ECMO & REBOA: ADVANCES IN TREATMENT

Joseph Shiber, MD, FACP, FACEP, FCCMAssociate ProfessorDirector ECMO Service & Co-Director NSICU Emergency Medicine, Neurology, and Surgery UF College of Medicine - Jacksonville

ECMO Background: since 1972 Adults• ECMO does NOT fix anything BUT allows time for treatment • Sometimes Time is the Treatment• VA for pulmonary & cardiac support• VV pulmonary: true “lung rest” to allow recovery• Ultraprotective MV: not relying on lung for gas exchange• CO2 removal low blood flow (<1L/min) = smaller access• Oxygenation needs >60% CO (4-6L/min) = larger access

Flu A

ECMO• Dual Heart-Lung “bypass” parallel or Only Lung serial• Lung Rest: ARDS, Asthma/COPD, lung trauma, air leak• Heart: MI, PE, Blunt Cardiac Injury, Myocarditis, eCPR• Different configurations for VV or VA• Two Catheters vs Single dual-lumen catheter

VV: Pulmonary

VA: Cardiac and Pulmonary

Indications• ARDS: PaO2/FiO2 <80 mmHg despite optimization• Murray Score: P/F, PEEP, compliance, CXR quadrants• Hypercapnic respiratory failure: pH <7.20• Ongoing large air leak• Refractory cardiogenic shock• Cardiac arrest with chance of recovery• Failure to wean from cardiopulmonary bypass• As a bridge to cardiac transplantation or VAD

Severe Blunt Chest w/ TBI

VV: Fem/Fem

Contraindications

• If the cause is irreversible • Anticoagulation is contraindicated: bleeding, TBI, ICH• Respiratory failure: on MV>10 D = poor outcome• For cardiac failure, if VAD or transplant is contraindicated • May exclude: advanced age, morbid obesity, neurologic

dysfunction, poor preexisting functional status

Outcomes• Mortality severe ARDS 40-60% w/ ECMO reduced to 25%• Referral to an ECMO center significantly improves recovery

and survival from severe ARDS!• 15-25% of patients improve and recover without ECMO

• It is recommended that adult patients with severe ARDS be referred to an ECMO center, assuming that there are no contraindications

• Survival w/ GOOD Neuro Fxn s/p Cardiac Arrest ~ 1 - 2% but ~12% w/ ECMO

What is the difference?

Walking rehab on ECMO

Resuscitative Endovascular Balloon Occlusion of the Aorta

• Placement of an endovascular balloon in the aorta to control hemorrhage and to augment afterload in traumatic arrest and hemorrhagic shock 

• Endovascular balloons have been used to control hemorrhage in settings such as aortic aneurysm surgery, gastro-intestinal bleeding, postpartum hemorrhage as well as trauma

• Tends to cause less physiological disturbance and have higher rates of technical success than thoracotomy with aortic cross clamping

Anatomy• Zone I of the aorta extends from the origin of the left subclavian artery to the celiac artery (approx 20cm)

• Zone II extends from the celiac artery to the most caudal renal artery (approx 3cm) *NOT a target

• Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm)

Anatomy• Thoracic aorta is 20mm in diameter• Distal aorta is 15mm in diameter• Averages 2mm narrower in females• Increases by 0.5 mm/y

• Zone 1 is measured to the xiphoid• Zone 3 is measured to just above the umbilicus

Indications• PEA arrest (<10 minutes) secondary to exsanguination from sub-diaphragmatic hemorrhage and femoral vessels immediately identifiable on US

• Severe hypovolemic shock and SBP <70mmHg

• Agonal state due to non-compressible exsanguinating hemorrhage: non/partial responders to rapid volume resuscitation (causes of obstructive shock excluded)

Indications• Suspected or diagnosed intra-abdominal hemorrhage due to blunt trauma or penetrating torso injuries (Zone I)

• Blunt trauma with suspected pelvic fracture and isolated pelvic hemorrhage (Zone III)

• Penetrating injury to the pelvic or groin area with uncontrolled hemorrhage from a vascular injury of iliac or  common femoral vessels (Zone III)

ER-Reboa: Zone III

Contraindications• Age >70y• PEA arrest (<10 minutes) secondary to exsanguination

from sub-diaphragmatic hemorrhage and femoral vessels not immediately identifiable on ultrasound = open chest

• Cardiac arrest due to causes other than exsanguination due to severe subdiaphragmatic trauma

• PEA arrest >10 minutes• High clinical/radiological suspicion of proximal aortic injury• Pre-existing terminal illness or significant comorbidities

Procedure Steps• Access Common Femoral Artery (CFA) using ultrasound (or cutdown)• Zone I – Xiphoid (approx 50cm)• Zone III – Umbilicus (approx 40cm)

• Inflate balloon until moderate resistance (document time) • Zone I – 15 to 20 mL• Zone III – 10 to 15 mL

• X-ray – confirmation balloon position: 2 radiopaque bands • Zone I – T4 to L1• Zone III – L2 to L4

• Secure catheter• Expedite departure to OR/IR (no CT post-REBOA)

Zone I Zone III

Equipment: Coda• Cook arterial line kit• Percutaneous entry thin-wall needle (Cook: 18G, 7cm)• Cook 12 Fr sheath kit• Amplatz Extra-Stiff guidewire (Cook: 0.035 inch, 180cm)• Cook Coda Balloon Catheter 32mm, 9Fr shaft, 100cm length• Will need arterioraphy s/p catheter removal

Equipment: ER-Reboa• 7 Fr CFA Introducer• Prytime Medical 7 Fr ER-Reboa catheter• Arterial line transducer• Only need to hold pressure s/p removal

UMMS/STC Algorithm

QUESTIONS & COMMENTSREBOA: Dr. Skarupa is Leader at UF HealthECMO: Shiber, Skarupa, Yorkgitis; Mrs. Young