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

๐Ÿ”น Case 1 Summary

  • Setting: Manchester cardiac centre โ€“ 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.

๐Ÿ”น Complications and ECMO Configuration Changes

  1. Cardiac Arrest on Day 1 Post Cannulation

    • Developed severe LV failure โ†’ 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 (Northโ€“South syndrome)

    • Cerebral hypoxia and worsening hypoperfusion.

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

  4. Limb and Skin Complications

    • Right groin necrosis.

    • Bilateral breast necrosis.

    • Peripheral ischemia โ†’ 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.

๐Ÿ”น Learning Points โ€“ Clinical

  • ECMO Configuration

    • Dynamic, patient-dependent; required transition from VV โ†’ VA โ†’ 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 (50โ€“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.

๐Ÿ”น Learning Points โ€“ 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.

๐Ÿ”น Poll/MCQ Highlights from Webinar

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

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

  • COโ‚‚ management: Avoid >50% COโ‚‚ reduction in first 24h โ†’ risk of neurological injury.

  • Initial VA ECMO configuration: Split flow (2/3 venous, 1/3 arterial), ventilator FiOโ‚‚ 30โ€“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.

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