Ch 28 (s28.15, stopgap); Ch 36; Part VII
A rare instance of a guideline actively discouraging a monitor. The venovenous-versus-venoarterial distinction is the single most useful line in this section: the same haemorrhage produces a different anticoagulation answer depending on the circuit.
Prevent hematoma expansion by blood pressure control and discontinuing systemic anticoagulation; after intracranial haemorrhage, lower blood pressure (systolic under 140 mmHg and mean under 90 mmHg) is preferred because the haemorrhage is anticoagulation-associated. The duration of anticoagulation cessation varies by mode: venovenous ECMO may allow anticoagulation discontinuation until decannulation based on multiple reports of heparin-free venovenous ECMO with a heparin-coated circuit, whereas holding systemic anticoagulation carries a higher risk of thromboembolism with venoarterial ECMO, especially of the circuit. Early cessation without reversal and judicious resumption of anticoagulation with repeated neuroimaging appeared feasible. External ventricular drain insertion is a high-risk procedure associated with intra- and post-procedural bleeding and may be considered only in selected patients at risk of imminent death. Invasive intracranial pressure and brain tissue oxygenation monitoring have not been shown to improve long-term outcomes and may increase the risk of parenchymal haemorrhage in ECMO patients.
Intracranial haemorrhage on ECMO