Fixed and dilated pupils, not a contraindication for extracorporeal support: a case series

Extracorporeal membrane oxygenation is considered a relative contraindication for patients with severe neurological injury manifested by fixed and dilated pupils. The inability to provide adequate cardiopulmonary support while attempting to treat the underlying neurologic disease results in a fatal outcome. The impairment of cerebral perfusion, compounded by the underlying neurologic condition, results in signs of brainstem dysfunction often equated with a fatal prognosis. As a result, these patients are not considered to be candidates for initiation of extracorporeal membrane oxygenation. We present a case series of three patients with complex neurologic conditions with fixed and dilated pupils, who received extracorporeal membrane oxygenation. All three patients achieved a significant neurologic recovery. Two survived with a cerebral performance category scale of 1, and the third succumbed to multi-organ failure after achieving a Glasgow Coma Scale of 11T. The decision to initiate extracorporeal membrane oxygenation should be based upon the pathophysiology of the underlying neurologic condition and not solely upon isolated clinical findings. Extracorporeal membrane oxygenation use is normally reserved for patients with reversible underlying processes, and a neurologic exam with fixed and dilated pupils is often interpreted as an irreversible neurologic injury. The implementation and success of extracorporeal membrane oxygenation in this patient population require understanding of complex neurologic diseases, rapid recognition of neurocardiogenic shock, and expeditious initiation of cardiopulmonary support in carefully selected patients. The patients described demonstrate that fixed and dilated pupils are not a contraindication for extracorporeal support in select patients.