VA ECMO Management Guidelines

Facility and Equipment Requirements

A wet-primed ECMO circuit must be available 24/7 for immediate deployment, with circuit changes completed in under 15 minutes during malfunction, according to the American College of Cardiology 1
An Uninterrupted Power System (UPS) supporting all equipment for a minimum of 45 minutes is mandatory to prevent catastrophic power failures, as recommended by the American Heart Association 1
Backup components for all circuit elements must be immediately accessible at the bedside, as stated by the American College of Cardiology 1
Doppler echocardiography machines with physicians trained in vascular and cardiac echocardiography are required for cannulation guidance and ongoing surveillance, according to the American Society of Echocardiography 1

Maintain a nurse-to-patient ratio of 1:1 to 1:2 maximum, as recommended by the Society of Critical Care Medicine 1
An ECMO program director (physician) must oversee overall operations, training, equipment maintenance, and quality improvement, according to the Extracorporeal Life Support Organization 1
The multidisciplinary team should include intensivists, perfusionists, neurologists, surgeons, and specialized nursing staff, as stated by the Critical Care Society 2

Target initial ECMO flow of 3-4 L/min immediately post-cannulation, gradually increasing as tolerated, according to the American College of Cardiology 1, 3
Maintain arteriovenous oxygen difference between 3-5 cc O₂/100ml blood as the most reliable flow parameter, as recommended by the American Thoracic Society 1, 3
Target mean arterial pressure >70 mmHg to ensure adequate cerebral and end-organ perfusion while minimizing left ventricular afterload, according to the American Heart Association 1, 3

Maintain PaO₂ >70 mmHg to prevent hypoxemia-associated acute brain injury, while avoiding severe arterial hyperoxia (PaO₂ >300 mmHg), as recommended by the American Thoracic Society 3
Monitor for differential hypoxemia in peripheral VA ECMO, where poorly-oxygenated blood from the failing native heart may perfuse the upper body, according to the Extracorporeal Life Support Organization 4, 1

Obtain arterial blood gases from a right radial arterial line to best represent cerebral oxygenation, as this site approximates what the brain receives, according to the Neurocritical Care Society 4
A wide pulse pressure on right radial arterial line monitoring indicates significant left ventricular ejection reaching the upper body, suggesting a distal mixing point, as stated by the American College of Cardiology 4
When differential hypoxemia is detected, immediately increase ECMO flow to move the mixing point proximally toward the innominate artery, according to the Extracorporeal Life Support Organization 4

Implement protocolized neurological monitoring immediately, as VA ECMO carries a 19% acute brain injury risk, according to the Neurocritical Care Society 2, 5, 1, 3
Perform continuous cerebral oximetry to detect acute brain injury early, especially for peripheral VA ECMO patients at risk for differential hypoxia, as recommended by the Society of Critical Care Medicine 2, 5, 1
Conduct intermittent EEG and somatosensory evoked potentials (SSEP), particularly in comatose patients, according to the American Clinical Neurophysiology Society 5

Individualize blood pressure targets based on the type of acute brain injury present, as recommended by the Neurocritical Care Society 5
For acute ischemic stroke, allow permissive hypertension (BP ≤ 220/120 mmHg) to maintain adequate cerebral perfusion if the heart can tolerate the increased afterload, according to the American Heart Association 5
For intracerebral hemorrhage, target lower blood pressure (systolic BP < 140 mmHg and MAP < 90 mmHg) due to anticoagulation-associated bleeding risk, as stated by the American Stroke Association 5

Anticoagulation is required for cannulation and to prevent clot formation in the circuit and oxygenator, but must be balanced against high bleeding risk, according to the American College of Chest Physicians 6, 7
Recent analysis shows 42% of VV-ECMO patients experience thrombotic events, 37% experience bleeding events, and 21% experience both complications, as reported by the Anaesthesia journal 6, 7

Submit data to the ELSO registry or equivalent database for cross-institutional analysis, as recommended by the Extracorporeal Life Support Organization 1
Hold formal multidisciplinary meetings routinely to analyze activity and review equipment needs, according to the American College of Cardiology 1