ecmo by dj
TRANSCRIPT
EXTRACORPOREAL MEMBRANE OXYGENATION
• A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed.
• The blood is then returned to the patient via a central vein or an artery.
- ECMO guidelines Alfred Health Update Nov. 2015
INTRODUCTION
1950s Development of membrane oxygenator in laboratory
1971 First successful case
1972 First successful paediatric cardiac case
1975 First neonatal case (Esperanza)
1975-89 Trial in ARDS, 10% survival
1990 Standard practice for neonates and pediatrics in some
centers
2000 Standard practice for adults in some centres
2009 Publication of the CESAR trial which led to a significant
growth in the use of ECMO for ARDS cases
* CESAR Trial - Conventional Ventilation or ECMO for Severe Adult Respiratory failure trial
HISTORY
First successful ECMO patient in1971
Figure: The first successful extracorporeal life support patient, treated by J.
Donald Hill using the Bramson oxygenator (foreground), Santa Barbara, 1971.
• Desaturated blood is drained via a venous cannula
• CO2 is removed, O2 added through an “extracorporeal” device
• The blood is then returned to systemic circulation via another vein (VV ECMO) or artery (VA ECMO).
ECMO – PRINCIPLE
ECMO – BRIDGING THERAPY
bridge to RECOVERY :–
buying time for patient to recover
bridge to DECISION :-
provide temporary support to patient and allow clinicians to decide on the next step.
bridge to TRANSPLANT :-
provide support to patient while awaiting suitable donor organ.
• Veno-Arterial ECMO (VA-ECMO):• Used to support patients with severe
cardiac failure (with or without respiratory failure)
• Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central artery
- ECMO guidelines Alfred Health Update Nov. 2015
Veno-Arterial (VA) configuration
This infant has been cannulated for ECMO using the femoral artery and vein. Toprevent possible distal limb ischemia, antegrade flow has been provided via apercutaneously placed distal perfusion catheter.
• Veno-Venous ECMO (VV-ECMO):• Used to support patients with severe
respiratory failure refractory to conventional therapies
• Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central vein
- ECMO guidelines Alfred Health Update Nov. 2015
Veno-Venous (VV) configuration
• 4 configurations of VV-ECMO depending on the cannulation sites.
a) Femoro-femoral
b) High flow
c) Femoro-jugular
d) Double lumen single cannula (Avalon)
- ECMO guidelines Alfred Health Update Nov. 2015
Veno-Venous ECMO (VV ECMO)
ARDS
Pneumonia
Status asthmatics
Chemical pneumonitis
Inhalational pneumonitis
Near drowning
Bronchiolitis
Persistent air leak syndrome
RSV infection post CHD surgery.
Indications of ECMO for Respiratory failure: in Paediatric
• Presence of any two of the criteria from the following observed over a period of 4 to 6 hours after maximum medical resuscitation.
PaO2/FiO2 <75%
Oxygen index >40%
Murrays Score of >3
a-A gradient >600
Hypercapnia with PH of <7.2 observed over more than 3 hours.
Lung compliance <0.5 cc/cmH2O/kg
Inclusion criteria:
• Primary disease is irreversible (disseminated malignancy)
• Age >75 years
• On ventilator >15 days
• Irreversible / indeterminate neurological prognosis
• Immunosuppressed state
• Multi-organ failure
• Pre-existing coagulopathy
• Severe pulmonary hypertension
• Severe aortic regurgitation
Exclusion Criteria for ECMO
• Bleeding
• Thromboembolism
• Cannulation related
• Heparin induced thrombocytopenia
• VV ECMO specific complications
• VA ECMO specific complications
• Neurological complications
• THE HARLEQUIN SYNDROME (North South Syndrome)
COMPLICATIONS
Who comprises the ideal team?
Two intensivists (ECMO intensivist) and/or cardiothoracic surgeons: cannulation
One Medical Officer: monitor cannula position by ECHO
One Medical Officer: clinical management
Perfustionist: ECMO priming and maintenance
Respiratory Therapist: lung protective management, ventilator settings
Nurses
Radiologic Technician
• Once it has been decided to initiate ECMO, the patient is anticoagulated with I/V heparin and cannulae are inserted according to the ECMO configuration ( VV or VA ECMO)
• Following cannulation, patient is connected to ECMO circuit, the pump started with the flow of 20 ml/kg/min and gradually increased every 5-10 min by 10 ml/kg/min to reach the desired flow.
• Gas flow to blood flow ratio is adjusted to 0.5 : 1 & start with FiO2 of 21% 100% FiO2.
• Once desired flow achieved, ventilator settings are brought down to base line.
- ECMO UPTODATE 2013
INITIATION
• Once the initial respiratory and hemodynamic goals have been achieved, blood flow is maintained at that rate.
• Continuous venous oximetry, Pressure monitoring (MAP, pre-pump P, pre and post oxygenator P), vital parameters (HR, RR, TEMP), Flow rates (blood flow rate at 60-150 ml/kg/min), neurological status, vascular status to be monitored.
• Anticoagulation is sustained during ECMO with a continuous infusion of unfractionated heparin, titrated with activated clotting time(ACT) of 180-210 sec.
MAINTENANCE & MONITORING
• INDICATIONS :
-For patients with Respiratory failure, improvements in radiographic appearance, pulmonary compliance and arterial oxy-Hb saturation.
-With cardiac failure, enhanced aortic pulsatility correlates with improved left ventricular output.
-One or more trials of taking the patient off of ECMO should be performed prior to discontinuing ECMO permanently.
- ELSO General Guidelines Version 1.3 December 2013
WEANING & TRIAL OFF OF ECMO
CESAR TRIAL• Randomized control trial of adult ECMO vs Conventional
Ventilatory support.
• Adults were randomized either to VV ECMO at Glenfield Hospital, Leicester, England (90 patients) or continuing conventional care at referral hospitals (90 patients) i.e., conventional ventilator support.
Peek GJ, et.al. Lancet 2009;374:1351‐136
ECMO
• 57 out of 90 met primary end point.
• Survival rate at 6months is 63%
• Mortality 37%
CONVENTIONAL VENTILATORY SUPPORT
• 41 of 87 met primary endpoint
• Survival rate at 6months is 47%
• Mortality 53%
RESULTS
Increased accessibility and use
Reduction in costs
Insurance / government support
Smaller lines / volumes / oxygenators
Coated “stealth” tubing (Nano particles).
Smaller or portable ECMO machines
Future of ECMO