Extubation in VA ECMO
Extubation is a desirable aim in a patient on VA ECMO even fairly early in the course of their disease avoiding sedation, respiratory complication and facilitating physiotherapy. See also considerations for awake ECMO initiation.
Considerations should be given to
- Likelihood of pulmonary oedema with loss of PEEP
- Patient compliance with awake extracorporeal support
- Movement translation to cannulae
- Potential for active participation in physiotherapy
- Ability to involve the patient in conversations regarding more advanced therapies or goals of care
Awake patients can easily be monitored for development of neurological complications, delirium or development of pulmonary oedema. An increase in FiO2 requirements should be treated with scrutiny in regards to the aetiology.
Extubation in VV ECMO
In the early phase of the parenchymal pulmonary disease, almost invariably patient generation of negative pleural pressures by the patient is not desirable and extubation therefore not appropriate. CF patients may represent an exception where active chest physiotherapy and sputum clearance are wanted on the pathway to bridge to transplant to avoid manifest chest sepsis.
In the recovery phase/ weaning phase of VV ECMO extubation can be considered. Thereby the respiratory drive of the patient should be controlled and clinical judgment applied to the rate of recovery. A faster recovery that allows decannulation might be easier before extubation whereas longer ECMO dependence would favour extubation first where possible.
Many patients have been successfully extubated without the need for a tracheostomy following prolonged VV ECMO support. Percutaneous tracheostomy may be indicated during ECMO support in younger patients with particularly high sedation requirements and prolonged ECMO support. Percutaneous tracheostomy is uncommonly required in VA ECMO patients, However in each case, the risk-benefit ratio must be carefully assessed, particularly as it relates to anticoagulation. Anticoagulation should be paused for the immediate period prior to and post the insertion of a tracheostomy to minimize the risk of bleeding is advised. For IV heparin anticoagulation, stop the infusion 4 hours prior and 4 hours after the insertion of a tracheostomy. Where other forms of anticoagulation are being used we recommend seeking the advice of the pharmacy and/or haematology team.