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Zarragoikoetxea, A. Pajares, I. Moreno, J. Porta, T. Koller, V. Cegarra, A.I. Gonzalez, M. Eiras, E. Sandoval, J. Aurelio Sarralde, B. Quintana-Villamandos, R. Vicente Guillén" "autores" => array:12 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Zarragoikoetxea" "email" => array:1 [ 0 => "iratxezarra@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Pajares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Porta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "T." "apellidos" => "Koller" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "V." "apellidos" => "Cegarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "A.I." "apellidos" => "Gonzalez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "M." "apellidos" => "Eiras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 8 => array:3 [ "nombre" => "E." "apellidos" => "Sandoval" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 9 => array:3 [ "nombre" => "J." "apellidos" => "Aurelio Sarralde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 10 => array:3 [ "nombre" => "B." "apellidos" => "Quintana-Villamandos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 11 => array:3 [ "nombre" => "R." "apellidos" => "Vicente Guillén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso SEDAR/SECCE sobre el manejo de ECMO" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">An ECMO <span class="elsevierStyleItalic">(</span>extracorporeal membrane oxygenator) is a circulatory and respiratory support device indicated in cardiogenic shock and/or respiratory failure refractory to conventional medical treatment. It can be used as a bridge to cardiac and/or pulmonary recovery, transfer to a medium/long-term ventricular assist device, heart or lung transplantation, or to decision. ECMO-related mortality can be as high as 50%–60% in certain contexts, and therefore patient selection, prior treatment and multidisciplinary evaluation are essential<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) created a Circulatory Support Committee made up of anaesthesiologists and cardiovascular surgeons from different hospitals nationwide with extensive experience in perioperative ECMO management. The committee prepared this position statement for the purpose of standardising and improving the care of patients under ECMO. The use of ECMO has increased in contexts such as postcardiotomy shock, organ donation, primary heart graft failure, and bridging to lung transplantation, all of which are closely related to the fields of anaesthesiology, perioperative critical care and surgery. ECMO management in this context requires in-depth knowledge of both surgical and medical pathophysiology, and the interaction between the anaesthesiologist and surgeon is therefore essential.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Working method</span><p id="par0015" class="elsevierStylePara elsevierViewall">Working committees made up of anaesthesiologists and cardiovascular surgeons were created in the framework of the agreement signed between SEDAR and SECCE. The objective of the ECMO committee was to draw up a consensus statement that would help standardise the widely differing approaches to ECMO management. Different task forces were created within the committee to prepare general recommendations, which were subsequently reviewed by all committee members: indications and contraindications, cannulation, special considerations in postcardiotomy shock, organ donation, cardiac primary graft dysfunction (PGD), ECMO as a bridge to lung transplantation, non-cardiac surgery, complications, and ventilation weaning. Given the current SARS-CoV-2 virus pandemic, general recommendations related to COVID and to the management of acute respiratory distress syndrome were also included. A survey was conducted to rate the recommendations and their level of evidence. A recommendation was graded when it was accepted by at least 75% of committee members. If agreement was not reached in the first round, the recommendations was discussed individually until consensus was reached. As ECMO is rarely used the treat COVID-19 patients in most hospitals, committee members were not polled for consensus, and COVID-19-related recommendations were not graded. However, general recommendations were established based on prevailing practice in hospitals with the greatest number of COVID patients and evidence from the literature.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recommendations were rated following the GRADE system (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A B or C level of evidence does not imply a weak recommendation. Some ECMO management topics addressed in this document have not been evaluated in clinical trials or studies; therefore, the committee was unable to award them a grade I recommendation.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">ECMO components</span><p id="par0025" class="elsevierStylePara elsevierViewall">The ECMO circuit consists of the following elements<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,7</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">□</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cannulas and lines: venous drainage cannula (inflow) and arterial reinfusion cannula (outflow). In both veno-venous extracorporeal membrane oxygenation (VV EMCO) and veno-arterial extracorporeal membrane oxygenation (VA ECMO), the arterial cannula provides arterialized (oxygenated) blood. Different manufacturers pre-coat these cannulas with heparin or the molecular component of the cell membrane (phosphorylcholine), which reduces anticoagulation requirements and bleeding complications, and diminishes the inflammatory reaction. The venous line should never be handled and/or opened to ambient air due to the risk of massive air entry.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">□</span><p id="par0035" class="elsevierStylePara elsevierViewall">Pump: A continuous flow centrifugal pump is the most widely used. When adjusting ECMO flow it is important to bear in mind what is being modified are the revolutions per minute (rpm) of this centrifugal pump. Thus, the flow administered will vary at different revolutions, depending on the patient’s preload and afterload. Centrifugal pumps keep the rpm at a constant rate and increase flow when the preload increases or the afterload decreases, and vice versa. There is therefore no need to calculate flow based solely on rpm, and a flow meter must be added to the arterial line.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">□</span><p id="par0040" class="elsevierStylePara elsevierViewall">Membrane lung: the membrane lungs currently used in ECMO are durable and contain polymethylpentene fibres that are resistant to plasma leakage. These fibres extend the life of the oxygenator for several weeks while maintaining good gas exchange.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">□</span><p id="par0045" class="elsevierStylePara elsevierViewall">The console regulates the haemodynamics of the ECMO system: 1) it supplies electromotive force to the oxygenator pump and regulates its power, and 2) it records the information provided by the haemodynamic, biochemical and safety sensors built into the circuit.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">□</span><p id="par0050" class="elsevierStylePara elsevierViewall">The oxygen-air mixer regulates the oxygen/air ratio and the flow of this gas mixture that enters the gas phase of the oxygenator.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">□</span><p id="par0055" class="elsevierStylePara elsevierViewall">The heat exchanger allows the system to be cooled or heated.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Indications and contraindications</span><p id="par0060" class="elsevierStylePara elsevierViewall">Given the high complexity of patients who are candidates for ECMO, the decision to implant such a device must be made by a multidisciplinary specialist team (anaesthesiologist, cardiovascular surgeon, cardiologist, thoracic surgeon, pulmonologist, transplant specialist, critical care specialist, nurse). ECMO systems should be used in tertiary level hospitals that are experienced in their use and have the capacity to resolve any ECMO-related problems<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a>. Mobile ECMO teams made up of various specialists (cardiovascular surgeons, perfusion specialists, anaesthesiologists, critical care specialists, nurses) have been created in both Spain and other European countries, and are in charge of assessing ECMO candidates, performing the implantation, if applicable, and transferring the patient to the referral hospital<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10,11</span></a>.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is difficult to establish the timing of implantation of both VV and VA ECMO, but it must be performed once previous treatments have been implemented and optimized; the decision should be based on accurate haemodynamic and lung function monitoring, and should be made before multi-organ failure is established<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a>. Haemodynamic parameters such as cardiac output (CO), mixed venous oxygen saturation (SVO<span class="elsevierStyleInf">2</span>), pulmonary arterial pressure, and pulmonary capillary pressure (PCP) are used to guide strategies to optimise blood volume and left ventricular (LV) and right ventricular contractility. A pulmonary artery catheter (PAC) can determine the fundamental cause of myocardial dysfunction – left and/or right – and this datum can be used to target treatment (pulmonary vasodilators in the case of pulmonary hypertension and right heart failure). PAC is also useful in the differential diagnosis of entities such as inflammatory response syndrome, which requires a different approach from cardiogenic shock, and can also detect complications during VA ECMO and during ECMO weaning. This will be discussed later. Similarly, echocardiography, despite being a non-continuous monitoring system, plays a key role in both the differential diagnosis of hypotension and in the indication, monitoring and weaning of ECMO. Both monitoring methods give an accurate haemodynamic profile of patients requiring cardiorespiratory care, and their use is therefore recommended in the management of ECMO patients<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a>.</p><p id="par0070" class="elsevierStylePara elsevierViewall">ECMO should not be implanted in patients with contraindication for long-term ventricular assist devices or transplantation, or who are unlikely to recover from organ failure (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">VV or VA ECMO implantation should be performed on the basis of cardiac function, both left and right ventricular. VV ECMO is indicated in patients with isolated respiratory insufficiency, while VA ECMO should be used in the case of ventricular dysfunction.</p><p id="par0080" class="elsevierStylePara elsevierViewall">ECMO can be considered for life support in the following pathologies<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,17–30</span></a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">□</span><p id="par0085" class="elsevierStylePara elsevierViewall">Cardiogenic shock following acute myocardial infarction (AMI).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">□</span><p id="par0090" class="elsevierStylePara elsevierViewall">Fulminant myocarditis.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">□</span><p id="par0095" class="elsevierStylePara elsevierViewall">Decompensated cardiomyopathy.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">□</span><p id="par0100" class="elsevierStylePara elsevierViewall">Postcardiotomy shock.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">□</span><p id="par0105" class="elsevierStylePara elsevierViewall">Primary graft failure after heart or lung transplantation.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">□</span><p id="par0110" class="elsevierStylePara elsevierViewall">Pulmonary thromboembolism with right ventricular dysfunction.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">□</span><p id="par0115" class="elsevierStylePara elsevierViewall">Amniotic fluid embolism.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">□</span><p id="par0120" class="elsevierStylePara elsevierViewall">As a bridge to lung transplantation.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">□</span><p id="par0125" class="elsevierStylePara elsevierViewall">Respiratory failure: acute respiratory distress syndrome (ARDS), chest trauma, status asthmaticus, bronchopleural fistula.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">□</span><p id="par0130" class="elsevierStylePara elsevierViewall">Support during surgical procedures: tracheal surgery, large thoracic tumours, airway obstruction, diaphragmatic hernia repair, liver transplantation, organ donation, coronary intervention, or in arrhythmia ablation procedures.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">□</span><p id="par0135" class="elsevierStylePara elsevierViewall">Sepsis-induced cardiomyopathy.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">□</span><p id="par0140" class="elsevierStylePara elsevierViewall">Reversible intoxication.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">□</span><p id="par0145" class="elsevierStylePara elsevierViewall">Witnessed cardiac arrest with potentially reversible aetiology.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">□</span><p id="par0150" class="elsevierStylePara elsevierViewall">Severe accidental hypothermia.</p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">The following are absolute contraindications<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">□</span><p id="par0160" class="elsevierStylePara elsevierViewall">Terminal chronic illness.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">□</span><p id="par0165" class="elsevierStylePara elsevierViewall">Active malignancy.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">□</span><p id="par0170" class="elsevierStylePara elsevierViewall">Irreversible neurological damage.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">□</span><p id="par0175" class="elsevierStylePara elsevierViewall">Sepsis with multi-organ failure.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">□</span><p id="par0180" class="elsevierStylePara elsevierViewall">VA ECMO is contraindicated in severe aortic regurgitation.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">□</span><p id="par0185" class="elsevierStylePara elsevierViewall">VA ECMO is contraindicated in untreated aortic dissection.</p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">The following are relative contraindications:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">□</span><p id="par0195" class="elsevierStylePara elsevierViewall">Age: the use of ECMO in elderly patients is controversial, but the indication, the functional status of the patient, and the outcomes achieved in each hospital may determine whether ECMO is implanted<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">□</span><p id="par0200" class="elsevierStylePara elsevierViewall">Obesity: there is currently no absolute contraindication for ECMO implantation in obese patients, although management may be more complex both during implantation and oxygenation<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">□</span><p id="par0205" class="elsevierStylePara elsevierViewall">Contraindications for heparin anticoagulation.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">□</span><p id="par0210" class="elsevierStylePara elsevierViewall">VA ECMO is contraindicated in peripheral artery disease.</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Cannulation</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">VA ECMO</span><p id="par0215" class="elsevierStylePara elsevierViewall">Blood is drained from the right atrium (via a central or peripheral cannula) and oxygenated blood is reinfused into the arterial system (peripheral or central)<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,34</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">□</span><p id="par0220" class="elsevierStylePara elsevierViewall">Central cannulation: can be considered in postcardiotomy shock where separation from extracorporeal circulation is impossible<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>. In this configuration, the ECMO flow is antegrade (from the heart to the periphery) and prevents Harlequin syndrome (see Complications). The venous cannula is placed in the right atrium and the arterial cannula in the ascending aorta. Although the presence of sternotomy in patients with postcardiotomy shock would permit central cannulation, peripheral cannulation is more commonly used because it is less likely to cause bleeding<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">□</span><p id="par0225" class="elsevierStylePara elsevierViewall">Peripheral cannulation: by percutaneous or surgical access. Femoral access is the first choice due to its accessibility and speed. This route should be considered in patients with cardiogenic shock refractory to catecholamines and/or intra-aortic balloon pump (IABP) placement in the immediate postoperative period of cardiac surgery, cardiogenic shock (acute coronary syndrome, myocarditis, exacerbation of chronic heart failure) or in primary heart/lung graft failure. Most authors choose open over percutaneous cannulation - fewer complications, and even greater survival have been reported with open cannulation<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,37,38</span></a>. A mixed approach, involving exposing the femoral vessels surgically and tunnelling the cannulas through a counterincision, allows the femoral incision to be closed and reduces the risk of bleeding and infection at the insertion site. Alternatively, cannulation of the femoral artery can be performed through an end-to-side Dacron graft sutured to the artery. During decannulation it may be necessary to repair and patch angioplasty of the femoral artery<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,40</span></a>.</p></li></ul></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">Inserting the cannula directly into the subclavian artery or interposing a vascular graft is the first choice when the femoral vessels are not suitable for cannulation. Subclavian artery and jugular vein cannulation using a venous cannula advanced to the right atrium also has the advantage of allowing early mobilization, active rehabilitation, and avoiding Harlequin syndrome (see Complications)<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41,42</span></a>.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Since the femoral artery cannula can cause ischaemia in the implanted limb, an additional arterial cannula (∼10 Fr) must be inserted for adequate perfusion<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Performing percutaneous cannulation under ultrasound guidance can help rule out anatomical abnormalities and avoid vascular complications. It can also help estimate the size of the cannulas to be implanted, and is therefore recommended during ECMO implantation<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,39,43</span></a>.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">VV ECMO</span><p id="par0245" class="elsevierStylePara elsevierViewall">In VV ECMO, percutaneous implantation using the Seldinger technique is the gold standard (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">□</span><p id="par0250" class="elsevierStylePara elsevierViewall">Two-cannula technique:</p></li></ul></p><p id="par0255" class="elsevierStylePara elsevierViewall">Femoral-jugular approach: blood is drained from the inferior vena cava (IVC) via a multi-perforated cannula introduced through the femoral vein, and oxygenated blood is reinfused into the right atrium through a cannula in the right internal jugular vein.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Femoral-femoral: blood is drained from the IVC through a multi-perforated venous cannula, usually implanted in the left femoral vein with the tip located 10 cm below the cavoatrial junction, and is reinfused through a cannula a single distal orifice inserted into the contralateral femoral vein and positioned in the right atrium<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>.<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">□</span><p id="par0265" class="elsevierStylePara elsevierViewall">Single cannula technique:</p></li></ul></p><p id="par0270" class="elsevierStylePara elsevierViewall">An Avalon Dual Lumen Cannula® is inserted through the right internal jugular vein. One lumen allows deoxygenated blood from the IVC and the superior vena cava to drain from 2 ports, and a second lumen allows the oxygenated blood to return to the right atrium toward the tricuspid valve. The advantages of this system are: single point of entry, possibly less recirculation, and early patient mobilization. The disadvantages are: difficult implantation, limited flows, and potential for cardiac injury<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>.</p><p id="par0275" class="elsevierStylePara elsevierViewall">Transoesophageal ultrasound (TOE) guidance is recommended during the two-cannula technique, and is essential in the case of the single cannula technique (see Ultrasound in ECMO)<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,45–50</span></a>.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">VV ECMO in acute respiratory distress syndrome</span><p id="par0280" class="elsevierStylePara elsevierViewall">Recent evidence has shown that specific interventions, such as recruitment manoeuvres, neuromuscular nerve block, and prone positioning can improve oxygenation and reduce mortality in patients with severe ARDS<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>. However, the mortality rate in the subgroup of patients with severely impaired gas exchange despite all the aforementioned interventions is over 80%. The CESAR (Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure) clinical trial reported better outcomes in patients with ARDS treated with ECMO compared to conventional treatment<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>. However, due to certain methodological shortcomings, the level of evidence to support this finding is too low to warrant a recommendation. The controversy surrounding the benefit of treating ARDS with VV ECMO in the most seriously ill patients continued in the EOLIA (ECMO to Rescue Lung Injury in Severe ARDS) study, in which 60-day mortality among patients with severe ARDS was not significantly lower with ECMO compared with conventional mechanical ventilation (MV), although ECMO was used as rescue therapy in the latter group<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. In patients with severe ARDS, ECMO provides prolonged respiratory support and maintains protective lung ventilation while awaiting recovery of lung function<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53,54</span></a>.</p><p id="par0285" class="elsevierStylePara elsevierViewall">ECMO is considered "rescue therapy" in respiratory failure refractory to other measures that must always include the use of protective mechanical ventilation, and at least one attempt at prone positioning, unless contraindicated<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,51,54–57</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>):<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">□</span><p id="par0290" class="elsevierStylePara elsevierViewall">PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> < 60 for 6 h or persistence of PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> < 50 for 3 h, pH < 7.2 and PaCO<span class="elsevierStyleInf">2</span> > 80 mmHg over 6 h (FiO<span class="elsevierStyleInf">2</span> 100%).</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">□</span><p id="par0295" class="elsevierStylePara elsevierViewall">In patients with hypercapnic respiratory failure, the indications are PaCO<span class="elsevierStyleInf">2</span> > 80 mmHg or inability to ventilate while maintaining plateau pressure < 30 cmH<span class="elsevierStyleInf">2</span>O or CO<span class="elsevierStyleInf">2</span> retention despite plateau pressure > 30 cmH<span class="elsevierStyleInf">2</span>OR.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">□</span><p id="par0300" class="elsevierStylePara elsevierViewall">Patient on protective MV (tidal volume 6 ml/kg ideal) with differential pressure (plateau pressure-PEEP) < 15 cmH<span class="elsevierStyleInf">2</span>O with optimal PEEP.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">□</span><p id="par0305" class="elsevierStylePara elsevierViewall">Respiratory failure refractory to neuromuscular block in continuous infusion, failure of MV in prone position.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">□</span><p id="par0310" class="elsevierStylePara elsevierViewall">Reconsider/reassess whether the cause of respiratory failure is potentially reversible.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">□</span><p id="par0315" class="elsevierStylePara elsevierViewall">Murray score > 3<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p></li></ul></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0320" class="elsevierStylePara elsevierViewall">Once ECMO support has started, protective or ultra-protective ventilation should be maintained<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51,58–60</span></a>.</p><p id="par0325" class="elsevierStylePara elsevierViewall">Relative contraindications to VV ECMO in ARDS are<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">□</span><p id="par0330" class="elsevierStylePara elsevierViewall">VM > 7 days with airway pressure > 30 cmH<span class="elsevierStyleInf">2</span>0 and FiO<span class="elsevierStyleInf">2</span> > 90%.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">□</span><p id="par0335" class="elsevierStylePara elsevierViewall">Advanced age (>65 years).</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">□</span><p id="par0340" class="elsevierStylePara elsevierViewall">Body mass index > 45.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">□</span><p id="par0345" class="elsevierStylePara elsevierViewall">Contraindication for anticoagulation.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">□</span><p id="par0350" class="elsevierStylePara elsevierViewall">Central nervous system bleeding.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">□</span><p id="par0355" class="elsevierStylePara elsevierViewall">Severe immunodeficiency.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">ECMO in COVID-19</span><p id="par0360" class="elsevierStylePara elsevierViewall">Between 15% and 20% of patients with SARS-CoV-2 infection become seriously ill, and between 5% to 15% require admission to a critical care unit, depending on the series<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61–65</span></a>. According to reports, only 3% or 4% of patients in critical care units required VV ECMO during the first wave of the pandemic, and the use of VA ECMO has only been reported in specific cases. Currently, the mortality rate of patients with COVID-19 and refractory ARDS treated with ECMO is as high as 82.3% in series published in China<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65,66</span></a>.</p><p id="par0365" class="elsevierStylePara elsevierViewall">COVID-19 has been associated with a higher incidence of cardiovascular complications, such as AMI, fulminant myocarditis, ventricular arrhythmias, or pulmonary thromboembolism compared to other respiratory syndromes such as severe ARDS and Middle East respiratory syndrome<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61,67,68</span></a>. Although there is currently limited experience and scant scientific evidence, various guidelines have recommended the use of VV and VA ECMO in COVID-19 patients with ARDS/ refractory cardiogenic shock<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a>.</p><p id="par0370" class="elsevierStylePara elsevierViewall">The status of COVID-19 patients receiving ECMO must by continually reassessed. The following factors must be considered, and may determine the number of implanted devices:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">□</span><p id="par0375" class="elsevierStylePara elsevierViewall">The pressure of care.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">□</span><p id="par0380" class="elsevierStylePara elsevierViewall">Availability of trained personnel and ECMO devices.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">□</span><p id="par0385" class="elsevierStylePara elsevierViewall">Hospital management policy.</p></li></ul></p><p id="par0390" class="elsevierStylePara elsevierViewall">Given the expected shortage of resources during the pandemic, it is reasonable to prioritize younger patients with fewer comorbidities and better prognosis, and apply the standard absolute contraindications of VV-ECMO in ARDS indicated by EOLIA and ELSO (Extracorporeal Life Support Organization)<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a>.</p><p id="par0395" class="elsevierStylePara elsevierViewall">The personnel involved in ECMO implantation and management of COVID-19 patients must follow the recommendations and precautions established by the World Health Organization to prevent transmission of the infection<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>.</p><p id="par0400" class="elsevierStylePara elsevierViewall">In terms of centres with ECMO implantation capacity, patients should be concentrated in high-volume hospitals with extensive experience, so that these centres can provide care to secondary hospitals. ELSO recommends not starting new ECMO programs for the sole purpose of treating COVID-19 patients. ECMO is extremely complex and must be managed by a highly qualified team; therefore, its use should be limited to high-volume specialised hospitals, particularly in a pandemic situation in which resources are in short supply<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a>. The indications for the initiation and withdrawal of this therapy may differ when resources are limited; therefore, implantation centres must be prepared to adapt to different scenarios. According to recommendations, ECMO therapy should be withdrawn when there is no sign of either cardiac or pulmonary function recovery after approximately 21 days, particularly when resources are limited (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>)<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66,71,72</span></a>.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">VV ECMO</span><p id="par0405" class="elsevierStylePara elsevierViewall">ELSO recommends using EOLIA trial criteria for the indication of VV ECMO in patients with refractory ARDS receiving MV for less than 7 days. ECMO should be implanted as soon as possible in patients who meet the foregoing criteria.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">VA ECMO</span><p id="par0410" class="elsevierStylePara elsevierViewall">Implantation of VA ECMO can be considered in patients with circulatory compromise secondary to cardiac dysfunction refractory to the usual measures. The usual indications for VA ECMO should be followed, taking into account that risk factors associated with little benefit or poor outcome have been reported in patients with COVID-19<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a>:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">□</span><p id="par0415" class="elsevierStylePara elsevierViewall">Advanced age</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">□</span><p id="par0420" class="elsevierStylePara elsevierViewall">Sepsis.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">□</span><p id="par0425" class="elsevierStylePara elsevierViewall">Mixed or predominantly vasoplegic shock</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">□</span><p id="par0430" class="elsevierStylePara elsevierViewall">Prothrombotic status.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">□</span><p id="par0435" class="elsevierStylePara elsevierViewall">Concomitant ARDS.</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">□</span><p id="par0440" class="elsevierStylePara elsevierViewall">Multi-organ failure.</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">□</span><p id="par0445" class="elsevierStylePara elsevierViewall">High risk scores (SOFA, SAVE).</p></li></ul></p><p id="par0450" class="elsevierStylePara elsevierViewall">Due to the hypercoagulable status of these patients, setting a higher than usual activated clotting time (ACT) target (∼ 180) on ECMO may be considered. In the absence of evidence from large studies, the systematic administration of antiplatelet drugs cannot be recommended; however, this can be considered when frequent membrane changes are needed and/or in patients with thrombi. Echocardiography in this context is essential to determine the cardiovascular diagnosis and rule out COVID-related intravascular and intracavitary thrombi<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a>.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">ECMO in postcardiotomy shock</span><p id="par0455" class="elsevierStylePara elsevierViewall">Postcardiotomy shock in which disconnection from the cardiopulmonary bypass pump (CPB) is not tolerated leads to high mortality<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,73,74</span></a>. Disconnection from CPB can be difficult in 10%–45% of patients, and approximately 1% of patients present refractory cardiogenic shock<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75,76</span></a>. Despite VA ECMO implantation, published survival rates range from 16% to 52%, and overall survival is less than 40% in most hospitals<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>. A recent review of ECMO for postcardiotomy shock found a mortality rate of 60%, being the most frequent of all indications for VA ECMO<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a>. Multiple survival prediction scores for VA ECMO have been developed, including as SAVE (Survival after VA ECMO<span class="elsevierStyleItalic">)</span><a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> – created specifically for VA ECMO patients – and REMEMBER (Predicting Mortality in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenator after Coronary Artery Bypass Grafting)<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> – for patients on VA ECMO undergoing coronary revascularization. These scores can be used to select patients who are most likely to benefit from VA ECMO implantation. It is important to bear in mind that scores published to date have been created in specific populations (non-cardiac surgery, AMI, isolated coronary surgery), and may not be extrapolatable to patients with postcardiotomy shock.</p><p id="par0460" class="elsevierStylePara elsevierViewall">Despite numerous published studies, there are still no uniform criteria for defining postcardiotomy shock, and therefore for deciding when to indicate VA ECMO<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80,81</span></a>. Similarly, there is no mention in the literature of the maximum dose of inotropics to be administered in ECMO implantation in this context, and several authors recommend different timing for mechanical assist device implantation. Despite the lack of consensus between hospitals, maintaining vasoactive and inotropic drugs for more than 24 h after cardiac surgery has been associated with in-hospital mortality<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82–85</span></a>. The VIS score (vasoactive-inotropic score) was recently formulated to classify patient as low, moderate and high risk for mortality on the basis of the highest doses of vasoactive and inotropic drugs administered during the first 24 h post surgery<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a>. Subsequent studies have been performed to determine the VIS score that would indicate the need for early implantation of VA ECMO, thus reducing inotrope dosage and reducing the incidence of in-hospital mortality<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a>.</p><p id="par0465" class="elsevierStylePara elsevierViewall">Based on our experience and on different studies that have attempted to standardise the definition and management of low cardiac output syndrome and postcardiotomy shock, we defined refractory postcardiotomy shock as follows: persistent uni- or biventricular dysfunction that makes CPB disconnection impossible despite adequate control of temperature, rhythm, ionic changes and circulating volume, or postoperative cardiogenic shock presenting with cardiac index (CI) < 2 l/min/m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and hypotension defined as systolic blood pressure (SBP) < 90 mmHg or mean arterial pressure (MAP) < 60 mmHg, despite adequate volume replacement, high doses of inotropic agents (dobutamine > 20 mcg/kg/min; noradrenaline > 1 mcg/kg/min; adrenalin > 0.15 mcg/kg/min), intra-aortic balloon pump (IABP), resulting in organ damage, oliguria and/or elevated lactate<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">88–90</span></a>. Recent studies do not recommend IABP implantation in postcardiotomy shock if it will delay implantation of ECMO, particularly in the case of severe biventricular dysfunction, impossibility of CPB disconnection, and above all in the case of severe right ventricular dysfunction<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a>, and emphasise the need for ECMO implantation before multi-organ failure occurs. Likewise, in patients presenting hypotension in the immediate postoperative period it is essential to rule out complications, such as cardiac tamponade, systemic inflammatory response syndrome, dynamic LV outflow tract obstruction and/or hypovolaemia. Various authors recommended using different monitoring methods such as transthoracic or transoesophageal echocardiography, pulmonary artery catheter or transpulmonary dilution to rule out these complications and accurately characterise postcardiotomy shock (LV or right ventricular (RV) dysfunction, valvular heart disease, chamber diameters)<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,90–92</span></a>.</p><p id="par0470" class="elsevierStylePara elsevierViewall">VA ECMO, therefore, can be considered as a bridge to decision, recovery, transplantation or implantation of medium or long-term ventricular assist devices in postcardiotomy shock<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,19,36</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). In this context, the high flow rate provided by central cannulation has the advantage of avoiding increased LV afterload and Harlequin syndrome, and can be implanted while maintaining surgical cannulation. The main drawback of this type of cannulation is the high incidence of bleeding, which can lead to re-operation in up to 100% of cases; this is why peripheral cannulation, even in patients with a history of sternotomy, is more frequent in the studies published so far<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35–38</span></a>. Peripheral cannulation has a lower incidence of bleeding and reoperation, and also facilitates early extubation; however, it is associated with femoral artery and vein-related complications (infection, lymphocele, arterial ischaemia, venous thrombosis) and a greater increase in LV afterload<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,36</span></a>. The type of postoperative cannulation chosen should be based on the timing of cardiogenic shock (disconnected or not from CPB or within the first 24–48 postoperative hours), the quality of peripheral arterial vessels and the level of expertise of the medical team<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">ECMO in organ donation</span><p id="par0475" class="elsevierStylePara elsevierViewall">Preservation of abdominal organs with normothermic perfusion in the context of donation after circulatory death (DCD) is currently the technique of choice, and has shown better outcomes in terms of graft function, fewer post-transplant complications, shorter hospital stay, and better graft survival than other preservation techniques<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,94</span></a>. This approach to abdominal organs preservation facilitates intraoperative evaluation, biopsy, permits organ perfusion for up to several hours to mitigate the deleterious effects of ischaemia-reperfusion, and therefore helps to improve abdominal graft function. Although the differences between controlled and uncontrolled DCD will not be discussed in this position statement, a number of key points need to be taken into consideration when deciding on ECMO implantation and management in this context<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a>.</p><p id="par0480" class="elsevierStylePara elsevierViewall">The use of ECMO in controlled DCD (cDCD) is limited to VA ECMO. The special features of ECMO in organ donation are listed below:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">1</span><p id="par0485" class="elsevierStylePara elsevierViewall">In both controlled and uncontrolled DCD (uDCD), implant a Fogarty balloon in the supracoeliac aorta to avoid coronary and cerebral reperfusion when starting normothermic preservation with ECMO.</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">2</span><p id="par0490" class="elsevierStylePara elsevierViewall">Cannulate the left radial artery to check correct positioning and inflation of the balloon so that the Fogarty can be inflated and perfusion started from the ECMO once death has occurred and the 5-minute wait time required by Spanish legislation to determine death has elapsed. In this way, continuous pressure will be obtained in the femoral line and no flow in the left radial artery<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">3</span><p id="par0495" class="elsevierStylePara elsevierViewall">Open or percutaneous ECMO cannulation can be performed in both cDCD and uDCD. In the case of cDCD, the cannulation site must be defined in the protocol implemented in each hospital, operating room or critical care unit.</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">4</span><p id="par0500" class="elsevierStylePara elsevierViewall">The starting dose of heparin is 3 mg/kg; ACT should be monitored in case reheparinization is required.</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">5</span><p id="par0505" class="elsevierStylePara elsevierViewall">The ideal duration of organ perfusion in cDCD is unclear, and can vary from between 90 to 120 min and up to 6 h in uDCD. Throughout this process, ECMO flows and pressures, temperature, haematocrit and ions should be monitored, and samples should be drawn every 20 min for liver and kidney panels<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">6</span><p id="par0510" class="elsevierStylePara elsevierViewall">The flow rate needed to perfuse the abdominal viscera is lower than in therapeutic ECMO, and a rate of 1.7–2.5 l/min/m<span class="elsevierStyleSup">2</span> is usually sufficient to maintain adequate visceral perfusion<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">ECMO in primary heart graft dysfunction</span><p id="par0515" class="elsevierStylePara elsevierViewall">Primary graft dysfunction (PGD) is a complication that occurs in the immediate postoperative period of heart transplantation, with an incidence between 3%–30% and a mortality rate of 40%–50%<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96,97</span></a>. PGD can originate in the LV, RV, or both. Implantation of ECMO should be considered in patients with severed PGD refractory to treatment with inotropics, vasoconstrictors and pulmonary vasodilators<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>).</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><p id="par0520" class="elsevierStylePara elsevierViewall">ECMO, compared with a ventricular assist device, is more easily implanted and is associated with a lower rate of kidney failure and improved clinical outcomes<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a>. Survival outcomes are promising, with results at 1 year being similar to those in patients without PGD<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a>. When ECMO is implanted for PGD, mortality is lower (51.6%) than for any other aetiology (69.1%)<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,101</span></a>.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">ECMO in lung transplantation</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Pretransplant ECMO</span><p id="par0525" class="elsevierStylePara elsevierViewall">Despite sophisticated MV techniques, hypoxaemia and/or hypercapnia can be refractory in patients on the lung transplant waiting list<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102,103</span></a>. Considerable experience has been gained in supporting patients on spontaneous ventilation and ECMO, and survival is now longer compared to patients undergoing MV<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102,104–107</span></a>, since active participation in pre-transplant physiotherapy improves post-transplant outcomes.</p><p id="par0530" class="elsevierStylePara elsevierViewall">ECMO may be indicated as follows, depending on the baseline pathology (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>):<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">□</span><p id="par0535" class="elsevierStylePara elsevierViewall">VV ECMO: severe hypoxaemia or hypercapnia resulting in respiratory acidosis.</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">□</span><p id="par0540" class="elsevierStylePara elsevierViewall">VA ECMO: right ventricular failure, persistent pulmonary hypertension despite adequate antihypertensive (pulmonary) therapy and/or heart failure.</p></li></ul></p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><p id="par0545" class="elsevierStylePara elsevierViewall">Outcomes are usually unfavourable in patients who present or develop multiple organ failure, particularly liver failure, and the indication for extracorporeal support should be evaluated by a multidisciplinary team specialised in perioperative lung transplantation<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">104,108,109</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Intraoperative ECMO</span><p id="par0550" class="elsevierStylePara elsevierViewall">Cardiopulmonary bypass has traditionally been used during hypoxaemia/hypercapnia and haemodynamic instability that can occur during one-lung ventilation. Current evidence has shown that ECMO is associated with lower transfusion rates, shorter time on ventilation and critical care unit stay, and a lower 3-month lower mortality rate than CPB<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">83,110–112</span></a>. In addition, ECMO is more versatile during surgery and allows comprehensive perioperative management<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a>. With ECMO, reperfusion of the lung can be delayed and controlled, reducing reperfusion pressure and the risk of PGD<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a> and allowing protective MV. Survival rates are similar to patients undergoing lung transplantation without circulatory support<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">111</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p><p id="par0555" class="elsevierStylePara elsevierViewall">The indications for intraoperative ECMO are:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">□</span><p id="par0560" class="elsevierStylePara elsevierViewall">Refractory hypoxaemia (PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> < 80 mmHg).</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">□</span><p id="par0565" class="elsevierStylePara elsevierViewall">Haemodynamic instability (CI < 1.8−2 l/m/m<span class="elsevierStyleSup">2</span>, PCP > 20 mmHg, SBP < 90 mmHg).</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">□</span><p id="par0570" class="elsevierStylePara elsevierViewall">Suprasystemic pulmonary artery pressure.</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">□</span><p id="par0575" class="elsevierStylePara elsevierViewall">Impossibility of performing protective lung ventilation.</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Postoperative ECMO</span><p id="par0580" class="elsevierStylePara elsevierViewall">The presence of complications, such as PGD, hyperacute rejection, and haemodynamic alterations, are the main indications for ECMO implantation, and it is indicated when conventional treatments (MV, nitric oxide) fail<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,114–118</span></a>.</p><p id="par0585" class="elsevierStylePara elsevierViewall">VV-ECMO should be initiated early to provide protective lung ventilation and thus avoid MV-induced lung injury. VA ECMO should be used in patients presenting severe haemodynamic impairment despite appropriate treatment<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,118,119</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">ECMO in non-cardiac surgery</span><p id="par0590" class="elsevierStylePara elsevierViewall">Following technological advances and accumulated experience in management and cannulation strategies, ECMO is now used for cardiorespiratory assistance in various non-cardiac surgery procedures, such as thoracic surgery, abdominal surgery and even in obstetric complications. Although the use of ECMO in these contexts is minimal compared to cardiology or cardiac surgery, treating physicians should bear in mind that although recommendations for ECMO in these cases are based on patient series, it can be used safely if the following monitoring and management recommendations are applied.<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">□</span><p id="par0595" class="elsevierStylePara elsevierViewall">Thoracic surgery: cardiovascular and respiratory management during tracheal surgery, excision of large mediastinal or pulmonary tumours, surgical repair of severe penetrating chest trauma, airway obstruction and/or haemorrhage, among others, can be challenging, and the support (respiratory or cardiorespiratory) required can be provided by VV or VA ECMO, respectively<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">120,121</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">□</span><p id="par0600" class="elsevierStylePara elsevierViewall">Abdominal surgery: in abdominal surgery, ECMO can be used both intra- and postoperatively during liver transplantation in patients with technical difficulties, poor tolerance of standard techniques (total clamping of the inferior cava), or in patients with cardiorespiratory involvement. In these patients, a Y-connector can be attached to the femoral cannula in the standard VV cannulation (jugular or femoral) to collect the portal flow<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">122,123</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">□</span><p id="par0605" class="elsevierStylePara elsevierViewall">Obstetrics: the use of ECMO in the field of obstetrics has been described in series of patients diagnosed with ARDS, amniotic fluid embolism, peripartum cardiomyopathy or exacerbation of pre-existing heart disease. In this setting, caesarean section is the gold standard, and the use of neuraxial anaesthesia is relatively contraindicated<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">121,124</span></a>.</p></li></ul></p><p id="par0610" class="elsevierStylePara elsevierViewall">Implantation and management of ECMO should be evaluated by a multidisciplinary team that should include thoracic, gastrointestinal/liver surgeons, obstetricians and specialist anaesthesiologists together with cardiac surgeons, cardiac anaesthesiologists, perfusionists and neonatologists<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a>. Postoperative management should be performed in postoperative critical care units with experience in ECMO.</p><p id="par0615" class="elsevierStylePara elsevierViewall">Anticoagulation management in these patients is complex and special circumstances must be borne in mind, such as the increased risk of disseminated intravascular coagulation in the case of amniotic fluid embolism<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> or the risk of severe bleeding, head trauma, or spinal cord injury in the case of multiple trauma<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0050">Table 10</a>).</p><elsevierMultimedia ident="tbl0050"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Surgery or other procedures in a patient on ECMO</span><p id="par0620" class="elsevierStylePara elsevierViewall">Patients with VV or VA ECMO may require other procedures during their hospital stay, such as abdominal surgery, thoracic surgery, tracheostomy or endoscopy.</p><p id="par0625" class="elsevierStylePara elsevierViewall">Before transferring the patient (if needed for the procedure), the EMCO should be checked to ensure that the cannulas and vascular accesses are in the correct position and the airway is secured. It is also important to ensure that there is adequate battery supply and the oxygen cylinders are full. The following are the main complications that may occur during transfer, while positioning the patient on the operating table, or during the intervention (<a class="elsevierStyleCrossRef" href="#tbl0055">Table 11</a>):<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">□</span><p id="par0630" class="elsevierStylePara elsevierViewall">Risk of decannulation due to transfer and positioning in the operating room. The patient must be correctly positioned to avoid kinking and pulling on the cannulas. If the patient is to be placed in lateral decubitus and/or anti-Trendelenburg position, a fluid bolus can be administrated to prevent a decrease in preload with the resulting decrease in blood flow. ECMO is not an absolute contraindication for prone positioning, but the risk of decannulation, bleeding at insertion sites, kinking of the tubes, or incidents involving the airway or vascular accesses is greater<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">126</span></a>. If laparoscopic surgery is performed, pneumoperitoneum should be started slowly progressively.</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">□</span><p id="par0635" class="elsevierStylePara elsevierViewall">There should be sufficient trained staff in the operating room to re-position the patient. In the event of accidental decannulation, the cannulas should be clamped, the patient ventilated, and catecholamines and vasopressors administered while another system is flushed and the patients is re-cannulated.</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">□</span><p id="par0640" class="elsevierStylePara elsevierViewall">Risk of postoperative thrombosis and/or bleeding. Unfractionated heparin should be suspended 4 h before surgery, and high flow rates (> 2 l/min) should be maintained to minimize the risk of thrombosis. Vitamin K, fresh plasma, or prothrombotic complex is not recommended for reversal of anticoagulation, unless the risk of surgery-induced bleeding is very high. The platelet count should be corrected based on bleeding risk, and red blood cells, plasma, and platelets should be ordered in advance. It is not generally recommended to restart anticoagulation until at least 6−8 h after surgery. When started, dosage should initially be low, and the risk/benefit of administering anticoagulation should always be weighed up taking into consideration the surgical site and level of surgical aggression<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">127</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">□</span><p id="par0645" class="elsevierStylePara elsevierViewall">Risk of infection. If the patient is receiving antibiotic treatment at the time of surgery, it is recommended to continue with the same regimen and broaden the spectrum if greater protection is required. ECMO patients have a higher volume of distribution, and it may therefore be necessary to increase the loading doses of the drugs administered<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">□</span><p id="par0650" class="elsevierStylePara elsevierViewall">Haemodynamic and/or respiratory changes. In VA ECMO, the goal is to maintain MAP > 60 mmHg (see Perfusion, oxygenation and ventilation). General anaesthesia should be performed using a bispectral index to monitor anaesthesia depth, since surgical stimulation is the main cause of intraoperative arterial hypertension in these patients. Locoregional anaesthesia, though not contraindicated, is not recommended since these patients are under the effects of anticoagulant drugs. There is no gold standard general anaesthesia induction agent, but one that causes the least vasodilation should be chosen, and anaesthesia should be administered slowly and carefully. It may be necessary to administer a vasoconstrictor after induction.</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">□</span><p id="par0655" class="elsevierStylePara elsevierViewall">Arrhythmias can cause haemodynamic changes despite ECMO support, so they must be treated both pharmacologically and electrically if necessary. In the event of cardiorespiratory arrest, resuscitation should be performed according to prevailing guidelines, taking care not to dislodge the ECMO cannulas during the manoeuvres.</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">□</span><p id="par0660" class="elsevierStylePara elsevierViewall">Continuous monitoring, including cardiac output, should be performed. In patients on VA ECMO, continuous monitoring with TOE is recommended throughout surgery.</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">□</span><p id="par0665" class="elsevierStylePara elsevierViewall">Previously established protective MV parameters should be maintained and adjusted according to serial blood gas measurements. Ventricular function should be assessed if haemodynamics deteriorate with VV ECMO, since cardiovascular function is not assisted in this modality.</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">□</span><p id="par0670" class="elsevierStylePara elsevierViewall">Console alarms. In the event of a decrease in preload (bleeding, position, the patient’s expiratory effort, compression during surgical manoeuvres, excessive rpm, kinking/thrombosis in the venous cannula) negative pressure can generate suction in the venous cannula. In this case, the rpm should be reduced, fluids and or vasoconstrictors should be administered, and the patient’s position. The rpm can be increased once preload has been restored. It is important to connect the device to the power source and the oxygen and air intakes to the gas system. The pressure in the arterial cannula may also increase in the event of kinking/thrombosis or significant arterial hypertension. In the event of any variation in pressure in the console, the cannula entry sites and their position should be checked first. The air bubble alarm will be activated if air enters the circuit during the intervention (valves, decannulation, central line). If the air bubble is large, the device must be clamped, the patient must be placed in the anti-Trendelenburg position, and full ventilatory and cardiovascular support administered. The presence of ECMO specialists (perfusionist/cardiovascular surgeon/critical care specialists) is recommended during transfer and intervention<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p></li></ul></p><elsevierMultimedia ident="tbl0055"></elsevierMultimedia></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Management during support and complications</span><p id="par0675" class="elsevierStylePara elsevierViewall">In addition to the complications typically encountered in critically ill patients, such as organ dysfunction (kidney, liver) and infection, patients on ECMO are particularly at risk for the following:</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Coagulopathy: bleeding and thrombosis</span><p id="par0680" class="elsevierStylePara elsevierViewall">Although modern ECMO circuits are coated with heparin and are therefore less thrombogenic, patients with these devices will need anticoagulation therapy. Although femoral cannulation has significantly reduced the incidence of bleeding (35%)<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">129</span></a>, it is still the most frequent complication in ECMO for postcardiotomy shock and can be life-threatening<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">130</span></a>. (<a class="elsevierStyleCrossRef" href="#tbl0060">Table 12</a>)</p><elsevierMultimedia ident="tbl0060"></elsevierMultimedia><p id="par0685" class="elsevierStylePara elsevierViewall">To reduce or prevent bleeding and coagulopathy, the start of postoperative heparin administration should be delayed for 12−48 h, and should not be started if there is active bleeding, provided high flows are maintained (> 2–2.5 l/min) to avoid clot formation in the circuit<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,129,130</span></a>. In the event of massive, life-threatening bleeding, anticoagulation should be stopped<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84,131–133</span></a>, targeted blood transfusion should be started based on an established transfusion protocol<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">134–136</span></a> and, in the case of intractable life-threatening bleeding, prothrombin complex and factor VIIa can be administered, although there are reports of these products causing ECMO circuit thrombosis<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">137,138</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0065">Table13</a>).</p><elsevierMultimedia ident="tbl0065"></elsevierMultimedia><p id="par0690" class="elsevierStylePara elsevierViewall">Unfractionated heparin is the most widely used anticoagulant to prevent clotting in both the ECMO circuit and the heart. Administration must be monitored to maintain activated clotting time (ACT) at 160–180 and activated partial thromboplastin time (APTT) at 1.5−2 times baseline level<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Administration of a heparin reversal agent for cannulation is not indicated if peripheral percutaneous cannulation is performed without prior surgery. If central or peripheral cannulation is performed in the presence of a recently closed sternotomy, anticoagulant reversal agents should be administered.</p><p id="par0695" class="elsevierStylePara elsevierViewall">Some authors have reported series of patients anticoagulated with low molecular weight heparin (LMWH) and monitored with Anti Xa<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">139</span></a>. The combination of a specific plasma heparin test (anti Xa, APTT) with general whole blood tests (ATC, thermoelectrometry) could be superior to a single testing method<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">133,140–151</span></a>.</p><p id="par0700" class="elsevierStylePara elsevierViewall">If the ACT/APTT target is not reached, antithrombin levels can be routinely monitored for a target level of 80%–120%. If low, they can be supplemented with different agents<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,147</span></a>. Patients, particularly those on long-term ECMO, should also be monitored for haemolysis caused by circuit clotting, in which case the centrifugal pump and the oxygenator must be changed<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Daily monitoring with D-dimers can be useful to detect high clotting activity and, therefore, the need to change the membrane lung<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">152</span></a>.</p><p id="par0705" class="elsevierStylePara elsevierViewall">In patients presenting heparin-induced thrombocytopenia (HIT), direct thrombin inhibitors (TDI) such as argatroban or bivalirudin are safe alternative anticoagulants<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,153–157</span></a>.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">System monitoring: cannulas, oxygenating membrane, connections</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Air entrainment</span><p id="par0710" class="elsevierStylePara elsevierViewall">Air can enter the circuit through the connections, the circuit valves or through the membrane lung. If bubbles are detected in the arterial cannulas, the circuit should be inspected, the cannulas clamped in the event of considerable air entrainment, catecholamines should be administered to increase respiratory and haemodynamic support, and the patient should be placed in the Trendelenburg position to promote air migration to the upper level and avoid neurological injury.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Chattering</span><p id="par0715" class="elsevierStylePara elsevierViewall">Chattering - low-frequency jerking or shaking movement - occurs in the venous cannula and is accompanied by negative drainage pressures. This is caused by hypovolaemia, cardiac tamponade, pneumothorax, increased intra-abdominal pressure, malpositioning, kinking, clotting, or an undersized venous cannula.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Clotting</span><p id="par0720" class="elsevierStylePara elsevierViewall">The membrane lung, cannulas and connectors must be inspected regularly for slow and/or turbulent flow, as this can cause circuit clotting and cerebral embolism. Shining a flashlight through the circuit will reveal clots, which can lead to oxygen deficiency and even haemolysis. Correct operation of the ECMO circuit can be verified by measuring blood gas from the arterial line, which usually has a PaO<span class="elsevierStyleInf">2</span> > 300 mmHg<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. If clots are detected, the anticoagulation target should be increased or antiplatelets administered, and/or the membrane lung should be changed.</p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Monitoring LV afterload and unloading: cardiac chamber dilation and thrombosis</span><p id="par0725" class="elsevierStylePara elsevierViewall">This complication occurs in patients with severe ventricular dysfunction with no aortic valve opening and blood stasis in the LV or aortic root. It occurs mainly in patients on femerofemoral VA ECMO due to the increase in LV afterload caused by the ECMO flow, and leads to left ventricular distention and pulmonary oedema, myocardial failure, and the possibility of systemic embolism<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">158</span></a>. In these cases, LV unloading is indicated to avoid complications and facilitate myocardial recovery and weaning (<a class="elsevierStyleCrossRef" href="#tbl0070">Table 14</a>).</p><elsevierMultimedia ident="tbl0070"></elsevierMultimedia><p id="par0730" class="elsevierStylePara elsevierViewall">There are many strategies to prevent and/or treat left ventricular distention, some of the least invasive include: reduce ECMO flows if tolerated, increase inotropes, reduce vasoconstrictors, reduce intravascular volume with diuretics or extracorporeal clearance techniques, or implant an IABP<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">159,160</span></a>. The need for routine IABP implantation in all patients on ECMO is controversial, and no clinical trials to date have demonstrated the superiority of IABP implantation over ECMO without IABP<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">161,162</span></a>.</p><p id="par0735" class="elsevierStylePara elsevierViewall">Pulmonary artery wedge pressure, pulmonary radiography or ultrasound, pulse pressure, the size of the LV, the presence of spontaneous echo contrast, and aortic valve opening are the parameters that should be monitored to rule out this complication. Although there is no consensus in the literature on any of these parameters as an indication for LV unloading, echocardiographic monitoring and increased pulmonary artery wedge pressure are usually used to indicate the need for LV unloading and evaluate the effectiveness of the measure<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">159</span></a>. Taking into account the advantages and disadvantages of each technique, the degree of ventricular distention should be stratified in order to determine which will be the safest and most effective technique. Therefore, patients with pulmonary capillary pressure > 25 mmHg, arterial pulse pressure < 15 mmHg, echocardiographic LV distention, presence of spontaneous echo contrast, no aortic valve opening, and a radiological pattern of vascular redistribution may be candidates for more aggressive manoeuvres, such as direct LV decompression (apical cannula/venting through right superior pulmonary vein/Impella®), atrial septostomy or central ECMO (<a class="elsevierStyleCrossRef" href="#tbl0075">Table 15</a>)<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">163–167</span></a>.</p><elsevierMultimedia ident="tbl0075"></elsevierMultimedia><p id="par0740" class="elsevierStylePara elsevierViewall">In addition to the degree of distension and the invasiveness of the technique, it is essential to consider the possibility of transferring the patient to a medium or long-term ventricular assist device. In this case, prompt placement of an apical drainage cannula connected to the ECMO venous line will facilitate transfer of the patient to a left ventricular assist device. Another important factor to take into consideration is timing. If the diagnosis of left ventricular distention is made in the operating room, central ECMO, pulmonary venting, atrial septostomy, or pulmonary artery drainage may be feasible; if diagnosis is made in the immediate postoperative period, the Impella® or apical cannulation through a minithoracotomy, may be indicated. The risk/benefit of either procedure must be assessed individually<a class="elsevierStyleCrossRefs" href="#bib0830"><span class="elsevierStyleSup">166–168</span></a>.</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Peripheral venous and arterial vessels: cannulation-related complications</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Lower limb ischaemia (ipsilateral to arterial cannulation in peripheral ECMO)</span><p id="par0745" class="elsevierStylePara elsevierViewall">The widespread use of distal arterial infusion cannulas has significantly reduced the incidence of this complication<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">169</span></a>. Continuous monitoring of limb perfusion using regional near infrared spectroscopy (NIRS) monitoring can help detect ischaemia in peripheral ECMO at an early stage<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">170,171</span></a>.</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Deep vein thrombosis or lower limb oedema</span><p id="par0750" class="elsevierStylePara elsevierViewall">These complications arise when the femoral venous cannulas obstruct venous return. Oedema can be resolved by inserting a distal cannula in the femoral vein and connecting it to the venous line with a Y-connector, exchanging the femoral venous cannula for a smaller cannula, or changing to central cannulation.</p><p id="par0755" class="elsevierStylePara elsevierViewall">A higher incidence of deep vein thrombosis and thromboembolism has been reported after ECMO, so deep vein Doppler ultrasound to diagnose the presence of thrombi should be considered after the withdrawal of ECMO<a class="elsevierStyleCrossRefs" href="#bib0860"><span class="elsevierStyleSup">172,173</span></a>.</p></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Neurological complications</span><p id="par0760" class="elsevierStylePara elsevierViewall">Neurological injury during ECMO therapy is a serious and possibly life-threatening complication. Incidence varies greatly, and intracranial haemorrhage is the most common event<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">174,175</span></a>.</p><p id="par0765" class="elsevierStylePara elsevierViewall">The presence of polyneuropathy and myopathy in ECMO patients, in addition to ischaemic and haemorrhagic stroke, all but rule out the likelihood of motor and cognitive recovery after long-term ECMO support<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a>. As mentioned above, monitoring regional cerebral oxygen saturation can help in the early diagnosis and treatment of cerebral hypoperfusion.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Perfusion, oxygenation and ventilation</span><p id="par0770" class="elsevierStylePara elsevierViewall">The following parameters should be monitored throughout ECMO therapy and interpreted according to the particular modality used and the stage of support (<a class="elsevierStyleCrossRef" href="#tbl0080">Table 16</a>):</p><elsevierMultimedia ident="tbl0080"></elsevierMultimedia><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">VA ECMO</span><p id="par0775" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">□</span><p id="par0780" class="elsevierStylePara elsevierViewall">Systemic blood pressure. Arterial pulse pressure will fall after starting ECMO. The initial goal is to maintain a pulse pressure of at least 10 mmHg to maintain pulmonary and aortic flows and MAP > 60 mmHg. This will ensure correct perfusion.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,177</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">□</span><p id="par0785" class="elsevierStylePara elsevierViewall">Mixed venous oxygen saturation (SVO<span class="elsevierStyleInf">2</span>) and central venous oxygen saturation (SVcO<span class="elsevierStyleInf">2</span>). Since oxygenated blood is infused into the arterial system it does not mix with venous blood, and therefore SVO<span class="elsevierStyleInf">2</span> and SVcO<span class="elsevierStyleInf">2</span> remain valid in the VA ECMO setting<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">178,179</span></a>. Venous oxygen saturation can be determined through a central catheter or pulmonary artery catheter, and is also continuously monitored in the venous branch of ECMO<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">179</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">□</span><p id="par0790" class="elsevierStylePara elsevierViewall">Pulse contour analysis. Uncalibrated pulse contour analysis monitors are not validated for use in VA ECMO, because their readings can be distorted by arrhythmias and IABPs<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">180</span></a>, and should not therefore be used to monitor haemodynamics.</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">□</span><p id="par0795" class="elsevierStylePara elsevierViewall">Pulmonary/transpulmonary dilution and pulmonary pressures. Calculating cardiac output (CO) and CO-related parameters using methods based on the dilution of an indicator (thermal or lithium) in venous blood give a misleading picture of overall perfusion, because these calculations ignore ECMO flow, the effect of ECMO on pulmonary and systemic circulation, and tricuspid regurgitation. When using a pulmonary artery catheter, it is important to ensure that the ECMO venous cannula does not interfere with the position of either the thermal filament and the catheter. Pulmonary pressures must be interpreted relative to pulmonary flow, and therefore as a function of ECMO flow. Pulmonary wedge pressure is not distorted, and is a fundamental parameter in monitoring left ventricular distention. Despite its drawbacks, the pulmonary artery catheter together with echocardiography (see Section 15) are the most accurate methods for monitoring parameters used to indicate VA ECMO, to diagnose complications, and to decide when to wean from VA ECMO<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,179,181</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">□</span><p id="par0800" class="elsevierStylePara elsevierViewall">Regional cerebral oxygen saturation. A decrease in this parameter may indicate a decrease in global perfusion, and can indicate the need for prompt measures, such increasing CO (change flow rate, fluids or catecholamines), or changing the ventilation or transfusion strategy<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">182</span></a>. In Harlequin syndrome, the upper body is hypoxemic (cerebral and coronary hypoxia), while the lower body is well oxygenated. The syndrome occurs during VA ECMO, generally peripheral femorofemoral, and is the result of partially preserved cardiac function associated with poor lung function. To avoid this complication, arterial haemoglobin desaturation should be monitored in the right upper limb, and monitoring cerebral oxygenation by measuring regional oxygen saturation at the cerebral level should be considered. Treatment consists of improving MV parameters, re-evaluating cardiac function, and assessing the possibility of ECMO withdrawal, changing to VV ECMO if lung function is severely compromised, adding a subclavian artery cannula, or changing to central cannulation<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">□</span><p id="par0805" class="elsevierStylePara elsevierViewall">Mechanic ventilation. After setting optimal flow rates in VA ECMO, provided lung function is not severely compromised, mechanical ventilation parameters should be set for lung protective ventilation in order to avoid alveolar overdistention and atelectrauma. The respiratory rate should be set to < 11 breaths per minute, inspiratory time should be increased, the oxygen supply should be minimised, the plateau pressure should be maintained below 25 cmH2O, and PEEP should be set at between 5–15 cmH<span class="elsevierStyleInf">2</span>O. These parameters will deliver a tidal volume of 1−5 ml/kg. Ventilatory support should be increased as soon as weaning in initiated<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p></li></ul></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">VV ECMO</span><p id="par0810" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">□</span><p id="par0815" class="elsevierStylePara elsevierViewall">SVO2 and SVcO2. In VV ECMO, venous oxygen saturation determination in the drainage cannula can be invalidated by blood recirculation. Oxygenated blood can recirculate if the drainage and reinfusion cannulas are placed relatively close together. This will give high venous oxygen saturation measurements, and no colour difference will be observed between oxygenated and non-oxygenated blood<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">178</span></a>. In this case, the cannulas must be removed and separated under echocardiographic guidance, keeping the drainage cannula in the inferior cava and the reinfusion cannula in the right atrium<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. The percentage of recirculated blood from VV ECMO can be calculated using various formulas based on the saturation of blood entering the membrane oxygenator (SpreO<span class="elsevierStyleInf">2</span>), the saturation of blood leaving the membrane oxygenator (SpostO<span class="elsevierStyleInf">2</span>) and SVO<span class="elsevierStyleInf">2</span>: recirculation ratio = (SpreO<span class="elsevierStyleInf">2</span> − SvO<span class="elsevierStyleInf">2</span>)/(SpostO<span class="elsevierStyleInf">2</span> − SvO<span class="elsevierStyleInf">2</span>) × 100 (the latter is determined by momentarily turning off the sweep gas, if tolerated by the patient)<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">179</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">□</span><p id="par0820" class="elsevierStylePara elsevierViewall">Pulse contour analysis. Aside from their general limitations, these non-calibrated, minimally invasive haemodynamic monitors are not affected by VV ECMO<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">178</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">□</span><p id="par0825" class="elsevierStylePara elsevierViewall">Pulmonary/transpulmonary dilution. Thermodilution CO measurement can be unreliable, as the markers used interfere with the ECMO<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">183</span></a>. Likewise, SVO<span class="elsevierStyleInf">2</span> parameter obtained will not reflect the true oxygen delivery/consumption balance, since it will be based on a mixture of oxygenated blood from ECMO and venous return<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">179</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">□</span><p id="par0830" class="elsevierStylePara elsevierViewall">Mechanical ventilation. In patients with severe respiratory failure requiring VV ECMO, ventilatory parameters should gradually be decreased to the levels required for lung protective ventilation, the goal being to reduce the oxygen supply and maintain plateau pressures < 25 cmH<span class="elsevierStyleInf">2</span>O. Alveolar recruitment manoeuvres should only be performed if pulmonary inflammation has subsided. Lung ultrasound and changes in lung compliance can be used to monitor these manoeuvres. Once lung function has started to improve, patients should be extubated or tracheotomised to encourage spontaneous breathing. Non-invasive mechanical ventilation can be given for short periods if necessary<a class="elsevierStyleCrossRefs" href="#bib0920"><span class="elsevierStyleSup">184–186</span></a>.</p></li></ul></p><p id="par0835" class="elsevierStylePara elsevierViewall">During their evolution, patients with respiratory involvement can present events such as pneumothorax or pleural effusion that require thoracentesis. As the patient is being oxygenated with ECMO, thoracentesis can be delayed if the pneumothorax or pleural effusion is tolerable. The risk/benefit of thoracentesis should be assessed due to the risk of heparin-induced bleeding<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">187</span></a>.</p></span></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Ultrasound in ECMO</span><p id="par0840" class="elsevierStylePara elsevierViewall">Transthoracic and transoesophageal echocardiography monitoring is essential in the management of VA ECMO. These techniques provide information that will assist in patient selection, guide cannulation, and provide valuable parameters during ECMO maintenance and weaning<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,188,189</span></a>. Therefore, all hospitals providing VA ECMO support must have clinicians that are fully training in both echocardiography techniques, and echocardiography must be standard practice in the comprehensive evaluation of these patients<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">190</span></a>.</p><p id="par0845" class="elsevierStylePara elsevierViewall">Vascular and pulmonary ultrasound are also easily reproducible point-of-care management tools that provide data for a global evaluation, facilitate the management of the patient with ECMO, and reduce the need for transfer to radiology units<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,191</span></a>.</p><p id="par0850" class="elsevierStylePara elsevierViewall">This section describes all the ECMO ultrasound parameters that need to be monitored, and shows how healthcare teams can include ultrasound in their routine management of ECMO patients.</p><p id="par0855" class="elsevierStylePara elsevierViewall">In certain settings, such as ECMO as a bridge to lung transplantation, echocardiography is used in a specific way to study certain structures.</p><p id="par0860" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0085">Table 17</a> summarizes the echocardiographic planes recommended by different authors<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">92,192–194</span></a> for studying different structures and the complications that can be observed.</p><elsevierMultimedia ident="tbl0085"></elsevierMultimedia><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Ultrasound study in VA ECMO</span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Preimplantation ultrasound study</span><p id="par0865" class="elsevierStylePara elsevierViewall">Echocardiography play an important role in the aetiological diagnosis of <span class="elsevierStyleItalic">shock</span> before ECMO implantation. It also helps rule out anatomical abnormalities that may be a relative or absolute contraindication for ECMO, provides data that will help choose the type of ECMO to be implanted (VV, VA), and helps predict reversibility according to severity. Transthoracic echocardiography (TTE) may not be feasible in postoperative patients; instead, a transoesophageal study should be performed to resolve diagnostic uncertainties.<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">□</span><p id="par0870" class="elsevierStylePara elsevierViewall">Left ventricle</p></li></ul></p><p id="par0875" class="elsevierStylePara elsevierViewall">Systolic function and segmental changes in contractility. Quantitative determination of ventricular function (ejection fraction, fractional area change [FAC]) can be challenging in the immediate postoperative period of cardiothoracic surgery, so a subjective estimate can be made by an experienced operator. CO can be determined using pulsed Doppler placed on the LV (LVOT) or RV outflow tract (systolic volume = velocity time integral (VTI) LVOT × πr<span class="elsevierStyleSup">2</span>) if a good acoustic window is available. The VTI of the LVOT is a reproducible and validated measure in the diagnosis and monitoring of patients with postoperative low cardiac output syndrome<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a>.<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">□</span><p id="par0880" class="elsevierStylePara elsevierViewall">Right ventricle</p></li></ul></p><p id="par0885" class="elsevierStylePara elsevierViewall">Systolic function, morphology and size. RV function can be evaluated subjectively, or on the basis of = parameters such as TAPSE (tricuspid annular plane systolic excursion), tissue Doppler evaluation of the tricuspid annulus. RV function is often the sole cause of haemodynamic instability. Some signs can help guide the aetiological diagnosis of RV failure: free wall hypertrophy and RV dilation point to a chronic origin, McConnell's sign (basal wall hypokinesia with hyperdynamic outflow tract) suggests pulmonary thromboembolism.<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">□</span><p id="par0890" class="elsevierStylePara elsevierViewall">Interventricular septum (IVS) shift to the right or left indicates an increase in pressure in the left or right chambers, respectively.</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">□</span><p id="par0895" class="elsevierStylePara elsevierViewall">Valvular heart disease and valve prostheses.</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">□</span><p id="par0900" class="elsevierStylePara elsevierViewall">Aortic insufficiency. Severe AI is an absolute contraindication for ECMO unless it has been repaired. This is because the arterial cannula increases afterload in the aorta, causing the blood to return to and dilate the LV, thereby increasing intracavitary and pulmonary pressures.</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">□</span><p id="par0905" class="elsevierStylePara elsevierViewall">Tricuspid regurgitation and pulmonary pressures. Determining pulmonary artery pressure (PAP) by means of the tricuspid gradient in patients with cardiogenic shock due to right ventricular failure can give false low or normal readings due to the severity of RV dysfunction (decreased flow).</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">□</span><p id="par0910" class="elsevierStylePara elsevierViewall">Prosthetic heart valves. Impaired blood flow through the aortic and mitral valves increases the risk of thrombosis, particularly in patients with prosthetic heart valves.</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">□</span><p id="par0915" class="elsevierStylePara elsevierViewall">Cardiac tamponade. This is one of the principle post cardiac surgery complications in patients with low cardiac output. In this context, both the poor acoustic window and the characteristics of the effusion (small volume of fluid that can compromise heart function) make diagnosis more complex.</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">□</span><p id="par0920" class="elsevierStylePara elsevierViewall">Patent foramen ovale (PFO). The presence of PFO increases the risk of paradoxical embolism. Although it will not impair oxygenation during ECMO therapy, if myocardial function does not improve and the patient is considered a candidate for a left ventricular assist device, PFO should be ruled out due to the risk of right-left shunt and resulting hypoxaemia.</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">□</span><p id="par0925" class="elsevierStylePara elsevierViewall">Inferior vena cava. Determining the size and collapsibility of the inferior vena cava, together with other methods, will facilitate the calculation of blood volume.</p></li><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">□</span><p id="par0930" class="elsevierStylePara elsevierViewall">The Chiari network is an embryonic remnant found in approximately 2%–3% of the general population. A highly developed Chiari network can cause malpositioning of the venous cannula in the direction of the interatrial septum. It can also give an unclear image during ECMO therapy, and can be confused with vegetations and/or thrombi.</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">□</span><p id="par0935" class="elsevierStylePara elsevierViewall">Coronary sinus. Coronary sinus dilation is mainly due to right ventricular dysfunction and chronic pulmonary hypertension. It may also be due to the presence of a persistent left superior vena cava.</p></li><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">□</span><p id="par0940" class="elsevierStylePara elsevierViewall">Vascular. Thrombosis, dissection, atheromatosis. Before starting therapy, the presence of thrombi in the LV or in the left atrium, aortic dissection, and the presence of severe atheromatosis that may complicate arterial cannulation must be ruled out.</p></li></ul></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Ultrasound evaluation during cannulation</span><p id="par0945" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">□</span><p id="par0950" class="elsevierStylePara elsevierViewall">Cannula size. Vascular ultrasound can help decide the size of the ECMO cannula and minimize the risk of cannulation-related complications<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (French gauge = 3 <span class="elsevierStyleSmallCaps">×</span> vessel diameter in mm). The presence of significant arterial disease both at the femoral and aortic level should be ruled out.</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">□</span><p id="par0955" class="elsevierStylePara elsevierViewall">Visualization of guidewires and cannulas. Correct positioning of the venous cannula is of vital importance. In the case of peripheral cannulation, TOE can confirm the position of the venous guidewire in the right atrium using the ME bicaval plane, and TTE can confirm its position in the RV inlet-outflow tract using the parasternal plane or the subcostal long axis plane. In VA ECMO, the venous cannula should be positioned slightly above the cavoatrial junction to avoid the suction effect of the IVC walls. It should not be inserted too deep in the right atrium due to the risk of damaging cardiac structures. Ultrasound should be used to guide cannulation of the right chambers in both VV and VA ECMO to avoid complications, such as interatrial septum perforation, accidental coronary sinus cannulation, or cardiac perforation and the resulting pericardial effusion. The arterial guidewire can be seen in the descending aorta, and is not visible on TTE or TOE. Its position can be confirmed by vascular ultrasound at the level of the iliac artery or abdominal aorta.</p></li></ul></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Ultrasound evaluation during ECMO support</span><p id="par0960" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">□</span><p id="par0965" class="elsevierStylePara elsevierViewall">Flow alterations. Echocardiography and pulmonary ultrasound can help determine the cause of flow alterations with excessively negative venous pressures: tamponade, hypovolaemia, pneumothorax, thrombosis.</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">□</span><p id="par0970" class="elsevierStylePara elsevierViewall">Cardiac output. Overall cardiac output is calculated on the basis of the ECMO flow rate and the stroke volume ejected through the aortic valve.</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">□</span><p id="par0975" class="elsevierStylePara elsevierViewall">Pulmonary pressures. VA ECMO reduces pulmonary flow; therefore, the ECMO flow rate must be factored in when interpreting the tricuspid regurgitation gradient.</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">□</span><p id="par0980" class="elsevierStylePara elsevierViewall">Function, ventricular size, presence of thrombi. In the case of LV dilation, spontaneous echocontrast is observed in the LV or left atrium together with thrombi, particularly in aortic/mitral valve prostheses<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">195</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">□</span><p id="par0985" class="elsevierStylePara elsevierViewall">Position of ECMO cannulas and/or LV cannulas or drainage devices.</p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">□</span><p id="par0990" class="elsevierStylePara elsevierViewall">Blood volume. In VA ECMO, blood volume cannot be estimated exclusively on the size of the cardiac chambers, since these are decompressed by the partial cardiopulmonary bypass created by the device.</p></li></ul></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Ultrasound evaluation during ECMO weaning</span><p id="par0995" class="elsevierStylePara elsevierViewall">Once the patient is stable, weaning should begin after 48 h of full VA-ECMO support by gradually reducing the flow rate to < 2 l/min. At this point, the ECMO flow is further reduced to a rate of 1–1.5 l/min for 30 min, during which time some of the following parameters should be evaluated and compared to reference values to evaluate whether weaning can proceed<a class="elsevierStyleCrossRefs" href="#bib0940"><span class="elsevierStyleSup">188,196–198</span></a>:<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">□</span><p id="par1000" class="elsevierStylePara elsevierViewall">LV ejection fraction≥ 25%. If the endocardial borders cannot be clearly visualised, LVOT VTI > 12 cm or lateral tissue Doppler S' > 6 cm/s are favourable parameters for ECMO weaning.</p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">□</span><p id="par1005" class="elsevierStylePara elsevierViewall">RV function, FAC > 25%.</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">□</span><p id="par1010" class="elsevierStylePara elsevierViewall">Lungs. It is important to ensure good lung function. Lung ultrasound may be useful in these patients<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">191</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">□</span><p id="par1015" class="elsevierStylePara elsevierViewall">No tamponade</p></li></ul></p></span></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Ultrasound study in VV ECMO</span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Preimplantation ultrasound study</span><p id="par1020" class="elsevierStylePara elsevierViewall">Although VV ECMO can improve biventricular function by improving oxygenation and reducing afterload, particularly in the RV, this therapy is only suitable in patients with good cardiac function.</p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Ultrasound evaluation during cannulation</span><p id="par1025" class="elsevierStylePara elsevierViewall">In addition to the instructions for VA ECMO cannulation, the following considerations should be taken into account in VV ECMO:<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">•</span><p id="par1030" class="elsevierStylePara elsevierViewall">Two-cannula VV ECMO. In the case of VV ECMO with jugular-inferior vena cava cannulation, the lines should be kept far enough apart to avoid recirculation.</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">•</span><p id="par1035" class="elsevierStylePara elsevierViewall">VV ECMO with single Avalon® cannula. The Avalon® cannula can cause various complications, such as injury to the superior vena cava, migration of the cannula to the RV, IVC or hepatic vein, injury to the right ventricle, and tamponade. TOE-guided cannulation with or without fluoroscopy can ensure correct placement. The following must be assessed in the bicaval, modified bicaval and four-chamber mid-oesophageal planes (4C): 1) The tip of the cannula has been advanced as far as the cavoatrial junction over the guidewire inserted in the RA (IVC). 2) On colour Doppler, the reinfusion ports must be directed towards the tricuspid valve (modified bicaval plane). 3) On colour Doppler, a laminar flow must be observed in the direction of the tricuspid valve, since the existence of a turbulent flow will indicate that reinfusion is not fully directed towards the centre of the tricuspid valve, a situation that can cause recirculation<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a>.</p></li></ul></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Ultrasound evaluation during ECMO support</span><p id="par1040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">□</span><p id="par1045" class="elsevierStylePara elsevierViewall">Ventricular size and function. In patients with haemodynamic destabilization, cardiac function should be assessed mainly the RV (which can fail in the case of ARDS), since deterioration would indicate the need to switch to VA support, provided it is not contraindicated.</p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">□</span><p id="par1050" class="elsevierStylePara elsevierViewall">Cannula position. Since patients on ECMO can move, the position of the cannulas, particularly the proximity of the reinfusion and drainage cannulas, must be checked to rule out flow changes and prevent recirculation.</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">□</span><p id="par1055" class="elsevierStylePara elsevierViewall">Thrombi. Patients should be monitored for thrombi around the cannulas, cavities or valve prostheses.</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">□</span><p id="par1060" class="elsevierStylePara elsevierViewall">Lung ultrasound. Patients should be monitored for pleural effusion, vascular redistribution, atelectasis, consolidation, or pneumothorax.</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Ultrasound evaluation during ECMO weaning</span><p id="par1065" class="elsevierStylePara elsevierViewall">Echocardiography is not usually required during weaning from VV ECMO, although it is advisable to verify correct RV function and the absence of complications, such as thrombi that might migrate during decannulation.</p><p id="par1070" class="elsevierStylePara elsevierViewall">One of the main complications after decannulation from both VA and VV ECMO is the presence of thrombi in the right atrium, left atrium or vena cava<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,199</span></a>; therefore, these patients should undergo clinical and radiological follow-up.</p></span></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Weaning</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">VA ECMO</span><p id="par1075" class="elsevierStylePara elsevierViewall">The duration of ECMO is directly proportional to the mortality rate, since the longer the support, the greater the risk of complications<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">165,200</span></a>. Although ECMO weaning protocols differ in some aspects, it should generally be started after 48 h of support, provided haemodynamics have improved. Recovery of ventricular function should be assessed by observing clinical signs together and collecting pulmonary artery catheter and echocardiography data. Patients should be monitored for pulmonary wedge pressure, arterial pulse pressure, and the need for catecholamines. Adequate pulmonary function should be ensured before reducing ECMO flow, and MV parameters should be increased as blood flow is reduced. The blender should not be shut down during VA ECMO weaning. The flow rate should be reduced by 0.5 l/min every 8−12 hours over 24 h, until reaching a rate of 2–2.5 l/min. The flow should be maintained at 1.5−2 l/m for a further 12−24 hours. If haemodynamic stability persists (CI ≥ 2.2 l/min/m², MAP ≥ 65 mmHg, CVP ≤ 18 mmHg and SVO<span class="elsevierStyleInf">2</span> ≥ 70%<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>, with norepinephrine < 0.5 mcg/kg/min and/or dobutamine ≤ 5 mcg/kg/min) and the echocardiographic data are favourable, the patient can be decannulated.</p><p id="par1080" class="elsevierStylePara elsevierViewall">It is important to remember that heparin must be up-dosed when the flow rates is <1.5 l/min. Once ventricular function and haemodynamics have been evaluated at a flow rate of 1 l/min, flow can be increased to ∼ 2 l/min to reduce the risk of thrombosis if the patient is not decannulated immediately (<a class="elsevierStyleCrossRef" href="#tbl0090">Table 18</a>).</p><elsevierMultimedia ident="tbl0090"></elsevierMultimedia><p id="par1085" class="elsevierStylePara elsevierViewall">If the cause of myocardial dysfunction is reversible, normal function is usually restored in less than 7–10 days. If not, the patient may be a candidate for heart transplantation or a ventricular assist device. If the patient does not meet the criteria for transplantation or ventricular assist device implantation and ECMO weaning is not tolerated, limit therapeutic effort.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,200</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0090">Table18</a>).</p></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">VV ECMO</span><p id="par1090" class="elsevierStylePara elsevierViewall">Recovery of pulmonary function should be assessed with: radiology (CT/Rx/lung ultrasound), lung compliance, PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>, PaCO<span class="elsevierStyleInf">2</span> and MV parameters (ventilation with FiO<span class="elsevierStyleInf">2</span> 50%). In VV ECMO, the flow does not need to be reduced to less than 2 l/min, and anticoagulation does not need to be up-dosed. Instead, FiO<span class="elsevierStyleInf">2</span> and the flow rate of the blender that supplies the ECMO oxygenator should be gradually reduced until the blender is shut down. ECMO can then be withdrawn if the patient remains stable for 12−24 h<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,201</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0090">Table 18</a>).</p></span></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Limitations</span><p id="par1095" class="elsevierStylePara elsevierViewall">Given the extreme severity and mortality of patients on both VV and VA ECMO and the absence of large randomized clinical trials in this setting, the recommendations made are based on a low level of scientific evidence. Although this should not in itself limit the indication for medical action based on pathophysiology, some actions can only be recommended with a higher level of evidence once the results of multicentre trials have been published.</p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Conclusions</span><p id="par1100" class="elsevierStylePara elsevierViewall">ECMO is a highly complex life support therapy associated with high rate of morbidity and mortality, and must be started before multiorgan failure occurs. However, it is always the last therapeutic step, and the decision to start ECMO must be based on objective monitoring data. Implantation should be performed in hospitals with experienced staff that will be able to resolve any ECMO complications that may arise. The decision to start and withdraw ECMO is complex, and must be made by a multidisciplinary team.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:23 [ 0 => array:3 [ "identificador" => "xres1577908" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1421911" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1577909" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1421912" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Working method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "ECMO components" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Indications and contraindications" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Cannulation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "VA ECMO" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "VV ECMO" ] ] ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "VV ECMO in acute respiratory distress syndrome" ] 10 => array:3 [ "identificador" => "sec0045" "titulo" => "ECMO in COVID-19" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "VV ECMO" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "VA ECMO" ] ] ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "ECMO in postcardiotomy shock" ] 12 => array:2 [ "identificador" => "sec0065" "titulo" => "ECMO in organ donation" ] 13 => array:2 [ "identificador" => "sec0070" "titulo" => "ECMO in primary heart graft dysfunction" ] 14 => array:3 [ "identificador" => "sec0075" "titulo" => "ECMO in lung transplantation" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Pretransplant ECMO" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Intraoperative ECMO" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Postoperative ECMO" ] ] ] 15 => array:2 [ "identificador" => "sec0095" "titulo" => "ECMO in non-cardiac surgery" ] 16 => array:2 [ "identificador" => "sec0100" "titulo" => "Surgery or other procedures in a patient on ECMO" ] 17 => array:3 [ "identificador" => "sec0105" "titulo" => "Management during support and complications" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Coagulopathy: bleeding and thrombosis" ] 1 => array:3 [ "identificador" => "sec0115" "titulo" => "System monitoring: cannulas, oxygenating membrane, connections" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0120" "titulo" => "Air entrainment" ] 1 => array:2 [ "identificador" => "sec0125" "titulo" => "Chattering" ] 2 => array:2 [ "identificador" => "sec0130" "titulo" => "Clotting" ] ] ] 2 => array:2 [ "identificador" => "sec0135" "titulo" => "Monitoring LV afterload and unloading: cardiac chamber dilation and thrombosis" ] 3 => array:3 [ "identificador" => "sec0140" "titulo" => "Peripheral venous and arterial vessels: cannulation-related complications" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0145" "titulo" => "Lower limb ischaemia (ipsilateral to arterial cannulation in peripheral ECMO)" ] 1 => array:2 [ "identificador" => "sec0150" "titulo" => "Deep vein thrombosis or lower limb oedema" ] ] ] 4 => array:2 [ "identificador" => "sec0155" "titulo" => "Neurological complications" ] 5 => array:3 [ "identificador" => "sec0160" "titulo" => "Perfusion, oxygenation and ventilation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0165" "titulo" => "VA ECMO" ] 1 => array:2 [ "identificador" => "sec0170" "titulo" => "VV ECMO" ] ] ] ] ] 18 => array:3 [ "identificador" => "sec0175" "titulo" => "Ultrasound in ECMO" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0180" "titulo" => "Ultrasound study in VA ECMO" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0185" "titulo" => "Preimplantation ultrasound study" ] 1 => array:2 [ "identificador" => "sec0190" "titulo" => "Ultrasound evaluation during cannulation" ] 2 => array:2 [ "identificador" => "sec0195" "titulo" => "Ultrasound evaluation during ECMO support" ] 3 => array:2 [ "identificador" => "sec0200" "titulo" => "Ultrasound evaluation during ECMO weaning" ] ] ] 1 => array:3 [ "identificador" => "sec0205" "titulo" => "Ultrasound study in VV ECMO" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0210" "titulo" => "Preimplantation ultrasound study" ] 1 => array:2 [ "identificador" => "sec0215" "titulo" => "Ultrasound evaluation during cannulation" ] 2 => array:2 [ "identificador" => "sec0220" "titulo" => "Ultrasound evaluation during ECMO support" ] 3 => array:2 [ "identificador" => "sec0225" "titulo" => "Ultrasound evaluation during ECMO weaning" ] ] ] ] ] 19 => array:3 [ "identificador" => "sec0230" "titulo" => "Weaning" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0235" "titulo" => "VA ECMO" ] 1 => array:2 [ "identificador" => "sec0240" "titulo" => "VV ECMO" ] ] ] 20 => array:2 [ "identificador" => "sec0245" "titulo" => "Limitations" ] 21 => array:2 [ "identificador" => "sec0250" "titulo" => "Conclusions" ] 22 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-04" "fechaAceptado" => "2020-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1421911" "palabras" => array:6 [ 0 => "ECMO" 1 => "Perioperative" 2 => "Respiratory failure" 3 => "Cardiogenic shock" 4 => "Transplantation" 5 => "Complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1421912" "palabras" => array:6 [ 0 => "ECMO" 1 => "Perioperatorio" 2 => "Insuficiencia respiratoria" 3 => "<span class="elsevierStyleItalic">Shock</span> cardiogénico" 4 => "Trasplante" 5 => "Complicaciones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial.</p><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area.</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">La ECMO es un sistema extracorpóreo de asistencia cardiorrespiratoria cuya utilización se ha visto incrementada en la última década. La insuficiencia respiratoria, el shock postcardiotomía y el fallo primario del injerto cardiaco o pulmonar son complicaciones que pueden requerir la utilización de asistencia mecánica cardiorrespiratoria y en este escenario el conocimiento de las peculiaridades perioperatorias médicas y quirúrgicas es fundamental.</p><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">A pesar de la evolución tecnológica en el área de la asistencia extracorpórea la morbimortalidad de estos pacientes continúa siendo elevada, por lo tanto, la decisión del implante de la ECMO como la de su retirada debe establecerse dentro de un equipo multidisciplinar experto en el área.</p><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">El presente documento de consenso pretende unificar conocimientos y aportar recomendaciones basadas tanto en la bibliografía reciente como en la experiencia de los principales centros nacionales implantadores de ECMO con el objetivo final de mejorar la atención integral al paciente.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, et al. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. Rev Esp Anestesiol Reanim. 2021;68:443–471.</p>" ] ] "multimedia" => array:18 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Class 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Class IIa \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Class IIb \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Class III \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Weight of evidence/opinion is in favour of usefulness/efficacy. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Usefulness/efficacy is less well established by evidence/opinion. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Is recommended. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Should be considered. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Can be considered. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Is not recommended \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Level of evidence A</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous opinion that the treatment is effective. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight of evidence/opinion is in favour of usefulness/efficacy of the treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usefulness/efficacy is less well established by evidence/opinion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment is not helpful or may be harmful. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from multiple randomized clinical trials or meta-analyses of such studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from multiple randomized clinical trials or meta-analyses of such studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from multiple randomized clinical trials or meta-analyses of such studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from multiple randomized clinical trials or meta-analyses of such studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Level of evidence B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous opinion that the treatment is effective. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight of evidence/opinion is in favour of usefulness/efficacy of the treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usefulness/efficacy is less well established by evidence/opinion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment is not helpful or may be harmful. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from one randomized trial or from one or more non-randomized trials. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from one randomized trial or from one or more non-randomized trials. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from one randomized trial or from one or more non-randomized trials. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from one randomized trial or from one or more non-randomized trials. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Level of evidence C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous opinion that the treatment is effective. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight of evidence/opinion is in favour of usefulness/efficacy of the treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usefulness/efficacy is less well established by evidence/opinion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment is not helpful or may be harmful. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from consensus opinion of experts and/or small studies, retrospective studies, registries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from consensus opinion of experts and/or small studies, retrospective studies, registries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from consensus opinion of experts and/or small studies, retrospective studies, registries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Data derived from consensus opinion of experts and/or small studies, retrospective studies, registries \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705100.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Grade system.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indications and contraindications</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The decision to implant ECMO must be made within a multidisciplinary team. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO systems should be used in reference hospitals that are experienced in their use and have the capacity to deal with any ECMO-related problems. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Both VV and VA ECMO must be implanted once previous treatments have been completed; the decision should be based on accurate haemodynamic and lung function monitoring, and should be made before multi-organ failure is established. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary artery catheters and echocardiography are among the monitoring methods recommended for the treatment of cardiogenic shock, and the indication and management of ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO should not be implanted in patients with contraindication for long-term ventricular assist devices or transplantation, or who are unlikely to recover from organ failure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705093.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Indications and contraindications for ECMO.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">TOE: Transoesophageal ultrasound.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cannulation</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider central cannulation in patients presenting postcardiotomy shock who do not tolerate withdrawal of extracorporeal circulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Femoral access is the gold standard due to its accessibility and speed. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,37,38</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider inserting the cannula directly into the subclavian artery or performing a vascular graft when the femoral vessels are not suitable for cannulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41,42</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insert an additional arterial cannula for limb perfusion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VV ECMO, percutaneous implantation using the Seldinger technique is the gold standard. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ultrasound is recommended for both arterial and venous cannulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSup">6,39,40.43</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of TOE is recommended in the case of a single venous cannula. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,45–50</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705091.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommendations for cannulation.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO in ARDS</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider ECMO as rescue therapy in respiratory failure refractory to other measures that must always include the use of protective mechanical ventilation, and at least one attempt at prone positioning, unless contraindicated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,14,51,52,54–57,60</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Once ECMO support has started, protective or ultra-protective ventilation should be maintained. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSup">51.58−60</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705092.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the implantation of ECMO in ARDS.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Good planning and availability of ECMO resources in experienced hospitals. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Careful patient selection. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO implanted in specialised centres. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient/nurse ratio 1: 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ultrasound monitoring before and during implantation and in the follow-up of these patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strict monitoring of coagulation status due to the prothrombotic state associated with this pathology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO check list and management protocol. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Establish a protocol for promptly stopping ECMO support in both improved patients and futile cases, following ELSO recommendations. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous training of health personnel. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705095.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">General recommendations for the management of ECMO in ARDS.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO in postcardiotomy shock</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In postcardiotomy shock refractory to treatment, ECMO is recommended as a bridge to decision, recovery, transplantation or implantation of a medium or long-term ventricular assist devices. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleSup">1,7,19.36</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The choice of cannulation in the immediate postoperative period should be based on the time of cardiogenic shock, the quality of the peripheral arteries, and the experience of the medical staff. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705094.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the implantation of ECMO in postcardiotomy shock.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ACT: Activated clotting time.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO in organ donation</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal organs should be preserved with normothermic perfusion in the context of donation after circulatory death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,94</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The left radial artery should be cannulated to verify the position of the Fogarty balloon. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open or percutaneous ECMO cannulation, according to the experience of the medical team, is recommended in both controlled and uncontrolled donation after circulatory death. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flows and pressures, ACT, temperature, haematocrit and ions should be monitored, and samples should be drawn every 20 min for liver and kidney panels. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0465">93,94</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705105.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the use of ECMO in organ donation.</p>" ] ] 7 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PGD: Primary graft dysfunction.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO in primary heart graft dysfunction</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider implantation of ECMO in patients with severed PGD refractory to treatment with inotropics, vasoconstrictors and pulmonary vasodilators. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">99–101</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705089.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the implantation of ECMO in primary heart graft dysfunction.</p>" ] ] 8 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ECC: Extracorporeal circulation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO as a bridge to lung transplantation</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider ECMO in patients with rapidly deteriorating end-stage lung disease with hypoxaemia and hypercapnia refractory to treatment and respiratory acidosis despite maximal non-invasive mechanical support. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102,104–107</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider keeping patients awake, extubated, and tolerant to enteral nutrition and physical therapy during ECMO support, if tolerated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102,104–107</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO should not be indicated in patients with multiple organ failure, severe neurological failure and/or sepsis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">104,108,109</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraoperative ECMO is recommended over CPB. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">110–113</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VA or VV ECMO is recommended for refractory primary graft failure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,114–118</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with primary lung graft failure, VV or VA ECMO should be initiated early to provide lung protective ventilation and thus avoid MV-induced lung injury. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,118,119</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705101.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the implantation of ECMO as a bridge to lung transplantation.</p>" ] ] 9 => array:8 [ "identificador" => "tbl0050" "etiqueta" => "Table 10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO in non-cardiac surgery</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VV and VA ECMO can be considered in thoracic surgery: tumours, trauma, haemorrhage/airway obstruction. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">120,121</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VV and VA ECMO can be considered as a bridge to liver transplantation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">122,123</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VV and VA ECMO can be considered in obstetric pathology: amniotic fluid embolism, cardiomyopathies, ARDS. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The implantation and management of ECMO should be evaluated by a multidisciplinary team. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705102.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ECMO in non-cardiac surgery.</p>" ] ] 10 => array:8 [ "identificador" => "tbl0055" "etiqueta" => "Table 11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">TOE: Transoesophageal echocardiography.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Check device battery before transport. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Check O2 level before transport. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Check venous and arterial cannulas. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspend heparin 4 h before surgery. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Order blood products from the blood bank. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Check position of lines and cannulas. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">There must be sufficient personnel for positioning manoeuvres. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECMO specialist staff must be present during transport and when performing the procedure. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Correct positioning of the lines, cannulas and console on the operating room table. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Connect the device to the power network and the medical gas supply. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gradually induce anaesthesia to an adequate depth. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous monitoring with TOE and/or pulmonary artery catheter. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Restart heparin 6−8 h after surgery if no bleeding. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A back-up system must be available in the event of an emergency. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pay attention to the patient's haemodynamics and the ECMO console alarms. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705103.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">General recommendations for surgery/procedures in patients with ECMO.</p>" ] ] 11 => array:8 [ "identificador" => "tbl0060" "etiqueta" => "Table 12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">UFH: Unfractionated heparin, LV: Left ventricle, IABP: Intra-aortic balloon pump.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Anticoagulation/thrombosis prevention.</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systemic anticoagulation is recommended in the absence of active bleeding complications. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UFH is the anticoagulant of choice. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anticoagulant effects can be monitored with ACT, aPTT, anti-Xa activity, or viscoelastic tests. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">133–144</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antithrombin monitoring and supplementation may be considered. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,147</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D-dimer monitoring can be considered. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">152</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct thrombin inhibitors, such as argatroban or bivalirudin, are safe alternatives for the management of systemic anticoagulation if UFH is contraindicated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,153–157</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administration of heparin reversal agents for cannulation is not recommended if peripheral percutaneous cannulation is performed without prior surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anticoagulant reversal agents should be administered if central or peripheral cannulation is performed in association with a recently closed sternotomy. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The following anti-thromboembolic measures are recommended: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,129,130,159,160,163–165</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">-Maintain frequent aortic valve opening to avoid blood stasis in the left ventricle and the aortic root. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">-Maintain an ECMO flow rate of > 2 L/min. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">-Avoid circuit designs that can cause flow turbulence, such as kinks, unnecessary connectors and valves, etc. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">-Use biocompatible-coated circuits. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">-Unload the LV with IABP or LV venting, if required. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VA ECMO, echocardiography should be performed daily to rule out thrombosis of the LV, LV outflow tract, or aortic root. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0940"><span class="elsevierStyleSup">188,190,196–198</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider deep vein monitoring in the post-ECMO phase to identify the presence of thrombosis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0860"><span class="elsevierStyleSup">172,173</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705104.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Recommendations for anticoagulation and thrombosis prevention in ECMO.</p>" ] ] 12 => array:8 [ "identificador" => "tbl0065" "etiqueta" => "Table 13" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">LMWH: low molecular weight heparin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bleeding</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjust anticoagulation targets in the event of minor bleeding. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the event of moderate to severe bleeding, suspend systemic anticoagulation until bleeding stops. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,131–133</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stop anticoagulation and start blood transfusion to correct haemostasis in the event of severe, life-threatening bleeding. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">131–136</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the event of intractable, life-threatening bleeding, start administration of prothrombotic complex and factor VIIa, despite the increased risk of systemic thrombosis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">137,138</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider implementing a transfusion protocol for patients with ECMO and active bleeding. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">134–136</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider using goal-directed coagulopathy strategies to active bleeding. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">134–151</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider prophylactic anticoagulation with LMWH as an alternative to therapeutic anticoagulation in patients at risk of major bleeding complications. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">139</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705090.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the management of bleeding in ECMO.</p>" ] ] 13 => array:8 [ "identificador" => "tbl0070" "etiqueta" => "Table 14" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">IABP: Intra-aortic balloon pump.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-invasive/minimally invasive measures. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Invasive measures. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduce flow rate. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central ECMO. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Up-dose inotropes. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrial septostomy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Down-dose vasoconstrictors. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary artery catheter. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diuretics. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary vein venting. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal replacement. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical venting. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IABP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV unloading (Impella). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705106.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">LV unloading techniques.</p>" ] ] 14 => array:8 [ "identificador" => "tbl0075" "etiqueta" => "Table 15" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">IABP: Intra-aortic balloon pump.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mechanism of action \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drawbacks \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IABP</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduces afterload. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Less effective than direct decompression. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arrhythmia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Atrial septostomy</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left-right shunt. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No device required. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flow not regulated. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pulmonary artery catheter</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduces LV filling. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flow regulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficult to insert. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular injury and migration. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Pulmonary vein venting</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct unloading. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Access already available in postcardiotomy shock. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clotting. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reintervention. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac injury. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arrhythmia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Embolisms. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Apical venting.</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct unloading. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transfer to medium to long-term devices. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac injury. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mini thoracotomy. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arrhythmia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flow regulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical intervention. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Malpositioning. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Embolisms. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Impella</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct unloading from the LV to the aorta. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flow regulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular injury \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Migration. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">De-escalation to LV assist device after ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Haemolysis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arrhythmia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cost. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705096.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Invasive LV unloading: risks and benefits.</p>" ] ] 15 => array:8 [ "identificador" => "tbl0080" "etiqueta" => "Table 16" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oxygenation and perfusion monitoring</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MAP > 60 mmHg is recommended for correct perfusion. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,177</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VA ECMO, perform continuous monitoring of venous saturation in the venous cannula. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">179</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Swan-Ganz catheterisation is recommended over other haemodynamic monitors for VA ECMO implantation decision-making, oxygenation monitoring, and VA ECMO weaning. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,178,179,181</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VA ECMO, SVO2/SVcO2 parameters can be used to monitor O2 delivery/uptake. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,178,179,181</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VA ECMO, consider monitoring pulmonary wedge pressure to identify complications and decide whether weaning is indicated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIa</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,179–181</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monitor PaO2 in the arterial ECMO line to verify membrane lung function. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of pulse contour wave analysis monitors is not recommended in VA ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">180</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All hospitals providing VA ECMO support must have personnel trained in echocardiography, and this technique should be a routine part of the comprehensive care of ECMO patients. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0940"><span class="elsevierStyleSup">188,190,196–198</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NIRS can be used to monitor tissue oxygenation at the tip of the arterial cannula and to monitor brain parameters to rule out the presence of Harlequin syndrome. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">170,171,182</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VV ECMO, SVO2 or SVcO2 should not be used as an indicator of perfusion/oxygenation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">178</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705097.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Oxygenation and perfusion monitoring.</p>" ] ] 16 => array:8 [ "identificador" => "tbl0085" "etiqueta" => "Table 17" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0085" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">AV: Aortic valve, A: Apical, C: chambers, IVC: Inferior vena cava, IVS: Interventricular septum, LV: Left ventricle, ME: Mid-oesophageal, LVOT: Left ventricular outflow tract, PFO: Patent foramen ovale, PS: Parasternal, RV: Right ventricle, SC: Subcostal, TG: Transgastric, TOE: Transoesophageal echocardiography, TTE: Transthoracic echocardiography, TV: Tricuspid valve.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ETT planes \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TOE planes \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">LV</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS: Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ME: 4C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombi. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Echocontrast \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A: 4C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Size \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Segmental changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG: Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Venting cannula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcostal Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">RV and IVS</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS: RV inflow-outflow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ME: RV inflow-outflow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Septal shift \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombi. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A: Modified 4C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG: Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Size \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long axis RV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cannulas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SC: Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IVC</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SC: Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Size and collapsibility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cannulas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombi. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">LVOT</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS: Long axis LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ME: long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombi. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A: 5C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac output \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep TG. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">AV</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS: Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ME: Long axis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic insufficiency. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis AV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short axis AV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic leaflet opening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TG: Long axis LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep TG. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">TV</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PS: RV inflow-outflow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ME: RV inflow-outflow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avalon \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">RA</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV inflow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bicaval \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cannulas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A: 4C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Modified bicaval \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombi. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 C. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chiari Network \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary sinus. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PFO \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705099.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic planes.</p>" ] ] 17 => array:8 [ "identificador" => "tbl0090" "etiqueta" => "Table 18" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO weaning</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">References \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do not shut down the blender during VA ECMO weaning. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">III</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gradually decrease flows to wean from VA ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Confirm adequate pulmonary function before reducing ECMO flow for weaning, and increase MV parameters as blood flow is reduced. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduce FiO2 and fresh gas flow to wean from VV ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,201</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In VA ECMO, consider LV unloading to promote myocardial recovery and facilitate weaning. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">IIb</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">160–165</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assess symptoms, haemodynamics (pulmonary artery catheter) and echocardiography when weaning from VA ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16,188,196–198</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assess symptoms, blood gas, mechanical ventilation, pulmonary compliance and radiology images when weaning from VV ECMO. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identify possible local complications after venous and/or arterial decannulation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,35,40</span></a>.<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">199</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If cardiac or pulmonary function does not improve and the patient is not a candidate for transplantation or ventricular assist, limit therapeutic effort. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,200</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705098.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Recommendations for ECMO weaning.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:201 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "The Extracorporeal Life Support Organization (ELSO). 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