Ischemic Brain Injury on ECMO Neuromonitoring and Neuroprotection

Neuromonitoring

Techniques to aid in the early recognition of worsening neurological function

• Neurological examination
  • A comprehensive neurological examination, including 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
  • With concerning exam findings, obtain a non-contrast head computed tomography (CT). CT angiography (CTA) of the head and neck can be considered if there is a concern for a large vessel occlusion while on ECMO; however, the benefits of diagnosis in the context of candidacy for additional treatment options should be considered against the risks for cardiorespiratory instability with clamping of the ECMO circuit
• Electroencephalography (EEG)
  • Continuous EEG is recommended for a minimum of 48 hours from time of concern or diagnosis of the ischemic brain injury with consideration for longer in case of extended neuromuscular blockade (Consult Neurology when EEG monitoring is initiated)
  • Discontinuation of EEG should be a discussion between Neurology and the ICU

Neuroprotection

Therapies to hep preserve neurological function

• Keep the head of the bed (HOB) flat for 24 hours in patients with acute arterial ischemic stroke. Incline the HOB to 30 degrees if there is known cerebral edema or at the 24-hour mark
• Adjust ECMO circuit temperature to maintain a patient temperature goal of 36.5 °C. Avoid using rectal temperature probes on patients receiving systemic anticoagulation
• Cautiously consider treatment for systolic blood pressure greater than 95% for age/weight
• Titrate ECMO flow and FiO₂ as needed to keep saturation levels greater than 94% while avoiding hyperoxia
• Maintain sodium levels at least > 140 for a known acute injury. Patients with significant mass effect or cerebral edema may require higher individualized goals
• Maintain patient paCO₂ levels at 35 - 40 mmHg. If elevated ICP, ensure paCO₂ levels are maintained at 33 - 37 mmHg
• Treat hypoglycemia less than 60 mg/dL and aim for 100 - 180 mg/dL

References

Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS neurologic management and outcomes. Semin Pediatr Surg. 2023;32(4):151331. doi:10.1016/j.sempedsurg.2023.151331

Cho SM, Farrokh S, Whitman G, Bleck TP, Geocadin RG. Neurocritical care for extracorporeal membrane oxygenation patients. Crit Care Med. 2019;47(12):1773-1781. doi:10.1097/CCM.0000000000004060

Cho SM, Hwang J, Chiarini G, et al. Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines. Crit Care. 2024;28(1):296. doi:10.1186/s13054-024-05082-z

Laws JC, Jordan LC, Pagano LM, Wellons JC, Wolf MS. Multimodal neurologic monitoring in children with acute brain injury. Pediatr Neurol. 2022;129:62-71. doi:10.1016/j.pediatrneurol.2022.01.006

Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation. ASAIO J. 2023;69(10):895-900. doi:10.1097/MAT.0000000000001896

Themas K, Zisis M, Kourek C, et al. Acute ischemic stroke during extracorporeal membrane oxygenation (ECMO): A narrative review of the literature. J Clin Med. 2024;13(19):6014. doi:10.3390/jcm13196014

Waraich M, Ajayan N. Clinical neuroprotection and secondary neuronal injury mechanisms. Anaesth Intensive Care Med. 2023;25(1):16-22. doi: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.