Search Results (127)

Background and Objectives: The usefulness of extracorporeal membrane oxygenation (ECMO) therapy for acute respiratory distress syndrome (ARDS) in patients with traumatic brain injury (TBI), spontaneous intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) is limited. This study aimed to investigate the survival benefit of ECMO in ARDS that developed during hospitalization in high-risk neurological patients. Materials and Methods: This retrospective study evaluated patients with TBI or spontaneous ICH and SAH admitted to our hospital’s neurosurgery intensive care unit and who received ECMO therapy for ARDS between March 2017 and March 2024. Clinicodemographic characteristics, indications for and methods of ECMO application, occurrence of comorbidities, hospital survival rates, and ECMO weaning success rates were compared between survivors and non-survivors. Results: Among the 16 patients evaluated, seven (43.8%) were successfully discharged. The mean ages of the survivor and non-survivor groups were 52.1 and 58.6 years, respectively. The PaO₂/FiO₂ ratio pre-ECMO was similar in both groups (66.6 vs. 69.2); however, it improved significantly post-ECMO in the survivor group (264.1 vs. 209.4). The ECMO success rate was 100% in the survivor group and only 33.3% in the non-survivor group. The intensive care unit and hospital lengths of stay were longer in the survivor group. Most patients received veno-venous ECMO, and hemorrhagic complications were rare. Conclusions: ECMO for ARDS in patients with severe TBI or spontaneous ICH and SAH positively impacts survival and functional recovery and may be a beneficial treatment modality. Full article

Background: Nutritional support in patients receiving extracorporeal membrane oxygenation (ECMO) is a clinical challenge. Hemodynamic instability and concerns about gut perfusion delay enteral nutrition (EN), resulting in frequent use of total parenteral nutrition (TPN). This study aimed to compare nutritional practices in patients on venoarterial (VA) vs. venovenous (VV) ECMO, and to evaluate the associations between prolonged TPN use, feeding status, circuit change frequency, length of stay, and survival. Methods: Retrospective cohort study of ECMO patients in a quaternary pediatric intensive care unit. Nutritional variables included route and amount of nutrition delivery. The primary outcome was the nutrition type (enteral vs. parenteral) in association with ECMO mode (VV vs. VA). Secondary outcomes included associations between nutrition variables (TPN by Day 14, lack of EN by Day 5 or 7) and circuit changes, ECMO duration, ICU/hospital length of stay (LOS), and mortality. Analyses by Mann–Whitney and chi-square tests. Multivariable Poisson regression was used to identify independent predictors of circuit change frequency. Results: Patients on VV ECMO achieved higher enteral intake than those on VA ECMO. Persistent need for TPN by Day 14 was associated with longer PICU LOS, hospital LOS, and ECMO duration and was independently associated with 71% higher circuit change frequency. Survival did not differ significantly by TPN duration or early EN exposure. Conclusions: VV ECMO patients received higher enteral nutrition. Persistent need for TPN by day 14 was associated with worse outcomes. These findings underscore the need for standardized, evidence-based feeding strategies in this population. Full article

Background: Sickle cell disease (SCD) is a hereditary hemoglobinopathy associated with life-threatening complications such as acute chest syndrome (ACS), which may necessitate extracorporeal membrane oxygenation (ECMO) in refractory cases. Despite growing use, ECMO in SCD remains challenging due to risks of hemolysis, thrombosis, and anticoagulation complications. This systematic review consolidates existing evidence on ECMO outcomes in SCD, focusing on indications, complications, and survival. Methods: A systematic search of MEDLINE, Cochrane CENTRAL, and Google Scholar was conducted up to January 2025, identifying case reports/series on ECMO use in SCD. Studies reporting venovenous (VV) or venoarterial (VA) ECMO for acute cardiopulmonary failure were included. Data on demographics, laboratory findings, management, and outcomes were extracted. Quality assessment was performed using the Joanna Briggs Institute checklist. Results: Sixteen case reports (23 patients) were included. Most patients were female (65.2%), with ACS (47.8%) and pulmonary embolism (13.0%) as common ECMO indications. VV-ECMO (69.6% of cases) was primarily used for respiratory failure, with a 69% survival rate, while VA-ECMO (30.4%) had a 29% survival rate, often due to cardiogenic shock or cardiac arrest. Complications included hemorrhage (26.1%), neurological injury (21.7%), and thrombosis (13.0%). Exchange transfusion was frequently employed (43.5%), with post-ECMO echocardiography showing improved right ventricular function in survivors. Conclusions: VV-ECMO demonstrates favorable outcomes in SCD-related respiratory failure, whereas VA-ECMO carries higher mortality risks. Careful patient selection, anticoagulation management, and multidisciplinary coordination are essential. Larger prospective studies are needed to refine ECMO utilization in this high-risk population. Full article

Background and Objectives: The optimal effluent dose of continuous haemofiltration (CHF) when coupled to veno-venous extracorporeal membrane oxygenation (ECMO) for septic shock is unknown. We examined our 44-patient ECMO registry, contrasting a smaller high-dose subgroup (HDHF ≥ 45 mL kg⁻¹ h⁻¹; n = 13) with a larger standard-dose subgroup (SDHF 25–35 mL kg⁻¹ h⁻¹; n = 31). The primary endpoint was 72 h change in SOFA score (ΔSOFA). Materials and Methods: All adults cannulated for ECMO (January 2018–January 2025) and started on CHF within 2 h were eligible. Variables were abstracted at baseline, 24 h and 72 h. Continuous data were analysed by Student’s t or Mann–Whitney tests, categorical data by χ²/Fisher; and paired changes by Wilcoxon. Two-sided p < 0.05 signified significance. Results: Baseline characteristics were comparable (age 49.1 ± 15.2 vs. 50.4 ± 14.9 y; APACHE II 28.4 ± 5.3 vs. 27.5 ± 5.9). Median effluent reached 48.1 mL kg⁻¹ h⁻¹ (IQR 46.6–49.7) in HDHF and 29.7 mL kg⁻¹ h⁻¹ (27.5–31.9) in SDHF (p < 0.001). IL-6 fell by 1 061 ± 487 pg mL⁻¹ with HDHF versus 637 ± 425 pg mL⁻¹ with SDHF (p = 0.003). Mean arterial pressure rose 19.2 ± 8.1 vs. 12.7 ± 8.3 mmHg (p = 0.03), and norepinephrine declined 0.46 ± 0.22 vs. 0.30 ± 0.19 µg kg⁻¹ min⁻¹ (p = 0.04). ΔSOFA at 72 h was –4.4 ± 2.1 with HDHF and –2.6 ± 2.3 with SDHF (p = 0.01). Twenty-eight-day mortality was 38.5% (5/13) versus 45.2% (14/31), p = 0.64. Effluent dose correlated with ΔIL-6 (ρ = 0.53, p < 0.001) and ΔSOFA (ρ = 0.45, p = 0.003). Conclusions: In this ECMO cohort, high-dose haemofiltration, although applied in only 13 patients, appeared to achieve greater cytokine clearance, faster haemodynamic recovery and deeper early organ-failure improvement than standard dosing, without excess bleeding. Survival advantage was not demonstrable, underscoring the need for prospective randomised confirmation of the dose–response signal. Full article

Since extracorporeal membrane oxygenation (ECMO) is primarily used for patients in a high-risk state and is an invasive procedure, its unique application scenarios make it difficult to recruit suitable cases for clinical trials. Therefore, large animal models have become one of the most important models for preclinical evaluation of the safety and effectiveness of ECMO. This study aims to assess the safety and performance of a novel portable ECMO device with Small-tail Han sheep. Fifteen sheep were divided into a test group (LIFEMOTION, Chinabridge, Shenzhen, China) and control group (NOVALUNG XLUNG kit 230, Xonis, Heilbronn, Germany) with veno-venous ECMO (VV-ECMO) and veno-arterial ECMO (VA-ECMO) modes. Tracheal intubation, arteriovenous access, and ECMO support were performed. Vital signs and blood laboratory tests of the subjects were monitored and recorded. The main organs were examined pathologically at the end of day fourteen. The serum protein expression profile was analyzed by protein quantification techniques. All sheep were successfully weaned from ECMO without transfusion or cannula complications. No significant differences were observed between the two groups in terms of vital signs, oxygenation, hemodynamic stability, and physiological function (p > 0.05). According to the serum protein expression profile, no significant biomarkers associated with ECMO clinical complications were identified. The LIFEMOTION ECMO device demonstrated good safety and efficacy. Full article

During pregnancy and in the postpartum period, several diseases may arise or become exacerbated. Acute pancreatitis incidence during pregnancy is similar to the general population but increases in the first two years after delivery. This case report describes the evolution of necrotizing acute pancreatitis in a 30-year-old woman five months postpartum, with an atypical debut of acute pancreatitis, where the high levels of triglycerides caused by hormonal changes in the late postpartum period overlapped with an underlying hyperlipemia. Despite aggressive, multidisciplinary care, including surgical necrosectomy, continuous renal replacement therapy (CRRT), protective ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO), the prognosis was influenced by the hormonal changes both secondary to hypothalamic–pituitary–adrenal dysregulation and the postpartum hormonal changes, leading to an altered inflammatory response, evolution to MODS, ultimately resulting in death. The case highlights the complex interplay between postpartum immune and hormonal changes and the systemic inflammatory response of pancreatitis, emphasizing the critical need for postpartum-specific guidelines in managing acute pancreatitis, particularly regarding early risk stratification in order to prevent this pathology and its complications. Full article

Background/Objectives: Low-dose corticosteroids have gained popularity in the treatment of acute respiratory distress syndrome (ARDS); however, the efficacy of high-dose corticosteroids as pulse steroid therapy remains controversial. This study aimed to evaluate the efficacy of pulse steroid therapy in patients with severe ARDS requiring venovenous (V-V) extracorporeal membrane oxygenation (ECMO), where enhanced anti-inflammatory effects may be beneficial. Methods: Using data from the J-CARVE registry, which included patients with severe ARDS managed with V-V ECMO across 24 Japanese hospitals between January 2012 and December 2022, we identified 373 patients treated with corticosteroids. The patients were divided into two groups: pulse steroid therapy and non-pulse steroid therapy. Propensity score matching was performed, and all-cause hospital mortality and ECMO-free days within 28 days were compared between groups. Pulse steroid therapy was defined as methylprednisolone at a dose of 1000 mg/day. Results: After matching, 48 patients were included in each group. The all-cause hospital mortality rates were 41.7% (20/48) in the pulse steroid group and 47.9% (23/48) in the non-pulse steroid group, with no significant difference (odds ratio, 1.28; 95% confidence interval: 0.53–3.12, p = 0.68). The median ECMO-free days were 9.5 (interquartile range [IQR]: 0–17.3) in the pulse steroid group and 3 (IQR: 0–17) in the non-pulse steroid group, showing no significant difference (p = 0.69). Conclusions: Pulse steroid therapy did not improve all-cause hospital mortality or ECMO-free days in patients with severe ARDS who required V-V ECMO. Full article

Background and Objectives: Severe sepsis complicated by refractory shock is associated with high mortality. Adding continuous hemofiltration to venovenous extracorporeal membrane oxygenation (ECMO) may accelerate clearance of inflammatory mediators and improve haemodynamic stability, but evidence remains limited. We analysed 44 consecutive septic-shock patients treated with combined ECMO-hemofiltration (ECMO group) and compared them with 92 septic-shock patients managed without ECMO or renal replacement therapy (non-ECMO group). Methods: This retrospective single-centre study reviewed adults admitted between January 2018 and March 2025. Demographic, haemodynamic, laboratory and outcome data were extracted from electronic records. Primary outcome was 28-day mortality; secondary outcomes included intensive-care-unit (ICU) length-of-stay, vasopressor-free days, and change in Sequential Organ Failure Assessment (SOFA) score at 72 h. Results: Baseline age (49.2 ± 15.3 vs. 52.6 ± 16.1 years; p = 0.28) and APACHE II (27.8 ± 5.7 vs. 26.9 ± 6.0; p = 0.41) were comparable. At 24 h, mean arterial pressure rose from 52.3 ± 7.4 mmHg to 67.8 ± 9.1 mmHg in the ECMO group (mean change [∆] + 15.5 mmHg, p < 0.001). Controls exhibited a modest 4.9 mmHg rise that did not reach statistical significance (p = 0.07). Inflammatory markers decreased more sharply with ECMO (IL-6 ∆ −778 pg mL⁻¹ vs. −248 pg mL⁻¹, p < 0.001). SOFA fell by 3.6 ± 2.2 points with ECMO versus 1.6 ± 2.4 in controls (p = 0.01). Twenty-eight-day mortality did not differ (40.9% vs. 48.9%, p = 0.43), but ICU stay was longer with ECMO (median 12.5 vs. 9.3 days, p = 0.002). ΔIL-6 correlated with ΔSOFA (ρ = 0.46, p = 0.004). Conclusions: ECMO-assisted hemofiltration improved early haemodynamics and organ-failure scores and accelerated cytokine clearance, although crude mortality remained unchanged. Larger prospective trials are warranted to clarify survival benefit and optimal patient selection. Full article

Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) supports critically ill patients with respiratory failure. However, ECMO may induce systemic inflammation, hemolysis, and hemodilution, potentially resulting in endothelial activation and damage. Therefore, this study explored the longitudinal changes in circulating markers of inflammation, hemolysis, and endothelial activation and damage in patients with COVID-19 on VV-ECMO. Methods Plasma was obtained before, within 48 h as well as on day 4, week 1, and week 2 of ECMO support and after decannulation. Circulating markers were measured using Luminex, ELISA, and spectrophotometry. Human pulmonary endothelial cells were exposed to patient plasma, and in vitro endothelial permeability was assessed using electric cell-substrate impedance sensing. Results From April 2020 to January 2022, plasma was collected from 14 patients (71.4% male; age 54 (45–61) years). IL-6 levels decreased (1.238 vs. 0.614 ng/mL, p = 0.039) while ICAM-1 increased (667 vs. 884 ng/mL, p = 0.003) over time when compared to pre-ECMO. Angiopoietin-1 decreased after ECMO initiation (7.57 vs. 3.58 ng/mL, p = 0.030), whereas angiopoietin-2 increased (5.20 vs. 10.19 ng/mL, p = 0.017), particularly in non-survivors of ECMO. Cell-free hemoglobin decreased directly after VV-ECMO initiation but remained stable thereafter (55.29 vs. 9.19 mg/dL, p = 0.017). Moreover, the plasma obtained at several time points during the ECMO run induced in vitro pulmonary endothelial hyperpermeability. Conclusions This exploratory study shows that patients on VV-ECMO support due to COVID-ARDS exhibit progressive endothelial activation and damage but not inflammation and hemolysis. Larger prospective studies are necessary to elucidate pathophysiological pathways leading to endothelial activation and damage, thereby reducing organ failure in these critically ill patients. Full article

Background/Objectives: Extracorporeal membrane oxygenation (ECMO) is increasingly used in critically ill patients, but may significantly alter the pharmacokinetics (PK) of antifungals. Data on plasma concentrations of Isavuconazole (IsaPlasm) in ECMO patients are limited. Our objective is to evaluate Isavuconazole exposure and variability in critically ill COVID-19 patients receiving ECMO. Methods: We conducted a pharmacokinetic analysis of Isavuconazole in critically ill patients receiving Veno-Venous ECMO for respiratory support. Plasma concentrations were measured using therapeutic drug monitoring (TDM) at multiple time points, including sampling before and after the membrane oxygenator. PK parameters—Area Under Curve (AUC_0–24), Minimum Plasma Concentration (Cmin), Elimination Half-Life (T_1/2), volume of distribution (Vd), and clearance (CL)—were estimated and compared with published data in non-ECMO populations. Results: Five patients were included. The median AUC_0–24 was 227.3 µg·h/mL (IQR 182.4–311.35), higher than reported in non-ECMO patients. The median Vd was 761 L (727–832), suggesting extensive peripheral distribution and potential drug sequestration in the ECMO circuit. CL was increased (1.6 L/h, IQR 1.5–3.4). Two patients with recently replaced ECMO circuits exhibited significant drug loss across the membrane. Obesity and hypoalbuminemia were identified as factors associated with altered drug exposure. Conclusions: Isavuconazole pharmacokinetics show marked variability in critically ill ECMO patients. Increased AUC and Vd, along with reduced clearance, highlight the need for individualized dosing. Full article

Background: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a progressively adopted life-sustaining intervention worldwide, particularly in the management of acute respiratory distress syndrome. Nevertheless, data concerning the prognostic significance of fungal isolation in this setting remain unclear. This study aims (i) to assess the incidence of fungal infection and colonization in a homogeneous cohort of V-V ECMO patients, and (ii) to evaluate the association between fungal infection or colonization and 1-year mortality, with a focus on the impact of specific fungal species. Methods: All consecutive adults admitted to the Intensive Care Units of five Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records and survival < 24 h after V-V ECMO placement. A standard protocol of microbiological surveillance was applied and the distinction between different fungal species were made through in vivo and vitro tests. Cox-proportional hazards models, Kaplan–Meier curves and linear logistic regressions were applied for investigating mortality. Results: Two-hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall fungal isolation was 41% (n. 114): 23% infections and 18% colonizations. The overall 1-year mortality, among fungal isolations, was 40%, with no different risk in case of fungal infection (26 out of 63, 41%) (aHR 0.85, 95% CI [0.53–1.37], p-value 0.505) and colonization (20 out of 51, 39%) (aHR 0.86, 95%CI [0.51–1.43], p-value 0.556), as compared to patients never detecting fungi (68 out of 165, 41%, reference). According to the isolated mycotic species, as compared to Candida sp. group (reference), the risk of death was greater when different fungal species (e.g., Aspergillus sp. and Candida sp.) were concomitantly isolated in the same patient (OR 1.17, 95%CI [1.12–11.07], p-value 0.031. Conclusions: In the overall population, 23% V-V ECMO patients recorded ‘late’ fungal infections and 18% fungal colonizations, with a similar risk of death as compared to patients never experiencing fungi during the V-V ECMO course. The detection of concomitant different fungal species was an independent risk factor for 1-year mortality. Full article

Introduction: Desirable outcome after venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome (ARDS) is frequently defined by survival. However, quality of life (QoL) and mental health status may take precedence over mere survival, from a patient-centered perspective. We aimed to evaluate QoL and mental health status in survivors after V-V ECMO for coronavirus disease 2019 (COVID-19)-related ARDS, hypothesizing a similar QoL comparable to the general population. Methods: All patients supported with venovenous ECMO for COVID-19-related ARDS between 01/2020 and 03/2022 in our center were included. Survivors were invited to participate in a follow-up interview assessing QoL, anxiety, and depression one year after hospital discharge. Primary endpoint was the quality of life, measured by the SF-36 questionnaire, with results compared to data from the DEGS1 study (German normative population). Results: During the study period, 97 patients received venovenous ECMO for COVID-19 ARDS at our ICU. Overall, 43/97 (44.3%) survived, and 21/97 (21.6%) completed the SF-36 questionnaire. The median follow-up duration was 1.7 years. Patients who completed the SF-36 were significantly younger than those who did not (48.7 vs. 55.6 years, p = 0.012); other patient characteristics and ECMO parameters were similar between those with and without questionnaire. Anxiety, depression, and post-traumatic stress disorder were detected in 33%, 14%, and 29% of patients, respectively. Compared to the German normative population, ECMO survivors had significantly lower QoL (mean 77.2 vs. 61.0, p < 0.001). Conclusions: QoL and mental health status after venovenous ECMO for ARDS was significantly lower compared to the normative population. These findings highlight the importance of further research and comprehensive follow-up care for ECMO survivors. Full article

Veno-venous extracorporeal membrane oxygenation (vvECMO) is a life-saving intervention for severe respiratory failure unresponsive to conventional therapies. However, managing refractory hypoxemia in morbidly obese patients poses significant challenges due to the unique physiological characteristics of this population, including hyperdynamic circulation, elevated cardiac output, and increased oxygen consumption. These factors can limit the effectiveness of vvECMO by diluting arterial oxygen content and complicating oxygen delivery. Refractory hypoxemia in obese patients supported by vvECMO often stems from an imbalance between ECMO blood flow and cardiac output. Hyperdynamic circulation exacerbates the recirculation of oxygenated blood and impairs the efficiency of oxygen transfer. To address these challenges, a stepwise, individualized approach is essential. Strategies to reduce oxygen consumption include deep sedation, neuromuscular blockade, and temperature control. Cardiac output modulation can be achieved through beta-blockers and cautious therapeutic hypothermia. Optimizing oxygen delivery involves improving residual lung function; high positive end-expiratory pressure ventilation guided by esophageal pressure monitoring; prone positioning; and adjustments to the ECMO circuit, such as using dual oxygenators, larger membranes, or additional drainage cannulas. This review highlights the interplay of physiological adaptations and technical innovations required to overcome the challenges of managing refractory hypoxemia in obese patients during vvECMO. By addressing the complexities of high cardiac output and obesity, clinicians can enhance the effectiveness of vvECMO and improve outcomes for this high-risk population. Full article

Background and Objectives: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) was described in December 2019 for the first time, and it was responsible for a global pandemic. An alarming number of patients with coronavirus disease 2019 (COVID-19) also developed acute kidney injury (AKI), especially those who required extracorporeal membrane oxygenation (ECMO) therapy for acute respiratory distress syndrome (ARDS). The aim of our retrospective observational study was to assess the prognostic significance of AKI in these patients. This study observed, in COVID-19 patients admitted to an intensive care unit (ICU), AKI stages and the need for renal replacement therapy (RRT), assessing the risk factors and outcomes. Moreover, we evaluated the mortality rate of patients treated by ECMO. Materials and Methods: Between November 2020 and December 2022, among 396 patients admitted to our intensive care unit (ICU) diagnosed with SARS-CoV-2 infection, we selected patients with severe ARDS requiring veno-venous (vv) ECMO support and AKI. Results: The 30-day mortality after ECMO positioning was 85.7%. A Cox regression revealed a significant advantage for RRT with a high cut-off (HCO) hemofilter both for ICU mortality (HR 0.17 [95% CI: 0.031–0.935], p = 0.035) and 15 day-mortality after the start of vv-ECMO (HR 0.13 [95%CI: 0.024–0.741], p= 0.021), whereas the early onset of vasoplegic shock after ECMO implantation indicated a higher risk of death (HR 11.55 [95% CI: 1.117–119.567], p = 0.04) during the ICU stay. Conclusions: COVID-19 induces a high risk of AKI and RRT. In our cohort, hypertension, pre-existing renal disease, and mechanical ventilation represented independent risk factors for AKI. Patients requiring ECMO support had a high mortality rate. The early implementation of RRT reduced the risk of death during the ICU stay. Full article

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. Full article