IABP, Ventricular Devices & ECMO

ABPN Neurocritical Care Study Guide Exam

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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU

Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU

2 Chapter 2: Cerebral Physiology & Intracranial Dynamics

Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes

3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management

Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions

4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management

Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy

5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management

Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury

6 Chapter 6: Neuropharmacology, Analgesia & Sedation

ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU

7 Bleeding, Thrombosis & Hematologic Emergencies

Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity

8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine

Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention

9 Systemic Trauma & Environmental Injury

Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging

10 Cardiac Emergencies & Mechanical Support

IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies

11 Kidney Injury, Acid–Base & Renal Replacement

Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement

12 Systemic Infection & Endocrine Emergencies

Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies

13 Gastrointestinal & Hepatic Emergencies

Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects

14 Chapter 9: Neuroimaging in the Neuro-ICU

Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness

15 Chapter 10: Electrophysiology & Neuromonitoring

Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler

16 Angiography, Electrodiagnosis & CSF Analysis

Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage

17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria

Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria

18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies

Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction

19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage

Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH

20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia

Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations

21 Venous, Spinal & Traumatic Vascular Disease

Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury

22 Chapter 15: Traumatic Brain & Spinal Cord Injury

Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes

23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies

Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure

24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis

Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies

25 Neuroinflammation & Neurooncology

Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies

26 Pregnancy, Transplantation & Pediatric Care

Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care

27 Chapter 18: Neurosurgical & Perioperative Emergencies

Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies

28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU

Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor

IABP, Ventricular Devices & ECMO

Key Takeaways Explain This Topic AI

VV-ECMO supports gas exchange; it does not directly provide systemic circulatory support.

VA-ECMO supports circulation and gas exchange but introduces additional embolic, hemorrhagic, and perfusion risks.

IABP inflation during diastole and deflation before systole provide counterpulsation rather than full pump replacement.

New focal deficits, seizures, or pupillary changes on a support device require prompt assessment for stroke or hemorrhage.

Last updated: October 2026

Match the Device to the Failing Function

The official blueprint explicitly names intra-aortic balloon pumping, temporary ventricular devices, VV- and VA-ECMO, and neurologic complications of LVADs and ECMO. Their common purpose is to maintain organ support while a reversible disorder recovers or while a definitive treatment is arranged. Their mechanisms differ. Knowing whether the problem is gas exchange, left ventricular output, right ventricular output, or combined failure prevents selection of an inadequate device.

Mechanical circulatory support does not make the brain immune to hypotension, hypoxemia, embolism, or hemorrhage. Cannulation, anticoagulation, changing pulsatility, and device-related hemolysis add risks. Sedation and paralysis can hide new deficits, so document the examination before support when feasible and plan repeated neurologic assessments during treatment.

Counterpulsation and Temporary Ventricular Support

An intra-aortic balloon pump (IABP) inflates in diastole to augment diastolic aortic pressure and coronary perfusion, then deflates before systole to reduce LV afterload. It requires correct timing and provides limited support rather than replacing cardiac output. Severe aortic regurgitation and aortic dissection are important contraindications. Routine IABP placement does not confer a universal survival benefit in myocardial-infarction-related cardiogenic shock; selection is individualized, including selected mechanical complications or bridge situations.

Temporary microaxial or extracorporeal ventricular pumps can provide more active flow. Choice depends on ventricular function, anatomy, vascular access, valve disease, intracardiac thrombus, and the team's expertise. LV unloading can improve congestion in selected patients but may also create suction events, hemolysis, vascular injury, or inadequate flow when preload is poor. Device alarms must be evaluated physiologically rather than silenced by repeated fluid boluses without an examination.

• Support Main effect Important limitation
• IABP Diastolic augmentation and systolic unloading Limited output support; timing-dependent
• Temporary LV support Active systemic flow or unloading Does not necessarily treat RV or lung failure
• VV-ECMO Extracorporeal oxygenation and CO2 removal Relies on native cardiac output for systemic circulation

VA-ECMO Extracorporeal circulatory and gas-exchange support LV distension, differential oxygenation, vascular and neurologic risks

VV-ECMO and VA-ECMO

Venovenous ECMO drains systemic venous blood, oxygenates it, removes CO2, and returns it to the venous circulation. The native heart then pumps it systemically. It can support severe reversible respiratory failure despite optimized conventional care. It does not directly correct profound primary cardiogenic shock. Recirculation, cannula position, oxygenator performance, native cardiac output, and hemoglobin influence effective oxygen delivery.

Venoarterial ECMO returns blood to the arterial circulation and can support refractory cardiogenic shock or selected arrest situations. With peripheral femoral return, retrograde aortic flow can increase LV afterload. If the LV cannot eject adequately, ventricular distension and pulmonary edema may develop; specialist unloading strategies may be needed. Lower-body oxygenation may appear satisfactory while poorly oxygenated native LV output supplies the upper body, creating differential hypoxemia. Right-sided upper-extremity oxygenation measurements are useful in this configuration because they better reflect blood reaching the brain than a lower-limb value alone.

Rapid correction of severe hypercapnia at initiation can change cerebral vascular tone abruptly. Coordinate CO2 removal and serial gases rather than assuming an immediate normal number is always harmless. Pump flow, sweep gas, and oxygen delivery are different controls; changing one does not guarantee the expected response in all the others.

Neurologic Complications and Monitoring

Both ischemic stroke and intracranial hemorrhage can occur. Mechanisms include emboli, pre-support hypoxic-ischemic injury, anticoagulation, acquired hemostatic abnormalities, and unstable perfusion. Seizures may be nonconvulsive. Follow pupils, motor responses when assessable, sedation exposure, and gas exchange. EEG, CT, vascular imaging, or other monitoring is selected for the clinical problem; no single bedside monitor excludes a structural lesion.

If a new deficit appears, stabilize systemic support, obtain urgent neuroimaging, and convene the ECMO/device, stroke, neurosurgical, and critical care teams. Decisions about pausing or reversing anticoagulation must consider hemorrhage severity and circuit thrombosis risk together. Standard MRI access may be limited by device compatibility. A safe CT transport plan may resolve a question that cannot be answered at the bedside.

Durable LVAD patients can have low pulsatility, making ordinary cuff pressures and palpable pulses unreliable. Use the device-specific protocol for flow and pressure assessment. Neurologic complications include ischemic stroke, hemorrhage, and infection-related emboli. Verify device function, blood pressure, anticoagulation, and evidence of infection or pump thrombosis during the workup. Do not infer circulatory arrest solely from an absent palpable pulse in a continuous-flow device patient.

A Device-Based Vignette

A patient on peripheral VA-ECMO develops poor right-arm oxygenation despite reassuring lower-limb measurements. The key is to assess differential upper-body hypoxemia, native lung function, ventricular ejection, and circuit configuration. Simply increasing a sedative infusion for agitation may obscure a sign of inadequate cerebral oxygen delivery. A separate patient with preserved circulation and isolated refractory ARDS would generally require consideration of respiratory support, not automatic selection of an arterial circuit.

Source checked October 17, 2026: ELSO clinical guidelines and consensus statements , including neurologic monitoring guidance. Device selection and emergency management depend on configuration and center expertise.