ECMO Basic Concepts
Transcript of ECMO Basic Concepts
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ECMO Basic
Concepts
Anne-Marie Guerguerian
Critical Care Medicine, The Hospital for Sick Children
University of Toronto
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Disclosures
• Financial: none
• Volunteer :
• Heart and Stroke Foundation of Canada
Resuscitation Paediatric Task Force
• International Liaison Committee on
Resuscitation Pediatric Task Force 2015 &
Evidence Reviewer for E-CPR
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WHAT IS ECMO?
In the context of caring for the
ICU patient with ECMO
ECLS
ECMO VAD
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Extracorporeal Life Support
Systems’ Nomenclature
ECLS: ExtraCorporeal Life Support
ECMO: Extracorporeal Membrane Oxygenation Maquet Rotaflow™
iLA: Interventional Lung Assist ILA Novalung™ by Xenios
ECCO2R: Extracorporeal Carbon Dioxide Removal
VAD: Ventricular Assist Device Long term - LVAD: Berlin™, Heart Mate™
Short term - centrifugal cVAD:
Maquet Rotaflow™ & Levitronix Centrimag® & Pedimag™
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ECMO is a Type of ECLS
2 Main Physiologic Functions
Pulmonary Gas Exchange through an
artificial ‘lung’ or MEMBRANE
1. O2 delivery to meet metabolic needs
2. Removal of CO2
Care of patient on ECMO involves exposure to
anticoagulation and transfusion therapy
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O2 & Air
CO2
Membrane
Pump
Return of oxygenated blood
Drainage of blood to remove
CO2
ECLS System: ECMO Patient
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Oxygen Delivery
Key Determinants in ECLS
System:
• Oxygenation by artificial membrane
• Blood flow through the circuit
Patient:
• Blood flow to the native heart & circulation
• Blood flow and oxygenation through native
lungs
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Exchange of O2
Oxygenation function
• Inlet SvO2
• FiO2
• Membrane capacity
• Red cell exposure
gas exchange area
(duration of time)
• [Hb]
• Blood Flow Figure modified from Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914 without permission
Inlet
SvO2
FiO2
Membrane
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Exchange of CO2
Gas flow L/min
Carbon dioxide removal
• Gas flow rate (L/min)
called sweep flow
• CO2 gradient
• Relatively independent
of blood flow
Figure modified from Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914 without permission
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Membrane Efficiency Monitoring
• Thrombosis & fibrin ~ O2 & CO2
• Condensation ~ CO2
Parameters
• Post membrane O2
• CO2 removal gradient
• Pre-post blood flow
pressure
Figure modified from Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914 without permission
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Blood Flow From Patient to ECLS
• Pump and/or Native heart function
• Centrifugal (or pulsatile)
• Cannula & Vascular Access
• Drainage cannula (venous)
• Higher flow with ‘Larger and Shorter’
cannula
• Return cannula
• Pressures may increase with higher flow
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O2 delivery + CO2 removal
+/- Extracorporeal Pump
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Cannulation
Vascular access:
• Peripheral: neck and femoral
• Central
Sites:
• Single or dual or more
Cannula Types:
• Lumens: single, dual, multiple
• Flow rate capacity (L/min)
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WHAT MODE OF
ECMO?
ECLS
ECMO
VA ECMO
VV ECMO
iLA
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Need: Modes & Configurations
• Cardiopulmonary failure
• Cardiac or cardiopulmonary support
• Veno-Arterial VA ECMO
• Respiratory failure
• Respiratory Support
• Veno-venous or VA ECMO
• Respiratory Support with Right Heart Failure
• Pulmonary artery- to left atrium iLA
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ECMO or iLA
ECMO : pump + membrane iLA: membrane
Pump
Membrane
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ICU CARE WITH ECMO
DECISION MAKING
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Defining the Purpose
1. Failure of pulmonary or cardiovascular or
both? (Need)
2. Is the process leading to failure reversible?
3. Is it reversible within a reasonable amount of
time?
4. If not reversible with recovery, is organ
replacement by transplantation an option?
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Indications: Purpose > Diagnosis1. Bridge to organ recovery
• To provide time needed for recovery of function
• To facilitate therapy: surgery or medical
2. Bridge to receive organ transplant
3. Bridge to decision:
• To another other type ECLS device
• To palliative care
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Customization• Purpose
• Need: how much gas exchange and circulatory
support is needed?
• Anatomy
• Vascular anatomy and cannulation sites
• Age & size or weight & height
• Mode: veno-venous vs. veno-arterial
• Configurations
• Initial & alternatives anticipated to reach patient’s destination?
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Considerations > Contraindications
Irreversible lung or heart disease
• And organ transplantation is not an option
Massive active hemorrhage
• Uncorrectable coagulopathy
• Major acute intracranial hemorrhage
Multi-organ failure
• E.g., Renal failure, Marrow failure
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Complications - Mechanical
• Pump
• Membrane failure
• Air embolism
• Catheter related vascular or cardiac perforation
• Circuit clotting & Haemolysis
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Complications• Bleeding
Cerebral hemorrhage or stroke
Surgical site hemorrhage
• Ischemia & end organ multi-organ failure
• Stroke & Limb Ischemia
• Renal failure
• Lung injury or failure of lung recovery
• Skin ulcerations
• Infection & systemic inflammatory syndrome
• Exposure to transfusions and other blood products
• Pain, delirium, fear, awareness if awake & NMB
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Early Goals Focus
Resuscitation & Stabilization
3 Rs:
• Recovery
• Retraining
• Rehabilitation
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Later Goals Focus
Weaning to separate for
• Organ recovery
• Organ transplantation
• Palliative care when there is no expected
possible recovery nor transplantation
Functional Outcomes
Follow Up & Bereavement
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Acute Respiratory Failure
Pneumonia < 1 week ARDS
paCO2 > 100 paO2 < 80 mmHg
CMV or HFOV, prone, NMB
Bridge to Recovery
VV ECMO
Right internal jugular
Bicaval cannula
Expect 7-11 Days before recovery
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Inter-hospital Transport
Bridge to facilitate transport to destination
that can provide therapy
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Acute Respiratory Failure
Pneumonia < 1 week
ARDS
Bridge to Recovery
Need to transport
VA ECMO
Femoral artery & vein
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Cardiopulmonary Failure
• Mediastinal Mass with ALL
• Tumor Lysis Syndrome
• Arrhythmias
• Severe Pulmonary Edema
Bridge to recovery & facilitate acute therapy
VA ECMO with acute hemodialysis
Expect to weaning off < 24 hours
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Acute cardiopulmonary failure
Cardiopulmonary arrest or not?
Elective or urgent
VA ECMO
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To Facilitate Surgery or Therapies
Elective ECMO
• Cardiac surgery
• Post cardiac surgery
• Complex tracheal surgeries
• Oncological surgeries
• Lung transplantation
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Before Lung Transplantation
Bridge to and/ or bridge after surgery
Comprehensive assessment
Multi-system impact: physical & mental health
Vascular mapping and configurations
(Plan A, B, C,…)
Re-training
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RVF Pulmonary Hypertension
End stage pulmonary hypertension
Bridge to lung
transplantation
PA- LA with iLA
Expected months …
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ECMO During a Severe Illness
• Electively or Emergently
• Acute respiratory failure
• Acute heart failure• Myocarditis
• Pulmonary hypertension
• Sepsis
• Facilitate therapies & surgery• Pulmonary embolism
• Resuscitation
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Patient’s Journey on ECMO Starts
• Purpose
• Need
• Vascular access