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

Abstract

Background: The main objective of this study was to investigate the role of a multimodal neurological monitoring (MNM)-guided protocol in the precision identification of neural impairment and long-term neurological outcomes in venoarterial extracorporeal membrane oxygenation (VA-ECMO) supported patients.

Methods: We performed a cohort study that examined adult patients who underwent VA-ECMO support in our center between February 2010 and April 2021. These patients were retrospectively assigned to the "with MNM group" and the "without MNM group" based on the presence or absence of MNM-guided precision management. The differences in ECMO-related characteristics, evaluation indicators (precision, sensitivity, and specificity) of the MNM-guided protocol, and the long-term outcomes of the surviving patients were measured and compared between the two groups.

Results: A total of 63 patients with VA-ECMO support were retrospectively assigned to the without MNM group (n = 35) and the with MNM group (n = 28). The incidence of neural impairment in the without MNM group was significantly higher than that in the with MNM group (82.1 vs. 54.3%, P = 0.020). The MNM group exhibited older median ages [52.5 (39.5, 65.3) vs. 31 (26.5, 48.0), P = 0.008], a higher success rate of ECMO weaning (92.8 vs. 71.4%, P = 0.047), and a lower median duration of building ECMO [40.0 (35.0, 52.0) vs. 58.0 (48.0, 76.0), P = 0.025] and median ECMO duration days [5.0 (4.0, 6.2) vs. 7.0 (5.0, 10.5), P = 0.018] than the group without MNM. The MNM-guided protocol exhibited a higher precision rate (82.1 vs. 60.0%), sensitivity (95.7 vs. 78.9%), and specificity (83.3 vs. 37.5%) in identifying neural impairment in VA-ECMO support patients. There were significant differences in the long-term outcomes of survivors at 1, 3 and 6 months after discharge between the two groups (P < 0.05). However, the results showed no significant differences in ICU length of stay (LOS), hospital LOS, survival to discharge, or 28-day mortality between the two groups (P > 0.05).

Conclusion: The MNM-guided protocol is conducive to guiding intensivists in the improvement of cerebral protection therapy for ECMO-supported patients to detect and treat potential neurologic impairment promptly, and then improving long-term neurological outcomes after discharge.

Keywords: VA-ECMO; long-term outcomes; multimodal neurological monitoring; neurologic impairment; protocol.

Figure 1

Flow chart of the patient cohort. VA-ECMO, venoarterial extracorporeal membrane oxygenation; CNS, central nervous system; MNM, multimodal neurological monitoring.

Figure 2

Diagram of the MNM-guided protocol. ECMO, extracorporeal membrane oxygenation; qEEG, quantitative electroencephalogram; TCCD, transcranial color Doppler ultrasonography; rScO₂, regional cerebral oxygenation; GCS, Glasgow Coma Scale; MAP, mean arterial pressure; CT, computed tomography; MV, mechanical ventilation; CPC, cerebral performance category; bid, bis in die; qd, quaque die.

Figure 3

The MNM-guided protocol improves the precision management of VA-ECMO-supported patients. Guided by the MNM protocol, we can accurately adjust the ECMO flow rate (A), maintain appropriate afterload (MAP) and preload (CVP) (B,C), and accelerate the removal of lactic acid (D) to achieve the oxygen delivery and consumption balance of patients (E–G). ECMO, extracorporeal membrane oxygenation; MAP, mean arterial pressure; CVP, central venous pressure; ScvO₂, central venous oxygen saturation; LAC, lactic acid. All data are representative of the median, and the Mann–Whitney U test was used for the comparison. ***P < 0.001, **P < 0.01, *P < 0.05.