z ben ma ecmo pgy 3 talk

Extracorporeal Membrane Oxygenation (ECMO)

Z. BEN MA, MDPGY 3

BWH/MGH EMERGENCY MEDICINE

Extracorporeal Life Support (ECLS, ECMO)

Supports heart and/or lung function with mechanical devices (Modified cardiopulmonary bypass circuit used in cardiac surgery)

Temporary – days to weeks (months)

Life-saving supportive therapy – not a disease modifying treatment

Avoids iatrogenic injury

Sustains life while bridging to decision, organ recovery or replacement


Blood is removed from the venous system

Oxygenated

CO2 extracted

Returned back to body

History 1944 – Kolff and Berk – Blood oxygenated when passed through

cellophane chambers of artificial kidney

1953 – Gibbons – First successful open heart surgery w/ use of artificial oxygenation and perfusion therapy

1965 – Rashkind – Bubble oxygenator as support in neonate dying of resp failure

1969 – Dorson – Use of membrane oxygenator for cardiopulmonary bypass

1970 – Baffes – Successful use of ECMO as support in infants w/ congenital heart defects undergoing cardiac surgery

Makdisi, George, and I-wen Wang. "Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology." Journal of thoracic disease 7.7 (2015): E166.

History

1971 –J Donald Hill MD and Maury Bramson BMEFirst successful ECLS Patient; Survived after trauma and ARDS – “ECMO” x 75hrs; Santa Barbara, CA

History

1975 – Robert Bartlett MDFirst successful use of ECMO in neonatal patient w/ severe respiratory distress, UC Irvine

Esperanza, Age 1 Day, 1975

History

Esperanza, Age 21, w/ Dr. Bartlett

History

1979 – Zapol et al. - JAMA

NIH-Sponsored RCT

VA-ECMO vs. Conventional MV in Severe ARDS

90 Patients Randomized

Stopped for Futility90% Mortality in both groups

Zapol, Warren M., et al. "Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study." Jama 242.20 (1979): 2193-2196.

History

1994 – Morris et al Am J Respir Crit Care Med

ECMO vs. Conventional MV in Severe ARDS

40 Patients randomized

No difference in survival

Morris, A. H., et al. "Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome." American journal of respiratory and critical care medicine 149.2 (1994): 295-305.

History 1990’s-2000’s

Few centers around Europe and US provided VV ECLS + MV as last resort

2008-2009

Steep increase in cases for adult respiratory failure

ECMO use increased >400% btwn 2006 - 2011

Sauer, Christopher M., David D. Yuh, and Pramod Bonde. "Extracorporeal membrane oxygenation use has increased by 433% in adults in the United States from 2006 to 2011." ASAIO journal 61.1 (2015): 31-36.

History

2009 – Peek et. alLancet

UK-Based Multicenter RCT

ECMO vs. Conventional MV in Severe ARDS

Peek, Giles J., et al. "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial."The Lancet 374.9698 (2009): 1351-1363.

History

180 Patients Randomized; 1:1 “Severe but potentially reversible

respiratory failure” Conventional MV vs. ECMO

Consideration Referral to ECMO Specialty Center vs.

Stay at Primary Hospital 68/90 (75%) actually received ECMO

Pressure and volume limited lung rest strategy

70% of “Conventional Management” patients received lung rest strategy

History

Primary outcome: 6 Month Survival and Disability Status 63% (57/90) ECMO Group 47% (41/87)

Conventional MV Group

History

Controversy

Not a “true” randomized trial of ECMO vs. standard-of-care mechanical ventilation

Specialized center vs. non-specialized center

Differences with earlier RCT’s (Zapol 1979, Morris 1994)

ARDSNET Ventilation (2000) Improved medical equipment – oxygenators, cannulas


Supports heart and/or lung function with mechanical devices (Modified cardiopulmonary bypass circuit used in cardiac surgery)

Temporary – days to weeks (months)

Life-saving supportive therapy – not a disease modifying treatment

Avoids iatrogenic injury

Sustains life while bridging to decision, organ recovery or replacement

History 2009 H1N1 Pandemic

History Pandemic affected Southern Hemisphere

first Australia and New Zealand used ECMO for

young patients w/ severe disease

Survival rate range from 56-79% throughout centers, independent of applied strategy of mechanical ventilation

Davies, Andrew, et al. "Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome." JAMA: the journal of the American Medical Association 302.17 (2009): 1888-1895.

ELSO Registry Data

VV ECMO for ARDS and Bridge to Transplant are most common indications for ECMO therapy in adults

VA ECMO for Cardiogenic Shock is fastest growing indication in adults

1. Ventetuolo, Corey E., and Christopher S. Muratore. "Extracorporeal life support in critically ill adults." American journal of respiratory and critical care medicine 190.5 (2014): 497-508.

2. ELSO Registry - https://www.elso.org/Home.aspx

ECMO Indication

Acute, severe, cardiac or pulmonary failure unresponsive to optimal management with expected recovery or potential for organ replacement

Cardiac Support

Pulmonary Support

Cardiopulmonary Support

VenoVenous (VV) vs. VenoArterial (VA)

Cove, Matthew E., and Graeme MacLaren. "Clinical review: mechanical circulatory support for cardiogenic shock complicating acute myocardial infarction." Critical Care 14.5 (2010): 1.

Central vs. Peripheral ECMO (VA)

Marasco, Silvana F., et al. "Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients." Heart, Lung and Circulation 17 (2008): S41-S47.

Single vs. Double Cannula (VV)


VenoArterial (VA) vs. VenoVenous (VV) ECMO

VA ECMO VV ECMOProvides cardiac support to assist systemic circulation

Does not provide cardiac support to assist systemic circulation

Requires arterial + venous cannulation Requires only venous cannulation

Bypasses pulmonary circulationDecreases PA Pressures

Maintains pulmonary blood flow

Could be used in RV Failure Cannot be used in RV failureHigher PaO2 is achieved Lower PaO2 is achievedECMO circuit connected in parallel to heart and lungs

ECMO circuit connected in series to heart and lungs


ECMO Indications for Respiratory Support (VV)

Acute Respiratory Distress Syndrome (ARDS) Severe bacterial or viral pneumonia Aspiration syndromes Alveolar proteinosis

Extracorporeal Assistance to provide lung rest Airway Obstruction Pulmonary contusion Smoke inhalation

Lung Hyperinflation Status Asthmaticus Severe COPD

Lung transplant: Primary graft failure after transplant Bridge to lung transplant Intraoperative ECMO

Pulmonary hemorrhage or massive hemoptysis

Congenital diaphragmatic hernia, meconium aspiration


ECMO Indications for Cardiac Support (VA)

Cardiogenic shock/Severe Cardiac Failure due to almost any cause:

ACS Cardiac arrhythmic storm Sepsis w/ profound cardiac depression Drug/Tox-mediated profound cardiac depression Myocarditis Pulmonary Embolism Cardiac Trauma Acute Anaphylaxis

Chronic Cardiomyopathy: Bridge to long-term VAD Bridge to transplant Bridge to decision

Peri-procedural Post Cardiotomy

Inability to wean from cardiopulm bypass after cardiac surgery

Post Heart Transplant Primary graft failure

Peri-procedural Support High risk percutaneous cardiac

interventions


ECMO Contraindications Futile treatment without exit strategy (Absolute):

Unrecoverable heart and not a candidate for transplant or destination therapy of VAD support

Disseminated malignancy Known severe brain injury Unwitnessed cardiac arrest Prolonged CPR without adequate tissue perfusion Unrepaired aortic dissection Severe aortic regurgitation Severe chronic organ dysfunction (cirrhosis, renal

failure) Compliance (financial, cognitive, psychiatric, social

barriers)

Significant comorbid conditions (Relative): Anticoagulation tolerance Advanced age Obesity Severe peripheral vascular diseases

Makdisi, George, and I-wen Wang. "Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology." Journal of thoracic disease 7.7 (2015): E166. http://wikiality.wikia.com/wiki/

Bridge_to_Nowhere

Venovenous (VV) ECMO

http://columbiasurgery.org/conditions-and-treatments/ecmo-respiratory


Blood-flow circuit is in series with the ECMO system

Provides respiratory support

Must have stable hemodynamics Pump drawing blood out of circulation but systemic perfusion still

dependent on the heart

http://www.sciencebuddies.org/science-fair-projects/how-to-use-a-multimeter.shtml

Venovenous (VV) ECMO Fresh (Sweep) gas delivered

to Oxygenator

Gas composition (FDO2) adjusted by Blender

Gas exchange across membrane of oxygenator

Brodie, Daniel, and Matthew Bacchetta. "Extracorporeal membrane oxygenation for ARDS in adults." New England Journal of Medicine 365.20 (2011): 1905-1914.

Venovenous (VV) ECMO Elimination of CO2 controlled

by adjusting flow rate of sweep gas Targeted PaCO2/pH

Oxygenation controlled by adjusting amount of blood flow through ECMO circuit Limited by size of cannula Targeted PaO2/SpO2


Double vs. Single Cannula

Double R. Internal Jugular V. Cannula R.

Atrium R. Common Fem V Cannula IVC Blood drawn out of IVC ECMO Circuit

Returned to R. Atrium

Single R. Internal Jugular Cannulated Dual-lumen catheter positioned in

SVC/R.Atrium


Double vs. Single Cannula

Double Portion of oxygenated blood drawn back

into femoral venous cannula w/o passing through systemic circulation

Single Reinfusing port aimed across tricuspid

valve into R. Ventricle Reduces recirculated blood


VV Single Cannula

Lazar, David A., et al. "Venovenous cannulation for extracorporeal membrane oxygenation using a bicaval dual-lumen catheter in neonates."Journal of pediatric surgery 47.2 (2012): 430-434

VV Single Cannula

1. http://www.alung.com/products/hemolung-ras/catheter/2. MacLaren, G., Combes, A. & Bartlett, R.H. Intensive Care Med (2012) 38: 210. doi:10.1007/s00134-011-2439-2


Lung-protective ventilation Low Tidal Volume Low Peak/Plateau Pressure +PEEP – maintain airway patency Moderate FiO2 (0.3 in CESAR)

Hemodynamic management as usual (+vasopressors for shock, abx for sepsis, etc)

Wean ECMO support with improving respiratory function (Ventilator parameters) Plateau Pressure < 30 cmH2O FiO2 < 0.6

CO2 Removal

Rate of CO2 removal proportional to rate of sweep gas flow

Allows lungs to rest Decreases CO2 Improves acidosis decreases central respiratory

drive Decreases barotrauma, volutrauma, atelectrauma, etc.

Application in lung hyperinflation Reducing spontaneous ventilation Allowing for progressive lung deflation

VenoArterial (VA) ECMO Blood-flow circuit is in parallel with the ECMO system

Provides respiratory AND hemodynamic support

Greater improvement of systemic oxygenation as oxygenated blood directly perfuse distal organs

Bridge to recovery, device implantation or cardiac transplantation

http://www.sciencebuddies.org/science-fair-projects/how-to-use-a-multimeter.shtml

Central vs. Peripheral Cannulation

VA – Central Cannulation Blood extracted from IVC or R. Atrium Blood returned to ascending aorta Used more after cardiac surgery

Open vs. Closed Better oxygenated antegrade flow

1. http://www.slideshare.net/oliflower/ecmo-in-nz-by-mcguinness2. Marasco, Silvana F., et al. "Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients." Heart, Lung and Circulation 17 (2008): S41-S47.

http://www.slideshare.net/oliflower/ecmo-in-nz-by-mcguinness



VA – Peripheral Cannulation Fem V Fem A. Fem V – Carotid A. Fem V Axillary A. Better for emergent situations

Less invasive Faster insertion

Relies upon retrograde flow Admixing in aortic arch

Risk of Limb Ischemia

1.http://www.heartlungandvessels.org/index.php?pag=rivista_articles&id_numero=10&id_articolo=3882. Marasco, Silvana F., et al. "Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients." Heart, Lung and Circulation 17 (2008): S41-S47.

http://www.heartlungandvessels.org/index.php?pag=rivista_articles&id_numero=10&id_articolo=388




Venoarterial (VA) ECMOChallenges

Differential Hypoxia Risk of poor cerebral, upper extremity or R-Sided perfusion from admixing Monitor R. Femoral ABG vs. R. Radial ABG

Reduced oxygenated blood flow through coronary arteries Consider IABP to provide flow to coronaries Consider VAV ECMO for bad lungs

Can increase LV Preload and thereby O2 Demand Inotropes to maintain LV Ejection Placement of LV Drain

Poor perfusion to distal limb in Fem. Artery cannulation Separate arterial perfusion cannulation to reduce ischemia risk

VA ECMO “Mixing Point”

Sultan, Samir; “December 2015 Critical Care Case of the Month.” Southwest Journal of Pulmonary and Critical Care; Vol 11; 246-251

Whitehead, Daniel; “Successful Treatment of Carbon Monoxide Poisoning and Refractory Shock Using ECMO”; 2/21/2016

Venoarterial (VA) ECMO

Weaning VA ECMO – Factors in indicating cardiac recovery Lower R. Radial Artery PaO2

Suggestive that more blood pumped by anterograde flow Increasing blood pressure Pulsatility on arterial waveform EF Recovery (Echocardiogram – usually TEE)

Wean slowly and monitor variables (0.5L over 36-48hrs) Minimal baseline 2L/min flow

Below this increases risk of clot formation due to stasis


Veno-Arterial-Venous (VAV) ECMO For Differential Hypoxia

Peripheral (femoral) VA cannulation

+

Additional return cannula to Subclavian Vein Perfuses venous side with oxygenated blood

Combines VA + VV

Very limited evidence

Choi, Joon Hyouk, et al. "Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia." Multidisciplinary respiratory medicine 9.1 (2014): 1.

Extracorporeal Cardiopulmonary Resuscitation (ECPR)

VA ECMO use in Refractory Hypoxemic cardiac arrest

Longer duration of CPR, less chance of ROSC Cardiac arrest should be considered refractory to standard CPR after 15 min

Goal: Reduce time between arrest and cerebral perfusion

In-Hospital Cardiac Arrest (IHCA) patients are most likely to benefit Good neurologic outcome in UP TO 40-50% vs. 15-30% in OHCA

Time from onset of arrest to ECMO flow is critical factor to success


Single center, prospective observational study

ECPR + Mechanical compression device + Therapeutic Hypothermia

26 Patients Median time from collapse to

initial of ECMO – 56min (40, 78) Median time from ECPR team

arrival to ECMO – 20 min (16, 30)

54% w/ Favorable Neurological survival

ECMO Complications

Hemorrhage Surgical site hemorrhage Systemic anticoagulation - Pulmonary, intrathoracic, GI, RP

Thrombosis Systemic thrombus Circuit thrombus – life-threatening

Hemolysis Check plasma free Hgb levels

Thrombocytopenia Transfuse as needed

Heparin-induced thrombocytopenia (HIT) Use direct antithrombin agents – Argatroban, Bivalrudin


ECMO Complications

Neurologic Intracranial Hemorrhage (most fatal) Ischemia or Stroke Seizures

Infectious Underlying sepsis ECMO Circuit- Foreign Body

Cardiovascular Hypertension Arrhythmias

Gastrointestinal Ischemia Hemorrhage

Metabolic Fluid-shifting Medication range derangements Alteration in Kidney/Liver Function

Mechanical Clots in circuit

Oxygenator failure Consumption coagulopathy Pulmonary embolus Systemic emboli


ECMO ComplicationsVA - Specific

Cannulation – Related Vessel perforation Arterial dissection Distal ischemia Incorrect location Pseudoaneurysm development

Cardiac Thrombosis Secondary to retrograde flow and intraventricular stasis

Coronary/Cerebral Hypoxia Differential hypoxia from admixing


ED Applications

Case Series 18 Patients included 8 Survived 5 Neurologically-intact at discharge

Bellezzo, Joseph M., et al. "Emergency physician-initiated extracorporeal cardiopulmonary resuscitation." Resuscitation 83.8 (2012): 966-970.

ED Applications

1. http://edecmo.org/logistics/vv-ecmo/2. http://epmonthly.com/article/bypass-the-or-ecmo-in-the-ed/

http://edecmo.org/logistics/vv-ecmo/



http://epmonthly.com/article/bypass-the-or-ecmo-in-the-ed/



Ethical Considerations “Bridge to nowhere” for patients who are poor

candidates for device placement or transplantation

Little data on long-term complications

Cardiopulmonary recovery without neurologic recovery

Anxiety, Depression, PTSD in survivors

Prolonged ICU Lengths of Stay

Financial cost and resource utilization

http://wikiality.wikia.com/wiki/Bridge_to_Nowhere

ECMO Activation

References


Peek, Giles J., et al. "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial."The Lancet 374.9698 (2009): 1351-1363.



Stub, Dion, et al. "Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial)." Resuscitation86 (2015): 88-94.

Bellezzo, Joseph M., et al. "Emergency physician-initiated extracorporeal cardiopulmonary resuscitation." Resuscitation 83.8 (2012): 966-970.

Mosier, Jarrod M., et al. "Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions." Critical Care 19.1 (2015): 1.

Fagnoul, David, Alain Combes, and Daniel De Backer. "Extracorporeal cardiopulmonary resuscitation." Current opinion in critical care 20.3 (2014): 259-265.

All other references as noted in corresponding slides

Questions [email protected]

z ben ma ecmo pgy 3 talk

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