oa Nightmares during ECMO run

Extracorporeal membrane oxygenation (ECMO) is an increasingly used life support modality in both respiratory and cardiac cases. The ECMO run may last from a few hours to several months and is usually associated with many major and minor events that can be overseen and may not always be documented. These ECMO complications are related to the circuit, the patient, or other factors such as procedures, drugs, environment, and personnel. The circuit may show some events that are usually predictable, manageable but require training to be dealt with effectively without compromising patient safety. Fortunately, the circuit-related complications are the most documented,¹ which include: oxygenator failure, clotting, inflammatory response, disseminated intravascular coagulopathy, thrombopenia, hemolysis, air embolism, cannula-related blood stream infections, cannula dislodgement, bleeding, injury during insertion, malpositioning, recirculation, hypothermia, chattering, and oxygenator malfunction. The commonest complications include the oxygenator failure (occurs in 10% of ECMO runs), infections (reported in 17% of ECMO runs), and cannula-related problems (present in 19–20% of ECMO runs in one form or another).¹ Patient-related complications include: neurologic complications including hemorrhages or strokes, infections, bed sores due to prolonged recumbency, deep vein thrombosis and subsequent pulmonary embolism, limb ischemia, sepsis and septic shock, acute kidney injury, pneumothorax and pneumomediastinum, psychological complications, musculoskeletal weakness, and hemolysis.¹ Procedures-related complications include pneumothorax, surgical emphysema, catheter-related complications, and others. Drug-related issues include hemorrhage from anticoagulation, acute kidney injury from antibiotics, heparin-induced thrombocytopenia,^2–4 some other iatrogenic incidents related to the staff, equipment, and facility (environment), which may include transport-related complications, electricity-related events, and medical gases-related events, and these are usually unexpected and require special skills in communication and management.^5,6 These complications may represent a major distress to the patient, caring medical team, and family members. Proper training, adequate preparation in anticipation of potential issues, and team work are the key and only way to handle these complications.⁷ Among other nightmares are ethical and legal considerations about the end of life that are still a major area of debate especially in countries without transplantation programs and clear legalization to support withdrawal.⁸ In summary, nightmares during ECMO runs may occur, and hence, they should be expected. Complications and incidents may occur at any point in time during ECMO runs, and hence, careful and continuous monitoring and regular staff training to manage these complications are the key principles for safe daily ECMO practice.