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Updated: Jun 30, 2025
Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting
Published on: January 17, 2025
Changes in autonomic function and cerebral and somatic oxygenation with arterial flow pulsatility for children
Brian Appavu1, Elise Dunning2, Kara Hildebrandt1
1Barrow Neurological Institute at Phoenix Children's Hospital, Department of Neurosciences, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, 85016, USA.
Insights
High arterial flow pulsatility (AFP) during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in children is linked to autonomic dysfunction and reduced tissue oxygenation. Lower pulsatility was associated with baroreflex sensitivity reduction and increased heart rate.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular physiology
- Neuromonitoring
Background:
- Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-support measure for severe cardiac or respiratory failure.
- Arterial flow pulsatility (AFP) during VA-ECMO can vary significantly, potentially impacting organ perfusion and function.
- Understanding the effects of AFP variability is crucial for optimizing VA-ECMO management in pediatric patients.
Purpose of the Study:
- To investigate the association between different levels of arterial flow pulsatility (AFP) and changes in cerebral and somatic oxygenation, hemodynamic parameters, and autonomic function in children undergoing VA-ECMO.
- To identify potential risks of brain injury associated with varying AFP levels.
Main Methods:
- A prospective study involving 53 children on VA-ECMO who underwent neuromonitoring.
- AFP was quantified and categorized into no, minimal, moderate, and high pulsatility.
- Cerebral oximetry index (COx), regional cerebral oxygenation (rSO2), peripheral oxygen saturation (SpO2), baroreflex sensitivity (BRs), LF/HF ratio, and heart rate variability (HRsd) were assessed.
- Statistical analyses included linear mixed-effects models and logistic regression to determine associations and risks.
Main Results:
- Moderate to high AFP was associated with decreased rSO2, SpO2, and LF/HF ratio, and increased HRsd.
- Reductions in BRs were observed with increasing pulsatility (none to minimal and minimal to moderate).
- No to low pulsatility correlated with reduced BRs and arterial blood pressure (ABP), but increased SpO2 and heart rate. Arterial ischemic stroke was linked to higher AFP.
Conclusions:
- Elevated AFP during VA-ECMO in children is associated with autonomic dysregulation.
- Compromised cerebral and somatic tissue oxygenation occurs with increasing AFP.
- AFP monitoring may be important for managing pediatric patients on VA-ECMO.
Background:
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) carries variability in arterial flow pulsatility (AFP).
Research Question:
What changes in cerebral and somatic oxygenation, hemodynamics, and autonomic function are associated with AFP during VA-ECMO?
Methods:
This is a prospective study of children on VA-ECMO undergoing neuromonitoring. AFP was quantified by arterial blood pressure pulse amplitude and subcategorized: no pulsatility (<1 mmHg), minimal pulsatility (1 to <5 mmHg), moderate pulsatility (5 to <15 mmHg) and high pulsatility (≥15 mmHg). CVPR was assessed using the cerebral oximetry index (COx). Cerebral and somatic oxygenation was assessed using cerebral regional oximetry (rSO2) or peripheral oxygen saturation (SpO2). Autonomic function was assessed using baroreflex sensitivity (BRs), low-frequency high-frequency (LF/HF) ratio and standard deviation of heart rate R-R intervals (HRsd). Differences were assessed across AFP categories using linear mixed effects models with Tukey pairwise comparisons. Univariate logistic regression was used to explore risk of AFP with brain injuries.
Results:
Among fifty-three children, comparisons of moderate to high pulsatility were associated with reductions in rSO2 (p < 0.001), SpO 2 (p = 0.005), LF/HF ratio (p = 0.028) and an increase in HRsd (p < 0.001). Reductions in BRs were observed across comparisons of none to minimal (P < 0.001) and minimal to moderate pulsatility (p = 0.004). Comparisons of no to low pulsatility were associated with reductions in BRs (p < 0.001) and ABP (p < 0.001) with increases in SpO2 (p < 0.001) and HR (p < 0.001). Arterial ischemic stroke was associated with higher pulsatility (p = 0.0384).
Conclusion:
During VA-ECMO support, changes toward high AFP are associated with autonomic dysregulation and compromised cerebral and somatic tissue oxygenation.
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