2. • INTRODUCTION
• HISTORY
• PRINCIPLE
• CIRCUIT & COMPONENTS
• INDICATIONS
• CONTRAINDICATIONS
• ECMO MECHANISM
• COMPLICATIONS
• OUTCOMES OF ECMO
• EXTRA CORPOREAL CO2
REMOVAL
• EXTRA CORPOREAL CPR
3. INTRODUCTION
• 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.
SOURCE :ECMO guidelinesAlfredHealthUpdate nov 2015
5. 5
5
History of Extracorporeal LifeSupport
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 paediatrics in
some centres
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
6. Firstsuccessful ECMO patientin1971
Figure 3.4. The first successful extracorporeal life support patient, treated by J. Donald
Hill using the Bramson oxygenator (foreground), Santa Barbara, 1971.
9. ECMOPRINCIPLE
• 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).
10.
11. • ECMO serves as a BRIDGING THERAPY and not a curative
therapy.
• Used as a
-bridge to recovery :– i.e., 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.
12. ECMOCIRCUIT& COMPONENTS
• The basic components of
ECMO circuit includes
• - a blood pump
• - membrane oxygenator &
heat exchanger
• -controller
• -cannulas
• -tubings
13.
14.
15. PUMPS:
• They are basically of 3
types.
• - Roller pump
• - Impellar pump
• - centrifugal pump
16. CENTRIFUGAL
PUMPS :
• Roller pumps are now being
replaced by centrifugal
pumps.
• The perfusion pressure is
controlled by RPM (0-4000
RPM)
• Can deliver flow upto 8 L/min
• Very reliable upto 21 days.
17. Membrane Oxygenator:
• ECMO circuits have a gas
exchange device called
oxygenator, to add Oxygen
and remove CO2 from
blood.
18. • Previously, silicon membrane
oxygenators were used
which are being replaced by
Hollow fibre
PMP(polymethyl pentene)
membrane oxygenators.
• These are extremely efficient
at gas exchange and
demonstrate minimal
plasma leakage, low
resistance to blood flow.
19. GASEXCHANGE:
OXYGEN exchange depends
on :
• Type of membrane &
diffusion characteristics
• Thickness of the blood
pathway
• Surface area of the
membrane
• FiO2 in the gas phase
• Rate of blood flow
CO2 exchange depends on :
• Difference in CO2 conc.
between blood and gas
• Size of membrane
• Fresh gas flow
• Blood pathway thickness
• Blood flow rate
20. HEATEXCHANGER:
• In adults, it is usually built within the oxygenator.
• In paediatric cases, it is connected separately
after the oxygenator in the circuit.
• It is used for temperature regulation of the
extracorporeal blood.
24. TUBINGS:
• Depending on the heparin
coating, they are of 2
types :
• - regular
• - heparin coated
25. 25
25
Different CONFIGURATIONSinECMO
Most common configurations:
• 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
• 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 guidelinesAlfredHealthUpdate nov 2015
26. • Arterio-Venous ECMO (AV ECMO) :
An arteriovenous (AV) extracorporeal circuit that uses
the patient’s own arterial pressure or incorporates a
pump to drive blood across an oxygenator can partially
support the respiratory system by effectively removing
carbon dioxide (CO2) (extracorporeal CO2 removal
[ECCO2R]).
ECMO guidelinesAlfredHealthUpdate nov 2015
27.
28. VENO-VENOUSECMO(VV ECMO)
• Venous blood is accessed from large central veins, pumped
through the oxygenator and returned to the venous system
near right atrium.
• There are 4 configurations of VV-ECMO depending on the
cannulation sites.
a)Femoro-femoral
b) high flow
c)femoro-jugular
d) double lumen single canula (Avalon)
ECMO guidelinesAlfredHealthUpdate nov 2015
29. Femoro-Femoral:
• Access cannula is inserted via
the femoral vein with the tip sited
within the ivc.
• Return cannula is inserted via
contralateral femoral .v with the tip
in right atrium.
• Advantages : quick and safe to
insert, easy to secure cannulae.
• Disadvantages : limited maximum
flow rates, often requires
conversion to a high flow
configuration.
30. High Flow:
• Uses the same bi-femoral
cannulation.
• An additional short access cannula is
inserted via the right internal jugular
vein with tip in svc.
• Advantages : allows higher circuit
blood flows as they draw blood from
the great veins (svc & ivc).
-It is required in severe cases of
respiratory failure when single access
canula circuit flow is inadequate to
maintain sufficient levels of gas
exchange.
31. • Disadvantages :
-occupies 3 veins.
- relatively complex to secure and dress the jugular
cannula.
- patient remains bed bound.
- potential source of air embolism and pressure injury.
ECMO guidelinesAlfredHealthUpdate nov 2015
32. Femoro-Jugular:
• Access cannula – via femoral
vein with tip sited just below the
inferior cavo-atrial junction.
• Return cannula – into right
internal jugular vein with the tip
in lower svc.
• Advantages : nearly can
provide adequate support
(5-7 l/min).
33. • Disadvantages :
- relatively complex to secure and dress the
jugular cannula.
- requires two sterile fields to be done during
ECMO cannulation.
- access insufficiency can be more difficult to identify
in early stages without negative pressure
monitoring.
ECMO guidelinesAlfredHealthUpdate nov 2015
34. Double lumen/Two stagesinglecannula
( Avalon):
• Single cannula with two lumens
for access and return inserted
via the right internal jugular
vein.
• Advantages : single vein
cannulation. Allows
movement from bed and
ambulation.
• Disadvantages : care on
insertion to avoid right
ventricular placement/rupture.
Difficult to position return port
towards the tricuspid valve.
35. VENO-ARTERIALECMO(VA-ECMO)
• Venous blood is accessed from the large central veins, pumped
through oxygenator and returned to the systemic arterial system
in the aorta.
• It provides support for severe cardiac failure with or without
associated respiratory failure.
• Different configurations of VA ECMO are :
-standard Femoro-Femoral
-emergency Femoro-Femoral
-High Flow
-Central : specialised cannula
-Central : Bypass cannula
36. Standard Femoro-Femoral:
• Access cannula is inserted via femoral
vein with tip in right atrium.
• Return cannula : via common femoral
artery with tip lying in common iliac
artery or lower aorta.
• Advantages : provides full or partial
cardiac support.
• Disadvantages : risk of differential
hypoxia – may need conversion to high
flow configuration if native cardiac
function improves in the setting of
significant respiratory failure.
37. EmergencyFemoro-Femoral:
• Similar to standard femoro-femoral but uses SMALLER
cannula which are quicker to insert in an emergency.
• Standard cannula : 21-25
Fr Emergency cannula :
19-21 Fr
Advantages : faster to insert. Used for ECMO-CPR or in
peri-arrest patients.
Disadvantages : risk of differential hypoxia.
ECMO guidelinesAlfredHealthUpdate nov 2015
38. High Flow:
• Uses the same bi-femoral
cannulation with additional
access cannula inserted via
the right internal jugular vein
with tip in svc.
• Advantages : used to
minimise differential hypoxia
when native cardiac function
improves.
39. INDICATIONSOFECMO
• ELSO GUIDELINES:
-Acute severe cardiac failure or respiratory failure with
high mortality risk and reversible and non-responsive to
optimal conventional therapy.
-ECLS is considered at 50% mortality risk and indicated at
80% risk.
SOURCE :ELSO General Guidelines Version 1.3 December2013
ELSO- EXTRA CORPOREAL LIFE SUPPORT ORGANIZATION
40. ELSOGUIDELINESFORADULTRESPIRATORY
FAILURE
• INCLUSION CRITERIA:
1.In hypoxic resp failure due to any cause (primary or secondary)
a) 50% mortality risk associated with a PaO2/FiO2 < 150 on FiO2
>90% and Murray score 2-3
b) 80% mortality risk is associated with a PaO2/FiO2 <100 on FiO2
>90% and Murray score 3-4 despite optimal care for 6 hrs or more.
2. CO2 retention on Mechanical Ventilation despite high Pplat (>30cm
H2O)
SOURCE :ELSO General Guidelines Version1.3 December2013
41. 3. Need for intubation in a patient on lung transplant
list
4. Immediate cardiac or respiratory collapse (Pulmonary
Embolism, blocked airway) unresponsive to optimal care.
SOURCE :ELSO General Guidelines Version1.3 December2013
42. Parameter /
Score
0 1 2 3 4
PaO2/FiO2
(On 100%
Oxygen)
≥300mmHg
≥40kPa
225-299
30-40
175-224
23-30
100-174
13-23
<100
<13
CXR normal 1 point per quadrant infiltrated
PEEP(cmH2O) ≤5 6-8 9-11 12-14 ≥15
Compliance
(ml/cmH2O)
≥80 60-79 40-59 20-39 ≤19
ECMO inclusion criteria -
Murray score
= average score of all 4
parameters
43. INDICATIONS:
Reversible Respiratory Failure:
• ARDS
• Severe Pneumonias
• Severe Acute Asthma
• Chemical and Inhalation hypersensitivity Pneumonitis
• Near Drowning
• Post traumatic Lung Contusion
• Bronchiolitis Obliterans
• Autoimmune lung diease - Vasculitis, Good Pasture Syndrome
SOURCE :ELSO General Guidelines Version1.3 December2013
44. Irreversible or Chronic Respiratory Failure:
• It is indicated as a bridge, only when-
-patient is for lung assist device. Eg : PAL (paracorporeal
artificial Lung)
-patient is waiting for lung transplant.
SOURCE :ELSO GeneralGuidelines Version1.3 December2013
45. •CONTRAINDICATIONS:
• No absolute contraindications to ECLS in respiratory failure.
• Relative contraindications due to poor outcome are :
- Mechanical Ventilation at high settings ( FiO2 >90%, P-plat >30) for 7
days or more.
- Major pharmacological immunosuppression (absolute neutrophil
count < 400/mm3)
- CNS haemorrhage which is recent or expanding
- Non recoverable co-morbidity such as major CNS damage or
terminal Malignancy
-Age : no specific age contraindication but increasing risk with age
SOURCE :ELSO General Guidelines Version 1.3December2013.
46. ELSO GUIDELINES FOR CARDIAC FAILURE:
• Cardiogenic shock
-inadequate tissue perfusion manifested as hypotension
and low cardiac output despite adequate intravascular
volume.
-shock persists despite volume administration, ionotropes
and vasoconstrictors and intraaortic balloon
counterpulsation if appropriate.
SOURCE :ELSO General Guidelines Version1.3 December2013
47. typical
causes : -Acute myocardial infarction
-Myocarditis
-Decompensated chronic cardiac
failure
-Post cardiotomy shock
-Peripartum cardiomyopathy
• Septic shock
SOURCE :ELSO General Guidelines Version 1.3 December 2013
48. • ECMO advantages in cardiac failure :
-Biventricular support, Bedside immediate application and
oxygenation in Biventricular failure, Refractory malignant
arrhythymias, heart failure with severe respiratory failure.
• ECMO is a Bridge to
Recovery : Acute MI after revascularisation,
Myocarditis, Postcardiotomy
Transplant :Unrevascularizable acute MI, Chronic heart
failure Implantable circulatory support : VAD
SOURCE :ELSO General Guidelines Version1.3 December 2013
49. CONTRAINDICATIONS
• ABSOLUTE :
-Unrecoverable heart & not a candidate for transplant /VAD
-Chronic organ dysfunction (Emphysema, cirrhosis, renal
failure)
-Prolonged CPR without adequate tissue perfusion
• RELATIVE :
-Anticoagulation
-Obesity
-Advanced age
SOURCE :ELSO GeneralGuidelinesVersion1.3 December2013
51. INITIATION
• 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.
SOURCE :ECMO UPTODATE2013
52. • Reasonable targets are :
- an arterial oxy Hb saturation
of-
>90% for VA
ECMO,
>75% for VV
ECMO
- A venous oxy Hb saturation of 70-80% for VA ECMO
-Adequate tissue perfusion as determined by arterial blood
pressure, venous oxygen saturation and blood lactate level.
SOURCE :ECMO UPTODATE2013
53. MAINTENANCE& MONITORING:
• Once the initial respiratory and hemodynamic goals have been
achieved, blood flow is maintained at that rate.
• Continuous venous oxymetry, Pressure monitoring (MAP, prepump
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.
54. WEANING& TRIALOFFOFECMO
• INDICATIONS :
-For patients with Respiratory failure, improvements in
radiographic appearance, pulmonary compliance and arterial
oxyHb 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.
SOURCE :ELSO General Guidelines Version1.3 December2013
55. • Decrease flow in steps to 1 L/min at FiO2 100% or decrease flow to
2L/min then decrease sweep gas FiO2 to maintain SaO2 >95%
• When SaO2 stable on these settings,
-VV ECMO trials are performed by eliminating all countercurrent sweep gas
through oxygenator. Blood flow remains constant, but gas transfer doesnot
occur. Ventilator settings are adjusted.
-VA ECMO trials need temporary clamping of both drainage and infusion lines,
while allowing to circulate through a bridge between the arterial and venous
limbs.
- VA ECMO trials are generally shorter duration than VV ECMO trials because
of higher risk of thrombus formation.
SOURCE :ELSO General Guidelines Version 1.3December2013
56. COMPLICATIONS
• Bleeding
• Thromboembolism
• Cannulation related
• Heparin induced
thrombocytopenia
• VV ECMO specific complications
• VA ECMO specific complications
• Neurological complications
57. •BLEEDING :
- Occurs in 30-40% of patients on ECMO
-Due to continuous heparin infusion and platelet
dysfunction. treatment :
-maintaining platelet count > 1 lakh/mm3, target ACT
reduces the risk of bleeding.
- surgical exploration if major bleeding occurs.
- if bleeding occurs, decrease heparin infusion & maintain
ACT at 160 sec.
- plasminogen inhibitors can be given but may increase
risk of circuit thrombosis.
58. THROMBOEMBOLISM:
• It is more common with VA
ECMO than VV ECMO as
infusion is into systemic
circulation.
• A sudden change in
pressure gradient
indicates thrombus
formation.
59. CANNULATIONRELATED:
• Vessel perforation
with haemorrhage.
• Arterial dissection
• Bleeding
• Distal ischemia in VA
ECMO
-treatment : inserting
distal perfusion cannula in
femoral artery distal to
ECMO cannula.
60. HEPARININDUCEDTHROMBOCYTOPENIA
• HIT can occur in patients receiving ECMO.
• When HIT is proven, heparin infusion should be
replaced by non-heparin anticoagulant.
61. VVECMOSPECIFICCOMPLICATIONS
•RECIRCULATION :
-Here, reinfused blood is withdrawn through the drainage
cannula without passing through the systemic circulation.
- The degree of recirculation determines the efficiency of
ECMO in providing oxygenation.
INTERVENTION :
- Increasing the distance between cannulae
- Use of single site double lumen cannula
- Addition of another drainage cannula
SOURCE : ELSO guidelines for management of recirculation
May 2015
62. VAECMOspecificcomplications
• Pulmonary haemorrhage
• Cardiac thrombosis
-retrograde blood flow in the ascending aorta in VA ECMO.
-stasis of blood can occur if left ventricular output is not
maintained leading to thrombosis.
• Coronary or cerebral hypoxia
-coronary usually gets blood from native circulation (from LV)
-With compromised LV & LUNGS, relatively hypoxic
perfusion occurs.
63. THEHARLEQUINSYNDROME(north south
syndrome)
• Saturation of upper part of the body is lower than that of lower
half.
• This is due to flow competition in the aorta
– recovering heart vs ECMO pump
High cardiac output from native recovering heart
prevents the retrograde flow of ECMO to perfuse upper
part.
If pulmonary function is impaired :
-”BLUE HEAD” : deoxygenated blood to upper part
-”RED LEGS” : hyperoxygenated blood to lower part
65. • TREATMENT :
-increase the ECMO flow if no cardiac stunning
-higher ventilator setting or consider HFOV (High
Frequency Oscillatory Ventilation)
-switch to VV ECMO if persistent lung failure.
69. CESARTRIAL
• 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
70. ECM
O
• 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%
Peek GJ,et.al.Lancet2009;374:1351‐136
73. • 68 patients with severe influenza associated ARDS were
treated with ECMO.
• Out of 68, -influenza A - 61 (H1N1 -53)
-Not subtyped -7
• Survival rate : 71% (48 out of 68)
74.
75. EXTRACORPOREALCO2REMOVAL(ECC02R)
• The process by which an extracorporeal circuit is used for the
primary purpose of removing CO2 from the body, thereby
providing partial respiratory support.
• First described in 1977 by Kolobow and Gattioni.
• Where as ECMO is indicated in treating refractory
hypoxemia in severe cases of ARDS, ECC02R is indicated
to facilitate protective ventilation in all stages of ARDS.
76.
77. EXTRACORPOREALCPR
• It is a method of cardiopulmonary resuscitation that
uses ECMO as an adjunct to standard CPR.
• The application of ECMO allows the return of
cerebral perfusion in a more suitable manner than
with external compressions alone.
