Intracranial Hemorrhage on ECMO Neuromonitoring and Neuroprotection

Neuromonitoring

Techniques to aid in the early recognition of worsening neurological function

• Neurological examination
  • A comprehensive neurological examination, including assessment of pupillary reactions and changes, muscle tone, strength and movement, and response to stimuli, should be performed frequently to monitor for signs of neurological deterioration, such as cerebral edema or seizures
• Cerebral oximetry using near-infrared spectroscopy (NIRS)
  • A reduction of > 20% from baseline or absolute crSO₂ < 50% in regional cerebral oximetry is concerning for neurological injury
  • May be useful in determining prognosis for infants and children supported on ECMO
• Neuroimaging
  • A head computed tomography (CT) scan is the preferred method to detect acute hemorrhagic or ischemic changes while receiving ECMO support, and should be obtained if there are findings concerning for worsening neurological function or complications
• Electroencephalography (EEG)
  • Continuous EEG monitoring is recommended for infants and children due to their increased risk for seizures, including subclinical seizures, for a minimum of 24 - 48 hours
  • Discontinuation of EEG should be a discussion between Neurology and the ICU
• Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring
  • Hemorrhage and ischemic brain injuries can be complicated by intracranial hypertension
  • Maintain ICP < 20 mmHg (if monitor present)
  • Maintain CPP above age-based targets (if monitor present)

Neuroprotection

Therapies to help preserve neurological function

• Keep the head of the bed elevated at 30 degrees
• Determine and maintain systolic blood pressure (upper limit), MAP, and/or CPP goals in collaboration with Neurosurgery
• Maintain normoxemia and normothermia
• Maintain sodium levels at least > 140. Patients with significant mass effect or cerebral edema may require higher individualized goals
• Maintain patient paCO₂ levels at 35 - 40. Patients with significant mass effect or cerebral edema may require tighter control 
• Monitor for seizures:
  • Respond as soon as able with any suspected seizure activity
  • Consult Neurology for any patient on continuous EEG monitoring

References

Callier, K., Dantes, G., Johnson, K., & Linden, A. G. (2023). Pediatric ECLS neurologic management and outcomes. Seminars in Pediatric Surgery, 32(4), 151331. https://doi.org/10.1016/j.sempedsurg.2023.151331

Cho, S M., Farrokh, S., Whitman, G., Bleck, T. P., & Geocadin, R. G. (2019). Neurocritical care for extracorporeal membrane oxygenation patients. Critical Care Medicine, 47(12), 1773-1781. https://doi.org/10.1097/CCM.0000000000004060

Cho, S. M., Hwang, J., Chiarini, G., Amer, M., Antonini, M. V., Barrett, N., Belohlavek, J., Brodie, D., Dalton, H. J., Diaz, R., Elhazmi, A., Tahsili-Fahadan, P., Fanning, J., Fraser, J., Hoskote, A., Jung, J. S., Lotz, C., MacLaren, G., Peek, G., Polito, A.,...Lorusso, R. (2024). Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines. Critical Care (London, England), 28(1), 296. https://doi.org/10.1186/s13054-024-05082-z

Laws, J. C., Jordan, L. C., Pagano, L. M., Wellons, J. C., & Wolf, M. S. (2022). Multimodal neurologic monitoring in children with acute brain injury. Pediatric Neurology, 129, 62-71. https://doi.org/10.1016/j.pediatrneurol.2022.01.006

Pandiyan, P., Cvetkovic, M., Antonini, M. V., Shappley, R. K. H., Karmakar, S. A., & Raman, L. (2023). Clinical guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation. American Society for Artificial Internal Organs Journal, 69(10), 895-900. https://doi.org/10.1097/MAT.0000000000001896

Waraich, M., & Ajayan, N. (2023). Clinical neuroprotection and secondary neuronal injury mechanisms. Anaesthesia and Intensive Care Medicine, 25(1), 16-22. https://doi.org/10.1016/j.mpaic.2023.11.009

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.