Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review

Abstract

Purpose Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. Recent findingsThe most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness. Summary Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.

Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation Program in the United States During the Coronavirus Disease 2019 Pandemic

“…The head imaging was performed due to the increased risk of neurological injuries in ARDS, ECMO, and possibly COVID-19. 23,25 The majority of mobile ECMO patients had no recent neurologic exam due to sedation and neuromuscular blockade administration prior to ECMO cannulation. Additionally, some patients were too unstable to safely transport to radiology prior to ECMO.…”

“…The arterial partial pressure of carbon dioxide (P a CO 2 ) was adjusted by the ECMO sweep gas flow rate to maintain normal pH(7.35-7.45). Mild to moderate respiratory acidosis was tolerated in an effort to reduce rapid P a CO 2 changes due to concern for increased neurologic complications in patients on ECMO 22,23. Two separate arterial blood gases were reviewed prior to transport to adjust the ECMO sweep gas flow rate.…”

Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation

“…The recognition of deterioration in neurologic exam and subsequent evaluation for stroke can be delayed in ECMO patients due to use of heavy sedation and neuromuscular blockade to prevent ventilator desynchrony and cannula dislodgment. There is a movement toward discontinuing neuromuscular blockade and lightening sedation after ECMO initiation [13]. All patients in our case series received neurologic evaluations at least every 4 h with sedation pauses unless the patient was too unstable from cardiopulmonary standpoint for sedation pauses.…”

Neurologic Statistical Prognostication and Risk Assessment for Kids on Extracorporeal Membrane Oxygenation—Neuro SPARK

“…For instance, variable reporting of neurologic injury across institutions can potentially introduce bias. 26 Also, the temporal window of data capture is another limitation. We had access only to two time points one before and one after the initiation of ECMO.…”