Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure –A clinical practice Guideline Level 3

Abstract

Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment. Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements. Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.

A Standardized Multimodal Neurological Monitoring Protocol-Guided Cerebral Protection Therapy for Venoarterial Extracorporeal Membrane Oxygenation Supported Patients

“…The traditional viewpoint is to maintain myocardium intrinsic contractility and left ventricular ejection with minimal ECMO flow and conservative circulation volume, combined with positive inotropic drugs, while maintaining systemic circulation and end-organ perfusion ( 23 , 24 ). We have long believed that an ECLS facility should achieve at least 20 cases per year to ensure good and adequate patient outcomes and as an indicator for evaluating an experienced ECLS facility ( 25 ). In our opinion, it is more important for the good outcome of patients to strengthen precision management during ECMO support, including the adjustment of anticoagulants, prevention of catheter-related bloodstream infection and lower limb ischemic necrosis, especially the early identification and prevention of CNS complications.…”

Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation

“…Data on vascular complications in association with decannulation are lacking besides a case series comparing a percutaneous closure device with surgical decannulation reporting higher complication rates after the surgical approach ( 21 , 22 ). The best method for decannulation either surgically or percutaneously is still unclear ( 23 ). In this analysis, decannulation was conducted percutaneously in more than 60% of patients with similar complication rates than with surgical decannulation.…”

“…However, it is noteworthy that, irrespective of the decannulation method, limb ischemia, bleeding, and pseudoaneurysm were observed in 6, 5, and 3%, respectively. In consequence, all patients should routinely be screened after decannulation for potential complications ( 23 ).…”

Akute Herzinsuffizienz und kardiogener Schock – Bedeutung der ECLS

“…Analysen des internationalen ELSO-Registers zeigen deutlich, dass der Einsatz der ECMO in den vergangenen Jahren insbesondere für die Indikation CS drastisch zugenommen hat [23]. In Deutschland stieg beispielsweise die Fallzahl von unter 300 im Jahr 2010 auf 2852 in 2020 [6]. Unter den CS-ECLS-Fällen sind ca.…”

“…Die Indikationsstellung sollte daher weiterhin in Anbetracht der individuellen Patientencharakteristika durch ein erfahrenes Team unter Einbeziehung aller verfügbaren Faktoren (Alter, Komorbiditäten, Gefäßstatus) und basierend auf dem klinischen und hämodynamischen Phänotyp mit klarem Therapieziel erfolgen. Hierfür wird von den aktuellen Expertengremien eine Therapie in CS-Zentren anhand von strukturierten Therapiekonzepten mit spezialisierten Teams empfohlen [6,14].…”