Expert consensus on analgesia, sedation and delirium management in adult patients receiving extracorporeal membrane oxygenation(2025 edition)

Echocardiographic Image of a Cannula in the Inferior Vena Cava After Decannulation of Venoarterial Extracorporeal Membrane Oxygenation

What is New in ECMO for COVID-19?

BackgroundPEEP selection in severe COVID-19 patients under extracorporeal membrane oxygenation (ECMO) is challenging as no study has assessed the alveolar recruitability in this setting. The aim of the study was to compare lung recruitability and the impact of PEEP on lung aeration in moderate and severe ARDS patients with or without ECMO, using computed tomography (CT).MethodsWe conducted a two-center prospective observational case–control study in adult COVID-19-related patients who had an indication for CT within 72 h of ARDS onset in non-ECMO patients or within 72 h after ECMO onset. Ninety-nine patients were included, of whom 24 had severe ARDS under ECMO, 59 severe ARDS without ECMO and 16 moderate ARDS.ResultsNon-inflated lung at PEEP 5 cmH2O was significantly greater in ECMO than in non-ECMO patients. Recruitment induced by increasing PEEP from 5 to 15 cmH2O was not significantly different between ECMO and non-ECMO patients, while PEEP-induced hyperinflation was significantly lower in the ECMO group and virtually nonexistent. The median [IQR] fraction of recruitable lung mass between PEEP 5 and 15 cmH2O was 6 [4–10]%. Total superimposed pressure at PEEP 5 cmH2O was significantly higher in ECMO patients and amounted to 12 [11–13] cmH2O. The hyperinflation-to-recruitment ratio (i.e., a trade-off index of the adverse effects and benefits of PEEP) was significantly lower in ECMO patients and was lower than one in 23 (96%) ECMO patients, 41 (69%) severe non-ECMO patients and 8 (50%) moderate ARDS patients. Compliance of the aerated lung at PEEP 5 cmH2O corrected for PEEP-induced recruitment (CBABY LUNG) was significantly lower in ECMO patients than in non-ECMO patients and was linearly related to the logarithm of the hyperinflation-to-recruitment ratio.ConclusionsLung recruitability of COVID-19 pneumonia is not significantly different between ECMO and non-ECMO patients, with substantial interindividual variations. The balance between hyperinflation and recruitment induced by PEEP increase from 5 to 15 cmH2O appears favorable in virtually all ECMO patients, while this PEEP level is required to counteract compressive forces leading to lung collapse. CBABY LUNG is significantly lower in ECMO patients, independently of lung recruitability.

Gene expression signatures identify paediatric patients with multiple organ dysfunction who require advanced life support in the intensive care unit.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

See article on page 933–941, in this issue

Extracorporeal Membrane Oxygenation for Very High-risk Transcatheter Aortic Valve Implantation

Essential Topics in the Management of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Acute Respiratory Distress Syndrome

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Infections induced by multidrug-resistant (MDR) pathogens are one of the most common and serious complications in extracorporeal membrane oxygenation (ECMO) patients. However, there is currently little research about "ECMO and MDR bacteria". The purpose of our study was to clarify the epidemiological characteristics of MDR bacteria and provide references for empiric antibiotic treatments according to the drug susceptibility tests for ECMO patients. There were 104 patients admitted to our department and receiving ECMO treatments between January 2014 and December 2022. Altogether, 61 veno-arterial ECMO (VA-ECMO) and 29 veno-venous ECMO (VV-ECMO) patients enrolled. The data on other intensive care unit (ICU) patients in our department in the same period are summarized. A total of 82 MDR bacteria were detected from ECMO patients, and most of these were MDR Gram-negative bacteria (MDR-GNB). There were also 5559 MDR-GNB collected from other patients in our department in the same period. We found that the distribution of MDR-GNB in ECMO patients was different from other critical patients. The proportion of Klebsiella pneumoniae (MDR-KP) in VV-ECMO patients was higher than other critical patients (35.1% and 21.3%, respectively). Moreover, the proportions of MDR Acinetobacter baumannii (MDR-AB) of VA-ECMO and VV-ECMO were higher than other critical patients (54.6%, 43.2% and 30.5%, respectively). In addition, MDR-AB and MDR-KP in ECMO patients exhibited higher percentages of drug resistance to possibly appropriate antibiotics for other critical patients, but showed better sensitivity to colistin. Infections induced by MDR-GNB in ECMO patients were serious and exhibited higher degrees of drug resistance compared with other ICU patients. Colistin might be an option to consider if there is no medical contraindication. However, widespread use of broad spectrum antibiotics is something that should be discouraged, and alternative options are being explored.

We thank Mertens and colleagues not only for commending us for this first prospective study on isavuconazole exposure in critically ill extra-corporeal membrane oxygenation (ECMO) patients, but also for raising valuable points that need to be further discussed and investigated.1 First, Mertens et al. mentioned that distribution volumes of lipophilic substances such as isavuconazole are only minimally influenced by the ECMO priming solution and circuits and that the critical condition of the patients primarily contributes to the high distribution volumes regardless of the application of extracorporeal circuits. Nevertheless, in recent reviews addressing optimized antimicrobial dosing in patients receiving ECMO, an increased volume of distribution has also been mentioned for lipophilic drugs in patients receiving ECMO.2,3 Due to the fact that our measurements showed no evidence of extracorporeal clearance or sequestration we concluded therefore that isavuconazole concentrations might be influenced rather by the higher volume of distribution but not by drug sequestration during ECMO treatment, but agree that further research is needed to elucidate other factors that may contribute. Mertens et al.4 also mentioned that increasing the loading dose should not be narrowed to ECMO patients as the contribution of ECMO versus critical illness cannot be derived from our study. We fully acknowledge this important fact as we did not additionally collect data from matched critically ill patients without ECMO. Therefore, our data do not preclude that isavuconazole trough concentrations might be below 1 mg/L in critically ill patients without ECMO or in patients with ECMO and another extracorporeal treatment.4 In another mixed ICU cohort (as yet unpublished) comprising 34 patients with isavuconazole administration, we determined 74 isavuconazole concentrations (minimum 0.2, maximum 6.79, median 1.38 mg/L); a total of 53 measurements revealed isavuconazole trough concentrations >1 mg/l whereas 21 were below that threshold. One additional ECMO patient (BMI 27) treated with isavuconazole for invasive aspergillosis after thoracic surgery had eight isavuconazole trough concentrations with a median of 0.6 mg/L (range 0.45–0.78 mg/L). After cessation of ECMO, seven isavuconazole trough concentrations revealed a median of 0.73 mg/L (range 0.57–0.86). Isavuconazole dosage was subsequently increased from 200 mg of isavuconazole once to twice a day and trough concentrations were 0.96 mg/L on the next day and 1.78, 1.74 and 1.88 mg/L on the following days. Obviously, in this critically ill ECMO patient the underlying critical condition might have influenced isavuconazole concentrations and ECMO termination had no effect. Thus, even in the absence of ECMO an increase of isavuconazole dosage might be necessary to achieve concentrations above 1 mg/L. We performed our study as a pilot trail in a hypothesis-generating manner to plan further trials and show first insights into isavuconazole pharmacokinetics of ECMO patients. We agree that the implementation of multiple covariates optimally in a time-dependent approach or within mixed linear-effect models could better elucidate the impact of body composition or organ dysfunction on pharmacokinetics. But, due to the small number of patients and related difficulties in defining relevant outcomes for the efficacy of isavuconazole dosing, we demonstrated baseline variables at time of inclusion.

Critically ill patients with cardiac and/or respiratory failure may require extracorporeal membrane oxygenation (ECMO) to restore physiological function. The use of ECMO in intensive care units (ICUs) in the United States has increased over the past decade, most recently with the COVID-19 pandemic. In July 2020, an estimated 33 000 patients received ECMO support, with survival rates of 59% (pulmonary) and 43% (cardiac).1 Approaches for ECMO support are either venoarterial or venovenous cannulation aimed at restoring the patient’s cardiopulmonary or pulmonary function. Extracorporeal membrane oxygenation is indicated for severe cardiogenic shock, ventricular arrhythmias, cardiopulmonary resuscitation, and acute respiratory distress syndrome refractory to conventional therapies.2 Its management requires trained and experienced critical care providers (eg, nurses) as well as institutional infrastructure with robust leadership to ensure safety and quality patient care.2,3 The Extracorporeal Life Support Organization (ELSO) recommends that ECMO training should consist of didactic courses, hands-on experience, and continuing education.3 To that end, this column begins with the description of the role of the bedside registered nurse (RN) in ECMO management in the cardiothoracic ICU followed by the acute care nurse practitioner’s (ACNP) leadership in ECMO training tailored to the bedside RN’s educational needs.The management of patients receiving ECMO support is usually orchestrated by critical care multidisciplinary teams. In recent years, bedside RNs in ICUs have increasing responsibility in the technical aspects of ECMO care (ie, management of the ECMO system) (see Figure 1) traditionally performed by cardiovascular perfusionists. The increasing use of ECMO, technological refinements, and ELSO guidelines collectively influence the recent trends of ECMO management by bedside RNs. Unfortunately, there are no data about bedside RNs’ training and outcomes in ECMO care. However, there is consensus in the literature that adherence to ELSO guidelines is essential to quality patient care and outcomes. Notably, nurses at facilities with high or increasing ECMO cases can acquire a wide range of ECMO management skill sets including the associated nursing care.3Bedside RNs must be competent in managing patients receiving ECMO support and are expected to promptly intervene when problems arise, such as adjusting pump speed and flows to prevent complications and/or reduce mortality, as well as manage anticoagulation levels and trend hemodynamics. Thus, bedside RNs require training and continuing education tailored to their competency development, maintenance, and eventually, mastery.4 Nursing management competency for patients supported with ECMO is typically acquired through didactic and hands-on training. Didactic content includes ECMO physiology, procedures, emergencies, and anticoagulation management in patients receiving ECMO support. Although hands-on training varies among institutions, there is consensus that bedside RNs should and could manage ECMO including its circuit (see Figure 1) to meet the immediate needs of these highly acute and complex patient populations.Because of the emerging role of bedside RNs being directly responsible for managing ECMO circuits, there is a need for implementing education and training programs beyond the conventional didactic course (eg, simulation) for ICU RNs that is tailored for optimizing their knowledge, skill, and overall competence with ECMO patient management.As an example, a medical center in the western suburbs of Chicago identified a need to develop and implement an ECMO training program that facilitates the optimization of the ICU bedside RN knowledge and skills (competence) with ECMO. The medical center set this organizational priority because of insufficient ECMO training, needing 24-hour ECMO coverage at the bedside, and ensuring that bedside RNs deliver safe and quality patient care. On the basis of increasing evidence supporting high-fidelity simulation as an effective strategy for training health care providers in the management of ECMO, its circuit, and complications, the medical center selected simulation as the training methodology.4 Providing current evidence-based training to ECMO specialists can improve patient safety and the quality of care by improving communication and teamwork and optimizing confidence among ICU nurses.5 Simulation training provides bedside RNs the opportunity to apply theory into practice, make mistakes, and improve ECMO management skills in a risk-free learning environment. Simulation-based ECMO courses have demonstrated an improvement in cognitive, technical, and behavioral skills by providing active learning experiences.6 Extracorporeal membrane oxygenation simulation training can replicate the ICU room setting and emergent situations (eg, cardiac arrest), allows troubleshooting ECMO circuits in a controlled setting, and provides the ability to debrief. Debriefing allows the ICU team to process and evaluate how they respond in each scenario. In ECMO simulation, ACNPs can share their clinical expertise and experiences and lead the team as well as help the RN/team process, reflect, understand, and modify how they manage patients including responding to ECMO emergencies. It is worth mentioning that doctoral-prepared ACNPs (ie, doctor of nursing practice) are suited for taking on leadership roles in designing ECMO simulation training because of their advanced clinical practice and leadership education and training in critical care.In a rapidly changing health care system, ICU ACNPs can make significant contributions in improving patient care quality outcomes through leading clinical nursing education initiatives.Such training took place in the western suburbs of Chicago at a quaternary care facility designated as a level 1 trauma center with over 500 beds. The CTICU was comprised of about 15 beds and over 50 nurses. Half of the nursing staff was certified in a variety of specialties (eg, CCRN, CSC, CMC). Years of nursing experience ranged from 35 years at the bedside to new graduate nurses.The unit lacked formalized ECMO training and skill competencies for its bedside nurses. The previous training was ever-changing. It consisted of direct observations of senior nursing care to ECMO patients lasting a total of 4 hours. The former training did not meet standards set by ELSO. For instance, ELSO recommends that ECMO centers, certified or not, should have a well-defined program for staff training.2 The program should include didactic lectures, laboratory training, bedside training, and a defined system for testing staff proficiency.2 Bedside RNs must be properly trained to think critically in emergent situations and to adequately and promptly troubleshoot complications.An ECMO training program developed with the support of the ACNP was designed to meet ELSO guidelines. As an initial strategy to systematize formal ECMO training, a survey was conducted to gain insight into the current ECMO training from bedside RNs. Ninety percent of the nurses that participated in the survey were not content with the current training. The survey results indicated that a more robust, innovative training tailored to the needs of the nursing staff caring for patients on ECMO would be beneficial. An ECMO simulation training for ECMO specialists was developed that took into account the lack of ECMO training and education on the unit, as well as the increasing acuity of patients in the CTICU; the training developers also compared the current training to ELSO guidelines. The purpose of this training was to improve the self-efficacy and knowledge of the nursing staff in the CTICU through the implementation of standardized ECMO education and simulation training that met ELSO standards.The proposed training was drafted in collaboration with the chief perfusionist. The CTICU followed an RN-perfusion model of ECMO management. The goal was to train CTICU RNs as ECMO specialists to be able to manage the ECMO circuit as well as the patient’s hemodynamics. The didactic consisted of ECMO physiology, patient care management, and troubleshooting venoarterial and venovenous mechanical components of the ECMO system (see Figure 2). The wet lab was a review of the ECMO circuit and priming. Each nurse was expected to correctly prime the circuit and was checked off individually as correctly completing the task. In the simulation training, nurses were divided into groups and participated in 6 scenarios including a mock code with ECMO cannulation (See Table 1).Following synthesis and evaluation of evidence-based literature, the ACNP presented the simulation training proposal to nursing administration but was met with resistance. The lack of leadership knowledge regarding the complexity of patients requiring ECMO was the main reason for resistance. The CTICU was the only unit capable of caring for patients receiving ECMO support, and the unit lacked a nurse educator; nursing management lacked an ICU background, so there was little understanding among leadership of what was required to care for these patients safely and effectively. Time and cost were also important factors in obtaining approval for implementing the training. Nursing leadership’s concern was with the cost of using the simulation laboratory, scheduling the nursing staff for the training, and compensating the chief perfusionist and ACNP. The chief perfusionist, ACNP, and the RNs who participated in the training volunteered their time without compensation for the training. The simulation laboratory was free of cost to the hospital as this was presented as a pilot study that was part of a DNP project. The costs of miscellaneous educational resources for the nursing staff were covered by the ACNP.The proposal was rejected by nursing administration for being infeasible. The proposal was then presented to members of the hospital executive team. Several meetings were organized with the unit medical director, a cardiac surgeon who served as director of the ECMO program, the president of the hospital, and the vice president of patient safety. The proposal was presented as an opportunity to improve the safety and quality of care provided to patients receiving ECMO therapy. After approval was obtained, the ACNP in collaboration with the chief perfusionist formed an ECMO specialist group and submitted approval to the institutional review board. The ACNP was responsible for developing assessment tools to evaluate knowledge and self-efficacy of the nursing staff.The second phase evaluated nurses’ perceived ability to troubleshoot ECMO before the didactic lectures and required nurses to take an anonymous exam consisting of 20 multiple-choice questions on ECMO physiology and a 10-item Likert scale self-efficacy survey. The goal of the simulation training was to empower nurses by giving them the tools necessary to increase their knowledge base on ECMO and improve their perceived ability to care for these patients.The 2-hour didactic lectures were developed based on ELSO recommendations. The didactic focused on introducing ECMO and advanced ECMO troubleshooting, focusing on ECMO physiology, procedures, emergencies, and anticoagulation management in patients receiving ECMO support.Twenty nurses completed a 1-hour wet lab reviewing the ECMO circuitry, alarm troubleshooting, and priming of the circuit (see Figure 1). The 2-hour simulation training was held at the simulation laboratory at the Midwest academic medical center. The simulated room was set up to resemble an ICU room. Six scenarios of issues commonly encountered in patients receiving ECMO therapy were developed as a part of the simulation training. Twenty nurses completed the 6 scenarios proctored by the ACNP and chief perfusionist. Nurses were able to debrief, allowing them to understand the actions taken and the implications of those actions. After completing the simulation training, each nurse retook the same deidentified ECMO knowledge exam and self-efficacy survey.Twenty nurses (100%) completed the training and surveys; knowledge and self-efficacy both showed significant improvement. Pretraining scores on the knowledge exam averaged 70%. Posttraining knowledge exam scores averaged 85%. Posttraining self-efficacy scores improved on each item of the survey. Refer to Table 2 for changes in confidence before and after training.After implementation of the training, a schedule was created with 2 ECMO specialists scheduled on each shift. Patients receiving ECMO support were preassigned to ECMO specialists for 5 months. During those 5 months, it was noted that there was a significant decrease in the number of pages to perfusionists. Nurses were better able to troubleshoot and prevent detrimental events. An ECMO committee was developed comprised of the ICU medical director, unit manager, chief perfusionist, ACNPs, pharmacist, and cardiac surgeons. The committee met monthly for 5 months. The ICU multidisciplinary team collaboratively developed an ECMO policy, created an order set for ECMO patients, revised an anticoagulation policy, and designated an ECMO cart fully equipped for emergent cannulation be stationed on the unit. Electronic health record documentation of ECMO was also updated to reflect the data provided by the Cardiohelp Console, which includes change in pressure, arterial and venous pressures, hemoglobin levels, hematocrit levels, mixed venous oxygen saturation, and activated clotting time results.Another important change in the unit was in how patients receiving ECMO support were signed out to the oncoming shift. An ECMO circuit check was now mandated at every change of shift. This check included the nurse review settings and cannulation sites, along with hemodynamic trends and the most recent postoxygenator gas levels. One of the most important changes because of this training was the approval for an ECMO coordinator position. This would assure nursing staff would receive formal ECMO training to maintain competencies.The level of stress endured during emergencies influences clinical performance. To ensure safe, high-quality ECMO management during emergencies, bedside RNs need technical, behavioral, and independent decision-making skills. This is essential for outstanding teamwork and improved patient outcomes.7 This simulation training enhanced nurses’ ability to identify and initiate an intervention promptly. There was an improvement in scores of the knowledge exam after training. Nurse self-efficacy was improved as evidenced by the improved percentages in the posttraining self-efficacy survey. These results indicate that nurses improved their self-efficacy and knowledge. Of note, in the simulation laboratory, regardless of years of experience, nurses had difficulty with more complex scenarios, further supporting the need for training and competencies.After training, nurses recognized acute events and intervened before these events could cause harm to patients. An example of the impact of this training was when nurses who participated in the training were able to promptly identify recirculation occurring in a patient receiving venovenous ECMO support. The nurses recalled this ECMO complication from a scenario practiced in the simulation laboratory. They were able to visualize this in a controlled setting and were able to apply what they learned to the bedside. A limitation of this education/training was that the nurses who participated in this training were highly specialized ICU nurses. The outcome of this training might be different in a group of less specialized nurses.This simulation training demonstrated the importance of using ACNPs to increase patient access to care in a critical care setting and to set the standards for care.8 Acute care nurse practitioners are instrumental resources because of their direct patient care skills.8 Both RNs and physicians consider education, research, collaboration, and leadership vital roles of the ACNP that are indispensable in any critical care unit.8 An ACNP with ECMO experience is vital to a CTICU because they can play a role in decreasing hospital lengths of stay and mortality, improving patient care, and promoting continuity of care. Acute care nurse practitioners are a strong liaison between bedside nurses and the ICU multidisciplinary team.This column outlines the essential role of the ACNP in ECMO in a CTICU. The goal of this training was to implement an ECMO simulation training led by an ACNP. Fundamental to this training was that it would improve the knowledge and self-efficacy of bedside RNs. Acute care nurse practitioner– led educational initiatives enhance structural empowerment through leadership and improved communication, which positively influences staff morale. Empowering bedside RNs through education increases staff retention and improves the quality and safety of patient care. The health care system in the United States is dynamic. As nursing leaders, ACNPs are essential resources that can empower bedside RNs to provide safe and quality nursing care to our most complex patients.

OBJECTIVES:To investigate the ICU survival of venovenous extracorporeal membrane oxygenation (ECMO) patients suffering from COVID-19–related acute respiratory distress syndrome (ARDS) versus ECMO patients without COVID-19 (non-COVID-19)–related ARDS.DESIGN:Preliminary analysis of data from two prospective ECMO trials and retrospective analysis of a cohort of ARDS ECMO patients.SETTING:Single-center ICU.PATIENTS:Adult ARDS ECMO patients, 16 COVID-19 versus 23 non-COVID-19 patients. Analysis of retrospective data from 346 adult ARDS ECMO patients.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:COVID-19 and non-COVID-19 ARDS patients did not differ with respect to preexisting disease or body mass index. ICU survival rate was 62% for COVID-19 ECMO patients and 70% for non-COVID-19 ECMO patients. COVID-19 ECMO survivors were supported with ECMO for a median of 43 days (interquartile range [IQR], 18–58 d) versus 16 days (IQR, 19–39 d; p = 0.03) for non-COVID-19 patients. The median duration of ECMO therapy for all ARDS patients between 2007 and 2018 was 15 days (IQR, 6–28 d). The subgroup of patients suffering from any viral pneumonia received ECMO support for a median of 16 days (IQR, 9–27 d), survivors of influenza pneumonia received ECMO support for 13 days (IQR, 7–25 d).CONCLUSIONS:COVID-19 patients required significant longer ECMO support compared with patients without COVID-19 to achieve successful ECMO weaning and ICU survival.

Epidemiology of blood stream infection in adult extracorporeal membrane oxygenation patients: A cohort study

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.