > 6 hours with FiO2>80% and PEEP >10, or arterial pH < 7.25 with paCO2 ≥ 60 mmHg for > 6 hours while trying to maintain Pplat < 32 despite a respiratory rate of 35 breaths per minute.

Recommendation:

Patients with severe respiratory failure who are not responding to conventional management should undergo early transfer to a hospital with ECMO capabilities if clinically feasible.

Bridge to transplant:

In select cases clinicians have elected to use ECMO as a bridge to lung transplant. rECMO in this context is used to facilitate reduced sedation, reduced ventilator support and to promote participation in rehabilitation and ambulation in the pre-transplant period [5, 28, 29]. The evidence is limited to observational cohort studies or expert opinion.

1.4. Patient Selection and Timing for Cardiac ECMO (cECMO) Support

Bridge to Recovery:

cECMO uses a venoarterial configuration primarily to support heart failure and cardiogenic shock [1]. cECMO as a bridge to recovery is initiated for reversible conditions, such as acute myocardial infarction, refractory ventricular arrhythmias, pulmonary embolism, acute myocarditis, or post-cardiotomy shock [8]. The decision to initiate cECMO should include evaluation of the benefits and risks of the other modes of MCS (6).

Recommendation:

cECMO can be considered for patients with cardiogenic shock, especially with signs of poor perfusion and failure of medical therapy, transferring to a specialty center capable of both long term and short-term support options when clinically appropriate.

Bridge to transplant or mechanical circulatory support:

cECMO provides a rapidly deployable cardiopulmonary support option that can provide a bridge to a temporary MCS device, heart transplant, or long-term ventricular assist device. cECMO may be advantageous to alternative MCS strategies in biventricular failure, cardiac arrest, or combined cardiopulmonary failure.

Extracorporeal cardiopulmonary resuscitation (ECPR):

ECPR is emergently deployed venoarterial ECMO for circulatory support in a patient who has failed to achieve sustained return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR) [1]. Although trials are ongoing, there are currently no randomized controlled trials that address the efficacy of ECPR. Data from observational studies and entry criteria for ongoing trials suggests that patients with younger age, shockable rhythms, reversible etiologies of arrest, witnessed arrests with bystander CPR, and shorter transition times to definitive care are more like to be considered candidates for ECPR [9, 30].

Recommendation:

ECPR requires emergent, time-sensitive deployment of invasive life support; therefore, we recommend centers offering ECPR establish a multidisciplinary ECMO team with explicit guidelines for patient selection, exclusion, and team member notification. Intensivists should play a central role in the formation of these guidelines and the delivery of subsequent intensive care needs.

Topic 2. The Role of the Intensivist in Cannulation for ECMO

Variation exists in the type of clinicians performing cannulation for ECMO. Cardiothoracic surgeons, general surgeons, vascular surgeons, interventional cardiologists, interventional radiologists, emergency medicine physicians, and intensivists have reported effective and safe cannulation for ECMO [3133]. Physicians should practice within their trained skill set and be prepared for life-threatening complications can occur during cannulation. Consequently, there must be a plan to address complications including identifying surgical support for intrathoracic surgical emergencies [8, 34].

Regardless of who performs cannulation, intensivists should be involved in decision-making surrounding cannulation, which will ultimately impact the long-term intensive care unit (ICU) management of these patients. These decisions include ECMO configuration and anatomic cannulation site selection, access approach strategy, cannula size, the use of distal perfusion catheters, and ventricular venting strategy. At times intensivist involvement may not be possible because ECMO cannulations will occur emergently in the operating room, catheterization suite, or emergency department.

Recommendation:

Many specialists, including intensivists, can successfully perform cannulation for ECMO. For cases where the intensivist does not cannulate, the intensivist should remain involved in the decisions surrounding cannulation such as timing, configuration, and cannula size, all of which can impact ICU management.

Recommendation:

Intensivists performing cannulation should use percutaneous access in lieu of open cannulation techniques.

2.1. Cannulation Decisions Related to rECMO

In rECMO there are two types of cannulas: single- and dual-lumen cannulas. Single-lumen cannulas require a minimum of two cannulation sites, while dual-lumen cannulas allow for drainage and return of blood from a single site. Relative to dual-lumen cannulas, single-lumen cannulas can be easier to place, but two-site cannulation has the potential for more recirculation than single-site cannulation [35, 36].

2.2. Cannulation Decisions Related to cECMO

cECMO may be initiated with central cannulation through a sternotomy site (e.g. when there is an inability to wean from cardiopulmonary bypass) or peripheral cannulation of an artery and vein, usually via the femoral vasculature. Peripheral cannulation for cECMO places the ipsilateral lower extremity at risk for ischemic injury (see cannula-related complications section below).

Section 3. Avoiding and Rescuing Patients from ECMO-related Complications

Adults receiving ECMO are at risk for patient and mechanical complications (see Table 3) [2]. A role of the intensivist is to attempt to avoid complications when possible, monitor for complications, and manage those complications that occur.

Table 3.

Adverse events during ECMO among adults from 2013-2017, by indication

Respiratory n=11,507 Cardiac n=11,920
Patient Complications
Surgical Site Hemorrhage 808 (7.0) 1,886 (15.8)
Pulmonary Hemorrhage 493 (4.3) 297 (2.5)
Intracranial Hemorrhage 389 (3.4) 243 (2.0)
Central Nervous System Infarction 212 (1.8) 441 (3.7)
Seizure EEG confirmed 46 (0.4) 71 (0.6)
CPR Required 446 (3.9) 348 (2.9)
Cardiac Tamponade due to blood 111 (1.0) 496 (4.2)
Limb Amputation 28 (0.2) 68 (0.6)
Mechanical Complications
Pump malfunction 116 (1.0) 72 (0.6)
Oxygenator failure 697 (6.1) 339 (2.8)
Cannula malfunction 590 (5.1) 407 (3.4)

Recommendation:

Intensivists should be familiar with complications specific to ECMO and should participate in developing institution-specific protocols for preventing and managing these complications.

3.1. Cannulation-related Complications

There is variability in the tools utilized to visualize the wire and cannula in the vessels during ECMO cannulation – including ultrasound, echocardiography, radiography, and fluoroscopy [37]. These adjunctive modalities can minimize damage to underlying structures, bleeding, and improper cannula placement [38, 39].

Recommendation:

Ultrasound, radiography, and/or fluoroscopy should be used to aid in the visualization of vessels, wire, and cannula during cannulation.

Recommendation:

Post-cannulation plain radiographs should be obtained to confirm cannula positioning.

3.2. Extremity Ischemia and Venous Thrombosis

Arterial cannulation places the cannulated limb at risk of ischemic injury by obstructing distal arterial blood flow, and untreated ischemia can lead to compartment syndromes or amputation (Table 3). The decision to perform arterial ECMO cannulation should be accompanied by a plan to ensure adequate circulation and monitoring of circulation to the distal extremity. Options include end-to-end side graft to the femoral artery, selection of a smaller arterial cannula, or addition of a distal reperfusion cannula, [4043]. Intensive neurovascular evaluation of the distal extremity is required. Following removal of venous cannulae, deep venous thromboses can be common.

Recommendation:

Intensive evaluation of the distal extremity is necessary with arterial ECMO cannulation, with particular attention to any signs of ischemic injury which can be limb threatening.

3.3. Increased Left Ventricular Afterload

cECMO cannulation can be associated with increased left ventricular (LV) distension, particularly in the case of peripheral cECMO, due to retrograde arterial blood flow and increased LV afterload. In the setting of poor LV function, this can lead to LV distension, pulmonary edema, or pulmonary hemorrhage. LV decompression can be considered via a surgically placed left atrial or LV vent, catheter-based septostomy, or peripherally inserted axial flow pump [44, 45].

Recommendation:

Intensivists should be aware of the clinical manifestations of left ventricular distension and develop clinical thresholds and strategies for decompressing the left ventricle.

3.4. Bleeding

Bleeding is one of the most common complications associated with ECMO (Table 3). A critical role of the intensivist is to manage bleeding risk, monitor for bleeding complications and respond to bleeding complications. Intracranial hemorrhage can come to clinical recognition incidentally or overtly, but in either case requires timely evaluation and response [46, 47]. Intracranial hemorrhage can lead to fatal herniation and brain death. Giani et al provide Guidance on brain death evaluation among ECMO supported patients [48].

Recommendation:

For bleeding patients on ECMO, the intensivist role is to evaluate if clinically significant bleeding is present, evaluate the patient’s ability to form and maintain clot, evaluate the ECMO circuit’s clot burden, and assimilate the information to decide if anticoagulation should be reduced or held and assess if bleeding will require further medical or procedural interventions.

Recommendation:

Intracranial hemorrhage on ECMO can be life threatening. Potential options for the managing intensivist include holding/decreasing anticoagulation, evaluation for ECMO discontinuation, serial neurological examination, neuroimaging, and neurosurgical evaluation as appropriate.

There are no consensus recommendations for the optimal anticoagulation strategies, anticoagulation monitoring, or strategies to avoid hemorrhagic complications during ECMO support [49]. Potential targets for anticoagulation include activated clotting time, partial thromboplastin time, anti-Xa levels, or thromboelastogram values.

Bleeding can be a complication of procedures performed during ECMO (48). While procedures commonly performed in the ICU (e.g., tracheostomy or tube thoracostomy) are often well tolerated, they may lead to life-threatening hemorrhage in patients receiving ECMO.

Recommendation:

The decision to perform any procedure on patients supported by ECMO should be carefully weighed against the risk of hemorrhage, and performed by clinicians with significant expertise after a plan has been developed for how anticoagulation will be adjusted.

3.5. Thrombosis and Mechanical Failure

Thrombosis during ECMO is common and can lead to mechanical inefficiency or failure as well as embolic or thrombotic complications to the patient. Severe mechanical thrombosis can require elective or emergent circuitry replacement [2, 50]. A plan for rapidly replacing failed equipment is an essential part of the management plan for ECMO patients.

Recommendation:

Hospitals should have a ready and rapidly deployable plan for replacing failed ECMO equipment, as well as a protocol for monitoring equipment in order to diminish the risk of failure.

Topic 4. Leading a Multidisciplinary Team

Expert consensus recommendations suggest ECMO should be delivered with a formalized multidisciplinary team that encourages communication, invites multidisciplinary perspective, and regularly reviews cases for improvement [9, 10, 51, 52]. Participants in the ECMO multidisciplinary team may include nurses, physicians, ECMO specialists/perfusionists, nutritionists, pharmacists, respiratory therapists, physical and occupational therapists, hospital administrators, members of the palliative care team, and other key stakeholders at the institution. A process for balancing the expertise of the ECMO multidisciplinary team with the expertise of the remaining critical care team is imperative. The process should address care continuity, emergent decision-making, routine decision-making, and family and team communication.

In the absence of high quality evidence to guide the care of patients on ECMO, process improvement is an essential part of assessing data and applying it to the care of this specific patient population. Intensivists are in a unique position to lead these multidisciplinary efforts to improve quality of care for patients on ECMO.

Recommendation:

The establishment of a multidisciplinary care team responsible for daily rounds to provide continuity of care, surveillance of quality metrics, and a mechanism to perform case review at regular intervals is essential.

Topic 5: Surrogate Decision-Maker Communication

When patients are considered for and managed with ECMO, they often lack decision-making capacity [12], and therefore surrogate decision-makers (SDM) usually partner with the medical team for medical decision-making. Although there is limited evidence regarding family communication in the ECMO population, a trial in critically ill patients found that a family support intervention improved SDM ratings of quality of communication [53]. We recommend that intensivists have established processes for ensuring effective communication with SDMs. Palliative care physicians, case managers, and ethicists may be helpful partners in facilitating family communications for selected patients requiring ECMO [54, 55].

Recommendation:

Established processes should exist for ensuring family-centered communication. Other team members involved in surrogate communications (e.g., palliative care, case management) should be familiar with the unique challenges related to the care of patients receiving ECMO.

DISCUSSION

Although complex and resource intensive, ECMO plays an important role in the care of patients with severe cardiac and respiratory failure. The increasing availability and utilization of ECMO underscores the expanding role that intensivists will be expected to play in the management of patients supported by this technology. As with other aspects of critical care, the provision of ECMO is best performed by a multidisciplinary team, which the intensivist is in a unique position to engage, involve, and lead. However, intensivists can only play this role if they are knowledgeable and familiar with ECMO physiology, indications, and complications. This position paper provides 18 strong and 5 weak recommendations in 5 topic areas of ECMO initiation and management.

There are many essential components of care of patients on ECMO to include anticoagulation, pharmacokinetics, and mechanical ventilation. However, although vital to the daily management of these patients, there is limited evidence demonstrating the superiority of any particular approach. Further efforts will be required to collect and consolidate evidence, garner expert opinion, and develop practice guidelines, in order to properly prepare critical care professionals to manage this complex patient population.

Footnotes

CONFLICTS OF INTEREST

Ryan P. Barbaro, MD, MS: Extracorporeal Life Support Organization Steering Committee Member as the ELSO Registry Chair

Daniel Brodie, MD: ELSO Board of Directors and Steering Committee; Trial Steering Committee, VENT-AVOID trial, ALung Technologies; previously Medical Advisory Board (MAB), ALung Technologies; currently, MAB for Baxter, BREETHE, Hemovent and Novalung

Jeremy W. Cannon, MD: simulation equipment provided to Penn Medicine Sim Center by PryTime Medical

Eddy Fan, MD, PhD: personal fees from MC3 Cardiopulmonary and ALung Technologies outside the submitted work; a New Investigator Award from the Canadian Institutes of Health Research; Chair-elect of ATS Critical Care Program Committee

Lena M. Napolitano, MD, MCCM: American College of Surgeons committee, American Association for Surgery of Trauma Committees, American Board of Surgery Director

Matthieu Schmidt, MD, PhD: receiving personal fees from Getinge, Xenios and Drager

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The views expressed are those of the author(s) and do not reflect the official policy or position of the US Army Medical Department, Department of the Army, Department of the Air Force, Department of the Navy, Department of Defense or the U.S. Government.

Contributor Information

Jeffrey DellaVolpe, Methodist Hospital, San Antonio, Texas, USA.

Ryan P. Barbaro, University of Michigan, Ann Arbor, Michigan, USA.

Jeremy W. Cannon, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Eddy Fan, University of Toronto, Toronto, Ontario, Canada.

Wendy R. Greene, Emory University Healthcare, Atlanta, Georgia, USA.

Kyle J. Gunnerson, University of Michigan Health System, Ann Arbor, Michigan, USA.

Lena M. Napolitano, University of Michigan, Ann Arbor, Michigan, USA.

Ace Ovil, Honor Health/John C. Lincoln Hospital, Phoenix, Arizona, USA.

Jeremy C. Pamplin, Madigan Army Medical Center, Dupont, Washington, USA.

Matthieu Schmidt, Sorbonne University, Pitié Salpêtrière Hospital, Paris, France.

Lauren R. Sorce, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA.

Daniel Brodie, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York, USA.

References

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