ECMO An Overview

Nicole Shilkofski, M.D. MEd.

Pediatric Critical Care Johns Hopkins School of Medicine Perdana University School of Medicine

Extracorporeal Membrane Oxygenation (ECMO)

Temporary support of heart and lung function by partial cardiopulmonary bypass in patients with reversible cardiopulmonary failure

January 10, 2014

History of ECMO
1930s-1950s: research into bypass for cardiac surgery; invention of roller-pump
1956: Invention of membrane lung

History
1957 cardiopulmonary bypass used in OR 1965-75 ECMO tried in premature infants (universally fatal) 1972 1st human survivor adult patient 1975 1st term neonate survivor 1981- Began use for PPHN By 1986 used in 715 newborns at 18 centers

Basic mechanics
Blood is drained from the right atrium Blood is warmed and oxygenated Excess CO2 is removed Oxygenated blood is returned to the aorta
(or for VV ECMO into the right atrium)

ECMO blood mixes with blood ejected from the left ventricle

Diagram: CNMC ECMO Training Manual, Short BL, Mikesell G, and Muir R (eds), 2004

VA ECMO
Used for respiratory failure Used for cardiac failure Used for both

VA cannulation

VV ECMO
Used primarily for respiratory failure Indirectly improved cardiac function

VV cannulation

Venous drainage
Primarily a passive process Depends on sufficient preload (volume) Lack of venous return results in drop in pressure in the bladder pump stops Improved by height of patient Improved by intravascular volume

Oxygen delivery
Depends on dissolved O2 in plasma and O2 bound to hemoglobin CaO2 = (SaO2 x Hb x 1.36) + (PaO2 x 0.003) On ECMO depends on
Lungs Membrane oxygenator

Ventilation
CO2 removal
Via lungs
May be quite limited Depends on minute ventilation

Membrane oxygenator
Very efficient May be excessive- can put CO2 back into circuit if needed

Rationale and Indications

ECMO is purely supportive therapy Ensures delivery of adequate oxygenated systemic blood flow ECMO does nothing for underlying primary cardiac or respiratory pathology Allows reduction in vent settings avoiding volutrauma, barotrauma and oxygen toxicity ECMO indicated in acute severe reversible cardiac or respiratory failure when risk of dying from primary disease despite optimal conventional treatment is high (50-100%)

Indications
Hypoxic respiratory failure not manageable by other means Neonates (Pulmonary hypertension -meconium aspiration, asphyxia, HMD, sepsis, D hernia) Older children (ARDS, pneumonia, status asthmaticus) Cardiac failure not manageable by other means Post cardiac surgery, myocarditis, cardiomyopathy, intractable arrythmias, drug overdose Unlikely to be successful if not off in 5-7 days post bypass Should not be a bridge to cardiac transplant Septic shock not manageable by other means Cardiac arrest ??????????????

Extracorporeal CPR (ECPR)

Use of ECMO to support failed conventional CPR PALS guidelines recommend consideration when conditions leading to CPA are potentially reversible or amenable to heart transplant Recent series report survival 33% to 55%
Fiser and Morris, Ped Clin N Am, 2008

Respiratory ECMO Criteria

Oxygenation Index 40

OI = MAP x FiO2 x 100 PaO2

Common Conditions in Infants

Hyaline membrane disease Meconium Aspiration Persistant Fetal Circulation Congenital Diaphragmatic Hernia Cardiac Anomalies

Common Conditions in Older Children and Adults

Adult Respiratory Distress Syndrome (ARDS) Non-necrotizing pneumonias Pulmonary contusion Other reversible respiratory and cardiac failure not responsive to other measures Post cardiac surgery

Contraindications
Severe Bleeding (Contraindication to anticoagulation)
Neonates-intraventricular hemorrhage > Grade 1 or 2 Major trauma, severe burns??, head injury with bleeds Major coagulopathy

Size limitation (neonates)

< 2 kg, < 34 weeks gestation

Irreversible lung disease

Mechanical ventilation > 10 days Other irreversible lung diseases such as necrotizing pneumonia

Immunosuppression? (Cancer, transplantation, primary immunodeficiencies)

Survival
Neonatal respiratory failure 80% Pediatric respiratory failure 60% Adult respiratory failure 50% Pediatric cardiac 45% Adult cardiac 40%
Univ. of Michigan ECMO website

Neonatal Outcomes- vary with underlying disease

Aspiration syndromes Persistent pulm HTN Infection Congenital D Hernia Congenital Heart Dz Cardiomyopathy 90% 80% 65% 50% 40% 50%

Pre-cannulation preparation
Neonates:
Head ultrasound- r/o bleed Echocardiogram evaluate for structural heart disease

Labs: Hb, platelets, coags and metabolic panel Lines, tubes, procedures BEFORE bypass
Foley catheter with balloon Nice to have a central line and arterial line Need peripheral access at minimum

Pre-cannulation preparation
Prepare anesthetic
Fentanyl Pancuronium/vecuronium

Volume for resuscitation

5% albumin, saline, blood

Resuscitation meds
Epinephrine, CaCl, NaHCO3

Heparin 100u/Kg Ensure access to IV

Circuit Components

Cannulae :VA ECMO

Neonates: Usual location for VA ECMO:
Venous right internal jugular to RA Arterial right carotid to aortic arch

Older child /adult

Venous R internal jugular or femoral vein Arterial Femoral, right carotid Monitor distal leg perfusion (Pulse oximeter, dorsalis pedis arterial line)

Cannulae:VV ECMO
VV ECMO:
Double lumen right atrial RA femoral; femoral femoral or RA

Available double lumen: 12 31 Fr Usually placed by surgical cutdown in neonates Can be percutaneous in children / adults CXR, sometimes echo, to check position

Venous Reservoir
Also known as bladder On most ECMO circuits, venous return from the patient is completely passive, by gravity Bladder acts as venous resevoir to avoid negative pressure generated by pump, which could cavitate air out of the blood Automatic feedback control to shut off pump when bladder collapses (chirping)

Roller Pump
Reliable use for many years Correct occlusion essential to calculate correct blood flow rate,( flow rate is CALCULATED and NOT MEASUREDrevolutions/min, tubing diameter, occlusion) and avoid hemolysis Hand crank available for power failure

How much flow?

Normal cardiac output Neonates 150-200 cc/kg/min, infants 100 cc/kg/min, older children 75 cc/kg/min, adults 50 cc/kg/min Pump flow often expressed as % of presumed CO VA ECMO increase flow to improve oxygenation or blood pressure VV ECMO inotropes to increase CO Titrate flows using
Pulse oximetry, ABGs Mixed venous sats 65%, normal lactate, no acidosis BP and perfusion

Oxygenator
More accurate name: membrane lung Oxygenation:
FiO2 to oxygenator Blood flow rate Membrane surface area (can add second oxygenator)

CO2 removal
Very efficient removal Affected by gas sweep flow Usually have to add some CO2 back to gas mixture

Heat exchanger

Required Monitoring
Mixed venous sats Pressure monitoring (prepump, postpump, postmembrane) Bubble detector 3 sets of blood gases: post-oxygenator, patient, mixed venous End tidal CO2 very low while on ECMO - low pulmonary blood flows Daily Head U/S in infants

CAVH
Most patients on ECMO develop fluid overload, sometimes anuria, despite diuretics Non-pulsatile flow to kidneys may affect their function Possible to put hemofilter in line with ECMO pump for UF, CAVH or CAVHD Diuretics vs. Ultrafiltration

CAVH circuit in-line with pump

Heparinization
Heparin bolus (100 units/kg) given just before bypass Activated clotting time at bedside hourly Usual ACT goal: 180-220 Circuit usually needs to be changed every 7-10 days due to clots

Ventilator management on ECMO

Rest vent settings on VA ECMO:
Goal: minimal settings to keep lungs recruited but also avoid volutrauma Typical: PEEP 10, PIP ~ 20, Rate ~ 10, FiO2 < 40%

Higher settings needed for VV ECMO

Venovenous ECMO
Advantages:
Coronary arteries & lungs receive oxygenated blood Spare carotid Less risk of embolic stroke, air embolus Pulsatile flow to organs

Disadvantages:
No cardiac support- only use for pulmonary indications Lower patient pO2

Conversion rate from VV to VA: 5-15%

PROBLEMS and COMPLICATIONS

Complications of ECMO
Hemorrhage (pulmonary, intracranial, GI, surgical site) CNS infarction Seizures (metabolic or CNS cause) Renal failure Hyperbilirubinemia Sepsis

Bleeding
Topical agents Lower ACT goal (180-200, or even 160-180) Set platelet goal higher FFP or fibrinogen/cryoprecipitate Add Amicar Surgical exploration Dont discontinue heparin, give more cryo and platelets Discontinue ECMO

Cardiac Stun
Case: Neonate on VA ECMO x 24 hours, heart rate falls to 20. What do you do? 5-10% of patients on VA ECMO More common in neonates Worsened by hypertension Dont do CPR turn up pump flow

ELSO registry
Founded 1989 145 participating centers worldwide Goal: include All ECMO patients To date:
18,000 newborns 4,000 pediatric patients 1,000 adults

www.elso.med.umich.edu

Team Training for ECMO Deployment Role of Simulation

January 10, 2014

Practicing on Plastic: In Situ Simulation

Summary Points
ECMO is supportive therapy considered for cardiorespiratory failure with reversible cause Consider VA vs VV ECMO depending on underlying pathophysiology Circuit components are complex and require multidisciplinary team effort for effective routine and emergency management