Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines

Sung-Min Cho; Jaeho Hwang; Giovanni Chiarini; Marwa Amer; Marta V Antonini; Nicholas Barrett; Jan Belohlavek; Daniel Brodie; Heidi J Dalton; Rodrigo Diaz; Alyaa Elhazmi; Pouya Tahsili-Fahadan; Jonathon Fanning; John Fraser; Aparna Hoskote; Jae-Seung Jung; Christopher Lotz; Graeme MacLaren; Giles Peek; Angelo Polito; Jan Pudil; Lakshmi Raman; Kollengode Ramanathan; Dinis Dos Reis Miranda; Daniel Rob; Leonardo Salazar Rojas; Fabio Silvio Taccone; Glenn Whitman; Akram M Zaaqoq; Roberto Lorusso

doi:10.1186/s13054-024-05082-z

Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines

Crit Care. 2024 Sep 6;28(1):296. doi: 10.1186/s13054-024-05082-z.

Authors

Sung-Min Cho^{1

2}, Jaeho Hwang³, Giovanni Chiarini^{4

5}, Marwa Amer^{6

7}, Marta V Antonini⁸, Nicholas Barrett⁹, Jan Belohlavek¹⁰, Daniel Brodie¹¹, Heidi J Dalton¹², Rodrigo Diaz¹³, Alyaa Elhazmi^{6

7}, Pouya Tahsili-Fahadan^{3

14}, Jonathon Fanning¹⁵, John Fraser¹⁵, Aparna Hoskote¹⁶, Jae-Seung Jung¹⁷, Christopher Lotz¹⁸, Graeme MacLaren¹⁹, Giles Peek²⁰, Angelo Polito²¹, Jan Pudil¹⁰, Lakshmi Raman²², Kollengode Ramanathan¹⁹, Dinis Dos Reis Miranda²³, Daniel Rob¹⁰, Leonardo Salazar Rojas²⁴, Fabio Silvio Taccone²⁵, Glenn Whitman²⁶, Akram M Zaaqoq^#²⁷, Roberto Lorusso^#⁴

Affiliations

¹ Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA. [email protected].
² Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. [email protected].
³ Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
⁴ Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
⁵ Division of Anaesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy.
⁶ Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, 11564, Al Mathar Ash Shamali, Riyadh, Saudi Arabia.
⁷ Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
⁸ Bufalini Hospital, AUSL della Romagna, Cesena, Italy.
⁹ Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK.
¹⁰ 2nd Department of Medicine, Cardiology and Angiologiy, General University Hospital and 1st School of Medicine, Charles University, Prague, Czech Republic.
¹¹ Division of Pulmonary, and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹² Departments of Surgery and Pediatrics, Creighton University, Omaha, NE, USA.
¹³ Programa de Oxigenación Por Membrana Extracorpórea, Hospital San Juan de Dios Santiago, Santiago, Chile.
¹⁴ Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA.
¹⁵ Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital and University of Queensland, Rode Rd, Chermside, QLD, 4032, Australia.
¹⁶ Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for, Children National Health Service Foundation Trust, London, UK.
¹⁷ Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea.
¹⁸ Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany.
¹⁹ Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore.
²⁰ Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA.
²¹ Pediatric Intensive Care Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland.
²² Department of Pediatrics, Section Critical Care Medicine, Children's Medical Center at Dallas, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
²³ Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.
²⁴ ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia.
²⁵ Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium.
²⁶ Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
²⁷ Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA.

^# Contributed equally.

Abstract

Background: Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support.

Methods: These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels.

Results: We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts.

Conclusions: The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.

Keywords: Acute brain injury; ECMO; Guidelines; ICU care; Neurological care; Neurological outcomes; Neuromonitoring; Stroke.

Publication types

Review
Research Support, N.I.H., Extramural

MeSH terms

Adult
Brain Injuries / physiopathology
Brain Injuries / therapy
Consensus*
Delphi Technique
Extracorporeal Membrane Oxygenation* / methods
Extracorporeal Membrane Oxygenation* / standards
Humans
Monitoring, Physiologic / methods
Monitoring, Physiologic / standards

Abstract

Publication types

MeSH terms

Grants and funding