• Michael A Fierro, Benjamin Dunne, David N Ranney, Mani A Daneshmand, John C Haney, Jacob A Klapper, Matthew G Hartwig, Desiree Bonadonna, Michael W Manning, and Raquel R Bartz.
• Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin. Electronic address: mfierro@mcw.edu.
• J. Cardiothorac. Vasc. Anesth. 2019 Jul 1; 33 (7): 1855-1862.

ObjectivesTo analyze the perioperative management of veno-venous extracorporeal membrane oxygenation (VV ECMO) in patients undergoing major noncardiac surgical procedures, which is poorly described in the literature. In doing so, perioperative challenges related to hemodynamic instability, impaired gas exchange, bleeding, and coagulopathy will be quantified.DesignRetrospective, nonrandomized, observational study.SettingA single, university-affiliated, quaternary medical center.ParticipantsFourteen patients who underwent 21 noncardiac surgical procedures during the period of January 1, 2014, through April 1, 2016. Approval for this study was obtained from the Duke University Medical Center Institutional Review Board (study Pro00072723).InterventionsNone.Measurements And Main ResultsFifty percent of subjects were alive at 1 year after ECMO cannulation. Anesthetic type was variable with an inhaled anesthetic utilized in 71.4% of events, a presurgical continuous sedative was continued in 81.0% of cases, fentanyl was utilized in 100% of encounters, and midazolam was utilized in 71.4% of encounters. Intraoperatively, 50% of encounters resulted in an oxygen desaturation with a peripheral oxygen saturation assessed by pulse oximetry (SpO2)<90%, and 15% of procedures resulted in a SpO2 <80%. A vasopressor, most commonly epinephrine, was used during 66.7% of procedures. Intraoperatively, blood was administered in 52.4% of procedures, fresh frozen plasma was administered in 23.8% of procedures, and platelets were administered in 28.6% of procedures. Hemoglobin levels remained stable throughout the perioperative period, averaging 9.5 g/dL preoperatively, 9.7 g/dL immediately postoperatively, and 9.5 g/dL 24 hours after surgery.ConclusionsVV ECMO patients can be anesthetized using either inhalational or intravenous anesthetics. Patient hemodynamics, oxygenation, and decarboxylation require frequent interventions, but can typically be optimized to meet clinically acceptable thresholds.Copyright © 2019 Elsevier Inc. All rights reserved.

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