ECMO (Extracorporeal Membrane Oxygenation )

PARAS KHANDHAR SENIOR TALK

When I think about Ecmo, I think

ECMO in Adults? Isn

t this a Peds thing?

y 1000 patients supported on ECMO at the University

of Michigan were reviewed (retrospectively)

y VV-ECMO for respiratory failure provided survival to

discharge:
  

88% of 586 cases of respiratory failure in neonates 70% for 132 cases of respiratory failure in children 56% for 146 cases of respiratory failure in adults

Introduction

y Mechanical circulatory support has evolved markedly

over recent years.

y ECMO (extra corporeal membrane oxygenation) has

become more reliable with improving equipment, and increased experience, which is reflected in improving results.

Introduction

y 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.
y ECMO is essentially a modification of the

cardiopulmonary bypass circuit which is used routinely in cardiac surgery.

Introduction

y Instituted in an emergency or urgent situation after

failure of other treatment modalities.

y It is used as temporary support, usually awaiting

recovery of organs.

Dynamics of ECMO
y 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

y Blood is then returned back to the body either

peripherally via a femoral artery or centrally via the ascending aorta.

Indications for ECMO

y Divided into two type


Cardiac Failure Respiratory Failure

Indications Cardiac Failure

y Post-cardiotomy  when unable to get pt off cardiopulmonary bypass following cardiac surgery y Post-heart transplant  usually due to primary graft failure y Severe cardiac failure due to almost any other cause  Decompensated cardiomyopathy  Myocarditis  Acute coronary syndrome with cardiogenic shock  Profound cardiac depression due to drug overdose or sepsis

Indications Respiratory Failure

y Adult respiratory distress syndrome (ARDS) y Pneumonia y Trauma y Primary graft failure following lung transplantation. y ECMO is also used for neonatal and pediatric

respiratory support


This is where most of the research on ECMO has been done

Decision to Institute ECMO

y Several considerations must be weighed:


     

Likelihood of organ recovery.: only appropriate if disease process is reversible with therapy and rest on ECMO Cardiac recovery: to either wait for further cardiac recovery to allow implant of device (LVAD) or to list for transplantation. Disseminated malignancy Advanced age Graft vs. host disease Known severe brain injury Unwitnessed cardiac arrest or cardiac arrest of prolonged duration. Technical contraindications to consider: aortic dissection or aortic incompetence

Configurations for ECMO

y ECMO can be inserted in 2 configurations:



Veno-venous Veno-arterial

y Veno-arterial (VA) configuration  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

Central ECMO Cannulation

y Veno-Venous (VV) configuration  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.

Peripheral ECMO Cannulation

Central vs. Peripheral Cannulation

y Advantages


Flow from Central ECMO is directly from the outflow cannula into the aorta provides antegrade flow to the arch vessels, coronaries and the rest of the body In contrast, the retrograde aortic flow provided by peripheral leads to mixing in the arch.

y Disadvantages


Previously insertion of central ECMO required leaving chest open to allow the cannulae to exit.
Increased the

risk of bleeding and infection Newer cannulae are designed to be tunneled through the subcostal abdominal wall allowing the chest to be completely closed.


Central cannula are costly (approximately 4 times as much as peripheral)

Things to Think About

y Mechanical ventilation must be continued during ECMO

support to try to maintain oxygen saturation of blood ejected from the left ventricle to at least above 90%.
y ECMO flow can be very volume dependent y ECMO flow will drop:
   

Hypovolemia Cannula malposition Pneumothorax Pericardial tamponade.

Weaning of ECMO VV ECMO

y Actual ECMO flows do not need to be altered to assess

native respiratory function



Done by altering gas flow through the ECMO circuit

y Pt may be weanable:  Gas exchange is able to be maintained with a low FiO2 (<30%)  Low fresh gas flow rates into the circuit (<2 L/min) y Caveat: RR and PEEP set on ventilator are not too high

(e.g. <25 breaths/min and <15cmH2O, respectively).

Weaning of ECMO VA ECMO

y Depends on cardiac recovery, Factors:  Increasing blood pressure  Return or increasing pulsatility on the arterial pressure waveform  Falling pO2 by a right radial arterial line
indicating more

blood is being pumped through the heart which may be less well oxygenated,

Falling central venous and/or pulmonary pressures.

y It is important to note that cardiac outputs from

pulmonary artery catheter are inaccurate on ECMO



Most of the circulating blood volume is bypassing the pulmonary circulation

Complications
Falls into one of three major categories 1) Bleeding associated with heparinization 2) technical failure 3) neurologic sequelae

Complications of ECMO
y Bleeding/Hemolysis  Out of proportion to the degree of coagulopathy and patient platelet count y Coagulopathy  Continuous activation of contact and fibrinolytic systems by the circuit  Consumption and dilution of factors within minutes of initiation of ECMO

Complications of ECMO
y Thrombocytopenia  Platelets adhere to surface fibrinogen and are activated  Resultant platelet aggregation and clumping causes numbers to drop y Non-pulsatile perfusion to end organs  Kidneys  Splanchnic circulation seems to be particularly susceptible  GI bleeding, ulceration and perforation  Liver impairment

Complications of ECMO
y Mechanical Complications  Tubing rupture  Pump malfunction  Cannula related problems y Local complications: Leg ischemia  Particularly at peripheral insertion site of VA y Air embolism/Thromboembolism y Neurological: Intracerebral bleeds  Largely associated with sepsis  Manifest as seizures or brain death

Management of Complications
y Regular measurements of blood tests (Q6-Q8h)  Coagulation Profile  Platelet Count  Hemoglobin  Creatinine to evaluate for renal insufficiency y Aggressive replacement of clotting factors,

electrolytes, PRBC

Outcomes of ECMO
y Good quality RCT of ECMO outcomes in adult

population are lacking

y There are very promising studies in the Pediatric

populations, however it is hard to know if this translates into the adult population.
y Completed yet unpublished CESAR Trial shows

some potential impact in ECMO research

CESAR

y Conventional Ventilation or ECMO for Severe Adult

Respiratory Failure
y Preliminary results released at 37th Society of Critical

Care Medicine Congress in Honolulu February 2008

CESAR

y Randomized controlled trial to assess the impact of

ECMO on survival without severe disability by 6 months in patients with potentially reversible respiratory failure
y Severe disability was defined as confined to bed and

unable to dress or wash oneself

CESAR
y Conducted from 2001-2006 y Adults were randomized either to VV ECMO at

Glenfield Hospital, Leicester, England (90 patients) or continuing conventional care at referral hospitals (90 patients).
y The conventional group underwent standard clinical

practice in the UK


Conventional Ventilator

CESAR
y ECMO  57 of 90 met primary endpoint y Conventional ventilation group  41 of 87 met primary endpoint

CESAR
y RRR 0.69 (95% CI, 0.050.97; P = 0.03) y Benefit of ECMO seen regardless of age, duration of

high-pressure ventilation, primary diagnosis at trial entry, and number of organs failing.

Further Studies
y CESAR study shows potential impact for VV ECMO,

however studies to evaluate impact for VA ECMO are lacking

y This is where potential studies can be done

Summary
y 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. y ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery. y ECMO can be inserted in 2 configurations: Venovenous & Veno-arterial y Completed yet unpublished CESAR Trial shows some potential impact in ECMO research

Questions??

Bibliography
y Bartlett RH. Extracorporeal life support registry report 1995. ASAIO J 1997;43:1047. y Conrad SA, Rycus PT, Dalton H. Extracorporeal life support registry report 2004. y y

y y

ASAIO J 2005;51:410. Fiser S, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, Kron IL. When to discontinue ECMO for postcardiotomy support. Ann Thorac Surg 2001;71:2104. Glauber M, Szefner J, Senni M, Gamba A, Mamprin F, Fiocchi R, Somaschini M, Ferrazzi P. Reduction of haemorrhagic complications during mechanically assisted circulation with the use of a multi-system anticoagulation protocol. Int J Artif Organs 1995;18:64955. Hitt E. CESAR trial: extracorporeal membrane oxygenation improves survival in patients with severe respiratory failure. Medscape Medical News www.medscape.com; 2008 Marasco SF, Esmore DS, Negri J, Rowland M, Newcomb, A, Rosenfeldt F, Bailey M, Richardson M. Early institution of mechanical support improves outcomes in primary cardiac allograft failure. J Heart Lung Transplant 2005;24(12): 203742. Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, Killer H, Mugford M, Thalanany M, Tiruvoipati R, Truesdale A,Wilson A. CESAR: conventional ventilatory support vs. extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res 2006;23(6):163. www.emedicine.com www.uptodate.com