Early recognition of ECMO cannulation-related complications using NIRS trend monitoring

Abstract High-risk pulmonary embolism is a life-threatening condition. Early initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is crucial for circulatory stabilization. However, ECMO may be associated with severe complications, including acute limb ischemia. We report a case of a 42-year-old female referred to our center with high-risk pulmonary embolism complicated by obstructive shock and cardiac arrest. Thrombolytic therapy (100 mg of alteplase + 20,000 IU UFH i.v.) was initiated as first-line treatment but did not lead to circulatory stabilization. Therefore, the PERT team was activated and VA-ECMO was initiated. A 19 Fr arterial cannula was inserted via the right femoral artery and a 21 Fr venous cannula via the left femoral vein. Due to anatomical conditions, distal limb perfusion could not be established. Near-infrared spectroscopy (NIRS, Massimo, Irvine, CA, USA) monitoring using two calf and two cerebral sensors was applied as part of standard care in our department. One day after ECMO initiation, a progressive decrease in tissue oxygen saturation of the right lower limb was detected by NIRS, suggesting developing limb ischemia (Fig. 1). However, clinical signs of ischemia were not yet apparent. Hemodynamic stabilization with discontinuation of vasopressors and improvement in echocardiographic findings allowed rapid ECMO weaning. After removal of the arterial cannula, right limb perfusion quickly normalized. Continuous tissue oxygenation monitoring using NIRS is essential for the early detection of limb ischemia and should be considered standard of care in all ECMO patients. It enables early recognition of perfusion impairment and timely intervention before irreversible damage occurs.