Correct!
5. All of the above
The patient has developed ECMO "harlequin" syndrome. This results from inadequate mixing of blood in the aorta where the relatively deoxygenated blood from the left heart is not adequately mixed with the oxygenated blood from ECMO (Figure 2).
Figure 2. Schematic showing inadequate mixing of deoxygenated and oxygenated blood resulting in cyanosis in the upper extremities and head.
The deoxygenated blood is directed more towards the upper body while the oxygenated blood is directed more towards the lower extremities. Increasing the mixing or another mode of ECMO are strategies to deliver more oxygenated blood to the head and upper extremites. The flow rate of the ECMO was increased along with administration of esmolol to decrease the flow rate out of the left ventricle to allow more adequate mixing. If these had failed, moving the arterial line from the ECMO could be considered. Switching to another mode of ECMO such as venous-arterial-venous (VAV) where oxygenated blood is returned to both the arterial and venous circulation is another consideration.
The patient eventually improved after two days on ECMO and eventually was extubated and transferred to the floor.
References