A case study

A Case Study of Bed 25

Manaen Ma BSMShanghai Children Medical Center

April 2011, Shanghai, China

• Case Report (Time-Line) - Medical Time-Line - 2010/12/07 Admission - 2010/12/14 DSA - 2010/12/21 Op day - 2010/12/22 ECMO - 2010/12/24 ECMO weaning - 2010/12/27 Rescue - 2010/12/29 Bronchoscopy - 2011/01/04 EPS - 2011/01/10 PICC

Framework

• ECMO - Introduction of ECMO - Hemodynamic of ECMO - Construction of ECMO - Indications for ECMO - Configurations for ECMO - Weaning of ECMO - Complications of ECMO - ECMO Beyond the CICU

2010/12/07Admission-CHD (post-op)-Pneumonia-Cardiac insufficiencyExamination2DE: PA/VSD/PDA/PFOMRI: PA/VSD, collateral

vesselsMeds:-Cloxacillin + Ceftazidime-LASIX + Spironolactone-Milrinone

2010/12/07Admission-CHD (post-op)-Pneumonia-Cardiac insufficiencyExamination2DE: PA/VSD/PDA/PFOMRI: PA/VSD, collateral


2010/12/14DSA-RPA well-developed-LPA hypoplasia-Collateral vessels from

DA supply to the left lower lung

Transferred to CICU

DSA

RPA well-developed LPA hypoplasia

Collateral vessels from DA supply to the left lower lung

2010/12/07Admission-CHD-Pneumonia-Cardiac insufficiencyExamination2DE: PA/VSD/PDA/PFOMRI: PA/VSD, collateral


2010/12/14DSA-RPA well-developed-LPA hypoplasia-Collateral vessels

from DA supply to the left lower lung

Transferred to CICU

2010/12/21Operation Day-IV & Gas Anes-CPB-LP arterioplastyAbdominal Dialysis-Urine ↓-BP unstable-CVP↑

2010/12/22ECMO-BP ↓-Weak heart beatMeds:-Dopa + Mil + Adr-Morphine + Vecuronium-Abdominal Dialysis-Ceftazidime-Gas check-Reptilase-Albumin

ECMO

Ascending aorta

Right atrial appendage

2010/12/22ECMO-BP ↓ -Weak heart beatMeds:-Dopa + Mil + Adr-Morphine + Vecuronium-Abdominal Dialysis-Ceftazidime-Gas check-Reptilase-Albumin

2010/12/23Meds:-Dopa + NTG + 5%CaCl2-Morphine + Vecuronium-Abdominal Dialysis-Ceftazidime + Vancocin + Ambroxol -Gas check-Lidocaine-TPN+ Milk (gastric tube)-Concern on ACT (>200s)-Blood transfusion (HCT↓)-Albumin

2010/12/24ECMO WeaningMeds:-Symptomatic

treatment-Organ-protective

treatment


treatment-Organ-protective

treatment

2010/12/27Rescue A lot of dark

red blood clots in Thoracic cavity with HR/BP dropping


treatment-Orgen-protective

treatment

2010/12/27Rescue A lot of dark

red blood clots in Thoracic cavity with HR/BP dropping

2010/12/29Bronchoscopy-Lung secretion ↑-Partial atelectasis-Ventilator-

dependent

2010/01/04EPS-Na+ ↑-The side-effect of

sedative drugs


sedative drugs

2010/01/10PICC-Ventilator-dependent-Continuous application

of intravenous high-risk drugs

PICC

2010/01/10PICC-Ventilator-

dependent-Continuous

application of intravenous high-risk drugs


sedative drugs

2010/01/24Transferred to ward

from CICU

• ECMO is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful.

• ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery.

Introduction of ECMO

• Instituted in an emergency or urgent situation after failure of other treatment modalities.

• It is used as temporary support, usually awaiting recovery of organs.

• Extracorporeal membrane oxygenation (ECMO) Extracorporeal Life Support (ECLS)

Introduction of ECMO

• Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium,

- Oxygenate - Extract carbon dioxide

• Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.

Hemodynamic of ECMO

Construction of ECMO

Indications for ECMO

• Divided into two type - Cardiac Failure - Respiratory Failure

Indications – Cardiac Failure

• Post-cardiotomy - when unable to get pt off cardiopulmonary bypass following

cardiac surgery

• Post-heart transplant - usually due to primary graft failure

• Severe cardiac failure due to almost any other cause - Decompensated cardiomyopathy - Myocarditis - Acute coronary syndrome with cardiogenic shock - Profound cardiac depression due to drug overdose or sepsis

Indications – Respiratory Failure

• Adult respiratory distress syndrome (ARDS)• Pneumonia• Trauma• Primary graft failure following lung transplantation. • ECMO is also used for neonatal and pediatric

respiratory support - This is where most of the research on ECMO has been done

Configurations for ECMO

• Veno-Venous (Respiratory ECMO)

• Veno-Arterial (Cardiac and Respiratory ECMO)

Veno-Venous ECMO

• Provides oxygenation • Blood being drained from

venous system and returned to venous system.

• Only provides respiratory support

• Achieved by peripheral cannulation, usually of both femoral veins.

Veno-Arterial ECMO

• Blood being drained from the venous system and returned to the arterial system.

• Provides both cardiac and respiratory support.

• Achieved by either peripheral or central cannulation

V-V, V-A, A-A ECMO

V V

A V

A A

Cannulation I for ECMO

Cannulation II for ECMO

Cannulation III for ECMO

Weaning of ECMO – VV ECMO

• Actual ECMO flows do not need to be altered to assess native respiratory function

- Done by altering gas flow through the ECMO circuit

- Gas exchange is able to be maintained with a low FiO2 (<30%)

- Low fresh gas flow rates into the circuit (<2 L/min)

Weaning of ECMO – VA ECMO

• Depends on cardiac recovery, Factors: - Increasing blood pressure - Return or increasing pulsatility on the arterial pressure

waveform - Falling pO2 by a right radial arterial line Indicating more blood is being pumped through the heart

which may be less well oxygenated

- Falling central venous and/or pulmonary pressures.

Complications of ECMO

• Bleeding associated with heparinization• Technical failure• Neurologic sequelae

• Bleeding/Hemolysis - Out of proportion to the degree of coagulopathy - Continuous activation of contact and fibrinolytic systems

by the circuit

- Consumption and dilution of factors within minutes of initiation of ECMO

- Patient platelet count - Platelets adhere to surface fibrinogen and are activated

- Resultant platelet aggregation and clumping causes numbers to drop


• Mechanical Complications - Tubing rupture - Pump malfunction - Cannula related problems

• Air embolism/Thromboembolism• Neurological: Intracerebral bleeds - Largely associated with sepsis - Manifest as seizures or brain death


ECMO Beyond the CICU

1 Procedure is a highly modified

Cesarean delivery which requires an experienced multi-disciplinary team. The goal is to partially deliver the baby, but maintain placental support to be able to perform surgery before the baby is completely delivered.

2 Conditions requiring an EXIT

Procedure due to anticipated airway obstruction include giant neck masses (cervical teratoma / cervical lymphangioma) and congenital high airway obstruction syndrome (CHAOS).

3 The EXIT-ECMO procedure

provides a smooth transition from the womb to ECMO (a heart-lung bypass machine) for babies with anticipated pulmonary or cardiac failure at birth.

4 During the EXIT-ECMO procedure,

the airway is secured and a trial of ventilation is performed. If the infant fails the trial of ventilation, ECMO cannulation is performed while the infant is stable on placental support.

• In the future, can ECMO be an alternative for ventilators for all patients?

When people breathe naturally, they generate a negative pressure, so a positive pressure can be injurious to the lungs. ECMO allows you to avoid excessive ventilation of the lungs in other words, to rest the lungs -- and in fact, that’s one of the principles by which lung recovery can occur.

ECMO Beyond the CICU

Robert H. Bartlett, M.D.

Patients in intensive care, especially those suffering from pneumonia, respiratory failure from trauma or infection, or cardiac failure, often need to let their organs rest while they are in recovery.

Reference• Bartlett RH. Extracorporeal life support registry report 1995. ASAIO J 1997;43:104–7.• Conrad SA, Rycus PT, Dalton H. Extracorporeal life support registry report 2004.

ASAIO J 2005;51:4–10.• Fiser S, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, Kron IL. When to

discontinue ECMO for postcardiotomy support. Ann Thorac Surg 2001;71:210–4.• Glauber M, Szefner J, Senni M, Gamba A, Mamprin F, Fiocchi R, Somaschini M,

Ferrazzi P. Reduction of haemorrhagic complications during mechanically assisted circulation with the use of a multi-system anticoagulation protocol. Int J Artif Organs 1995;18:649–55.

• Hitt E. CESAR trial: extracorporeal membrane oxygenation improves survival in patients with severe respiratory failure. Medscape Medical News www.medscape.com; 2008

• Marasco SF, Esmore DS, Negri J, Rowland M, Newcomb, A, Rosenfeldt F, Bailey M, Richardson M. Early institution of mechanical support improves outcomes in primary cardiac allograft failure. J Heart Lung Transplant 2005;24(12): 2037–42.

• Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, Killer H, Mugford M, Thalanany M, Tiruvoipati R, Truesdale A,Wilson A. CESAR: conventional ventilatory support vs. extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res 2006;23(6):163.

Question Time

Manaen Ma

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A case study