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1
Adult ECMO
Dennis Disney, RRT-ACCS
Cardiovascular Clinical Specialist
ECMO Clinician
Respiratory Care
Indiana University Health - Methodist Hospital
Objectives
• Review history of ECMO.
• Describe different types of ECMO and the
indications for each.
• Understand how ECMO works.
2
“Father of ECMO”
• Dr. Robert Bartlett
3
History of ECMO
• First Heart/Lung machine used in 1956.
• Prolonged life support began in 1960’s.
• ECMO initially studied for adult use.
• First successful case in 1971.
4
NIH Study of Adult ECMO
in early 1970’s
• Patients critically ill with acute respiratory
failure from a variety of causes (pneumonia,
pulmonary emboli, shock lung) were randomly
assigned treatment with conventional
ventilation or ECMO.
• Trial halted after 90 patients due to a mortality
rate of 90% in both groups.
5
NIH Study – early 1970’s
• Although ECMO could support patients in the
short term, most developed irreversible
pulmonary fibrosis from their primary disease
process or the deleterious effects of the high
ventilatory settings they had been on before
ECMO.
• Authors concluded that there was no benefit of
ECMO in terms of survival.
• Use of ECMO in adults all but ceases.
6
Neonatal ECMO
• 1974 – Desperately poor, illiterate peasant
farmer in Baja, Mexico discovers she is
pregnant, decides her child will have a better
life as a US Citizen and crosses into Los
Angeles.
• During journey her membrane ruptures, she
exits freeway ASAP and enters Orange County
Medical Center, where her daughter is born.
• Complications due to meconium aspiration, and
despite maximum ventilator settings, it appears
the child will not survive.
7
• When the babies pO2 was 12 the situation was
considered hopeless.
• Orange County Medical Center thoracic
surgeon Dr. Robert Bartlett brings a device
from the lab called ECMO. At that time,
approximately 150 adults have been tried with
a 10% – 15% survival rate.
• No neonates had ever been attempted.
8
• “Consent” obtained through an interpreter.
Mother signs with an “X” and disappears.
• Baby is named Esperanza (Hope) by the staff.
• After 3 days of ECMO, Esperanza completely
recovers.
• Esperanza (age 34) and Dr. Bartlett in 2008.
9
• Dr. Bartlett continues to treat neonates.
• Despite a 90% predicted mortality, 75% survive.
• Why the improvement over adult survival?
1. Reversible causes.
2. Neonatal lung may be inherently more
capable of repair.
3. Neonates were placed on ECMO much
earlier than adults.
10
What about Adult ECMO
11
All hail CESAR
• Conventional Ventilation or ECMO for Severe
Adult Respiratory Failure
• United Kingdom
• July 2001 – August 2006.
• Published in February 2009
12
CESAR
• ECMO patients transferred to an ECMO center.
• Conventional Therapy patients treated at
outlying hospitals.
• 180 patients total – 90 Conventional, 90 ECMO
• Conventional survival = 47%
• ECMO survival = 63%
• Successful study – right?????
13
CESAR
• Of the 90 patients selected for ECMO, 22 did
not receive ECMO because they improved with
conventional therapy.
• Therefore ECMO survival = 51% (51% vs 47%).
• Suspect evidence, but we think ECMO works.
14
What Revived Adult ECMO
H1N1 Influenza Virus
• April 15, 2009 – first US case.
• April 21, 2009 – CDC working on vaccine.
• April 26, 2009 – US declares H1N1 a public
health emergency.
• By June, 18,000 US cases, mostly young
previously healthy patients.
• CDC estimates 43 – 89 million people had
H1N1 between April 2009 and April 2010 with
8,870 – 18,300 deaths. 15
ECMO
• Due to the severity of the patients, ECMO was
tried at centers capable of providing the
therapy.
• There are about 40 Adult ECMO centers world
wide with a patient survival rate of 50%.
• Indiana University Health is the only ELSO
registered Adult ECMO program in Indiana.
• ECMO does not “treat” the lungs or heart. We
are allowing them time to heal.
16
ECMO Team
• ECMO Physicians : Thoracic Surgeons and
Pulmonary/Critical Care Physicians
• Perfusionists
• ECMO Clinician (RN’s & RRT’s)
• RN
• RRT
17
ECMO Team
• Communication is CRITICAL!!
• Each team member must be aware of
responsibilities in the event of an emergency.
18
Types of ECMO
• V-V
Venous blood drained and returned to the
venous system. Supports the lungs only.
• V-A
Venous blood drained and returned to the
arterial system. Supports both heart and lungs.
• ECPR
V-A access initiated during CPR.
19
Patient Selection
V-V
• ARDS
• IPF
• Pneumonia
• TRALI
• PGD
• Bridge to Lung Transplant
• Transition through Transplant
20
Patient Selection
V-V
• ECMO used after all available “lung salvage”
modalities have been tried.
o ARDSnet protocol
o Prone Positioning
o Inhaled pulmonary Vasodilators
o HFOV
21
Timing of ECMO consideration for
ARDS
• Three phases of ARDS
I. Exudative (inflammatory) phase (0-7 days)
II. Proliferative phase (7-21 days)
III. Fibrotic phase (after 7-10 days)
ECMO must be initiated during the exudative
phase to be effective
22
Patient Selection
V-A
• Refractory Cardiogenic Shock.
• Cardiac Arrest.
• Failure to wean from Cardiopulmonary Bypass
after Cardiac Surgery.
• Bridge to either cardiac transplant or placement
of a Ventricular Assist Device.
23
Patient Selection
• Must be a reversible process.
• Patient should be placed on ECMO within first 5
days.
• Have an “exit strategy”.
24
VA ECMO Cannulation
25
VA ECMO Cannulation
26
VV ECMO Cannulation
27
Avalon Elite Double Lumen
Catheter
28
Avalon
29
Avalon Malpositioned
30
ECMO Circuit
31
ECMO Pump & Oxygenator
32
Quadrox Oxygenator
• The Quadrox has a surface area of 1.8 m2
• Oxygen added via blender
• CO2 removal determined by “sweep”
33
ECMO Management
• Maintain ABG.
• In V-A, may assist maintaining blood pressure.
• Maintain hemostasis (ACT/aPTT).
34
Weaning ECMO
• Begin thinking about weaning as soon as you
initiate ECMO.
• Decrease support from ECMO as patient is able
to take on the workload.
• Particularly V-V, watch CXR.
35
Ambulatory ECMO
36
Ambulatory ECMO
37
Ambulatory ECMO
38
39
• 68 total ECMO runs
• 62 patients 63 patients supported on ECMO
• V-V: pts = 31; runs = 34
• V-A: pts = 27; runs = 29
• eCPR: pts = 4; runs = 5
• V-V Survival off ECMO = 29/32 (91%) – 60% Nat’l.
– Survival to discharge = 24/28 (86%) – 50% Nat’l.
• V-A Survival off ECMO = 12/28 (43%) – 55% Nat’l.
– Survival to discharge = 11/28 (39%) – 36% Nat’l.
• eCPR Survival off ECMO = 2/5 (40%) – 40% Nat’l.
– Survival to discharge = 1/5 (20%) – 25% Nat’l
2015 Data (as of 09/08/2015)
40
• 214 ECMO Runs
• 198 patients Supported with ECMO
• V-V: pts = 123; runs = 133
• V-A: pts = 66; runs = 68
• eCPR: pts = 10; runs = 13
• V-V Survival off ECMO = 117/131 (89%) – 60% Nat’l.
– Survival to discharge = 101/127 (80%) – 50% Nat’l.
• V-A Survival off ECMO = 35/67 (52%) – 55% Nat’l.
– Survival to discharge = 25/67 (37%) – 36% Nat’l.
• eCPR Survival off ECMO = 6/13 (46%) – 40% Nat’l.
– Survival to discharge = 3/13 (23%) – 25% Nat’l.
Overall Program Data –
2011 to 2014 (as of 09/08/2015)
Case Study
41
Brief History – A.C.
• 18 yr old male post
MVA with prolonged extrication.
GCS = 3
• Diffuse Axonal Injury
• Cerebral Edema
• Pulmonary Contusion
• Scalp & Left hand Laceration
• Foreign Bodies in Nasopharynx
42
Day 1 CXR
43
Day 1 Data
44
ABG Vent ECMO
7.40 PRVC
37 550
250 20
22.5 60%
5
Day 2 CXR
45
Day 2 Data
46
ABG Vent ECMO
7.39 PRVC
38 550
256 16
22.9 40%
5
Day 7 CXR
47
Day 7 Data
48
ABG Vent ECMO
7.33 BiVent
42 Phigh 22 /Peep 5
61 Thigh 3.2/Tlow0.8
22.3 RR 15
70%
Day 8 CXR
49
Day 8 Data
50
ABG Vent ECMO
7.29 BiVent - Prone
53 Phigh 22 /Peep 5
76 Thigh 4.5/Tlow0.6
25.6 RR 12
100%
Day 10 CXR
51
Day 10 Data
52
ABG Vent ECMO
7.38 BiVent Flow 4.6
45 Phigh 30 /Peep 0 RPM 4100
64 Thigh 4.5/Tlow0.6 FiO2 100%
26.3 RR 12 Sweep 2.0
Post ECMO 60% Initiate @ 1715
Day 12 CXR
53
Day 12 Data
54
ABG Vent ECMO
7.38 BiVent Flow 4.8
45 Phigh 28 /Peep 5 RPM 4300
75 Thigh 2.3/Tlow0.5 FiO2 100%
26.3 RR 21 Sweep 3.5
100%
Day 14 CXR
55
Day 14 Data
56
ABG Vent ECMO
7.44 BiVent Flow 4.9
39 Phigh 28 /Peep 5 RPM 4400
84 Thigh 3.0/Tlow0.5 FiO2 100%
26.6 RR 17 Sweep 5.0
60%
Day 16 CXR
57
Day 16 Data
58
ABG Vent ECMO
7.48 PRVC Flow 4.27
37 500 RPM 3800
64 20 FiO2 100%
27.6 50% Sweep 3.0
10
Day 18 CXR
59
Day 18 Data
60
ABG Vent ECMO
7.42 PRVC Flow 4.43
42 700 RPM 4000
95 20 FiO2 60%
27.1 50% Sweep 2.0
13
Day 20 CXR
61
Day 20 Data
62
ABG Vent ECMO
7.49 PRVC Flow 4.39
42 600 RPM 4000
77 20 FiO2 30%
32.2 50% Sweep 1.5
12
Day 23
• Off ECMO @ 1235
63
Day 24 CXR
64
Day 24 Data
65
ABG Vent ECMO
7.47 PRVC
52 550
134 20
37.3 50%
12
Day 29
• Discharged to rehab facility
• And then …….
66