Presented by:Dr. Dharmendra Joshi (DJ)

ECMO (Extracorporeal Membrane

Oxygenation)

EXTRACORPOREAL MEMBRANE OXYGENATION• A form of extracorporeal life support where an external artificial circuit

carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed.

• The blood is then returned to the patient via a central vein or an artery.

- ECMO guidelines Alfred Health Update Nov. 2015

INTRODUCTION

1950s Development of membrane oxygenator in laboratory1971 First successful case1972 First successful paediatric cardiac case1975 First neonatal case (Esperanza)1975-89 Trial in ARDS, 10% survival1990 Standard practice for neonates and pediatrics in some

centers

2000 Standard practice for adults in some centres2009 Publication of the CESAR trial which led to a significant

growth in the use of ECMO for ARDS cases

* CESAR Trial - Conventional Ventilation or ECMO for Severe Adult Respiratory failure trial

HISTORY

First successful ECMO patient in1971

Figure: The first successful extracorporeal life support patient, treated by J. Donald Hill using the Bramson oxygenator (foreground), Santa Barbara, 1971.

First Neonatal ECMO survivor…

Esperanza, Age 1 day 1975 Esperanza, age 21

FROM THIS

TO THIS

• Desaturated blood is drained via a venous cannula• CO2 is removed, O2 added through an

“extracorporeal” device• The blood is then returned to systemic circulation

via another vein (VV ECMO) or artery (VA ECMO).

ECMO – PRINCIPLE

ECMO – BRIDGING THERAPY

bridge to RECOVERY :– buying time for patient to recoverbridge to DECISION :- provide temporary support to patient and allow clinicians to decide on the next step.bridge to TRANSPLANT :-provide support to patient while awaiting suitable donor organ.

Modes of ECMO

• Veno-Arterial ECMO (VA-ECMO):• Used to support patients with severe

cardiac failure (with or without respiratory failure)

• Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central artery

- ECMO guidelines Alfred Health Update Nov. 2015

Veno-Arterial (VA) configuration

This infant has been cannulated for ECMO using the femoral artery and vein. To prevent possible distal limb ischemia, antegrade flow has been provided via a percutaneously placed distal perfusion catheter.

• Veno-Venous ECMO (VV-ECMO):• Used to support patients with severe

respiratory failure refractory to conventional therapies

• Blood is drawn from a central vein, pass through an ECMO machine and then returned back via a central vein

- ECMO guidelines Alfred Health Update Nov. 2015

Veno-Venous (VV) configuration

• 4 configurations of VV-ECMO depending on the cannulation sites. a) Femoro-femoral b) High flow c) Femoro-jugular d) Double lumen single cannula (Avalon)

- ECMO guidelines Alfred Health Update Nov. 2015

Veno-Venous ECMO (VV ECMO)

1. Femoro-Femoral: 2. High Flow:

3. Femoro – Jugular: 4. Double lumen/Two stage single cannula (Avalon):

Indications of VA-ECMO

Indications of VV-ECMO

ARDS Pneumonia Status asthmatics Chemical pneumonitis Inhalational pneumonitis Near drowning Bronchiolitis Persistent air leak syndrome RSV infection post CHD surgery.

Indications of ECMO for Respiratory failure: in Paediatric

• Presence of any two of the criteria from the following observed over a period of 4 to 6 hours after maximum medical resuscitation.

PaO2/FiO2 <75% Oxygen index >40% Murrays Score of >3 a-A gradient >600 Hypercapnia with PH of <7.2

observed over more than 3 hours.

Lung compliance <0.5 cc/cmH2O/kg

Inclusion criteria:

• Primary disease is irreversible (disseminated malignancy)

• Age >75 years• On ventilator >15 days• Irreversible / indeterminate neurological

prognosis• Immunosuppressed state• Multi-organ failure• Pre-existing coagulopathy• Severe pulmonary hypertension• Severe aortic regurgitation

Exclusion Criteria for ECMO

• Bleeding• Thromboembolism• Cannulation related • Heparin induced thrombocytopenia• VV ECMO specific complications • VA ECMO specific complications • Neurological complications• THE HARLEQUIN SYNDROME (North South Syndrome)

COMPLICATIONS

Who comprises the ideal team?

Two intensivists (ECMO intensivist) and/or cardiothoracic surgeons: cannulation

One Medical Officer: monitor cannula position by ECHO

One Medical Officer: clinical management Perfustionist: ECMO priming and

maintenance Respiratory Therapist: lung protective

management, ventilator settings Nurses Radiologic Technician

INITIATION

MAINTENANCE

DISCONTINUATION

ECMO MECHANISM

• Once it has been decided to initiate ECMO, the patient is anticoagulated with I/V heparin and cannulae are inserted according to the ECMO configuration ( VV or VA ECMO)

• Following cannulation, patient is connected to ECMO circuit, the pump started with the flow of 20 ml/kg/min and gradually increased every 5-10 min by 10 ml/kg/min to reach the desired flow.

• Gas flow to blood flow ratio is adjusted to 0.5 : 1 & start with FiO2 of 21% 100% FiO2.

• Once desired flow achieved, ventilator settings are brought down to base line.

- ECMO UPTODATE 2013

INITIATION

• Once the initial respiratory and hemodynamic goals have been achieved, blood flow is maintained at that rate.

• Continuous venous oximetry, Pressure monitoring (MAP, pre-pump P, pre and post oxygenator P), vital parameters (HR, RR, TEMP), Flow rates (blood flow rate at 60-150 ml/kg/min), neurological status, vascular status to be monitored.

• Anticoagulation is sustained during ECMO with a continuous infusion of unfractionated heparin, titrated with activated clotting time(ACT) of 180-210 sec.

MAINTENANCE & MONITORING

• ELSO Data: 117 days

• Average: a. V-V ECMO: 14-21days b. V-A ECMO: 5-14 days

• INDICATIONS : -For patients with Respiratory failure, improvements in radiographic appearance, pulmonary compliance and arterial oxy-Hb saturation. -With cardiac failure, enhanced aortic pulsatility correlates with improved left ventricular output. -One or more trials of taking the patient off of ECMO should be performed prior to discontinuing ECMO permanently.

- ELSO General Guidelines Version 1.3 December 2013

WEANING & TRIAL OFF OF ECMO

Published online : 16 September 2009

CESAR TRIAL• Randomized control trial of adult ECMO vs Conventional

Ventilatory support. • Adults were randomized either to VV ECMO at Glenfield

Hospital, Leicester, England (90 patients) or continuing conventional care at referral hospitals (90 patients) i.e., conventional ventilator support.

Peek GJ, et.al. Lancet 2009;374:1351 136‐

ECMO

• 57 out of 90 met primary end point.

• Survival rate at 6months is 63%

• Mortality 37%

CONVENTIONAL VENTILATORY SUPPORT

• 41 of 87 met primary endpoint• Survival rate at 6months is 47%• Mortality 53%

RESULTS

Increased accessibility and use Reduction in costs Insurance / government

support Smaller lines / volumes /

oxygenators Coated “stealth” tubing (Nano

particles). Smaller or portable ECMO

machines

Future of ECMO

When God is going to do something wonderful, He begins with a difficulty.If He is going to do something very wonderful, He begins with an ECMO Machine.

(Quote by an ECMO survivor)