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Erschienen in:
19.02.2024 | What's New in Intensive Care
Use of vasopressors and inotropes in ECMO
Erschienen in: Intensive Care Medicine | Ausgabe 3/2024
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Currently, there is a lack of guidelines regarding the administration of vasopressors and inotropes in patients undergoing extracorporeal membrane oxygenation (ECMO). In such clinical scenarios, it is imperative to assess both the clinical context necessitating ECMO initiation and the physiologic alterations induced by or associated with ECMO support. Venoarterial ECMO (VA-ECMO) and venovenous ECMO (VV-ECMO) share contributing factors including severe right and/or left ventricular failure, sepsis, severe ischemia–reperfusion injuries, hemorrhage, vasoplegia and hypoxia (Fig. 1).
Fig. 1
A Contributing factors common to both VA and VV-ECMO. B Specific therapies. Vasoplegia, prevalent in both VA and VV-ECMO, can be severe. The primary vasopressor is NE, with vasopressin as a potential addition to reduce NE requirements or in cases of NE failure. In refractory vasodilatory shock, methylene blue and/or angiotensin-2 may be considered as a salvage therapy. During VA-ECMO, inotropes play a specific role. Dobutamine or milrinone are typically employed as the first-line agent to maintain a certain level of contractility, ensuring the opening of the aortic valve. In some instances, levosimendan, a calcium-sensitizing agent with a long half-life may be useful to facilitate both VA-ECMO weaning and transition to alternative supportive therapies. In VV-ECMO, persistent right ventricular failure during VV-ECMO might necessitate inhaled nitric oxide to reduce pulmonary artery pressure, the use of vasopressors to maintain right ventricular perfusion, and the administration of inotropes. Area of research: Long-term and high-dose exposure to catecholamines are associated with serious side effects especially at the heart level. Notably, in VA-ECMO, a strategy of decatecholamination can be explored by employing non-catecholaminergic vasopressors (vasopressin, angiotensin-2) and inotropes (IPDE3, levosimendan), with or without the addition of landiolol. AVP arginine vasopressin; I/R ischemia–reperfusion; iNO inhaled nitric oxide; IPDE3 phosphodiesterase 3 inhibitor
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