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Multidisciplinary Update in Pulmonary & Critical Care

Medicine 2017ECMO UPDATE for Respiratory

FailureBhavesh Patel, MD, FRCP(C), RDMS

Assistant Professor of Anesthesiology, Medicine and Neurology,Mayo Clinic College of Medicine

Consultant, Department of Critical Care MedicineMedical Director, Department of Respiratory Care

©2017 MFMER | slide-2

No financial disclosuresI will be speaking about off label uses of products

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ECMO vs ECLS

ECLS

VV ECLS

VA ECLS

VAV ECLS

ECPR

VV‐ECCO2R

AV‐ECCO2R

Circulatory Failure

Respiratory Failure

Combined Cardiac/Respiratory

Failure

Cardiac Arrest

CO2 Retention

Gaffney AM et al. BMJ 2010

ECLS WILL BE IN YOUR ICU

Barbaro RP et al. AJRCCM 2015

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©2017 MFMER | slide-5

ELSO Registry January 2017

Adult Respiratory Cases

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

0

500

1000

1500

2000

2500

Cum

ulat

ive

Run

s

Ann

ual R

uns

CESAR trialQuadrox D oxygenatorAvalon DLVV cannulaH1N1 pandemic

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CESAR

63% vs 47% survival at 6 months

ANZICS database 2009 H1N1 70% survival to discharge

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Italian 9 days (7-15)The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med. 2011 Sep;37(9):1447-57.

Japanese 9 days (6.5–12.5)Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) severe respiratory failure in Japan. J Anesthesia 2012

Australian/New Zealand 10 days (7-15)Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA. 2009 Nov 4;302(17):1888

Canadian 15 days (14-15)Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada. Can J Anesthesia 2010 Mar;57(3):240-7

Swedish 16 days (9.5-30.5)Extracorporeal membrane oxygenation for pandemic H1N1 2009 respiratory failure. Minerva Anestethio. 2010 Dec;76(12):1043-51.

Chinese 18 days (2.8–90)Extracorporeal Membrane Oxygenation for Critically Ill Patients With 2009 Influenza A (H1N1)-Related Acute Respiratory Distress Syndrome: Preliminary Experience From a Single Center. Artif Organs. 2012 Sep;36(9):780-6

French 23 days(3-47)

Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome: single-centre experience with 1-year follow-up. Eur J Cardiothorac Surg. 2012 Mar;41(3):691-5 ELSO

Italian 9 days (7-15)The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med. 2011 Sep;37(9):1447-57.

Japanese 9 days (6.5–12.5)Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) severe respiratory failure in Japan. J Anesthesia 2012

Australian/New Zealand 10 days (7-15)Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA. 2009 Nov 4;302(17):1888

Canadian 15 days (14-15)Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada. Can J Anesthesia 2010 Mar;57(3):240-7

Swedish 16 days (9.5-30.5)Extracorporeal membrane oxygenation for pandemic H1N1 2009 respiratory failure. Minerva Anestethio. 2010 Dec;76(12):1043-51.

Chinese 18 days (2.8–90)Extracorporeal Membrane Oxygenation for Critically Ill Patients With 2009 Influenza A (H1N1)-Related Acute Respiratory Distress Syndrome: Preliminary Experience From a Single Center. Artif Organs. 2012 Sep;36(9):780-6

French 23 days (3-47)Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome: single-centre experience with 1-year follow-up. Eur J Cardiothorac Surg. 2012 Mar;41(3):691-5

Legacy/Emanuel (193 hours) 8 days (3-15) ELSO

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©2017 MFMER | slide-9

ELSO Registry January 2017

Adult Respiratory Survival by Diagnosis and Year

0%

25%

50%

75%

100%

Viral Pneum Bact Pneum Aspir ARDS ARF Others

©2017 MFMER | slide-10

ELSO Registry January 2017

Adult Cardiac Cases By Year

0

2000

4000

6000

8000

10000

12000

0

500

1000

1500

2000

2500

88 90 92 94 96 98 00 02 04 06 08 10 12 14 16

Cum

ulat

ive

case

s

Ann

ual c

ases

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©2017 MFMER | slide-11

ELSO Registry January 2017

Adult Cardiac Survival by Diagnosis and Year

0%

25%

50%

75%

100%19

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

1220

1320

1420

1520

16

Congenital Defect Cardiac Arrest Cardiogenic ShockCardiomyopathy Myocarditis Others

Slutsky AS Ranieri VM NEJM 2014

LUNG PROTECTIVE VENTILATION

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RIGHT VENTRICLEPROTECTIVE VENTILATION

Paternot A et al. Respir Care 2016

AVOIDHigh airway pressureHypercarbiaHypoxia

PulmHypertension. Edited Elwing J and Panos R .

Alpard SK et al. Cardiopulmonary Bypass: Principles and Practice 2nd Edition

ADJUNCTIVE THERAPY

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EXTRAPULMONARY SUPPORT

EXTRAPULMONARY GAS EXCHANGE

VV ECLS

VA ECLS

VAV ECLS

IVOX

VV‐ECCO2R

AV‐ECCO2R

PARTIAL CO2 EXCHANGE

TOTAL CO2 EXCHANGE

TOTAL O2 and CO2 EXCHANGE and CIRCULATORY SUPPORT

TOTAL O2 AND CO2 EXCHANGE

ARDS

MILD MODERATE SEVERE

200mmHg < PaO2/FIO2 ≤ 300mmHgwith PEEP or CPAP ≥ 5cmH2O 

100mmHg < PaO2/FIO2 ≤ 200mmHgwith PEEP ≥ 5cmH2O 

PaO2/FIO2 ≤ 100mmHgwith PEEP ≥ 5cmH2O 

CO2 removal Oxygenation

Low‐flow ECCO2R High‐flow V‐V ECMO

M Ranieri

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GOALS OF VV ECMO

TEMPORARILY

Improve O2 

saturation and CO2 Removal

Treat disturbance

Rest injured lungs

Avoid / minimize injurious therapy

Maintainstability of end‐organ function

TO

RECOVERYOF ORGAN 

FUNCTION

BRIDGETO DEFINITIVE TREATMENT

While minimizing

complicationsfrom ECLS 

therapy

UNTIL

GOALS OF VA ECMO

TEMPORARILY

Improve CirculationO2 sat and 

CO2 Removal

Treat disturbance

Rest injured heart/lungs

Avoid / minimize injurious therapy

Maintainstability of end‐organ function

TO

RECOVERYOF ORGAN 

FUNCTION

BRIDGETO DEFINITIVE TREATMENT

While minimizing

complicationsfrom ECLS 

therapy

UNTIL

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→ Cellular Oxygenation

Cells

DO2(mL/min)

= CO(L/min)

x

CaO2(mL O2 / L blood)

[1.34∙ Hgb ∙ SaO2]

+ [0.003 ∙PaO2]DO2 normally 4‐5 times that 

of VO2

VO2(mL/min)

CO(L/min)

CaO2 – CvO2(mL O2 / L blood)

=x

OER = VO2 / DO2  [Normal~25%]

determined by tissue metabolic rate

RATIONALE FOR ECMO

©2017 MFMER | slide-20

Mechanical Ventilator

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©2017 MFMER | slide-21

©2017 MFMER | slide-22

DRAINAGEInlet - V

PUMPInlet - V

MOTOR

MEMBRANEOXYGENATOR

GAS MIXTURE

BLENDERO2 / AIR

High Pressure

MONITORING INTERFACE

HEAT EXCHANGER

BACK-UPHAND CRANK

FLOW SENSOR

PRESSURE MONITORING

Integrated

ECMO CIRCUIT

RETURNOutlet – A or V

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Extra‐Corporeal Membrane Oxygenation?

http://edecmo.org/get‐started/what‐is‐ecls‐ecmo/

GAS EXCHANGEO2 & CO2

PUMP‐DRIVEN FLOWCentrifugal

DRAINAGEInlet ‐V

RETURNOutlet –A or V

ECMO vs ECLS

Respiratory ORCardiopulmonary

Support

VV ECBFDETERMINANTS AND LIMITATIONS

•Cannula size & position

•Venous capacitance ,compression or collapse 

•Tubing

•Pump function (i.e. thrombosis)

•Oxygenator resistance

PRELOAD

AFTER‐LOAD

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©2017 MFMER | slide-25

19% increase in radius with double

the flow volume

©2017 MFMER | slide-26

→blood protec ve flowECMO CANNULA

ECMO for adult resp failure – Turner. Resp Care 20

Biggest, shortest cannula = least resistance to flowAim for pressure drop < 100mmHg across cannula

Insertion of Bicaval Dual Lumen ECMO cath with Image Guidance - Javidfar. ASAIO 2011

Dual Lumen Bicaval

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©2017 MFMER | slide-27

→PumpECMO CIRCUIT

CENTRIFUGAL PUMP

• Non-occlusive pump• Pre-load sensitive• Afterload dependent (must

overcome positive resistance)

RPM

Flow

NO Direct relationship between RPM and Flow

- Flowmeter is necessary

Impeller designMagnetically coupled to motor

©2017 MFMER | slide-28

→OxygenatorECMO CIRCUIT

MICROPOUROUS HOLLOW FIBER

• Gas inside fibers, blood on outside

• Very small ‘nano’ pore size → • ‘plasma‐tight’• High gas permeability

• Low pressure drop across membrane

Maquet.comECLS in critically ill adults - Ventetuolo. AJRCCM 2014

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©2017 MFMER | slide-30

→Gas BlenderECMO CIRCUIT

Connected to oxygenatorMixes air and oxygen

O2• Dial for FiO2 (21-100%)• Connects to 30-70PSI inlet

Air• Gas flow = ‘Sweep’• 2 dials• 0-10 LPM

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VCO2200ml/min

BF < 1L/minSwgas = 10xBF

CaCO2=480ml/LPaCO2=40mmHg

CvCO2=520ml/LPvCO2=45mmHg

CO2 Removal(of at least 250ml/min)

DO2600ml/min/m2

CI=3L/minSatO2=100%CaO2=20ml/dl

VO2120ml/min/m2

= 5x

BF ≥ 4L/minSwgas= BF DO2 = (CoutO2‐CinO2) x BF

Low‐flow ECCO2R

High‐flow V‐V ECMO

Physiology of CO2 removal during ECMO Physiology of O2 delivery during ECMO

A B

CvO2=16ml/dlSatvO2=80%

M Ranieri

To Cannulate?SELECTION CRITERIA

Brodie – NEJM 2011

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To Cannulate?PRE‐ECMO PREDICTORS

RESP Score

ECMOnet Score

Pre‐ECMO SOFA Score

PRESERVE Score

SAVE Score

?helpful

Recirculation on VV ECMO

Brodie D and Abrams D

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Recirculation

1. Cannula Positioning

2. Venous Chamber Compliance

3. High RPM

4. Low CO

CAUSES

Hemostatic balance during ECLS ‐ Andrews. Trans Med Reviews. 2016

COMPLICATIONS

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Lim – ECLS physiological concepts and clinical outcomes. J of Card Failure 2016

Cheng ‐ Complications of ECMO. Ann Thorac Surg 2014

COMPLICATIONS

VAVV

COMPLICATIONS

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Complications of ECMO ‐ Cheng. Ann Thorac Surg 2014

ECMO and nosocomial infection ‐ Schmidt. CID 2012

COMPLICATIONS

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ECMO programs for ARF in adults ‐ Combes. 2014

Non ICU Support Services 

CONSIDERATIONS

ECMO –VENTILATORINTERACTION

A        B        CVitals / Pressures / Waveforms

SaO2  RR  HR  BP  CVP

Physical Exam

IMAGINGMEDSLABS

PATIENT

GAS EXCHANGE

FiO2 PEEPRR     VT

PIPOXYGEN‐ATOR

PUMPCANNULASTUBING

VO2

CaO2

CO

RPMFLOWS

PRESSURES

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International ECMO network ‐ECMOnet• EOLIA – ECMO to rescue Lung Injury in severe ARDS ‐ RCT

• The REST Trial – pRotective vEntilation with veno‐venouS lung assisT in respiratory failure

• The SOLVE ARDS Study Program – Strategies for Optimal Lung Ventilation in ECMO for ARDS

• The SUPERNOVA Trial – Strategy of UltraProtective lung ventilation with Extracorporeal CO2 Removal for New Onset moderate to seVereARDS

• ASAP ECMO –Antibiotic, Sedative and Analgesic Pharmacokinetics during ECMO

• LIFEGARDS Study – ventiLatIon management oF patients with Extracorporeal membrane oxyGenation for Acute Respiratory Distress Syndrome

• HELP ECMO – HEparin Low‐dose Protocol in ECMO patients – RCT

ECMO vs ECLS

ECLS

VV ECLS

VA ECLS

VAV ECLS

ECPR

VV‐ECCO2R

AV‐ECCO2R

Circulatory Failure

Respiratory Failure

Combined Cardiac/Respiratory

Failure

Cardiac Arrest

CO2 Retention

Gaffney AM et al. BMJ 2010

EOLIA

SOLVE ARDS

The REST TrialThe SUPERNOVA Trial

ASAP ECMOLIFEGARDS StudyHELP ECMO

Prague OHCA (Hyperinvasive)The Vienna Project

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October 27‐28, 2017

Ann of Cardiac Anesth 2016 

QUESTIONS

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SIM 4

‐DO2 normally 4‐5 times that of VO2

OER = VO2 / DO2  [Normal~25%]ILLNESS

If DO2:VO2 is < 2:1→ Anaerobic Metabolism

SvO2 < 50‐60%

RATIONALE FOR ECMO→ Improve Cellular Oxygenation

O2 delivery and consumption, macrocirc perpective ‐ Nichols. Crit Care Clin 2010Monitoring DO2 in the crit ill ‐ Huang. Chest 2005

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→ Configura onVV ECMO

Cells

Native Lung Function

Recirculation

Inlet / Drainage

Venous Return

Bypassed Venous Flow

ECMO

Venous Admixture

Outlet / Return

flow

NO cardiac supportNO↓ in pulmonary blood flow

Usually PARTIAL pulmonary support

→ Based on ECBF : CO Ratio

VV perfusate mixes with ‘mixed’ venous blood return, bypassed by ECMO

→ Venous Admixture

‘mixed’

Patient Cardiac Output

A

For Best Ratio:

membrane oxygenated 

blood

SinletO2

MO FiO2

MO Properties &Dynamics

Blood Flow Rate

Moto

rPump

MO

Air/O2Blender

V

lung oxygenated blood

‘true’ SVO2

Lung Function

Ventilator Settings

↑ Effec ve ECBF↓ Recircula on↓ CO

VV

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Femoral High ECMO Red Arrows.wmv

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