Neurological Considerations
The use of a combination bilateral cerebral oximetry/anesthetic depth
monitor during hybrid ECMO allows for monitoring of anesthetic depth and
ensuring adequate cerebral oxygenation. Anesthetic depth must be
monitored and titrated, due to the use of inhaled anesthetic in both the
mechanical (hybrid ECMO) and native (lungs via the anesthesia machine)
cardiac outputs to assure both adequate depth of anesthesia and to
provide theoretical protection against the development of PGD. Hybrid
ECMO cannulation can be either central or peripheral, and the use of
cerebral oximetry monitoring provides information regarding both
cerebral perfusion and oxygenation in hopes to avoid differential
hypoxemia (north-south syndrome) associated with peripheral
VA-ECMO.1
We previously described a hybrid ECMO-CPB circuit that provides lung
transplantation teams the ability to provide ECC via either VA-ECMO or
CPB.2 While the goals for intraoperative management of
ECMO include maintenance of systemic perfusion and controlled
reperfusion of the newly implanted lungs, achieving the balance between
native and mechanical cardiac outputs can be challenging. Despite these
challenges, successful implementation of VA-ECMO is important as it can
provide theoretical attenuation of the ischemic-reperfusion injury and
improved perioperative outcomes.5 As summarized in
Table 1, the use of an organ system-based approach based on best
evidence and anesthetic monitors that are multi-faceted yet
complementary in design has enabled use of the hybrid ECMO circuit for
intraoperative ECC since September 2017. Future concepts of
investigation for intraoperative management of the hybrid circuit
include the utility of goal-directed perfusion using DO2and TEE-guided quantification of native cardiac output through the
implanted grafts. Appropriately designed studies, both within our
institution and in coordination with other centers, are needed to assess
the efficacy of our approach for lung transplantation.