**Author details**

Prashant N. Mohite\* and André R. Simon Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, United Kingdom

\*Address all correspondence to: p.mohite@rbht.nhs.uk

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**Acknowledgements**

**Conflict of interest**

Maunz for helping with manuscript editing.

Authors do not have any conflicts of interest.

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

may avoid its catastrophic consequences (**Figure 5**).

**4. Conclusions**

 Several authors confirm that the procedure is effective provided it is performed as soon as the diagnosis of compartment syndrome is established. It can be performed bedside under local anaesthesia [36, 37]. Four chamber fasciotomies essentially involve decompression of anterior and posterior compartment of the thigh and anterolateral and posteromedial compartments of lower leg. Primary closure of these wounds can be

A last and unfortunate resort in the management of advanced limb ischemia to save a life is to give up a limb. Irreversible ischemic damage to skin and muscles causes rhabdomyolysis, acute kidney injury, and metabolic acidosis. In such cases, amputation of the limb remains the only option to save the patient's life. Contemporary retrospective observational studies report incidence of lower limb amputation in patients supported with ECLS between 1 to 10% [11, 13, 15, 20, 21, 38]. However, some prospective studies with utilisation of newer technology and ideas such as NIRS for early detection of ischemia and distal arterial pressure based or pre-emptive introduction of DPC reported no amputations [23, 24, 31]. However, apart from the obvious benefit of these newer techniques, patients in studies focusing on limb ischemia may have received significant additional attention and care to prevent and treat limb ischemia at early stage. This in itself may have had a profound effect, further corroborating that early detection of limb ischemia with expectant monitoring and protocol-based prompt intervention

Care of the cannulated limb with maintenance of adequate perfusion to avoid ischemia is as important as the preservation of vital organ function. Limb ischemia plays a seminal role in the fate of a patient supported on ECLS. Vascular complications, particularly limb ischemia negatively affect survival in patients on ECLS. Expectant continuous monitoring utilising NIRS, if used, a flow monitored distal perfusion cannula and hourly surveys of flow in distal arteries and signs of ischemia are key in timely detection of limb ischemia. A prophylactic distal perfusion cannula should always be used in patients with risk factors for development of limb ischemia and can most likely be avoided in others if a small calibre systemic cannula is used. Acceptance of lower ECLS flow, maintenance of pulsatility and avoidance of vasopressors are additional important elements. Prompt intervention to re-establish adequate blood supply after suspicion of limb ischemia is essential to avoid its catastrophic consequences. The safest method of prophylactic or therapeutic introduction of a distal perfusion cannula remains the open cut-down and exposure. Percutaneously inserted distal perfusion cannulas should be checked for their position by fluoroscopy. Also, change of cannulation site and bridging ECLS to a substantive therapy should be part of any strategy for patients on ECLS. If properly integrated into an institutional protocol and adhered to, these strategies allow for successful treatment of patients in need of extracorporeal life support with low complication and high success rates.

Authors are not funded for preparation of this manuscript. Authors thank Olaf

performed following explantation of ECLS and decrease of limb swelling.
