Monitoring of the Adult Patient on Venoarterial Extracorporeal Membrane Oxygenation

Table 5

Summary of monitoring in VA ECMO.

	Monitor for	Treatment
Rhythm	Dysrhythmias such as ventricular fibrillation that may prevent ventricular ejection	Antiarrhythmics; Cardioversion; Pacing; Ablation
MAP	Hypotension (MAP = CO × SVR); (i) Inadequate VA ECMO flow; (ii) Inadequate SVR	(i) See “Flow” below; (ii) Start vasoconstrictor
Pulsatility	Lack of pulsatility on arterial waveform caused by; (i) poor myocardial function; (ii) excessive VA ECMO support; (iii) Inadequate preload; (iv) RV failure; May result in; (i) thrombus; (ii) myocardial ischemia; (iii) pulmonary edema (assess CXR, wedge)	If poor myocardial function, consider: decreasing VA ECMO flow; starting or increasing inotrope; starting or increasing vasodilator; IABP; myocardial decompression
Flow (liters/min)	Low flows (assuming centrifugal pump); (i) Inadequate preload; (a) Hypovolemia (may see hemolysis,; chattering); (b) Mechanical obstructive; (ii) Excessive afterload (thrombus, kink, SVR); (iii) Inadequate RPM	(i) Volume: crystalloid/colloid/transfusion; Release of mechanical obstruction; (ii) Exchange oxygenator, relieve cannula kink,; vasodilator to decrease SVR; (iii) Increase RPM
Gas exchange	Inadequate PaO2 inadequate or excessive CO2 elimination
	(i) VA ECMO settings; (a) FDO2; (b) VA ECMO flow; (c) Sweep gas flow rate	(i) If hypoxemia, increase FDO2 or flow.; If hypercarbia, increase sweep. If; hypocarbia, decrease sweep or add CO2.
	(ii) Oxygenator function; (a) Pre- and postmembrane pressures; (b) Pre- and postoxygenator gases	(ii) Increased Δ𝑃 and inadequate arterialization; of postoxygenator gases suggest oxygenator; malfunction
	(iii) Upper body hypoxemia (femoral-femoral; cannulation)	(iii) Increase pulmonary venous O2 content; Adjust ventilator settings; Treat etiology of pulmonary dysfunction; Increase VA ECMO flow; Change to axillary/carotid cannulation; VA-V ECMO; VV ECMO
Oxygen delivery: SvO2 and lactate	Decreased SvO2 and increasing lactate suggest inadequate oxygen delivery (DO2 = CO × CaO2); (i) VA ECMO flow; (ii) Hemoglobin; (iii) SaO2; Excessive oxygen consumption (ER = VO2/DO2); (i) Febrile; (ii) Shivering	(i) Increase VA ECMO flow; (ii) Transfuse; (iii) Ensure adequate gas exchange; (i) Antipyretics; (ii) Consider agents such as meperidine or; dexmedetomidine
Distal limb ischemia	Loss of pulses; Cyanosis and coolness of limb	Femoral-femoral cannulation: DP or PT anterograde perfusion catheter
Anticoagulation	Adequate heparinization by PTT
Temperature	Normothermia unless therapeutic hypothermia