Review

. 2024 Sep 6;28(1):296.

doi: 10.1186/s13054-024-05082-z.

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

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. csungmi1@jhmi.edu.
² Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. csungmi1@jhmi.edu.
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.

PMID: 39243056
PMCID: PMC11380208
DOI: 10.1186/s13054-024-05082-z

Review

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

Sung-Min Cho et al. Crit Care. 2024.

. 2024 Sep 6;28(1):296.

doi: 10.1186/s13054-024-05082-z.

Authors

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. csungmi1@jhmi.edu.
² Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. csungmi1@jhmi.edu.
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.

PMID: 39243056
PMCID: PMC11380208
DOI: 10.1186/s13054-024-05082-z

Erratum in

Correction to: Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines.
Cho SM, Hwang J, Chiarini G, Amer M, Antonini MV, Barrett N, Belohlavek J, Brodie D, Dalton HJ, Diaz R, Elhazmi A, Tahsili-Fahadan P, Fanning J, Fraser J, Hoskote A, Jung JS, Lotz C, MacLaren G, Peek G, Polito A, Pudil J, Raman L, Ramanathan K, Dos Reis Miranda D, Rob D, Rojas LS, Taccone FS, Whitman G, Zaaqoq AM, Lorusso R. Cho SM, et al. Crit Care. 2024 Oct 7;28(1):327. doi: 10.1186/s13054-024-05107-7. Crit Care. 2024. PMID: 39375794 Free PMC article. No abstract available.

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.

PubMed Disclaimer

Conflict of interest statement

Dr. Cho is a consultant for Hyperfine, Inc. and supported by NIH (1K23HL157610 and 1R21NS135045). Dr. Brodie received research support from and consults for LivaNova. He has been on the medical advisory boards for Xenios, Medtronic, Inspira, and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of the Executive Committee of the International ECMO Network (ECMONet), and he writes for UpToDate. Dr. Daniel is supported by MH CZ (DRO-VFN64165) and receives consulting honoraria from Abiomed and Resuscitec. Dr. Lorusso received research support from Medtronic and LivaNova, is consultant for Medtronic and Livanova, Member of the Medical Advisory Board of Eurosets and Xenios, and receives speaker fee from Abiomed.

Figures

**Fig. 1**
Recommendations for neurological monitoring and neuroimaging on ECMO. ABI: acute brain injury; EEG: electroencephalography; rSO₂: regional oxygen saturation; SSEP: somatosensory evoked potential; VA ECMO: venoarterial extracorporeal membrane oxygenation

**Fig. 2**
Recommendations for bedside management on ECMO. ABG: arterial blood gas; BP: blood pressure; ECMO: extracorporeal membrane oxygenation; MAP: mean arterial pressure; PaCO₂: partial pressure of carbon dioxide; PaO₂: partial pressure of oxygen; VA: venoarterial; VV: venovenous

**Fig. 3**
Recommendations for interventional neurology, neurosurgery & neurocritical care on ECMO. CT: computed tomography; ECMO: extracorporeal membrane oxygenation; ICH: intracranial hemorrhage; ICP: intracranial pressure; PbtO₂: brain tissue oxygenation; tPA: tissue plasminogen activator; VV: venovenous; VA: venoarterial

See this image and copyright information in PMC

References

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1. Lorusso R, Gelsomino S, Parise O, Di Mauro M, Barili F, Geskes G, Vizzardi E, Rycus PT, Muellenbach R, Mueller T, et al. Neurologic injury in adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure: findings from the extracorporeal life support organization database. Crit Care Med. 2017;45(8):1389–97. - PubMed
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1. Ong CS, Etchill E, Dong J, Shou BL, Shelley L, Giuliano K, Al-Kawaz M, Ritzl EK, Geocadin RG, Kim BS, et al. Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg. 2023;165(6):2104–10. - PubMed

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

Affiliations

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

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

Figures

References

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Grants and funding

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