ECMO

introduction for CVS

ECMO

extracorporeal membrane oxygenation

ECMO

(Extracorporeal Life Support)

ECLS

ECMO

prolonged partial cardiopulmonary bypass

ECMO

prolonged partial cardiopulmonary bypass

Up to several weeks

ECMO

prolonged partial cardiopulmonary bypass

The patient’s heart & lungs must work.

ECMO vs CPB

• Venous reservoir

CPB

CPB vs ECMO CPB ECMO

Site OR ICU

Venous reservoir Yes No

Heparin (ACT) >600 160-220

Autotransfusion Yes No

Hypothermia Yes No

Hemolysis Yes No

Hemodilution Yes No

Arterial filter Yes No

ECMO

• Short-term cardiopulmonary support

• Buy time to decide the next step

– Recovery

– Transplantation

– long-term device (ventricular assist device)

– Operation (CABG, pulmonary embolectomy,..)

– Give-up

for lung

1. support : O2 supply & CO2 removal

2. rest : reduce ventilator induced lung injury

for heart

support : improve systemic perfusion

rest :

↓catecholamine

↓myocardial work

decrease preload requirement and congestion

ECMO Mode

• VV - ECMO

• VA - ECMO

VV-ECMO

indication : for lung disease only

purpose : to decrease barotrauma ( to prevent ventilator-induced lung injury)

ventilator setting :

PC mode, PEEP >10 , PIP < 30

VR --> PaCO2, FiO2--> PaO2

VA-ECMO

advantage :

1. both lung & heart support

2. higher PaO2

For hemodynamic support

ECMO type

• Centrifugal pump + hollow fiber oxygenator

– Advantages: rapid priming, heparin binding

– Disadvantages: plasma leak, pump thrombosis

ECMO type

• Centrifugal pump + hollow fiber oxygenator

– Advantages: rapid priming, heparin binding

– Disadvantages: plasma leak, pump thrombosis

• Roller pump + silicone membrane oxygenator

– Advantages: prolonged use, less hemolysis (?)

– Disadvantages: difficult priming, no heparin binding

ECMO choice for a patient

• Emergency? centrifugal

• Duration? roller

• Bleeding risk? centrifugal

• Transport ? centrifugal

ECMO is mainly for neonatal respiratory diseases. (45.9%)

Surfactant therapy

NO inhalation

High frequency oscillatory ventilation

Prone positioning

General critical care

ECMO for neonatal lung diseases is decreasing.

ECMO in NTUH

( 1994 Aug. 11 2013 Dec. 31 )

Neonatal lung disease 17（11） MCS 1517

ARDS 298（121） Post-cardiotomy 481（148）

Lung THx 55（33） Acute myocarditis 125（80）

Pulmonary embolism 28（13） Cardiomyopathy 203（71）

Neurosurgery 4（3） AMI 301（97）

NHBD 26 CHD 63（22）

Others 20（13） Septic shock 116（10）

PH and RV failure 32（9）

Acute rejection 33（8）

Others of MCS 163（55）

TOTAL : 1965

ECMO for adult ARDS

H1N1

Why there is ECMO at NTUH ?

NTUH Heart Transplantation

0

5

10

15

20

25

30

35

40

45

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

What happened in 1995?

• Try to increase heart transplantation number!

• Our advantage?

• strategy vs tactics

• If a low cardiac output patient come to our

hospital, what can we do ?

• A complete heart failure treatment program

Treatment of low cardiac output

• Drug

digoxin, diuretics, ACEI, ARB, aldosterone antagonist

Carvedilol, metoprolol, bisoprolol

milrinone

dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol

PGE1

NO inhalation

• Mechanical circulatory support

IABP

VAD (Heartmate, Thortec, biopump, roller pump, others)

ECMO

• Surgery

Batista operation, SVR

heart transplantation (orthotopic, heterotopic)

heart-lung transplantation

Treatment of low cardiac output

• Drug

digoxin, diuretics, ACEI, ARB, aldosterone antagonist

Carvedilol, metoprolol, bisoprolol

milrinone

dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol

PGE1

NO inhalation

• Mechanical circulatory support

IABP

VAD (Heartmate, Thortec, biopump, roller pump, others)

ECMO

• Surgery

Batista operation, SVR

heart transplantation (orthotopic, heterotopic)

heart-lung transplantation

Case Demonstration

ECMO

mechanical circulatory support

VA-ECMO

• A good condition before HTx

• This can guarantee a good result !

• In the past?

ECMO VAD HTx

Mechanical circulatory support

Heart failure:

Medical treatment

MCS

• IABP (intra-aortic balloon pump)

• ECMO (extracorporeal membrane oxygenation)

• VAD (ventricular assist device)

• TAH (total artificial heart)

IABP Because of its relative non-invasiveness,

The first choice of MCS

But, disadvantages:

– Small BW

– RV failure

– Tachyarrhythmia

– CPR

– AR

– Aortic aneurysm

– Atherosclerosis

– etc (KTx)

– Limited cardiac support ( ~1 L/min)

VAD disadvantage :

1. thoracotomy: time delay, general anesthesia,

transport to OR, OP risk

2. technique demanding

3. RV failure in LVAD

LV failure in RVAD

too complex in BVAD

4. Bleeding

5. Pediatric sized device for children (?)

Ventricular Assist Device

(VAD)

• Only in stable patients with anticipated

long-term use

• Not for critical patients with unsure

diagnosis

ECMO advantage :

1. Rapid priming, bedside, local anesthesia,

→ easy, quick, safe (ECPR)

2. Much cheaper than VAD

3. support for RV, LV, lung

(safe in unknown conditions)

4. Carmeda Bioactive Surface (BAS)

5. for both adults and children

6. neck, femoral, thoracic

ECMO advantage :

1. Rapid priming, bedside, local anesthesia,

→ easy, quick, safe (ECPR)

2. Much cheaper than VAD

3. support for RV, LV, lung

(safe in unknown conditions)

4. Carmeda Bioactive Surface (BAS)

5. for both adults and children

6. neck, femoral, thoracic

flexible

ECMO

mode site oxygenator pump

V-A Neck Medtronic Centrifugal

V-V Axillar Medos roller

VV-A Thoracic Jostra

VV-V Femoral silicone

V-VA

A-V

Very flexible

ECMO VAD HTx

Different patients

different situations

different treatments

2005 Jan. 5

Press conference at NTUH

11 y/r, boy, HTX after 18 days of ECMO support

ECMO --- > VAD --- > HTx

Treatment of low cardiac output

• Drug

digoxin, diuretics, ACEI, ARB, aldosterone antagonist

Carvedilol, metoprolol, bisoprolol

milrinone

dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol

PGE1

NO

• Mechanical circulatory support

IABP

ECMO

VAD (Heartmate, Thortec, biopump, roller pump)

• Surgery

Batista operation, SVR

heart transplantation (orthotopic, heterotopic)

heart-lung transplantation

A part, but important part of the whole system.

ECMO

respiratory support for ARDS

VV-ECMO

An Example

• A 33-yr-old, male

• Flame burn

– 20% TBSA 2nd burn

– 2.5% TBSA 3rd burn

– Inhalation injury

Vicious cycle in ARDS

personal experience

ARDS

hypercarbia Vs hypoxemia

1. permissive hypercarbia

2. do not overventilate to improve ABG

3. treat ARDS with ECMO earlier

Result

survivors Non-survivors

Sex (M/F) 4/3 11/6

age 31.7+13.5 41.4+22.1

PaO2/FiO2 66 54

PEEP 12 12

ARDS score 3.6 3.6

ATN 1/7 10/17

Patient source

Burn 2 2

CVS 2 2

GS 1 8

Med

NS

1

1

4

1

ECMO for ARDS

1/3 successful rate, why ?

1. ARDS vs MOF

2. time competition

a. slow recovery of ARDS

b. complication of long-term ECMO

Indications of ECMO in the near future • As a mechanical circulatory support:

– Post-cardiotomy cardiogenic shock

– Double bridge (ECMO VAD HTx)

– Acute myocarditis

– AMI cardiogenic shock (ECPR)

– Shock due to heart stunning

• Replace CPB:

– Lung transplantation

– Heart-lung support during the operation

– Non-heart-beating-donor support

– Rescue for acute pulmonary embolism

– Airway surgery, airway trauma

– hypothermia

• Ventilatory support

– Asthma

– ARDS

– Neonatal pulmonary diseases

ECMO in NTUH

( 1994 Aug. 11 2009 Dec. 31 )

Neonatal lung disease 2 MCS 990

ARDS 179 ( 73 ) Post-cardiotomy 379 ( 115 )

Lung THx 50 Acute myocarditis 78 ( 45 )

Pulmonary embolism 19 ( 8 ) Cardiomyopathy 119 ( 45 )

Neurosurgery 4 AMI 194 ( 50 )

NHBD 26 CHD 25 ( 6 )

Others 13 ( 6 ) Septic shock 66 ( 8 )

PH and RV failure 17 ( 2 )

Acute rejection 17 ( 2 )

Others of MCS 98 ( 29 )

TOTAL : 1283 ( ) survival

Why ECMO succeeds in NTUH?

Why ECMO succeeds in NTUH ?

1. NTUH

2000 beds, national hospital, 114 years

Totem of Taiwan society

Critical mass

A good background

SICU Technician

• 24 hr /day

• 365 day/ year

366 days / leap year

Core team

• A core team

• A large team

• A society

Because we can dream,

we become human being!

History is created by few people.

How to recruit a core team?

Selection?

Training?

Select trainable people.

Why ECMO succeeds in NTUH ?

1. NTUH

2000 beds, national hospital

2. extended indications enough cases (>100 cases/year)

Economic scale

Indications of ECMO in the near future • As a mechanical circulatory support:

– Post-cardiotomy cardiogenic shock

– Double bridge (ECMO VAD HTx)

– Acute myocarditis

– AMI cardiogenic shock (ECPR)

– Shock due to heart stunning

• Replace CPB:

– Lung transplantation

– Heart-lung support during the operation

– Non-heart-beating-donor support

– Rescue for acute pulmonary embolism

– Airway surgery, airway trauma

– hypothermia

• Ventilatory support

– Asthma

– ARDS

– Neonatal pulmonary diseases

Why ECMO succeeds in NTUH ?

1. NTUH

2000 beds, national hospital,

2. extended indications enough cases (>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

• A locomotive engine Vs a whole train

• Skyscraper Vs modern city

• One more step forwards

• But reasonable enough

Why ECMO succeeds in NTUH ?

1. NTUH

2000 beds, national hospital,

2. extended indications enough cases (>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

4. team work

CVS, ICU, nurse, technician

Why ECMO succeeds in NTUH ?

1. NTUH

2000 beds, national hospital,

2. extended indications enough cases (>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

4. team work

CVS, ICU, nurse, technician, bypass ?

5. training program & protocol

Protocol, protocol, protocol

http://www.sicu.org

Why ECMO succeeds in NTUH ?

1. NTUH 2000 beds, national hospital,

2. extended indications enough cases (>100 cases/year)

3. excellent SICU background ECMO is a high technology treatment

4. team work CVS, ICU, nurse, technician, bypass ?

5. training program & protocol Protocol, protocol, protocol

6. continuous revision Long term development

• Case record

• M & M conference for every case

• RCA (root cause analysis)

• Continuously Revise system (0.9 theory)

Why ECMO succeeds in NTUH?

• Strong background

• A core team (select trainable team member)

– responsible

• Economic scale

• Team work

• SOP (mass production)

• Work hard and smart

All you need to set up ECMO

Put everything on the wheel

Then, OR, ICU, cath room, ES, ward, etc

ECMO cart

Taipei city/Taipei county area

= 12

ECMO success need :

1. underlying problem soon reversible

2. no severe 2nd organ damage

3. no complication from ECMO use

ECMO success need :

1. case selection (treat pt. , not Dr.)

2. early use

3. intensive ECMO care

Indications of ECMO in the near future • As a mechanical circulatory support:

– Post-cardiotomy cardiogenic shock

– Double bridge (ECMO VAD HTx)

– Acute myocarditis

– AMI cardiogenic shock (ECPR)

– Shock due to heart stunning

• Replace CPB:

– Lung transplantation

– Heart-lung support during the operation

– Non-heart-beating-donor support

– Rescue for acute pulmonary embolism

– Airway surgery, airway trauma

– hypothermia

• Ventilatory support

– Asthma

– ARDS

– Neonatal pulmonary diseases

AMI with cardiogenic shock

• 60 y/r, male, chest tightness ES, sudden

VT/Vf, DC shock, now, BP:80/50 under

dopamine 20 mcg/kg/min

• 60 y/r, male, stable angina, frequency ,

cath PTCA, LAD dissection, BP, HR

IABP, BP: 80/50

• AMI, refractory VT/Vf, DC shock 40 times

AMI & CS ECMO Cath off pump CABG ICU support

ECMO rescue for AMI with CS

• Pre-cath:

– to stabilize the patients

• During cath & revascularization

– to support the patients for procedure

• After revascularization

– To support hemodynamics until heart recovery

Post-CABG VT/Vf

J Formos Med Assoc 2002:101:283-286

A dancer

A modern medical miracle

ECMO

• Strategy weapon

• Front-line weapon

A necessity in a medical center