Program Code: SCF-DBI-PECMO-OPS-0003**
Operational Window: ECMO Stabilization Phase → Recovery Preservation Phase
Primary Objective: Optimize extracorporeal support while preserving neurocardiac adaptation, endothelial integrity, immune competence, organ recovery potential, and developmental resilience.
SECTION 3.1
ECMO PHYSIOLOGIC POSITIONING
Traditional ECMO Management
Focuses on:
Circuit flow
Blood gases
Oxygenation
Hemodynamics
SCF-DBI ECMO Management
Focuses on preserving:
Oxygen Delivery Intelligence
Neurocardiac Intelligence
Endothelial Intelligence
Neuroimmune Intelligence
Recovery Intelligence
Core Principle
ECMO support should restore physiologic adaptation rather than merely normalize physiologic variables.
SECTION 3.2
VA-ECMO OPERATIONS MANUAL
Primary Purpose
Provide temporary support for:
Cardiogenic shock
Cardiac arrest
Severe myocardial dysfunction
Primary graft dysfunction
Refractory LCOS
Physiologic Goals
Maintain systemic perfusion
Preserve cerebral oxygenation
Maintain coronary perfusion
Support myocardial recovery
Prevent multi-organ dysfunction
Core Monitoring
ECMO flow
Cardiac output
Lactate
NIRS
Echocardiography
NCRS
SECTION 3.3
VA-ECMO FLOW MANAGEMENT FRAMEWORK
Flow Objective
Maintain adequate:
Oxygen delivery
Organ perfusion
Recovery reserve
Flow Classification
Green Zone
Optimal adaptation
Characteristics:
Lactate improving
Stable NIRS
Improving perfusion
Yellow Zone
Adaptive stress
Characteristics:
Mild perfusion abnormalities
Increased vasoactive burden
Orange Zone
Threatened adaptation
Characteristics:
Rising lactate
Declining NCRS
Red Zone
Adaptation failure
Characteristics:
Severe oxygen debt
Progressive organ dysfunction
SECTION 3.4
MYOCARDIAL UNLOADING FRAMEWORK
Clinical Positioning
Excess ventricular workload impairs recovery.
Strategic Objectives
Reduce myocardial oxygen demand
Improve coronary perfusion
Promote myocardial recovery
Reduce ventricular distension
Monitoring Variables
Ventricular dimensions
Ventricular pressures
Echocardiography
Lactate
NCRS
RHENOVA Output
Myocardial Recovery Potential Score (MRPS)
SECTION 3.5
VA-ECMO HEMODYNAMIC OPTIMIZATION ALGORITHM
Domain 1
Preload Optimization
Monitor:
Filling status
Venous return
Circuit drainage
Domain 2
Afterload Optimization
Monitor:
Systemic vascular resistance
Ventricular loading
Domain 3
Contractility Optimization
Monitor:
Ventricular function
Recovery trends
Domain 4
Perfusion Optimization
Monitor:
Lactate
Organ perfusion
NIRS
SECTION 3.6
VV-ECMO OPERATIONS MANUAL
Primary Purpose
Provide support for:
Severe respiratory failure
ARDS
Pulmonary hypertension-associated respiratory failure
Refractory hypoxemia
Strategic Objectives
Preserve oxygen delivery
Minimize ventilator injury
Promote pulmonary recovery
Preserve developmental potential
Core Monitoring
Oxygenation
Carbon dioxide clearance
Pulmonary compliance
NIRS
EII
SECTION 3.7
VV-ECMO OXYGEN DELIVERY INTELLIGENCE FRAMEWORK
Clinical Positioning
Oxygen delivery is viewed as:
Systemic Adaptive Resource
Components
Oxygen Supply
ECMO flow
Hemoglobin
Oxygen saturation
Oxygen Transport
Cardiac output
Perfusion
Endothelial function
Oxygen Utilization
Lactate
Metabolic reserve
Recovery status
Output
Oxygen Delivery Intelligence Score (ODIS)
SECTION 3.8
PULMONARY RECOVERY SUPPORT SYSTEM
Strategic Objective
Promote lung healing while minimizing secondary injury.
Recovery Domains
Alveolar recovery
Endothelial recovery
Pulmonary vascular recovery
Gas exchange recovery
Monitoring Variables
Compliance
Oxygenation
Pulmonary pressures
EII
Primary Output
Pulmonary Recovery Index (PRI)
SECTION 3.9
ECMO PHYSIOLOGIC COMMAND CENTER
Strategic Objective
Integrate all physiologic systems into a unified operational framework.
Operational Domains
Cardiac adaptation
Pulmonary adaptation
Endothelial adaptation
Immune adaptation
Recovery adaptation
Command Outputs
Stability status
Escalation risk
Recovery probability
Decannulation readiness
SECTION 3.10
NEUROCARDIAC SURVEILLANCE DURING ECMO
Purpose
Prevent occult cardiovascular deterioration.
Monitoring Domains
Ventricular function
Cardiac reserve
Coronary perfusion
NCRS
NCRS Classification
Green
80
Yellow
60–79
Orange
40–59
Red
<40
SECTION 3.11
ENDOTHELIAL PRESERVATION OPERATIONS
Clinical Positioning
Endothelial injury is a major determinant of ECMO morbidity.
Surveillance Domains
Glycocalyx integrity
Capillary leak
Microcirculation
Organ perfusion
Monitoring Variables
EII
Lactate
NIRS
Fluid balance
RHENOVA Output
Endothelial Recovery Potential Score (ERPS)
SECTION 3.12
DAILY ECMO PHYSIOLOGY REVIEW
Hourly
Flow assessment
Circuit assessment
Perfusion assessment
Every Shift
ANMS review
NCRS review
EII review
STRI review
Daily
Echocardiography
Recovery review
Decannulation review
SECTION 3.13
ECMO ESCALATION MATRIX
Level 1
Enhanced Monitoring
Triggers:
Rising lactate
NCRS decline >10%
Level 2
Focused Intervention
Triggers:
EII decline >15%
ODIS decline >15%
Level 3
Multidisciplinary Escalation
Triggers:
Ventricular deterioration
Pulmonary deterioration
Level 4
Advanced Rescue Activation
Triggers:
ANMS <50
Progressive organ dysfunction
Level 5
System Recovery Failure Response
Triggers:
ANMS <40
Multi-organ collapse trajectory
SECTION 3.14
RECOVERY PRESERVATION OPERATIONS
Immediate Objectives
Preserve myocardial recovery
Preserve pulmonary recovery
Preserve neurologic recovery
Preserve developmental recovery
Monitoring Outputs
CRIS
MRPS
PRI
ERPS
SECTION 3.15
PAGE 3 SUCCESS ENDPOINTS
Clinical
Stable ECMO physiology
Improved perfusion
Improved oxygen delivery
Organ stabilization
Recovery
Positive recovery trajectory
Early rehabilitation readiness
Reduced secondary injury
Biological Intelligence
ANMS stabilized
NCRS >80
EII >80
ODIS >80
CRIS >80
PAGE 3 COMPLETION
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