10, 8, 9, 18, 53, 91
The operational spine of VV ECMO liberation. Two findings change behaviour most: ventilator support must be increased before a trial is meaningful, and structured protocols liberate patients safely at support levels clinicians would not have trialled — implying unaided judgement is systematically too conservative. The Red Book's recommendation is that institutions implement a local standardised liberation protocol; the benefit appears to come from standardisation itself, not from any particular protocol.
None — textbook chapter; the chapter itself notes no randomised comparison of weaning methods exists
Structured liberation from VV ECMO — recovery recognition, support down-titration, sweep gas off trial, decannulation
Textbook chapter. The chapter states plainly that no prospective randomised trials comparing weaning methods have been conducted and that the approaches in use are based on expert opinion; clinical efficacy trials of protocolisation are lacking. Every quantitative figure used in Chapter 10 (192-trial study, SIRS incidence, 8-35% infection range, DVT prevalence, 100% COVID series) is cited by this chapter to its own references, none of which were retrieved. The ELSO 2021 VV guideline behind its numeric targets was not read; its DOI and PMID were not verified and are deliberately not recorded. Publication year of the 6th edition not independently confirmed.
Four steps of liberation. Blood flow weans oxygenation (FsO2 titration optional); sweep gas flow weans CO2 removal. Judge CO2 clearance by arterial pH rather than PaCO2 because metabolic compensation of hypercapnia is frequent. Ventilator during weaning: FiO2 30-60%, PEEP at least 5-10 cmH2O, RR 30/min or fewer; volume control tidal volume increased in 1-2 mL/kg PBW steps to a maximum 6-8 mL/kg PBW with plateau 28 cmH2O or less; pressure modes driving pressure no more than 15-20 cmH2O. P-SILI possible whether or not intubated. Sweep gas off trial eliminates ALL extracorporeal support despite blood still flowing, and applies ONLY to VV — dangerous in VA or V-VA. It is the standard of care for predicting successful decannulation; sweep flow thresholds and the 100% oxygen challenge test are less reliable. Pass: within lung-protective bounds, SpO2 at or above 88-92%, PaO2 at or above 70 mmHg, pH at or above 7.30, no new tachycardia/hypertension/hypotension/increased work of breathing. Durations 2-24 h used; a study of 192 trials found no significant blood-gas change after 2 h; ELSO recommends a 2-3 h minimum. Hold anticoagulation at least 30-60 min before decannulation. Full bedside decannulation procedure described. Post-decannulation SIRS 50-60% at 48 h with confirmed infection in only 8-35% of febrile patients and no mortality association absent infection; no evidence for prophylactic antibiotics. DVT prevalence over 60% after decannulation even in anticoagulated patients; Doppler of at least the cannulated vessels at 24 h in all patients.
Adults on VV ECMO for respiratory failure