AANA August 2025 Journal Course : Initiation and Anesthetic Management of ECMO in the Adult Noncardiac Surgical Patient-Initiation and Anesthetic Management of ECMO in the Adult Noncardiac Surgical Patient

Initiation and Anesthetic Management of ECMO in the Adult Noncardiac Surgical Patient

Pdf Summary

This AANA Journal course reviews extracorporeal membrane oxygenation (ECMO) use in adult noncardiac surgical patients, emphasizing its growing perioperative role. ECMO, providing life support for lungs and/or heart outside the body, has nearly doubled in use over the past decade, improving survival to approximately 67%. This growth necessitates anesthesia practitioners’ familiarity with patient selection, initiation, and intraoperative management of ECMO, as updated clinical guidelines remain limited.<br /><br />Two main ECMO types are venovenous (VV) for pulmonary support and venoarterial (VA) for cardiopulmonary support. Elective preinduction ECMO is considered for patients at risk of respiratory compromise or difficult airway—such as those with >50% tracheal obstruction, diameter ≤5 mm, or vascular compressions—to reduce morbidity and mortality better than conventional airway management. Emergent ECMO may be needed intraoperatively for undiagnosed critical issues like mediastinal masses causing airway obstruction, anaphylaxis, amniotic fluid embolism, cardiomyopathy, or bone cement implantation syndrome. Extracorporeal cardiopulmonary resuscitation (ECPR) involves ECMO initiation during refractory cardiac arrest and is time-sensitive with better neurologic outcomes if started within 10 minutes of failed conventional CPR.<br /><br />Intraoperative anesthesia management includes: continuous right upper extremity arterial monitoring for oxygenation (important due to potential "watershed" circulation zones in VA ECMO), preference for total intravenous anesthesia due to circuit limitations with inhaled anesthetics, careful ventilatory strategies emphasizing lung protection, and hemodynamic goals targeting mixed venous oxygen saturation ≥70% and mean arterial pressure 65–80 mm Hg. ECMO circuitry causes hemodilution and drug sequestration, requiring adjusted anesthetic dosing, particularly for fentanyl; morphine is preferred for analgesia.<br /><br />Coagulation balance is critical to prevent thrombosis and bleeding; anticoagulation with unfractionated heparin is standard but may be paused for surgery. Monitoring via thromboelastography and anti-factor Xa assays guides therapy. Finally, multidisciplinary teamwork, prompt candidate identification, and institution readiness are pivotal to optimizing perioperative ECMO support and patient outcomes. This evolving field calls for continuous education and research to refine anesthesia practices around ECMO in noncardiac surgeries.

Keywords

ECMO

extracorporeal membrane oxygenation

perioperative management

venovenous ECMO

venoarterial ECMO

extracorporeal cardiopulmonary resuscitation

anesthesia management

coagulation monitoring

noncardiac surgery

anesthetic dosing adjustments