Dr. Kıvanç Metin Dokuz Eylül University Faculty of ...kisi.deu.edu.tr/kivanc.metin/ECMO.pdf · R = ExtraCorporeal CO 2 ... • Significant CPR ... •Prone position •Visual inspection

Dr. Kıvanç Metin

Dokuz Eylül University Faculty of Medicine

Department of Cardiovascular Surgery

Izmir, TURKEY

ECMO or ECLS

• ECMO = Extra Corporeal Membrane Oxygenation

• ECLS = Extra Corporeal Life Support

• ECCO2R = ExtraCorporeal CO2 removal

• ECLA = ExtraCorporeal Lung Assist

• PALP = Pump Assisted Lung Perfusion

• PECLA = Pumpless ExtraCorporeal Lung Assist

ECMO

• oxigenación extracorpórea con membrana

• Extrakorporale Membranoxygenierung

• extracorporeal membrane oxygenation

• 活体外部的膜氧化

• .الجسم من الخارجة الدموية للدورة األكسجة غشاء

• Εξωσωματική οξυγόνωση μεμβράνης

• ऑक्सिजनीकरण अवायवीय extracorporeal झिल्ली • 멤브레인 extracorporeal oxygenation

• 膜酸素化能体外

• экстракорпоральные оксигенаторы мембранной оксигенации

• سيار extracorporeal اينطور مچنين

Popularity

Life support something new?

Post Cardiotomy

Bridge to…

H1N1 Veno-Venous

• Provides cardiorespiratory support in patients

whose own cardiac and / or respiratory function is inadequate.

• Similar to what a cardiopulmonary bypass circuit provides during cardiac surgery.

WHAT DOES ECMO DO ?

• Take some blood out of the body

• Oxygenate / remove CO2

• Warm it back to body temperature

• Pump it back into the body

Respiratory

Support

Cardiac Support

WHEN? • Reversible Pathological Process

• Nature of the disease • Length of time already on mechanical ventilation

• Failure of maximal conventional medical therapy • Varies patient to patient • Varies between diseases • Varies center to center

HLS CANNULAE

DISPOSABLES

Arterial cannulae Venous cannulae

PERCUTANOUS INSERTION KIT

DISPOSABLES

Percutaneous cannulation

Accessing a peripheral

artery or vein via the

minimal invasive

“Seldinger Technique”

It does not involve any

surgical access

The skin should form a

tight seal around the

cannulae

Prevent Limb ischemia

A simple method of vascular access to perform emergency coronary angiograhy in patients with veno-arterial extracorporeal membrane oxygenaton Dierk H. Endemann, Alois Philipp, Christian Hengstenberg et. al. Intensive Care Med published Oct. 2011

SURGICAL CUT

Accessing a peripheral

artery or vein via a surgical

incision

Direct visual cannulation of

the vessel

Purse string or tape

snuggers for retention and

sealing.

PLACEMENT OF PERIPHERAL CANNULAE

• VenoArterial (VA)

– Two cannulas

• Arterial – Right Common Carotid Artery to Aortic Arch

• Venous – Right Internal Jugular Vein to Right atrium

– Provides cardiac and respiratory support

– Sacrifices the Right Carotid Artery

– Can use femoral vessels in larger patients

ECLS CANNULATION

ECLS CANNULATION

VA ECLS CANNULA POSITION

• VenoVenous (VV)

– Double lumen cannula inserted via the R Internal Jugular Vein to the RA/IVC

– Only provides respiratory support

– Cannula position critical

– Spares the carotid artery

– Less risk of arterial emboli

ECLS CANNULATION

V-V ECLS CANNULATION

13.01.2013 © MAQUET

V-V ECLS CANNULA POSITION

Pulmonary failure Circulatory failure

V-v ECMO V-a ECMO

4 essential components:

1. Vascular access (percutaneous dilatational technique)

2. Pump

3. Membrane oxygenator

4. Tubing

Extracorporeal Modality

Low hemolysis without heat generation No stagnant areas No leakage possible High durability

Oxygenator

Microporous Membrane Diffusion Membrane

Limitation:

Oxygenator long term

support

Plasma leak

Related to differences in partial pressures in gases

Sweep Flow – 100% oxygen

PO2 ↑, PCO2 ↓

PO2↓, PCO2 ↑

Mixed Venous Blood

Veno – Arterial ECLS THERAPY

in cases of serious cardiac insufficiency and/ or

respiratory failure.

Veno – Venous ECLS THERAPY

ARDS (Acute Respiratory Distress Syndrome) as a result of:

pneumonia, sepsis, multiple trauma or aspiration without

serious cardiac failure.

Arterial-Venous ECLS

gas exchange disorders e.g. inadequate CO2 elimination.

Indications

• Primary reversible respiratory failure

• ARDS (H1N1)

• Severe pneumonia (Bacteria, Viral or aspiration)

• Acute lung failure following LTX

• Pulmonary contusion

• Smoke inhalation/ Burns

• Near drowning/ Hypothermia

• Reversible cardiogenic shock

• Non ischaemic cardiogenic shock

• Cardiomyopathy (bridge to longer VAD)

• Post cardiac surgery (unable to wean)

• Drug overdose or Sepsis profound cardiac depression

Contra indications

• Unlikely to be reversed in 10 – 14 days

• Multi-organ failure

• Severe irreversible brain injury

• Significant CPR (out of Hospital arrest)

• Contraindication to anticoagulation (Hep. İnd.T, multitrauma)

• Uncontrolled metabolic acidosis

• Terminal disease / malignancy

• Chronic lung disease

• Chronic myocardial dysfunction

• Immunosuppression

Relative contraindications

• Mechanical ventilation >6 days

• Septic shock

• Severe pulmonary hypertension

(MPAP >45 or >75% systolic)

• Cardiac arrest

• Acute, potentially irreversible myocardial

dysfunction

CLINICAL APPLICATIONS

• Meconium Aspiration Syndrome

• Persistent Pulmonary Hypertension

• Hyaline Membrane Disease

• Pneumonia

• Sepsis

• Pulmonary Air Leak

• Congenital Diaphragmatic Hernia

Neonatal Respiratory Diseases

• Post-operative cardiopulmonary failure

• Post-operative cardiac transplant

• Myocarditis

• Cardiomyopathy

CLINICAL APPLICATIONS Cardiac Diseases

• Average run length depends on the reason for cannulation

– Shorter for PPHN, Meconium Aspiration, HMD

• ~5 – 7 days

– Longer for CDH, Sepsis

• ~7 – 14 days

• Can be on ECMO for longer

– ECMO Circuit has more risk of failure

– More likelihood of inability to survive without ECMO

HOW LONG?

SELECTION CRITERIA

• Cardiovascular / Oxygen Delivery Criteria

• Plasma lactate: >45 mg/dl (5 mM/L) and not improving, despite volume expansion and inotropic support.

• Inotropic equivalent (IE) >50 for 1 hour or >45 for 8 hours.

IE = DOPamine(mcg/kg/min) + DOBUTamine(mcg/kg/min) + EPInephrine (100Xs mcg/kg/min) + NORepinephrine (100Xs mcg/kg/min) + ISOproterenol(100Xs mcg/kg/min) + MILrinone (15Xs mcg/kg/min).

• Mixed Venous Sat of <55% for 30 min.

• Rapidly deteriorating or severe ventricular dysfunction

• Intractable arrhythmia with poor perfusion

• Cardiac Arrest

VA versus VV

VA VV

Cardiac failure +++ +/-

Hypoxia +++ +

Hypercapnia +++ +++

Bloodflow +++

0,5-8 l/min

+/++

0,2-4 l/min

Blood/Gasflow ratio 1 : 1 1 : 3-15

Cannulation Central

Periferal

Periferal

Invasive +++ +/++

Complications in ECLS

• Anticoagulation: Clotting PLS, Bleeding

• Vessel (Bleeding, Infection, ischemia, dislodgement Cannula)

• Air (Emboli)

• Volume management patient

• Steal effect

• Sepsis

• Renal failure

• Decubitis ulcers

• Neurologic damage

ECMO supported CPR

Patient Management during ECLS

• Anticoagulation – First 12 h after CPB: No hep. necessary

– After 12h, blood loss <5ml/h: Hep IV 400 IU/h

– No prev. CPB: 5000 IU bolus.

– Monitoring: • APTT 55-60

• ACT 180

• Ratio Ventilation PLS/ Respirator

• Gasflow

• Bloodflow

• Prone position

• Visual inspection of the system

Criteria for changing the system

• Massive deposition of fibrin, clots

• Severe hypoxia despite FiO2 100%

• Severe thrombopenia

• Massive Hemolysis

• Pump, Motor, Controller dysfunction

Insufficient anticoagulation

VA ECMO Weaning Protocol

• Hemodynamic stabilization

• Reducing Bloodflow under TEE monitoring

• Low flow < 2L/min -> Higher anticoagulation

VV ECMO Weaning Protocol

Weaning: Sweep gas flow set at 0 L/min Pump flow not modified

Adjust FiO2 and Vt on the respirator

PaO2 >60 mmHg, SaO2 >90% FiO2 on the respirator <60%

Inspiratory plateau pressure <30 cm H2O

if echocardiography reveals no signs of acute cor pulmonale

For at least 1-2 hours and up to 12 hours

Conclusion

ECMO

• Is not a therapy but always a bridge

To recovery

To decision

To transplant

• Has a high potential for complications

Bleeding

Leg ischemia

Thrombosis

Systemic emboli