Extracorporeal Life Support Organization Guidelines for Fluid Overload, Acute Kidney Injury, and Electrolyte Management

Abstract

Disclaimer: This guideline for extracorporeal membrane oxygenation (ECMO) fluid and electrolyte management for all patient populations is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS/ECMO, but these are not necessarily consensus recommendations. The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians’ and other health professionals’ judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians

“…Equation (1) explains why (1) more negative access pressure generated by higher revolutions per minute (RPM) is required to obtain the desired flow in cannulae with higher resistance (e.g., longer and/or with lower diameter), 44 (2) in multistage cannulae, flow is higher at the proximal ports (away from the tip) where the cannula offers lower resistance, 45 and (3) increasing P V by fluid administration is common, especially on ECMO initiation, to achieve the desired flow with lower access pressure (i.e., lower RPM). 46 Interestingly, P V has been reported to be similar from the iliac vein to the superior vena cava across a wide range of airway and abdominal pressures, [47][48][49][50] therefore its value reflects the central venous pressure (CVP) irrespective of the position of the access cannula. However, the proportion of venous return flowing through the access vein is different when the tip is located in the IVC, SVC, and right atrium.…”

“…Equation (1) explains why (1) more negative access pressure generated by higher revolutions per minute (RPM) is required to obtain the desired flow in cannulae with higher resistance (e.g., longer and/or with lower diameter), 44 (2) in multistage cannulae, flow is higher at the proximal ports (away from the tip) where the cannula offers lower resistance, 45 and (3) increasing P V by fluid administration is common, especially on ECMO initiation, to achieve the desired flow with lower access pressure (i.e., lower RPM). 46…”

Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…While there will be interinstitutional and regional variations in the delivery of ECMO services, use of the ELSO guidelines and textbooks (52) offer expert and societal recommendations for current practice. ELSO publishes peerreviewed general guidelines for management (51)(52)(53)(54)(55), pediatric-specific guidelines (56,57) and guidelines for the training and education (49). Collaborations between experienced and less-experienced providers may also improve care and refine practice.…”

Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation

“…Fluid overload, a frequent occurrence in ECMO patients, often results from large volumes of IV fluids administered during the initial resuscitation, blood product transfusions, and ongoing volume requirements due to a systemic inflammatory response to the inciting event that may last for days (55). Fluid administration should be carefully considered only for intravascular volume deficit.…”