**5.6 Delirium**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**5.2 Ischemic complications**

and treating seizures.

treated with the help of neurologists.

**5.4 Sensorineural hearing loss**

**5.3 Seizures**

practice to minimize and treat bleeding complications on ECMO.

ROTEM, activated clotting time, PT/PTT, heparin assays) and therapeutic targets for titration. Further research is needed to help develop guidelines and consensus on best

It occurs in about 5–6% of children and adults [8, 36], and is best identified on MR imaging. Due to multifactorial etiology for ischemic strokes such as hypotension, large vessel occlusion, thromboembolism, septic embolism, etc. it is difficult to characterize lesions anatomically or to prognosticate based on imaging. Timing of injury is also difficult to ascertain. There are conflicting reports on laterality of lesions [37] but seem to occur in the middle cerebral artery vascular territory. A single center pediatric study found that majority of strokes were bilateral, a few were unilateral right sided lesions and no patients had unilateral left sided strokes; majority of the lesions were in the anterior cerebral circulation distribution [22]. Ischemic lesions are associated with electrographic seizures and decreased survival [38]. Asymmetry in regional cerebral saturation or on continuous EEG monitoring might be suggestive of focal ischemia. Once detected, hemodynamics should be optimized through adequate pump flows on VA ECMO, vasoactives can be used if needed, and further neurologic injury should be minimized by avoiding hyperoxia

Although less common than intracranial hemorrhage and stroke, seizures can be difficult to recognize if they are nonconvulsive or subclinical. A study of children and neonates undergoing ECMO revealed that 18% of patients had electrographic seizures, with 61% of those patients having electrographic status epilepticus and 83% having exclusively electrographic seizures [39]. Another recent study of neonatal and pediatric patients found electrographic seizures in 23% of their patients, especially within the first 24 hours of ECMO [40]. Patients with seizures had decreased survival to discharge (44% versus 74%). Older studies that reported lower incidence of seizures may have missed patients if only clinical seizures were reported, as the routine use of continuous EEG monitoring for patients is not yet a widespread practice, although recent recommendations advocate for its use in ECMO. Given that patients on ECMO are a high risk population, seizures should be

Sensorineural hearing loss has been reported in neonatal ECMO graduates with a frequency of 3–21% [41]. Diagnosis of congenital diaphragmatic hernia, duration of ECMO, and aminoglycoside antibiotic use were associated with hearing loss [42]. A follow-up study found that even children diagnosed with hearing loss after

Prolonged immobilization, sedation and paralytics, hemodynamic instability, all contribute to neuromuscular weakness in ECMO patients. Studies have proved that active physiotherapy, with early mobilization, is feasible and safe in ECMO patients when performed with an experienced, multidisciplinary team [44, 45]. It may also shorten hospital duration and improve functional outcomes for patients [46].

ECMO can go on to have normal language development [43].

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**5.5 Myopathy**

A small study of pediatric cardiac ECMO patients diagnosed delirium in all their patients, in 21% of coma-free ECMO days [47]. Use of validated delirium screening tools can aid in early recognition and management of delirium. The move to liberate ICU patients should include patients on ECMO whenever feasible, with an emphasis on delirium prevention.
