ECMO (Extracorporeal
Membrane Oxygenation
)
ECMO in Adults? Isnt this a Peds
thing?
1000 patients supported on ECMO at the University of Michigan were
reviewed (retrospectively)
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
Mechanical circulatory support has evolved markedly over recent years.
ECMO (extra corporeal membrane oxygenation) has become more
reliable with improving equipment, and increased experience, which is
reflected in improving results.
Introduction
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.
ECMO is essentially a modification of the cardiopulmonary bypass
circuit which is used routinely in cardiac surgery.
Introduction
Instituted in an emergency or urgent situation after failure of other
treatment modalities.
It is used as temporary support, usually awaiting recovery of organs.
Dynamics of ECMO
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
Blood is then returned back to the body either peripherally via a
femoral artery or centrally via the ascending aorta.
Indications for ECMO
Divided into two type
Cardiac Failure
Respiratory Failure
Indications Cardiac Failure
Post-cardiotomy
Post-heart transplant
when unable to get pt off cardiopulmonary bypass following cardiac
surgery
usually due to primary graft failure
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
Adult respiratory distress syndrome (ARDS)
Pneumonia
Trauma
Primary graft failure following lung transplantation.
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
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
ECMO can be inserted in 2 configurations:
Veno-venous
Veno-arterial
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
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
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.
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
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%.
ECMO flow can be very volume dependent
ECMO flow will drop:
Hypovolemia
Cannula malposition
Pneumothorax
Pericardial tamponade.
Weaning of ECMO VV ECMO
Actual ECMO flows do not need to be altered to assess native
respiratory function
Done by altering gas flow through the ECMO circuit
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)
Caveat: RR and PEEP set on ventilator are not too high (e.g. <25
breaths/min and <15cmH2O, respectively).
Weaning of ECMO VA ECMO
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.
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
Bleeding/Hemolysis
Out
of proportion to the degree of coagulopathy and
patient platelet count
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
Thrombocytopenia
Platelets adhere to surface fibrinogen and are activated
Resultant platelet aggregation and clumping causes numbers to drop
Non-pulsatile perfusion to end organs
Kidneys
Splanchnic circulation seems to be particularly susceptible
GI bleeding, ulceration and perforation
Liver impairment
Complications of ECMO
Mechanical Complications
Tubing
Pump
rupture
malfunction
Cannula
related problems
Local complications: Leg ischemia
Particularly at peripheral insertion site of VA
Air embolism/Thromboembolism
Neurological: Intracerebral bleeds
Largely associated with sepsis
Manifest as seizures or brain death
Management of Complications
Regular measurements of blood tests (Q6-Q8h)
Coagulation Profile
Platelet Count
Hemoglobin
Creatinine to evaluate for renal insufficiency
Aggressive replacement of clotting factors, electrolytes, PRBC
Outcomes of ECMO
Good quality RCT of ECMO outcomes in adult population are lacking
There are very promising studies in the Pediatric populations,
however it is hard to know if this translates into the adult population.
Completed yet unpublished CESAR Trial shows some potential impact
in ECMO research
CESAR
Conventional Ventilation or ECMO for Severe Adult Respiratory Failure
Preliminary results released at 37th Society of Critical Care Medicine
Congress in Honolulu February 2008
CESAR
Randomized controlled trial to assess the impact of ECMO on survival
without severe disability by 6 months in patients with potentially
reversible respiratory failure
Severe disability was defined as confined to bed and unable to dress
or wash oneself
CESAR
Conducted from 2001-2006
Adults were randomized either to VV ECMO at Glenfield Hospital,
Leicester, England (90 patients) or continuing conventional care at
referral hospitals (90 patients).
The conventional group underwent standard clinical practice in the
UK
Conventional Ventilator
CESAR
ECMO
57 of 90 met primary endpoint
Conventional ventilation group
41 of 87 met primary endpoint
CESAR
RRR 0.69 (95% CI, 0.050.97; P = 0.03)
Benefit of ECMO seen regardless of age, duration of high-pressure
ventilation, primary diagnosis at trial entry, and number of organs
failing.
Further Studies
CESAR study shows potential impact for VV ECMO, however studies
to evaluate impact for VA ECMO are lacking
This is where potential studies can be done
Summary
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.
ECMO is essentially a modification of the cardiopulmonary bypass
circuit which is used routinely in cardiac surgery.
ECMO can be inserted in 2 configurations: Veno-venous & Venoarterial
Completed yet unpublished CESAR Trial shows some potential impact
in ECMO research
Questions??
Bibliography
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[Link]
