ECMO in NZ by McGuinness

The New Zealand Na,onal Adult ECMO Service

Dr Shay McGuinness Cardiothoracic & Vascular ICU

Auckland City Hospital

•  ECMO Background •  ECMO in New Zealand •  Outcomes •  Referral Guidelines

Extracorporeal Membrane Oxygena,on

•  First reported use 1971 •  Uses an Extracorporeal circuit, similar to a modified heart-‐lung machine, to support the lungs and/or the heart for an extended period (days – weeks).

•  In adults it is most widely used for respiratory support but can also be used for cardiac support.


•  2 Basic circuits – Veno-‐Venous (VV) used for respiratory support

VV ECMO circuit

VV ECMO

•  Blood drained via femoral vein and infused into jugular vein.

•  Usually 25/29Fr drainage, 19/21Fr return.

VV ECMO •  Disadvantages

– No direct cardiac support – Recircula,on

•  Advantages – No need to cannulate/sacrifice major artery – No risk arterial embolisa,on – normal pulmonary perfusion – normal LV a\erload, Coronary and cerebral perfusion.


•  2 Basic circuits – Veno-‐Venous (VV) used for respiratory support – Veno-‐Arterial (VA) used for cardiac support OR Cardio-‐respiratory support

VA ECMO circuit

VA ECMO •  Blood drained from Femoral

and/or Jugular Vein and re-‐infused into femoral artery (Peripheral VA)

•  Usually 25Fr drainage, 19 or 21Fr return. –  Occasionally 2 drainage required – VVA

–  Always require a distal femoral perfusion catheter

•  Central cannula,on can be used •  Flows 5-‐7 l/min

Peripheral VA Standard Cannula,on

VA Central Canula,on

VA ECMO

•  Advantages –  Cardio-‐respiratory support

•  Disadvantages –  Cannulate major artery –  Arterial embolisa,on (macro and micro) –  Reduce pulmonary perfusion –  Risk of decreased myocardial perfusion

•  Risk of LV distension. –  Differen,al perfusion (with poor lungs)

•  Hypoxaemic blood to coronary arteries •  Risk of hypoxaemic blood to Cerebral circula,on.

VA –Differen,al perfusion

•  LV ejec,ng and femoral cannula,on – Myocardial +/-‐ Cerebral hypoxaemia may occur

VA –Differen,al perfusion

•  LV ejec,ng and femoral cannula,on – Myocardial +/-‐ Cerebral hypoxaemia may occur

VA Support with Bad lungs

•  LV ejec,ng and femoral cannula,on – Must Either:

•  Increase flow to stop LV ejec,on

• Cannulate upper body artery

• Use VAV ECMO

VAV Circuit

VAV Circuit

•  ECMO programme started 1993 at Green Lane Hospital

•  Moved to ACH in 2003 •  Single na,onal service -‐ based at Auckland City Hospital Since 2005 •  Establishment of an ECMO Retrieval Service

ECMO in New Zealand

Mobile ECMO

•  Aim was to have the capacity to place pa,ents (adult/paeds/neonates) on VA or VV ECMO at any hospital in NZ and transfer them safely back to Auckland.

Mobile ECMO

In 2005….. •  Only a handful of places worldwide capable of mobile ECMO

•  Most only did neonates

Mobile ECMO – The NZ Way Design Issues

•  Team – 2 Drs, 1 Clinical perfusionist, 1 flight nurse •  Transport – Road, Fixed wing, Helicopter •  Fihng ECMO Circuit to transport stretcher •  Power Supplies – mul,ple backup systems for pump

•  Limited by available aircra\ types –  Largest fixed wing air ambulance = Metroliner –  Largest helicopter Sikorsky S76 –  Various road ambulances

Mobile ECMO -‐ Transport

System design

•  Designed along the principals of – Light weight

•  Maximum weight stretcher + pa,ent = 165 kg –  (clinical requirement some pa,ents up to 125 kg)

– All ECMO components within foot print of stretcher

– Mul,ple power supplies – Self contained oxygen supply

In the mean,me…..

? How not to do it?!

now

Mobile ECMO – In Transit

2005-‐2009

•  We were expec,ng perhaps 5-‐10 cases a year with maybe 2-‐3 transports

•  Then came H1N1……………..

2009

2014…..

•  31 Adults •  7 Children •  17 pa,ents retrieved by CVICU Team

– 14 placed on VV and then transported – 2 placed on VA and then transported – 1 transported conven,onally and then 24hrs later on ECMO

2014…..

•  17 pa,ents retrieved by CVICU Team –  14 placed on VV and then transported –  2 placed on VA and then transported –  1 transported conven,onally and then 24hrs later on ECMO

Hawkes Bay 1 Middlemore 3 Dunedin 1 Wellington 2 Christchurch 2 Waikato 3 Rotorua 3 North Shore 2

2014…..

•  Resource Usage :

Total ECMO hours 8327.07hrs (347 Days) Average ECMO hours per pa,ent 268.62hrs (11.2 Days)

Total CVICU LOS for ECMO pa,ents 12920.57hrs (538.36 Days) Average CVICU LOS per ECMO pa,ent 416.79hrs (17.37 Days)

ELSO Registry Data Summary

January 2015

Current ECMO U,lisa,on

120-130

Sites increasing by20-30/year

5626 cases in 2013 – Doubled in 5 years

Adult ECMO

•  Increasing use is primarily in Adult pa,ents – Respiratory support – 7x cases than 2008

Adult ECMO

•  Increasing use is primarily in Adult pa,ents – Respiratory support – 7x cases than 2008 – Cardiac support – 4x cases

ECMO Outcomes in Adults

Overall outcomes in Adults

•  Adult Respiratory – 60% survival

•  Adult Cardiac – 45% survival

Overall outcomes in Adults

•  Adult Respiratory – 60% survival

•  Adult Cardiac – 45% survival

But different outcomes according to indica,on

Cardiac Support Outcomes



Respiratory Support Outcomes



Infective cause vs non-infective

Respiratory Infec,ons

•  Suggests a difference In survival between viral (66%) and bacterial (61%) pneumonia.

Referral Guidelines

Referral Criteria (VV ECMO)

Typical pa,ents will include those with reversible disease associated with one or more of: •  Severe hypoxaemia (e.g. PaO2/FiO2 < 100mmHg) •  Severe hypercapnic acidosis (e.g. pH<7.20) •  Inability to achieve lung protec,ve ,dal volumes and

pressures (,dal volume < 6 mL/Kg predicted body weight, plateau pressure < 30 cmH2O)

•  Failure to improve with rescue therapies such as NO, RCM and prone posi,oning

•  Significant air leak/bronchopleural fistula

Indica,ons for VV ECMO •  Poten,ally reversible ae,ology •  Refractory Respiratory failure despite op,mal ven,la,on

–  Hypoxaemia (PaO2:FiO2 < 80-‐100mmHg) –  Hypercapnoea (pH < 7.2)

•  Adequate gases but inability to achieve lung protec,ve ven,la,on –  Vt >6ml/kg ideal body weight –  Pplat >30cmH2O

•  Severe Asthama (pH < 7.2) •  Murray score ≥3.0 (consider referral if ≥2.5 and rapid clinical

deteriora,on)

Contraindica,ons (Rela,ve)

•  Intracranial bleed (current or recent) •  Other contraindica,on to heparinisa,on •  High pressure (peak inspiratory pressure >30 cmH2O) and/or high FiO2 (>0.8) ven,la,on for more than 7 days

VA ECMO

•  Indica,ons are less clear – Response ,me dependent

VA ECMO

•  Myocardi,s •  Anaphylaxis •  Drug overdose •  Selec,ve Cardiomyopathies •  Very selec,ve cardiogenic shock post AMI •  eCPR only at ACH and “opportunis,c”

ECMO-‐The Future

•  ECMO is here to stay – NNT between 2-‐3 – Generally excellent func,onal status of survivors – O\en young adults

•  Recent Interna,onal Guidelines recommend; – Centralised Specialist ECMO Centres – Have Transport Capability – Accept “Pre-‐ECMO” Severe Respiratory failure pa,ents

ECMO-‐The Future

•  Applica,on to the Na,onal Health Board for ECMO to be designated as a na,onal service

•  Moving to a new FW provider in July – Faster aircra\ = shorter response ,mes

•  New ECMO transport stretcher under construc,on

The New Zealand Na,onal Adult ECMO Service

Dr Shay McGuinness Cardiothoracic & Vascular ICU

Auckland City Hospital

Health & Medicine

ECMO in NZ by McGuinness