Pink Toes and Blue Brain on VA ECMO (North South Syndrome on ECMO)

In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.

Show Highlights:

• Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
• Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
• Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
• Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
• Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
• Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
• Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
• Importance of monitoring and managing end-organ function in septic patients.
• Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
• Discussion of the risks and benefits of various ECMO configurations and management techniques.

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
• Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
• Reference 2 : Cove ME. Disrupting differential hypoxia in peripheral veno-arterial extracorporeal membrane oxygenation. Crit Care. 2015 Jul 22;19(1):280. doi: 10.1186/s13054-015-0997-3. PMID: 27391473; PMCID: PMC4511033.