ECMO-free protocol feasible, may aid earlier identification of patients for decannulation

A protocol for daily assessment of readiness for liberation from venovenous extracorporeal membrane oxygenation was feasible and safe, researchers reported in Chest.

“Prior data suggest that clinicians underestimate readiness for liberation from organ support and suggest that protocols to identify readiness for liberation are superior to clinician judgment. Compared to incremental weaning, spontaneous awakening trials and spontaneous breathing trials have been shown to dramatically shorten the duration of support, reduce intensive care costs and improve clinical outcomes,” Whitney D. Gannon, MS, MSN, assistant in medicine in the department of allergy, pulmonary and critical care medicine at Vanderbilt University Medical Center, and colleagues wrote. “To date, however, no protocols for daily assessment of readiness to liberate from ECMO have been described or evaluated. Whether such a protocol would shorten the duration of support or improve clinical and economic outcomes is unknown.”

Researchers conducted a prospective, single-arm, safety and feasibility study to analyze a protocol for daily assessment of readiness for liberation from venovenous ECMO among adults who received ECMO in four ICUs from June to November 2020. The ECMO-free protocol included a safety screen, non-ECMO fraction of inspired oxygen titration and an ECMO-free trial.

The ECMO-free protocol was used in 26 patients on 385 patient-days. The safety screen was passed during 59 (15.3%) ECMO-free daily assessments in 20 patients. These patients that passed the safety screen underwent the ECMO-free trial. Of those, 16 patients (61.5%) passed 28 (47.5%) ECMO-free trials. No missed safety screens, protocol deviations or adverse events were reported, according to the results.

In the 16 patients who passed the ECMO-free trials, 14 (87.5%) were decannulated from venovenous ECMO, with a median time of 2.5 days from first passed ECMO-free trial to decannulation. Twelve patients (85.7%) were decannulated the same day they passed the ECMO-free trial, six (42.9%) on the first day after they passed an ECMO-free trial and six (42.9%) after they passed an ECMO-free trial twice consecutively, according to the results.

There were nine deaths before decannulation. One patient who was decannulated required recannulation.

“A protocolized daily assessment of readiness for liberation from [venovenous ECMO] is feasible and may have a role in identifying patients for decannulation earlier than gradual approaches to weaning,” the researchers wrote. “Randomized controlled trials are needed to evaluate the effect of a protocolized daily assessment on time to decannulation and clinical outcomes.”