Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support

The effectiveness of NIRS technology to the early diagnosis of lower limb ischemia in patients on peripheral VA ECMO: A systematic review and meta-analysis

BACKGROUND

Acute lower limb ischemia is a major complication of peripheral venoarterial ECMO, significantly impacting patient outcomes and survival rates. Traditional methods for assessing limb perfusion, such as physical exams and Doppler ultrasound, are often unreliable and do not provide continuous monitoring. Near-infrared spectroscopy (NIRS), a non-invasive technique, shows promise for perfusion monitoring in venoarterial ECMO patients, but its effectiveness in the early detection of limb hypoperfusion remains unreviewed.

AIM

Evaluate the effectiveness of NIRS technology in the early diagnosis of lower limb ischemia in patients undergoing peripheral VA ECMO.

METHODS

The search strategy covered five databases. Inclusion criteria included studies in Portuguese, English, Spanish, or German involving participants aged 18 or older dependent on peripheral VA ECMO. The intervention assessed was limb perfusion monitoring using NIRS in VA ECMO patients. The primary outcome was the effectiveness of NIRS in the early diagnosis of limb ischemia. Exclusion criteria included review articles, book chapters, books, editorials, conference papers, and studies on pediatric patients, central VA ECMO, or venovenous ECMO. Study quality was evaluated using the ROBINS-I tool. Meta-analysis was performed using R package meta. Narrative synthesis was applied when meta-analysis was unfeasible.

RESULTS

Of 180 studies, 164 were excluded after initial screening. Of the remaining 16 studies, eight were removed for irrelevance, high bias risk, or pediatric focus, leaving eight studies. The results revealed a pooled sensitivity of the diagnostic method of 0.71 (95% CI: [0.67, 0.74]) and a pooled specificity of 0.68 (95% CI: [0.61, 0.74]).

CONCLUSIONS

NIRS technology is an effective diagnostic tool for reliably detecting true positive cases of limb ischemia.

IMPLICATIONS FOR CLINICAL PRACTICE

The decrease in NIRS values and the difference between limbs may indicate hypoperfusion, requiring further investigation. NIRS also helps assess distal perfusion catheter functionality, enhancing our ability to provide safe, high-quality care.

ECPR-the evolving role in cardiac arrest

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is a highly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

ECMO in trauma care: What you need to know

ABSTRACT

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature

The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.