ECMO Presentation by DJ as Resident Doctor

2. Presented by:
Dr. Dharmendra Joshi (DJ)
ECMO
(Extracorporeal Membrane Oxygenation)

3. 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


4. 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

5. 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.

6. First Neonatal ECMO survivor…


8. FROM THIS
TO THIS

10. • 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


11. 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. 

12. Modes of ECMO

13. • 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

14. 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.

15. • 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

16. • 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)


17. 1. Femoro-Femoral: 2. High Flow:


18. 3. Femoro – Jugular: 4. Double lumen/Two stage
single cannula
(Avalon):


19. Indications of VA-ECMO

20. Indications of VV-ECMO

21.  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

22. • 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:


23. • 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

24. • Bleeding
• Thromboembolism
• Cannulation related
• Heparin induced thrombocytopenia
• VV ECMO specific complications
• VA ECMO specific complications
• Neurological complications
• THE HARLEQUIN SYNDROME (North South Syndrome)
COMPLICATIONS


25. 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

26. INITIATION
MAINTENANCE
DISCONTINUATION
ECMO MECHANISM

27. • 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


28. • 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

29. • ELSO Data: 117 days
• Average: a. V-V ECMO: 14-21days
b. V-A ECMO: 5-14 days

30. • 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


31. Published online : 16 September 2009

32. 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

33. 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

34.  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

35. 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)