What ECMO IS and IS NOT: Appropriate Patient Selection

and Utilization of ECMO

ECMO aka ECLS• ECMO: Extracorporeal Membrane

Oxygenation• ECLS: Extracorporeal Life

Support• ELSO: Extracorporeal Life

Support Organization• www.elso.med.umich.edu/

ECLS• Use of Mechanical Device to

temporarily (days to months) support heart or lung function (partially or totally) during cardiopulmonary failure, leading to organ recovery or replacement

ECMO• Using an oxygenator to support

the cardiac or oxygenation of a patient for and extended period of time

• We still call it ECMO• ECMO does not describe the CO2

removal

History• First used in the 1970s on Adult

Respiratory patients• 1974 first Neonatal Respiratory

ECMO for MAS (Bob Bartlett)• NIH sponsored a study of Adult

Resp. but trial halted after only 90 patients b/c less than 10% survival

• Bartlett went on to treat respiratory distress infants with a 75% survival rate

Why use ECMO?• -Cardiac• -Respiratory• -Both

• “Acute severe heart or lung failure with high mortality risk despite optimal conventional therapy.”

• ECLS considered a 50% mortality risk

Disease Treated with ECMO

• Persistent Pulmonary Hypertension (PPHN)

• Meconium Aspiration Syndrome (MAS)

• Respiratory Distress Syndrome• Congenital Diaphragmatic Hernia• Sepsis/ Pneumonia• Congenital heart Disease

• Cardiomyopathy/myocarditis• ARDS• Aspiration Pneumonia• Pulmonary Embolism

ECMO Is NOT a tool for destination therapy in cases of

non-reversible, non-acute injury or

illness.

Contraindications:Relative

1. Conditions incompatible with ‘normal’ life

2. Preexisting conditions; affect quality of life– CNS Status– End Stage Malignancy– Risk of systemic bleeding with

Anticoagulation3. Age and Size of Patient4. Futility

ECMO IS for acute, reversible injury,

disease

ECMO IS NOT for non-reversible,

non-acute injury or illness

Neonatal Respiratory• Indications:

– Oxygen Index (OI)– OI= Mean Airway P x FiO2

x 100Post Ductal PaO2

– OI=20 Consider ECMO

– OI= 40 ECMO indicated

• Contraindications:– Lethal chromosomal

disorder– Irreversible brain or

organ damage– < 2 kg or < 34

week– Grade III or > IVH

Pediatric Respiratory• Indications:

– No Absolute indications are known• Best within 7 days

of Mechanical Ventilation

• Contraindications:– Neurosurgical

procedure or intracranial bleed within 10 days

– Recent Surgery or trauma

– Severe Neurologic compromise, genetic abnormalities

– Endstage hepatic failure, renal failure, primary PHTN

Cardiac Cases• Indications:

– Post Op failure– ICU: Pressor,

inotropic, Metabolic acidosis, decreased urine output for 6 hours

– Cardiac Arrest– Myocarditis,

myocardiopathy, toxic drug overdose

• Contraindications:– Untreatable

underlying disease

– Futility– CPR ongoing > 5

mins

Adult Respiratory Failure• Indications:

– Hypoxic Resp. Failure• 50% mortality:

PaO2<150 on >90% FiO2 or Murray Score 2-3

• 80% Mortality: PaO2 <80 on FiO2 >90%, Murray Score 3-4

– CO2 Retention PaCO2>80

• Contraindications:– High Vent settings

> 7 days– Major

immunosupprssion• (Neutophil <

400/ml3)– CNS Hemorrhage– Increase mortality

with increase age

Adult Cardiac• Indications:

– Cardiogenic Shock• Acute MI• Myocarditis• Peripartum

Cardiomyopathy• Decompensated

Chronic Heart failure

• Post cardiotomy shock

• Contraindications:– Unrecoverable

heart; not a candidate for transplant or VAD

– Chronic organ dysfunction

– Prolonged CPR– Anticoagulation

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