Anesthesiological management of major thoracic surgery with intraoperative ECMO support in adults

In patients undergoing thoracic surgery procedures with pre-existing severe limitations of the pulmonary function, protective ventilation under the conditions of one-lung ventilation (OLV) often leads to a severe dysfunction of the pulmonary gas exchange. In this situation, establishing a veno-venous extracorporeal membrane oxygenation (vv-ECMO) is a sufficient and safe method to facilitate perioperative treatment of these patients. Postoperatively, patients benefit from the continuation of conscious ECMO by augmentation of necessary therapeutic procedures such as physical and respiratory therapy or early mobilization as well as healing of air leakage of the operated lung. To avoid bleeding complications, ECMO can be operated without anticoagulation intraoperatively with heparin-coating of the tube system. Postoperatively, heparin, argatroban or bivalirudin are options for anticoagulation. Enhanced Recovery Programs have been developed for thoracic surgery over the last years, containing elements like minimally invasive surgery, the use of short acting anesthetics and regional analgesia, a balanced intraoperative fluid therapy, the avoidance of nausea and vomiting as well as protective ventilation modes. Perioperative ECMO has the potential to be part of multimodal enhanced recovery approaches even for patients with severe pulmonary dysfunction. Additionally, modern concepts like non-intubated thoracic surgery can be developed further with the use of perioperative ECMO.