Awake ECMO Management

Patient Selection

The American Thoracic Society recommends VV ECMO for isolated severe respiratory failure when cardiac function remains adequate, specifically when PaO₂/FiO₂ < 80 mmHg for at least 3 hours despite optimal ventilation 1
Patients with PaO₂/FiO₂ < 70 for ≥3 hours or < 100 for ≥6 hours despite optimization of conventional treatments are indicated for VV ECMO 1
Plateau pressure > 28 cmH₂O for ≥6 hours despite lung-protective ventilation strategies is a criterion for VV ECMO 1
Evidence of right ventricular overload with pulmonary artery systolic pressure > 40 mmHg and acute cor pulmonale on echocardiography is an indication for VV ECMO 1
Contraindications to anticoagulation are a critical exclusion criterion for VV ECMO 1
Prolonged mechanical ventilation (>9.6 days) before ECMO consideration is associated with worse outcomes and is an exclusion criterion 1
Cardiac dysfunction requiring hemodynamic support is a contraindication for VV ECMO, and these patients require VA ECMO instead 1

The Extracorporeal Life Support Organization recommends a minimum annual volume of 20-25 ECMO cases per year, with significantly better outcomes at higher-volume centers 1, 2
A 24/7 availability of multidisciplinary ECMO team including physicians, nurses, perfusionists, and ECMO specialists is required for ECMO 1
A nurse-to-patient ratio of 1:1 to 1:2 maximum is recommended for ECMO patients 1, 2
Quality assurance review procedures and robust expertise in ventilatory management of severe acute respiratory failure are necessary for ECMO centers 1
A catchment area of at least 2-3 million population is recommended to maintain adequate volume 1

The Society of Critical Care Medicine recommends avoiding arterial hypoxemia (PaO₂ < 70 mmHg) in ECMO patients 3
Avoiding severe arterial hyperoxia (PaO₂ > 300 mmHg) is recommended, especially where reperfusion injury risk is high 3
For patients with hypercapnia (PaCO₂ > 45 mmHg), avoiding rapid change in PaCO₂ within the first 24 hours of ECMO support is recommended 3
Serial arterial blood gas sampling in the first 24 hours of ECMO support is recommended 3
Maintaining mean arterial pressure > 70 mmHg is recommended, though individualized BP goals based on patient comorbidities are suggested 3
Target initial ECMO flow of 3-4 L/min immediately post-cannulation, gradually increasing as tolerated, is recommended 2
Maintaining arteriovenous oxygen difference between 3-5 cc O₂/100ml blood is recommended as the most reliable flow parameter 2
Continuous monitoring of core temperature and active prevention of fever (> 37.7 °C) are recommended 3
Hypothermia in VV ECMO is not recommended 3

Acute brain injury (ABI) occurs in 10% of VV-ECMO patients, requiring protocolized monitoring 2
For suspected stroke, obtaining non-contrast head CT immediately to rule out intracranial hemorrhage is recommended 3, 2
Administering tPA for acute ischemic stroke in ECMO patients is not recommended due to prohibitively high bleeding risk 3, 2
Proceeding with mechanical thrombectomy for acute large vessel occlusion after CT angiogram confirmation is recommended 3, 2
For intracranial hemorrhage, discontinuing systemic anticoagulation temporarily is recommended 3
VV ECMO may allow a longer anticoagulation-free period compared to VA ECMO 3
External ventricular drain insertion is high-risk but may be considered in selected patients at risk of imminent death from intraventricular hemorrhage and hydrocephalus 4

Recent data shows 42% of VV-ECMO patients experience thrombotic events, 37% experience bleeding events, and 21% experience both 2
Almost all ECMO patients develop acquired von Willebrand syndrome (AVWS) within hours of device implantation, contributing to bleeding complications 1

Physical therapy, occupational therapy, and speech therapy as tolerated are recommended for ECMO patients 2

Delaying ECMO initiation beyond 7 days of respiratory failure onset reduces optimal outcomes 1
Failing to optimize conventional treatments (low-volume, low-pressure, lung-protective ventilation or prone positioning) before considering ECMO is a common error 1
Inadequate neurological monitoring leading to delayed detection of acute brain injury is a critical pitfall 2
Over-aggressive anticoagulation without considering individual bleeding risk is a common error 2