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If you want to know how to sustainably wean your critically ill loved one off VA-ECMO (Veno-arterial extracorporeal membrane oxygenation) after cardiac arrest, stay tuned. I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com and I have another quick tip for families in intensive care.

So, we’re working with a client currently who has her father in ICU after cardiac arrest on VA-ECMO, and she’s asking, how can he sustainably be weaned off the VA-ECMO?

Now, the critical part here is sustainably. You want the VA-ECMO to be weaned off and not to go back on again because it’s such a high form of life support that you don’t want to take it off and reuse it.

So, weaning a patient off venoarterial ECMO, also known as VA-ECMO, is a complex and delicate process that must be done sustainably to ensure optimal outcomes. The goal is to transition the critically ill patient back to independent cardiopulmonary function while minimizing complications.

Here is an overview of the key steps and considerations. Of course, you need to assess patient readiness, which means you’ve got to assess cardiac function, ensuring sufficient myocardial recovery by assessing left ventricular ejection fraction (LVEF) by echocardiography or ultrasound.

Checking cardiac output using invasive monitoring such as thermodilution or pulse contour analysis, or also with a Swan-Ganz catheter or a PiCCO (Pulse index Continuous Cardiac Output) catheter.

Pulmonary function. Confirm adequate gas exchange and oxygenation without ECMO support. Assess arterial blood gases (ABGs) and oxygenation indications. Ensure the patient can maintain oxygen saturations above 90%, and PaCO2 (partial pressure of carbon dioxide in arterial blood) within normal limits on minimal ventilation support.

Hemodynamic stability. Confirm that blood pressure is stable and organ perfusion without reliance on excessive inotropes or vasopressors. However, inotropes or vasopressors can also help to wean a patient sustainably off VA-ECMO. For example, milrinone and dobutamine are known to increase cardiac contractility, which improves left ventricular function and also improves left ventricular ejection fraction. Another medication that can be used is Levosimendan, which is also known as Simdax and that can also be used to increase cardiac contractility, which is one of the main important ingredients to wean a critically ill patient off VA-ECMO. 

So, that’s why it’s so important to optimize conditions before weaning.

Also, you need to optimize volume status. Optimize pre-load and afterload using fluid management and diuretics.

Vasoactive support. Gradually reduce inotropic invasive pressure support to evaluate native cardiac performance. Well, you can, of course, reduce inotropic invasive pressure support, but sometimes you also need to increase it, especially once again, the inotropes, dobutamine, and milrinone.

Next, treat underlying causes. Address reversible conditions such as myocardial ischemia, infections, or electrolyte imbalances.

Next, perform trial of ECMO (extracorporeal membrane oxygenation) clamping trial. Gradually reduce EMCO flow to test the patient’s ability to maintain stable hemodynamics and oxygenation.

Next, use echocardiography to monitor left ventricular filling pressure, cardiac output, and stroke volume, right ventricular function, and absence of pulmonary hypertension. 

Assess arterial blood gases, lactate levels and mixed venous oxygen saturations to ensure adequate tissue perfusion. In order to assess mixed venous oxygen saturations, you actually need a Swan-Ganz catheter. The trial typically lasts 20 to 60 minutes, but duration may vary based on patient tolerance.

Next, monitor for signs of failure, hypertension, or hemodynamic instability, worsening metabolic acidosis or rising lactate, inability to maintain adequate oxygenation or ventilation, signs of end-organ dysfunction, such as reduced urine output or altered mental status.

Next, decannulation. Once the patient demonstrates sustained hemodynamic and respiratory stability during the clamping trial, surgical decannulation, remove cannulas in a controlled setting, typically the operating room or ICU. Hemostasis, ensure proper vascular closure and monitor for bleeding.

Next, post-decannulation monitoring. Closely monitor for complications such as vascular injury, bleeding, thrombosis, or recurrence of cardiac failure.

Then next, post-weaning management cardiac support. Continue optimized medical therapy, i.e., inotropes, vasodilators as needed, respiratory support, adjust ventilator settings to support lung recovery.

Rehabilitation. Initiate early mobilization and physiotherapy to aid recovery. 

Frequent monitoring. Reassess cardiac and pulmonary function using echocardiography, ultrasound, and hemodynamic studies.

Next, address long-term outcomes. Prevent recurrence, optimize treatment for the underlying cause, i.e., coronary revascularization or management of myocarditis.

Follow-up. Ensure regular follow-up for evaluation of heart and lung function, as well as psychological support.

Tips for sustainability. Avoid rushing the weaning process, allow time for myocardial and pulmonary recovery. Involve a multidisciplinary team, including cardiology, pulmonology, critical care, and surgical specialists. Use evidence-based protocols tailored to the patient’s clinical progress and underlying condition, and that concludes what needs to be done to sustainably wean VA-ECMO for a critically ill patient after cardiac arrest.

Now, another thing that can be done is to put patients on an LVAD (Left Ventricular Assist Device) or an RVAD (Right Ventricular Assist Device) or a VAD (ventricular assist device), basically taking over the function of the heart ventricles. That is another option but that often only happens when a patient is being put on a heart transplant list, but it’s not the case in our client’s situation at the moment. So, the goal here is to wean them off VA-ECMO sustainably and keep them off VA-ECMO mode, but another tip here is to get them from ECMO to an LVAD or an RVAD in case they can’t be weaned off VA ECMO.

So, that is my quick tip for today.

I have worked in critical care nursing for 25 years in 3 different countries where I have worked as a nurse manager for over 5 years in critical care, and I have been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. 

I can very confidently say that we have saved many lives as a part of our consulting and advocacy here at intensivecarehotline.com. You can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast where we’ve done client interviews. 

We have helped hundreds and hundreds of members and clients over the years to improve their lives instantly by making informed decisions, having peace of mind, control, power, influence, making sure their loved ones get the best care and treatment, always.

That’s why I do one-on-one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. I also talk to doctors and nurses directly with you or on your behalf. I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. 

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time, so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 e-books and 21 videos that I have personally written and recorded. All of that will help you to make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment, always.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.