Extra Corporeal Membrane Oxygenation or ECMO is more and more referred to as Extra Corporeal Life Support or ECLS, due to it being used more and more as a V-A system, supporting the circulation as well as the respiration. There are some case reports emerging on patients on ECLS being kept awake, talking, eating and drinking while their respiration and circulation is being supported. Here’s a case report on a long term awake V-A ECLS patient, and a case series on initiation of ECLS on awake patients.
37 days on ECLS. Awake.
In the case report case, a patient with severe heart failure came for an assessment for heart transplant, but arrested in the angio lab. They couldn’t stabilize him with pharmacology or IABP, so they put him on V-A ECLS. They woke him up after 36 hrs without any neurological impairment. Then kept him awake on ECLS for over a month(!).
Heres him exercising on an ergometer while in bed waiting for the transplant he finally got after 37 days on ECLS. If i was him I would freak out. ‘Would you please not step on that tube there?’
More commonly, patients waiting for prolonged periods of time get an LVAD, which makes them more mobile. But this long, awake ECLS run sure made an interesting case report!
5 awake ECLS cases
The other case series describes patients with severe cardiopulmonary failure due to pulmonary hypertension. In the case series all five patients were marginal at the time of the intervention, and had V-A ECLS inserted and initiated as an emergency procedure – unsedated: “ECMO insertion was performed under local anesthesia without sedation and resulted in immediate stabilization of hemodynamics and gas exchange as well as recovery from secondary organ dysfunction“. Go read the full article with the five case reports here – it’s science fiction come real.
I’ve seen awake V-V ECLS patients, and there are many reports on them, but I’ve never seen an awake patient on V-A ECLS before, and certainly never seen ECLS initiated on an awake, non-sedated patient. Being able to do this on awake patients, and keep them awake on extra corporeal life support gives a lot of new and exciting possibilities.
The bridge to transplant being reported here is one such use, but another, more short term use of ECLS might be for emergency surgery on haemodynamically unstable patients.
For emergency surgery, you could put critical, circulatory unstable patients on ECLS while they’re awake, just using local anaesthetics for the vascular access. Then stabilise them on ECLS before safely inducing general anaesthesia for the operation. You could always just induce them as you normally would, and have ECLS ready as a back-up rescue device if the patient crashes. But it just seems more elegant to avoid the total crash and cardiac arrest in the first place.
Possibilities and limitations of a miniaturized long-term extracorporeal life support system as bridge to transplantation in a case with biventricular heart failure, Interact Cardiovasc Thorac Surg, 2009.
Another article summarising 26 awake ECMO patients awaiting lung transplant: