A veno-venous ECMO weaning algorithm. Example of an algorithm used by staff at the bedside to decrease the level of ventilatory support in patients on veno-venous ECMO. RR, respiratory rate.
If the patient has been supported adequately and lung function has recovered sufficiently, the ECMO can be removed.
Liberating the patient on veno-arterial ECMO
Liberating a patient from veno-arterial ECMO is usually a complex exercise, except when it simply entails moving to another form of mechanical support.
If the heart has fully recovered, it will be obvious that the two circulations are competing. The patient can then be taken to the operating room for the arterial cannula to be removed under direct surgical vision (blind removal of a percutaneous cannula is possible but not as safe).
If it is unsure that the heart recovery is sufficient to sustain physiological demand, there is no universal protocol. Similar measures to those used to come off cardiopulmonary bypass are used, and an expert team is required.
One key difference compared with cardiopulmonary bypass is that in veno-arterial ECMO the liberation attempt can be stopped while the team review plans, including the possibility of non-reversibility or long-term support.
Various protocols have been proposed and several indices suggested as indicators of success, but none replaces experienced cardiac surgical teams in this endeavour.
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