Extracorporeal membrane oxygenation for accidental deep hypothermia-current challenges and future perspectives

The incidence of accidental hypothermia (core temperature ≤35 °C) is difficult to estimate, as the affected population is heterogeneous. Both temperature and clinical presentation should be considered while determining severity, which is difficult in a prehospital setting. Extracorporeal rewarming is advocated for all Swiss Staging System class IV (hypothermic cardiac arrest) and class III (hypothermic cardiac instability) patients. Veno-arterial extracorporeal membrane oxygenation (ECMO) is the method of choice, as it not only allows a gradual, controlled increase of core body temperature, but also provides respiratory and hemodynamic support during the unstable period of rewarming and reperfusion. This poses difficulties with the coordination of patient management, as usually only cardiac referral centers can deliver such advanced treatment. Further special considerations apply to subgroups of patients, including drowning or avalanche victims. The principle of ECMO implantation in severely hypothermic patients is no different from any other indication, although establishing vascular access in a timely manner during ongoing resuscitation and maintaining adequate flow may require modification of the operating technique, as well as aggressive fluid resuscitation. Further studies are needed in order to determine the optimal rewarming rate and flow that would favor brain and lung protection. Recent analysis shows an overall survival rate of 40.3%, while additional prognostic factors are being sought for determining those patients in whom the treatment is futile. New cannulas, along with ready-to-use ECMO sets, are being developed that would enable easy, safe and efficient out-reach ECMO implantation, thus shortening resuscitation times. Moreover, national guidelines for the management of accidental hypothermia are needed in order that all patients that would benefit from extracorporeal rewarming would be provided with such treatment. In this perspective article, we discuss burning problems in ECMO therapy in hypothermic patients, outlining the important research goals to improve the outcomes.