ECMO Management Guidelines

Introduction to ECMO Management

• The American College of Critical Care recommends maintaining arterial oxygenation with PaO2 >70 mmHg to prevent hypoxemia-associated acute brain injury, and avoiding severe arterial hyperoxia (PaO2 >300 mmHg), particularly in VA ECMO where reperfusion injury risk is high 1, 2
• The American College of Critical Care suggests that for patients with hypercapnia (elevated carbon dioxide levels), avoiding rapid changes in carbon dioxide levels within the first 24 hours of ECMO support can help prevent cerebrovascular complications 1, 3

Key Monitoring Parameters for ECMO Membrane Function

• The American College of Critical Care recommends targeting arterial oxygen saturation of 92-97% by adjusting the ECMO sweep gas oxygen percentage 4
• The American College of Critical Care suggests maintaining a goal of 3-4 L/min ECMO flow after cannulation, gradually increasing as tolerated, and monitoring arteriovenous oxygen difference, maintaining between 3-5 cc oxygen/100ml of blood as a reliable parameter for setting ECMO flow goals 4

Hemodynamic Considerations

• The American College of Critical Care recommends maintaining mean arterial pressure >70 mmHg to ensure adequate cerebral and end-organ perfusion 1, 2, 3
• The American College of Critical Care suggests monitoring for increased left ventricular afterload which can negatively impact cardiac recovery in VA ECMO patients 4

Neurological Monitoring During ECMO

• The American College of Critical Care recommends implementing continuous cerebral oximetry to follow ongoing trends and detect acute brain injury early, especially for patients with peripheral VA ECMO at risk for differential hypoxia 1, 5
• The American College of Critical Care suggests using pupillometry if available to objectively evaluate pupil size and reactivity, and considering intermittent EEG and somatosensory evoked potential (SSEP) monitoring, particularly in comatose patients 5, 6

Temperature Management

• The American College of Critical Care recommends continuously monitoring core temperature and actively preventing fever (>37.7°C), and considering mild-moderate hypothermia (33-36°C) for 24-48 hours in VA ECMO patients, especially those undergoing ECPR 1, 3

Fluid Management

• The American College of Critical Care suggests striving for daily negative fluid balance after ECMO flows are optimized and the patient is hemodynamically stable, and monitoring for fluid overload, which is associated with increased mortality by the third day of ECMO 4, 7