Extracorporeal Membrane Oxygenation

Part-1

Dr.Tinku JosephDM Resident

Department of Pulmonary medicineAIMS, Kochi

Email: tinkujoseph2010@gmail.com

Contents in ECMO part 1

What is ECMO ? Evolution of ECMO Types Indications Veno-venous V/S veno-Arterial

ECMO. Cannulation and Circuit

Contents in ECMO part 2

Monitoring ECMO patients Ventilatory strategies Sedation and pain control Anticoagulation Complications Weaning Various ECMO trials. ELSO guidelines. Recent advances

Introduction

Mechanical circulatory support has evolved markedly over recent years.

ECMO (extra corporeal membrane oxygenation) has become more reliable with improving equipment, and increased experience, which is reflected in improving results.

ECMO is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful.

ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery.

Introduction

Instituted in an emergency or urgent situation after failure of other treatment modalities.

It is used as temporary support, usually awaiting recovery of organs.

Introduction

Dynamics of ECMO

Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, – Oxygenate– Extract carbon dioxide

Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.

Extra corporeal Life Support is

achieved by :

- Draining venous blood

- Removing CO2

- Adding oxygen

- Returning to circulation

- Through either a vein or artery

Introduction

• The physiologic goal is to improve tissue oxygen delivery , remove CO2 and allow normal aerobic metabolism whilst the lung rests

• ECMO circulation: - Dual circulation - Nonpulsatile flow

Evolution of ECMO

1953-: Gibbon used 1st artificial oxygenation and perfusion support for the first successful open heart operation.

Direct exposure of anticoagulated blood to oxygen was successful.

Direct gas interface oxygenators -: Dennis, Morrow, Cross, Dewall and Rygg.

Kolobow T-: First attempt at ECMO

BARTLETT –Father of ECMO 1975-: Successfully applied bed

side ECLS device to treat newborn with meconium aspiration.

Developed of better membrane oxygenators.

Evolution of ECMO

First successful ECMO patient, 1971

J Donald Hill MD and Maury Bramson BME, Santa Barbara, Ca, 1971. (Courtesy of Robert Bartlett, MD)

First Neonatal ECMO survivor..

Esperanza, Age 1 day 1975

ESPERANZA-1975

“The Hope”

Esperanza, age 21ESPERANZA-at 21 years

First Neonatal ECMO survivor..

FROM THIS

TO THIS

1989-: Over 100 ECMO centers across the world established Extracorporeal Life Support Organization (ELSO).

Platform of communication and research.

Evolution of ECMO

Summary of History of ECMO

ECMO Society of India 2010 in

Mumbai

Modes of ECMO

Modes of ECMO

ECMO can be categorized according to the circuit used

– Veno-arterial - VA ECMO provides both gas exchange and circulatory support (Heart & Lung failure)

– Veno-venous –VAECMO allows gas exchange only (Isolated Lung failure)

INDICATIONS FOR ECMO

Indications for ECMO-VA

Indications for ECMO-VV

Proposed indications of ECMO in ARDS patients

Indications of ECMO for Respiratory failure- Adults

ARDS Pneumonia Trauma Primary graft failure post lung transplant Status asthmaticus Chemical pneumonitis Inhalational pneumonitis Near drowning

Post traumatic lung contusion Bronchiolitis obliterans Autoimmune lung disease-: Vasculitis, Goodpasture

syndrome. Airleak syndrome

Indications of ECMO for Respiratory failure- Adults

ARDS Pneumonia Status asthmatics Chemical pneumonitis Inhalational pneumonitis Near drowning Bronchiolitis Persistent air leak sydrome RSV infection post CHD surgery.

Indications of ECMO for Respiratory failure- In Pediatric

Inclusion criteria

• 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 aA gradient >600 Hypercapnia with PH of

<7.2 observed over more than 3 hours.

Lung compliance <0.5 cc/cmH2O/kg

Irreversibile disease- eg:malignancy Age >75 years Patient on ventilator for >15 days IC bleed Active bleeding from noncompressive

site Irreversible neurological status Unwitnessed arrest or arrest

>30minutes Gross multi organ failure

Exclusion criteria

Absolute Contraindications to all forms of ECMO

Age: > 70 years

Active malignancy

Severe brain injury

Previous Bone marrow transplant, previous

transplant (>30 days).

AIDS

End stage chronic organ failure (hepatic, renal)

End stage cardiomyopathy (except for bridge to VAD/transplant)

Chronic lung disease (except for bridge to transplant)

Multi organ failure

Severe mitral or aortic valvular insufficiency or aortic dissection

(VA only)

Weight >140kg

Unwitnessed cardiac arrest or CPR >60minutes

Absolute Contraindications to all forms of ECMO

Relative Contraindications to all forms of ECMO

Trauma with multiple bleeding sites

Multiple organ failure

VV ECMO-: Absolute contraindications

Anticoagulation issues Severe PAH Severe Rt or Lt heart failure Cardiac arrest

VV ECMO-: Relative contraindications

High pressure ventilation (peak insp pressure >30 cm of H2O) for >7days.

High FiO2 requirement (>0.8) for >7days

Limited vascular access. Refusal to accept blood products

Aortic dissection Severe aortic valve

regugitation Anticoagulation issues

VA ECMO-: Absolute contraindications

– Blood being drained from the venous system and returned to the arterial system.

– Provides both cardiac and respiratory support.– Achieved by either peripheral or central

cannulation.

VA ECMO

VA ECMO

Decreases cardiac work Reduces cardiac oxygen consumption Provides adequate systemic organ perfusion with

oxygenated blood. Prevents over distension of ventricles. Helps in

cardiac recovery. Indications: Already discussed.

VA ECMO

VA ECMO

VA ECMO

Advantages and Disadvantages

Advantages DisadvantagesBoth cardiac and pulmonary support.Instant haemodynamic support

Cannulation of major artery and sacrifice of one carotid in newborn

No mixing of arterial/venous blood. Poor coronary and pulmonary perfusion

Good oxygenation at low ECMO flows

Systemic thromboembolism

No recirculation. Nonpulsatile flow

Oxygenated blood returns to patients arterial circulation

Increased incidence of neurological events

– Provides oxygenation – Blood being drained from venous system and

returned to venous system.– Only provides respiratory support – Achieved by peripheral cannulation, usually of

both femoral veins.

VV ECMO

VV ECMO

Drainage from SVC, IVC, Femoral vein. Flow is determined by the size and placement of the

drainage catheter Centrifugal pump Membrane oxygenator Oxygenated blood returned to the right heart.

VV ECMO

Advantages Pulmonary

circulation/oxygenation is maintained.

No carotid ligation. Pulsatile waveform maintained.

Efficient CO2 removal.

Disadvantages No control of BP. Inefficiency

(recirculation). Hypoxemia (low PO2).

VV ECMO

Cannulation

The establishment and maintenance of adequate vascular access is essential for ECMO

- Patient age and size- Underlying disease & condition- Cause of the cardiorespiratory compromise- Type of support:

– Veno-venous (VV) ECMO – Veno-arterial (VA) ECMO

- Time of the event in relation to the peri-operative period

- Location

Cannulation

For each modality, there are different kinds and sizes of cannulae that can be used

Target ACT should be accomplished before ECMO (heparin 100 units/kg)

3 minutes before cannulation.

Cannulation

Cannulation-VV

Venous cannula should be with the largest lumen and shortest length possible.

Venous cannula should have side holes. Resist kinking Smallest double lumen cannula is size 12 Fr ( for V V ecmo in neonate)

Options For Cannulation in VV ECMOTwo Cannulas One double-lumen cannula

D Brodie, M Bacchetta; N Engl J Med 2011; 365:1905-14.

Drainage cannula– As central as possible– Not too close to the

return cannula Return cannula

– Close to the tricuspid valve

– But not too close to the drainage cannula

Cannula Placement

Fem – Fem Cannulation

Indication

Cannulation in jugular vein not possible.

Higher risk for femoral vein/caval

thrombosis(?)

Cannula Choice

Pedersen et al., Ann Thorac Surg 1997

Hemolysis & Cannula Diameter

Q =DP p r4

8 h L

Flow is proportional to the power of 4 of radius

inversely proportional to tubing length and viscosity

1797-1869

Poiseuille’s Law

Double Lumen Cannula

– Less Recirculation.– Single access.– Possible ambulation.

– Bigger cannula and smaller lumen.

– Image guidance is mandatory.

Double Lumen Cannula

Avantages:

Drawbacks:

Cannulation

Two Cannulas

Double-lumen

Mobilization: ECMO DevicesMobilization is possible .

It probably reduces critical illness polyneuropathy, delirium and muscle atrophy.

It may reduce time on ventilation and improve outcome post lung transplantation.

Insertion

Percutaneous insertion

Guide-wire – Dilators – Cannulas: Use the right tools

188 cannulation attempts.

11 cannulation failures.

3 arterial punctures.

• One leading to distal necrosis.

1 SVC laceration .

1 fatal hemothorax.

• SVC perforation by Reinfusion Cannula.

Venovenous Extracoporeal Life Support Via Percutaneous Cannulation in 94 Patients*

Thomas Pranikoff, MD; Ronald B. Hirschl, MD’; ‘Robert Remenapp, RRT; Fresca Swaniker, MD and Robert H. Bartlett, MD, FCCP

Chest 1999; 115:818-822.

Transesophageal Echocardiographic Guided Placement of a Right Internal Jugular Dual-Lumen

Venovenous Extracorporeal Membrane Oxygenation (ECMO) Catheter

Mazzeffi M J Cardiothorac Vasc Anesth, 2013

Mid-esophageal four-chamber TEE view with white arrow

showing improperly positioned cannula in the

right ventricle.

Modified mid-esophageal bicaval TEE view using color Doppler

compare mode showing return blood flow in the center of the

right atrium directed towards the tricuspid valve. (Color version of

figure is available online).

Dolch et al, ASAIO, 2011.

Always use ultrasound guidance…

Ultrasonic locating devices for central venous cannulation: meta-analysis

Daniel Hind, Neill Calvert, Richard McWilliams, Andrew Davidson, Suzy

Paisley, Catherine Beverley, Steven Thomas

Cannulation-VA

• Through neck vessels(RCC artery and RIJV and or an additional vein)

• Central cannulation

or

• Cannulation of groin vessels

Access and return cannula sites

Access Return

RA Aorta

Femoral Vein Femoral Artery

Subclavian Vein Axillary artery

Internal Jugular Vein Carotid artery

Circuit

• To be continued…• Part 2 Next week