When Nothing Is Going Right

Abstract

Extracorporeal life support (ECLS) will be required when the conventional measures to support the heart and lungs fail despite optimizing the care. In resource-limited countries where health care is not uniform, the referral times as well as the time for initiation of extracorporeal membrane oxygenation (ECMO) would be prolonged as the family members have to pool up resources for the financial implications of supporting their loved ones. History has shown that the longer the delay in initiating ECMO, the poorer the outcome. ECMO supports the body by optimizing oxygen delivery while helping the tissues to utilize the available oxygen in the circulation. Hence, optimizing oxygen-carrying capacity (Hb, circulating blood volume), rebalancing vasoconstriction/vasodilatation to the optimal extent while carefully watching the trend of metabolic end products, tissue oxygenation indices is the key to keep life going. The body might need time to set the metabolic processes back to near-normal levels. One can understand the damage done by cytokines and other inflammatory mediators liberated resulting in massive systemic inflammatory response. The injury caused by reperfusion to the ischemic area has been well described. At times, we might not be able achieve saturations greater than 85%. As long as the trend of the lactate and other metabolic end products are improving in the right direction, we may have to give time for the healing process and wait. Optimizing basal metabolic rate, minimizing the energy expenditure of the tissues, providing nutrition in right proportion resulting in normoglycemia, euthermia, and early initiation of hemofiltration if the kidneys are in a state of refractory shock, and preventing nosocomial infections are few of the measures in careful analysis and support of the body systems. The beauty of ECLS is caregivers need to have the strength to assess each and every organ system, compare the pathophysiology with the physiology, and take actions not resulting in harm.