Published on September 21, 2016
1. Presented by: Dr. Dharmendra Joshi (DJ) ECMO (Extracorporeal Membrane Oxygenation)
2. EXTRACORPOREAL MEMBRANE OXYGENATION • A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. • The blood is then returned to the patient via a central vein or an artery. - ECMO guidelines Alfred Health Update Nov. 2015 INTRODUCTION
3. 1950s Development of membrane oxygenator in laboratory 1971 First successful case 1972 First successful paediatric cardiac case 1975 First neonatal case (Esperanza) 1975-89 Trial in ARDS, 10% survival 1990 Standard practice for neonates and pediatrics in some centers 2000 Standard practice for adults in some centres 2009 Publication of the CESAR trial which led to a significant growth in the use of ECMO for ARDS cases * CESAR Trial - Conventional Ventilation or ECMO for Severe Adult Respiratory failure trial HISTORY
4. First successful ECMO patient in1971 Figure: The first successful extracorporeal life support patient, treated by J. Donald Hill using the Bramson oxygenator (foreground), Santa Barbara, 1971.
5. First Neonatal ECMO survivor…
6. FROM THIS TO THIS
7. • Desaturated blood is drained via a venous cannula • CO2 is removed, O2 added through an “extracorporeal” device • The blood is then returned to systemic circulation via another vein (VV ECMO) or artery (VA ECMO). ECMO – PRINCIPLE
8. ECMO – BRIDGING THERAPY bridge to RECOVERY :– buying time for patient to recover bridge to DECISION :- provide temporary support to patient and allow clinicians to decide on the next step. bridge to TRANSPLANT :- provide support to patient while awaiting suitable donor organ.
9. Modes of ECMO
10. • Veno-Arterial ECMO (VA-ECMO): • Used to support patients with severe cardiac failure (with or without respiratory failure) • Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central artery - ECMO guidelines Alfred Health Update Nov. 2015 Veno-Arterial (VA) configuration
11. This infant has been cannulated for ECMO using the femoral artery and vein. To prevent possible distal limb ischemia, antegrade flow has been provided via a percutaneously placed distal perfusion catheter.
12. • Veno-Venous ECMO (VV-ECMO): • Used to support patients with severe respiratory failure refractory to conventional therapies • Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central vein - ECMO guidelines Alfred Health Update Nov. 2015 Veno-Venous (VV) configuration
13. • 4 configurations of VV-ECMO depending on the cannulation sites. a) Femoro-femoral b) High flow c) Femoro-jugular d) Double lumen single cannula (Avalon) - ECMO guidelines Alfred Health Update Nov. 2015 Veno-Venous ECMO (VV ECMO)
14. 1. Femoro-Femoral: 2. High Flow:
15. 3. Femoro – Jugular: 4. Double lumen/Two stage single cannula (Avalon):
16. Indications of VA-ECMO
17. Indications of VV-ECMO
18. ARDS Pneumonia Status asthmatics Chemical pneumonitis Inhalational pneumonitis Near drowning Bronchiolitis Persistent air leak syndrome RSV infection post CHD surgery. Indications of ECMO for Respiratory failure: in Paediatric
19. • Presence of any two of the criteria from the following observed over a period of 4 to 6 hours after maximum medical resuscitation. PaO2/FiO2 <75% Oxygen index >40% Murrays Score of >3 a-A gradient >600 Hypercapnia with PH of <7.2 observed over more than 3 hours. Lung compliance <0.5 cc/cmH2O/kg Inclusion criteria:
20. • Primary disease is irreversible (disseminated malignancy) • Age >75 years • On ventilator >15 days • Irreversible / indeterminate neurological prognosis • Immunosuppressed state • Multi-organ failure • Pre-existing coagulopathy • Severe pulmonary hypertension • Severe aortic regurgitation Exclusion Criteria for ECMO
21. • Bleeding • Thromboembolism • Cannulation related • Heparin induced thrombocytopenia • VV ECMO specific complications • VA ECMO specific complications • Neurological complications • THE HARLEQUIN SYNDROME (North South Syndrome) COMPLICATIONS
22. Who comprises the ideal team? Two intensivists (ECMO intensivist) and/or cardiothoracic surgeons: cannulation One Medical Officer: monitor cannula position by ECHO One Medical Officer: clinical management Perfustionist: ECMO priming and maintenance Respiratory Therapist: lung protective management, ventilator settings Nurses Radiologic Technician
23. INITIATION MAINTENANCE DISCONTINUATION ECMO MECHANISM
24. • Once it has been decided to initiate ECMO, the patient is anticoagulated with I/V heparin and cannulae are inserted according to the ECMO configuration ( VV or VA ECMO) • Following cannulation, patient is connected to ECMO circuit, the pump started with the flow of 20 ml/kg/min and gradually increased every 5- 10 min by 10 ml/kg/min to reach the desired flow. • Gas flow to blood flow ratio is adjusted to 0.5 : 1 & start with FiO2 of 21% 100% FiO2. • Once desired flow achieved, ventilator settings are brought down to base line. - ECMO UPTODATE 2013 INITIATION
25. • Once the initial respiratory and hemodynamic goals have been achieved, blood flow is maintained at that rate. • Continuous venous oximetry, Pressure monitoring (MAP, pre-pump P, pre and post oxygenator P), vital parameters (HR, RR, TEMP), Flow rates (blood flow rate at 60-150 ml/kg/min), neurological status, vascular status to be monitored. • Anticoagulation is sustained during ECMO with a continuous infusion of unfractionated heparin, titrated with activated clotting time(ACT) of 180- 210 sec. MAINTENANCE & MONITORING
26. • ELSO Data: 117 days • Average: a. V-V ECMO: 14-21days b. V-A ECMO: 5-14 days
27. • INDICATIONS : -For patients with Respiratory failure, improvements in radiographic appearance, pulmonary compliance and arterial oxy-Hb saturation. -With cardiac failure, enhanced aortic pulsatility correlates with improved left ventricular output. -One or more trials of taking the patient off of ECMO should be performed prior to discontinuing ECMO permanently. - ELSO General Guidelines Version 1.3 December 2013 WEANING & TRIAL OFF OF ECMO
28. Published online : 16 September 2009
29. CESAR TRIAL • Randomized control trial of adult ECMO vs Conventional Ventilatory support. • Adults were randomized either to VV ECMO at Glenfield Hospital, Leicester, England (90 patients) or continuing conventional care at referral hospitals (90 patients) i.e., conventional ventilator support. Peek GJ, et.al. Lancet 2009;374:1351‐136
30. ECMO • 57 out of 90 met primary end point. • Survival rate at 6months is 63% • Mortality 37% CONVENTIONAL VENTILATORY SUPPORT • 41 of 87 met primary endpoint • Survival rate at 6months is 47% • Mortality 53% RESULTS
31. Increased accessibility and use Reduction in costs Insurance / government support Smaller lines / volumes / oxygenators Coated “stealth” tubing (Nano particles). Smaller or portable ECMO machines Future of ECMO
32. When God is going to do something wonderful, He begins with a difficulty. If He is going to do something very wonderful, He begins with an ECMO Machine. (Quote by an ECMO survivor)
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