A VENOVENOUS ECMO PRIMER

with 5 CERTAINTIES AND 4 CHALLENGES

Susan C Seatter, MDAbbott Northwestern IntensivistsInnovation SummitSeptember 26, 2015

DISCLOSURE There are no conflicts of interest or relevant financial interests in making this presentation. My presentation does not include discussion of an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose.

OBJECTIVES VV ECMO Indications VV ECMO Principles VV ECMO Circuit VV ECMO Outcomes VV ECMO Future

DEFINITION OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATIONFor respiratory failureMost commonly hypoxemic but also hypercarbic respiratory failureNo cardiac supportPatients may be supported for days to weeks (average 10 days)Bridge to lung transplantAdult respiratory distress syndrome (ARDS)

PATIENT+CANNULA+PUMP+OXYGENATOR+CANNULA= ECMODrainage from SVC and IVCFlow is determined by the size and placement of the drainage catheterCentrifugal pumpMembrane oxygenatorOxygenated blood returned to the right heart

VV ECMO: 5 CERTAINTIES

1. SEVERE ARDS HAS A HIGH MORTALITY

ARDSnet 2000Lung protective vent strategyDecrease volume of ventilator breath Decrease airway pressureMaintain recruitment with PEEPProne positioning

1. SEVERE ARDS HAS A HIGH MORTALITY

JAMA. 2012;():1-8. doi:10.1001/jama.2012.5669

PaO2 60 mmHg on 100% FiO2PaO2/FiO2 ratio = 60

ARDS: mild, moderate, severe based on degree of hypoxemia with mortality 27%, 32% and 45% respectively and increased ventilator days for survivors (6, 12 and 19 days respectively)

Subset in severe group with high dead space, poor compliance with mortality as high as 52%

2. VV ECMO IS A RESCUE THERAPY FOR REFRACTORY RESPIRATORY FAILUREARDS

ARDSnet 2000 Lung protective ventilation H1N1 2009 Berlin Consensus Conference 2012

ECMO

Extracorporeal life support organization: Dr. Robert Bartlett 1989

Conventional ventilatory support versus ECMO for ARDS (CESAR) 2009

Observational studies 2011-2012 Consensus recommendations Technology

ANW INTENSIVIST ARDS PROTOCOL

Patient with ARDS Patient with ARDS

LPVS

ARDSnet Volume control: 6 ml/kg IBW Pressure control: Pplat <30-32

Failing

Within first 24 hrs of LPVS. PaO2 <55 or SpO2 <88 on FiO2=1.0 and PEEP >20

Within 24 to 72 hrs of LPVS. PaO2 <55 or SpO2 <88 on FiO2 > 0.70 and PEEP >15

Uncompensated respiratory acidosis pH <7.20 despite optimization of vent support and sodium bicarbonate.

Address vent dyssynchrony PEEP titration Recruitment maneuver Epoprostenol inhalation Prone positioning

Failing Move towards salvage ventilation/support

Salvage Ventilation/Support

Pressure control inverse ratio ventilation Airway pressure release ventilation (APRV) High frequency oscillator ventilation (HFOV)

Identify patient with ARDSLPSV: lung protective vent strategyMinimize barotrauma, volutraumaDefine failure

3. THE MODERN VV ECMO CIRCUIT IS MUCH IMPROVED FROM THE PAST Decreased complications Simpler circuit Durable circuit Transportable circuit “Biocompatibility”

CANNULATIONBi-cavalDual lumen

DUAL LUMEN CATHETERSingle cannulaFluoroscopy, ECHO (TEE)Low recirculationFacilitate mobilityLess sedation

DUAL LUMEN CATHETER

MEMBRANE OXYGENATOR

MEMBRANE OXYGENATOR

CENTRIFUGAL PUMP

CENTRIFUGAL PUMP

CENTRIFUGAL PUMP

4. PATIENTS SURVIVE ON ECMO ECMO allows the lungs to “rest” ECMO allows the lungs to heal ELSO database: 60% survival (45-50% mortality for severe ARDS)

Single organ failure Long term outcome vs ARDS without ECMO Complications

RESULTS: ANW2012 to May 2015 14 patients Survival 8/14 or 57% 2 deaths after de-cannulationApril 2014 to May 2015 10 patients 4 VA to VV for sepsis Survival 7/10 or 70%2015 5 patients Survival 4/5 or 80%

5. CARE OF THE ECMO PATIENT REQUIRES A HIGHLY SKILLED TEAM 15 intensivists 6 advanced heart failure cardiologists 15 perfusionists 9 interventional cardiologists 5 CV surgeons 5 vascular surgeons 32 ECMO-trained nurses Minneapolis Heart Institute® CV Emergency System Allina Health metro hospitals: Mercy, United intensivists and CV surgeons

ECMO Operations Committee

VV ECMO: 4 CHALLENGES

1. PATIENT SELECTION AND TIMING Not too early and not too late Only absolute contraindication to ECMO is inability to anti-coagulate

Those that can survive ECMO After 7 days: unlikely recovery of pulmonary function Early (hours) better outcomes: EOLIA

1. PATIENT SELECTION AND TIMING: CONSIDER ECMO EARLY Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA)

This international multicenter, randomized, open trial will evaluate the impact of Extracorporeal Membrane Oxygenation (ECMO), instituted early after the diagnosis of acute respiratory distress syndrome (ARDS) not evolving favorably after 3-6 hours under optimal ventilatory management and maximum medical treatment

ARDS defined according to the following criteria : Intubation and mechanical ventilation for ≤ 6 days Bilateral radiological pulmonary infiltrates consistent with edema PaO2/FiO2 ratio < 200 mm Hg Absence of clinical evidence of elevated left atrial pressure and/or pulmonary arterial occlusion pressure ≤ 18 mm Hg

2. VENTILATOR MANAGEMENT Open vs closed lung Higher PEEP early Don’t use the lungs: tolerate low O2 sat as long as oxygen delivery exceeds consumption

Sedation: early trach, early mobilization, allow spontaneous breathing

Best O2 sat with no lung function: 75%

2. VENTILATOR MANAGEMENT: DON’T USE THE LUNGS Open vs closed lung Additional barotrauma and its consequences Atelectasis with apnea ventilation Improved survival on ECMO with higher PEEP days 1-3 Plateau pressure < 25 mm Hg, RR 10-20, Goal FiO2 < 0.5

Lung rest: 77% Lung recruitment: 18% Tidal volume < 6 cc/kg/IBW: 76% PEEP 6-10: 58% Assist-controlled ventilation: pressure or volume mode

3. ECMO TRANSPORT Transport early Transport prone Cannulate at outside facility Transport on ECMO Allina Health VV ECMO Transport Team

4. STANDARDIZATION OF CARE: REVIEW YOUR WORK High volume centers 30 VV ECMO patients/year Recommendation for regional centers 15 intensivists: all have completed ELSO-sponsored VV ECMO training course

ECMO privileges: prior experience or course, hours and CME ECMO Conference ECMO M&M ELSO Center of Excellence Partnerships in Allina Health system

4. STANDARDIZATION OF CARE 24/7 Allina-wide use of ARDS protocol Early call for failure of LPVS Abbott Northwestern Hospital Flagship Is it ECMO or is it the center? ELSO Center of Excellence Twin Cities ECMO Consortium

EXTRACORPOREAL LIFE SUPPORT ORGANIZATION

Guidelines for Adult Respiratory Failure

REFERENCES Extracorporeal life support for patients with acute respiratory distress syndrome: report of a Consensus Conference. Richard, C et al. Annals of Intensive Care. 2014, 4:15.

Mechanical ventilation during ECMO. An International Survey. Annals ATS. 2014; 11: 956-61.

Mechanical ventilation during ECMO. CC Forum. 2014, 18:203

Extracorporeal Cardiopulmonary Support in Critical Care. 4th Edition. Annich, G et al. ELSO. Ann Arbor, MI. 2012

VV ECMO for acute lung failure in adults. Schmid, C et al. J Heart Lung Transplant. 2012; 31:9-15.

REFERENCES Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era. MacLaren, G et al. Intensive Care Med. 2011.

ECMO for ARDS in adults. Brodie, D and Bacchetta , M. N Eng J Med. 2011; 365: 1905-14.

ECMO in adult ARDS. Park et al. Crit Care Clin. 2011; 27: 627-646.

Conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory distress syndrome (CESAR): a multicenter randomized control trial. Peek, GJ et al. Lancet. 2009; 374: 1351-63.

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. ARDSnet. N Eng J Med. 2000; 342:1301-8.

CONTACT susan.seatter@allina.com

ANW Intensivist Group would like to partner with your institution to improve the outcome of patients with ARDS in the region. We are on-call 24/7 at Abbott Northwestern Hospital and can be contacted at any time through One-Call 612-863-1000 to discuss a patient with acute respiratory failure. We are available for educational outreach and offer to speak about ARDS to any interested hospital group.