Weaning strategies for ECMO and awake-ECMO

Concepts for weaning of extracorporeal support through either vv- or va-ECMO (veno-venous or veno-arterial extracorporeal membrane oxygenation) is similarly important as the initial indication for ECMO implantation. Weaning from vv- or va-ECMO support requires detailed knowledge on the patient’s underlying disease as well as the previous and current hemodynamic situation. Weaning of a vv-ECMO can be initiated in the absence of infectious complications and stable hemodynamics, when ventilator parameters are normal with a fraction of inspired oxygen (FiO2) ≤0.4 and a normal inspiratory pressure. Decreasing pump flow and sweep gas flow should be performed under continuous monitoring of arterial blood gas analyses and in awake patients with observations of clinical signs of dyspnea such as tachypnea. Weaning of a va-ECMO may be started when vasoconstrictive drugs are weaned and the patient shows a sufficient recovery of cardiac function. Also, end-organ function such as renal failure and/or liver dysfunction due to congestion should be resolved prior to the first ECMO weaning attempt. Close monitoring of right and left ventricle pump function as well as invasive hemodynamic monitoring using a pulmonary artery catheter is recommended. In patients with a left or right heart failure, downgrading to a single left or right heart support device may be beneficial.