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
• 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
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
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.
• 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
• 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
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
Related to differences in partial pressures in gases
Sweep Flow – 100% oxygen
PO2 ↑, PCO2 ↓
PO2↓, PCO2 ↑
Mixed Venous Blood
Veno – Venous ECLS THERAPY
ARDS (Acute Respiratory Distress Syndrome) as a result of:
pneumonia, sepsis, multiple trauma or aspiration without
serious cardiac failure.
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
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
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