Summary of the ECMO case presentation and webinar:

Case Scenario: A Renewed Chance at Life & The Initiation of VV & VA ECMO

Case Scenario: Removal of ECMO with Persistent Hypotension

🔹 Case 1 Summary

• Setting: Manchester cardiac centre – large ECMO unit performing VV/VA ECMO, transplants, and MCS.

• Patient: 44-year-old female respiratory nurse with high BMI (44), developed severe pneumonia and type 1 respiratory failure.

• Initial course:

  • ICU admission, rapid deterioration requiring intubation and proning.

  • Transferred for ECMO: started on VV ECMO (femoral drainage and femoral return).

  • TOE: normal biventricular function initially.

🔹 Complications and ECMO Configuration Changes

1. Cardiac Arrest on Day 1 Post Cannulation

   • Developed severe LV failure → transitioned to VA ECMO (femoral arterial cannula added).

   • 40-minute downtime, but achieved return of spontaneous circulation (ROSC).

2. GI Bleed

   • Required PPI infusion and cessation of anticoagulation.

3. Harlequin Syndrome (North–South syndrome)

   • Cerebral hypoxia and worsening hypoperfusion.

   • Added left internal jugular return cannula → quadruple cannulation (VV-A with dual return).

4. Limb and Skin Complications

   • Right groin necrosis.

   • Bilateral breast necrosis.

   • Peripheral ischemia → four-limb ischemia likely requiring amputation.

5. Failure to Decannulate

   • Planned VV decannulation unsuccessful due to friable tissues, risk of uncontrollable bleeding.

   • Family discussion: patient was awake but severely debilitated; decision made to withdraw care.

🔹 Learning Points – Clinical

• ECMO Configuration

  • Dynamic, patient-dependent; required transition from VV → VA → VAV.

  • Use of return cannula in neck improves upper body oxygenation during Harlequin syndrome.

• Sedation in ECMO

  • Obese patients require higher lipophilic drug doses (e.g., propofol, midazolam).

  • Post-decannulation hypotension often due to redistribution of sedatives from adipose tissue.

  • Risk of prolonged sedation and hypotension if not tapered appropriately.

• SIRS after Decannulation

  • Common (50–60%), especially after long ECMO runs.

  • Needs to be differentiated from sepsis.

• DVT and Cannula Site Thrombosis

  • High incidence post-decannulation, especially with large-bore femoral cannulas.

  • Routine Doppler surveillance is recommended.

🔹 Learning Points – Ethical & Prognostic

• Prolonged ECMO Runs

  • No fixed duration limit (some >60 days).

  • Weekly multidisciplinary ECMO review essential for prognostication and planning.

• Scoring Systems

  • Risk scores are useful but not absolute; decisions consider age, reversibility, duration of MV, etc.

• Ethics of Withdrawal

  • Decision made by medical team, with explanation to family.

  • Family cannot override if ongoing care is medically inappropriate.

  • Honest, compassionate communication is key.

🔹 Poll/MCQ Highlights from Webinar

• Initial flow target on VV ECMO: ~60–80 mL/kg/min.

• Sweep gas strategy: Start low and increase gradually, especially in chronic hypercapnia.

• CO₂ management: Avoid >50% CO₂ reduction in first 24h → risk of neurological injury.

• Initial VA ECMO configuration: Split flow (2/3 venous, 1/3 arterial), ventilator FiO₂ 30–40%.

• Harlequin syndrome management: Add return cannula to upper body.

• Hypotension post-decannulation: Start with fluid bolus; rule out bleeding, sepsis, or RV dysfunction.

• Sedative redistribution: Major concern in obese patients post-decannulation.

• Thrombosis monitoring: Routine Doppler ultrasound of cannulated vessels recommended.