Program Code: SCF-DBI-PECMO-OPS-0002
Operational Window: Recognition of Failure → ECMO Activation → Cannulation → Stabilization (0–24 Hours)
Primary Objective: Identify ECMO candidates before irreversible biologic intelligence collapse, standardize activation pathways, optimize cannulation safety, and establish immediate recovery-preservation operations.
SECTION 2.1
ECMO ACTIVATION PHILOSOPHY
Traditional Model
ECMO often activated after:
Severe shock
Severe organ dysfunction
Cardiac arrest
Multi-organ failure
SCF-DBI Model
ECMO activated before:
Irreversible neurologic injury
Endothelial collapse
Recovery failure
Developmental injury
Multi-system adaptation failure
Core Principle
Early biologic intelligence preservation is superior to late rescue.
SECTION 2.2
UNIVERSAL ECMO CANDIDATE IDENTIFICATION FRAMEWORK
Candidate Category A
Progressive Cardiogenic Shock
Examples:
Myocarditis
Cardiomyopathy
LCOS
Cardiac surgery failure
Primary graft dysfunction
Candidate Category B
Progressive Respiratory Failure
Examples:
Severe ARDS
Pulmonary hypertensive crisis
Severe pneumonia
Viral respiratory failure
Candidate Category C
ECPR Candidate
Examples:
Witnessed arrest
In-hospital arrest
Refractory CPR
Candidate Category D
Bridge-to-Transplant
Examples:
End-stage heart failure
Refractory graft dysfunction
SECTION 2.3
SCF-DBI EARLY ECMO TRIGGERS
Hemodynamic Triggers
Progressive lactate elevation
Increasing vasoactive support
Declining perfusion
Reduced urine output
Persistent metabolic acidosis
Neurologic Triggers
CAI decline >15%
Cerebral NIRS decline
Progressive encephalopathy
Endothelial Triggers
EII decline >20%
Progressive microvascular dysfunction
Capillary leak progression
Global Triggers
ANMS decline >20%
NCRS decline >20%
Recovery trajectory collapse
SECTION 2.4
ECMO CONSULTATION ACTIVATION SYSTEM
Tier 1
ECMO Awareness
Patient identified as potentially vulnerable.
Actions:
Surveillance intensified
ECMO team notified
Tier 2
ECMO Consultation
Patient likely progressing toward support requirement.
Actions:
Multidisciplinary evaluation
Cannulation planning
Family communication
Tier 3
ECMO Alert
Patient deteriorating despite escalation.
Actions:
Cannulation team mobilized
Equipment prepared
Blood products prepared
Tier 4
ECMO Activation
Immediate deployment initiated.
SECTION 2.5
ECMO MULTIDISCIPLINARY ACTIVATION TEAM
Required Members
ECMO Intensivist
ECMO Surgeon
ECMO Coordinator
Perfusion Specialist
ECMO Nurse
Respiratory Therapist
Pharmacist
Blood Bank Liaison
Optional Members
Neurology
Cardiology
Transplant Team
Ethics Team
SECTION 2.6
ECPR ACTIVATION PROGRAM
Clinical Positioning
ECPR is viewed as:
Neuroprotective Rescue Intervention
Candidate Selection
Favorable Characteristics
Witnessed arrest
Immediate CPR
Reversible cause
Limited pre-arrest dysfunction
High-Risk Characteristics
Prolonged no-flow time
Severe neurologic injury
Terminal disease
ECPR Goal
Restore oxygen delivery before cerebral adaptation becomes irreversible.
SECTION 2.7
ECPR TIMELINE TARGETS
Goal 1
Recognition to Activation
≤ 5 Minutes
Goal 2
Activation to Cannulation Team Arrival
≤ 10 Minutes
Goal 3
Cannulation Initiation
≤ 20 Minutes
Goal 4
ECMO Flow Established
≤ 30 Minutes
RHENOVA Metric
Cerebral Preservation Time Index (CPTI)
SECTION 2.8
ECMO CANNULATION OPERATIONS
Cannulation Objectives
Establish flow rapidly
Preserve vessel integrity
Preserve neurologic perfusion
Minimize endothelial injury
Cannulation Strategies
VA-ECMO
Supports:
Cardiac failure
Cardiogenic shock
ECPR
VV-ECMO
Supports:
Respiratory failure
Severe pulmonary dysfunction
Hybrid Configurations
VAV
Central ECMO
Specialized transplant configurations
SECTION 2.9
RHENOVA CANNULATION PRESERVATION BUNDLE
Objective
Reduce cannulation-associated injury.
Bundle Components
Neuroprotection
Cerebral perfusion optimization
NIRS initiation
Endothelial Protection
Vessel preservation
Perfusion optimization
Recovery Preservation
Early rehabilitation planning
Recovery intelligence enrollment
SECTION 2.10
IMMEDIATE POST-CANNULATION CHECKLIST
First 15 Minutes
Confirm:
Circuit integrity
Adequate flow
Hemodynamic stabilization
Oxygen delivery
Neurologic perfusion
First 30 Minutes
Assess:
Lactate
NIRS
Perfusion
Echocardiography
Organ function
SECTION 2.11
FIRST-HOUR STABILIZATION PROTOCOL
Cardiovascular Objectives
Optimize flow
Optimize preload
Optimize afterload
Optimize coronary perfusion
Respiratory Objectives
Lung protection
Oxygen delivery optimization
Ventilator minimization strategy
Neurologic Objectives
CAI establishment
EEG planning
Cerebral oxygenation optimization
SECTION 2.12
ECMO SURVEILLANCE ENROLLMENT
Every patient automatically enrolled into:
ANMS
NCRS
EII
STRI
CAI
CRIS
ECMO Recovery Dashboard
SECTION 2.13
FIRST 6-HOUR INTELLIGENCE REVIEW
Neurocardiac Intelligence
Evaluate:
NCRS
Lactate clearance
Perfusion reserve
Neurovascular Intelligence
Evaluate:
EII
NIRS
Microvascular adaptation
Neuroimmune Intelligence
Evaluate:
STRI
Inflammatory burden
Recovery Intelligence
Evaluate:
CRIS baseline
Recovery probability
SECTION 2.14
FIRST 24-HOUR RHENOVA STABILIZATION BUNDLE
Bundle A
Neurologic Preservation
Bundle B
Endothelial Preservation
Bundle C
Myocardial Preservation
Bundle D
Immune Preservation
Bundle E
Recovery Intelligence Activation
SECTION 2.15
STABILIZATION SUCCESS ENDPOINTS
Clinical
Stable ECMO flow
Improved oxygen delivery
Improved perfusion
Stabilized organ function
Recovery
Recovery pathway established
Rehabilitation planning initiated
Family integration completed
Biological Intelligence
ANMS stabilized
NCRS stabilized
EII stabilized
STRI stabilized
CAI stabilized
CRIS baseline established
PAGE 2 COMPLETION
Next Page (Page 3):