ECMO: Choice/Technique

Joseph B. Zwischenberger MD Johnston-Wright Professor

Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare

859-229-6635 (mobile)jzwis2@uky.edu

The University of KentuckyLexington, Kentucky

Presenter Disclosure Information

Research supported in part through • Competitive funding: National Institutes of Health (SBIR,STTR,T-32)• Contracts:MC3, Ann Arbor MiExotherm, Lexington Ky W-Z Biotek, Lexington KyMaquet

Patent: Avalon Elite™ (4 more, 3 pending)NovalungFree App: “Zwisch Me”

Joseph B. Zwischenberger, M.D.

Bartlett/Zwischenberger 1984

VENOVENOUS ECMOSingle, Double Lumen CannulaFor total gas exchange alone

Zwischenberger/Drake Prototype ASAIO J 1984

Kendall 1989

Oxygen transferCarbon Dioxide Removal

CO2 RemovalCO2 removal and O2 transfer are

uncoupled: – CO2 is transferred across the

membrane gas exchanger– Low Frequency Ventilation:

O2 diffuses across the native lungs

Ted Kolobow 1977

AVCO2R: Carbon Dioxide Removal (get the bad air out) with a low-resistance gas exchanger in a simple arterio-venous shunt

Zwischenberger 1996

percutaneouscannulationof femoral artery(10-12 Fr) andvein (16-18 Fr)Flow 800-1000 ml/min forCO2 Removal

Arteriovenous CO2 Removal = PECLANOVALUNG (Europe): Survival 70%

>3000 patients

Impact of CO2 Homeostasis

CO2 flux is greatly reduced by AVCO2R, and may be important in:

• organ tissue neutrophil apoptosis • resolution of inflammation• maintaining a normal alveolar milieu

Zwischenberger et. al. Ann Surg 2007;246:512-521

The higher pump flow, the more recirculation (♦)Effective flow (■) no longer increases

as pump flow increases

VV Triple site cannulation–Minimizes

recirculation –maximizes

venous drainage

–improves gas exchange

2003

Avalon Elite® Catheter Placement: image guidance required

Flouro insertion with ECHO positioning

Wang/Zwischenberger 2007

Newborn with Meconium Aspiration on Avalon Elite® VVDL ECMO 6 days: No Recirculation

Blue blood out Red blood in2009

United Kingdom H1N1ECMO vs Conventional care

• 69 ECMO patients in 4 centers• Matched pairs study, 3 methods

ECMO CC survival %• Individual 77 48• Propensity score 76 53• Genmatch 76 49

• Conclusion: ECMO survival 76%Conventional Care 49%

IVC

SVC

RV

TV

IVC

SVC

56 yo idiopathic pulmonary fibrosis:uncomplicated bilateral lung tx 3/08 12/08 Trichosporon pneumonia, post-infectious obliterative bronchiolitis. Listed for redo transplant Feb ’08.

Alert 3-3-09 Chuck Hoopes (UCSF ): the first Ambulatory Lung Assist patient using Avalon Cannula, Quadrox and Centrimag!!

Total gas exchange - no recirculation

Exercise at the bedside

Securing cannula for ambulation and sterilization

VA ECMO “Sport Model”

Optional V-VA or WEAN to DLC VV

All configurations allow ambulation

Bacchetta 2012

21

Tips for percutaneous technique 1• Guidewire placement

– Ultrasound – vessel identification• Vascular transducer to guide needle

– Fluoroscopy – ensures guidewire location• Encouraged for single-lumen cannula placement• Recommended for dual-lumen cannula

placement– Echocardiography

• Precise placement for flow: dual-lumen cannula• Guidewire should have no resistance

22

Complications - prevention Vessel perforation Ultrasound for intraluminal placement Fluoroscopy to identify guidewire Atrial perforation Fluoroscopy for guidewire placement Wrong vessel cannulation Ultrasound for vessel identification Inadequate drainage Malpositioning Inadequate cannula size

This is ECMO ?

“walking ECMO”…dual lumen Avalon VV (hypoxia, hypercapnea secondary BOS.. to redo BLTx)

“ambulatory right heart bypass”…PA to LA cannulation (RV failure, hypoxia, PHTN s/p PEA..to BLTx)

“walking bypass”…RA to Ao cannulation(BiV failure, PHTN s/p PEA..to HLTx)

“walking bypass”… RA to Ao cannulationwith pump/oxygenator (BiV failure, PHTN s/p

PE..to HLTx)

28 angled metal tip RA outflow

10 mm Dacron PA inflow

graft

The “oxyRVAD” … RA to PA with pump/oxygenator

Pumpless ExtraCorporeal Lung Assist ( PA-LA)

“pulmonary bypass”… supra-systemic pulmonary pressures do not require a centrifugal pump …

Fem-Fem Walking VA

V-AV supportPartial VA ECMO/Partial VV ECMO

SVC

EuroELSO 2015: ambulatory FEM-FEM ECMO is feasible

Keshavjee ECMO Red Book, 4th edition, 2011

Selection of ECLS Support Mode /Configuration

*prevent barotrauma and activation of inflammatory mediators

*Limit end organ injury

*avoid sedation and muscle atrophy (frailty)

VV DLC ECMO pre BLTx (cystic fibrosis)

Does anyone with severe respiratory failure really benefit from mechanical intubation and positive pressure ventilation? …..With ECMO…..

20/22 consecutive ambulatory ECMO adult patients are alive to 6 months

AATS 5/2015: 12 ECMO talks

AATS Guidelines: Bridge to transplant and Extracorporeal lung support: Ambulatory ECMO recommended

(Bacchetta and Cypel 2015)

SUMMARY OF RECENT REPORTS* CHRONOLOGICALLY OF THE USE OF ECMO AS BRIDGE TO LUNG TRANSPLANT (*SERIES WITH MORE THAN 10 PATIENTS)

REFERENCE YR PATIENTSDURATION (RANGE)

MODE OF ECLS BRIDGE (%)

SURVIVAL 1 YR (%)

Hoopes 2013 31 13.7b (2-53) VV DLC (10)VV (1)VA (10)PA–LA (2)RA–Ao (3)Comb 5)

87

Dellgren 2015 20 9 (1-229) VV DLC (3)VV (11)VA (6)

80 62

Hayanga 2017 49 NA Not specified NA 80Hoetzenecker 2017 71 10 (0-95) VV DLC (23)

VV (7)VA (7)PA-LA (9)ECCO2R (12)Comb (13)

89 66

Todd 2017 12 2.2 (0.7-16.5) VV DLC (9)VV (2)

100 100

Hybrid ECMO for Heart and Lung Failure

Many now using Distal Limb perfusion routinely

2016

eCPR: ER ECMOSurvey of Centers participating in

Extracorporeal Life Support Organization (ELSO)

• VA ECMO with groin cannulation• Cardiology, CT, Emerg Med, Vascular• Over 33% of centers that submit adult

ECMO perform ED ECMO

Resuscitation 107 (2016) 38-46

Thiagarajan RR, et al. ASAIO 2017, 63(1):60-67

40% Peds

30% Adult

ECMO Transport• Safety and Outcomes of Mobile ECMO Using a

Bicaval Dual-Stage Venous Catheter – Improved in hospital survival 86% (44 pts)

vs Conventional ECMO 79% (126 pts)ASAIO J 2017; 63:351-355

• Transportation of Patients on ECMO: Center Experience and Literature Review– 38 manuscripts plus experience (1481 pts)– Survival: Adult (62%) Pediatrics (68%)

Ann Intensive Care (2017) 7:14

ECMO FUTURECatheter based Technology (Ambulatory)

– Recipient Support– Donor Support: DCD– Organ Block Support : Lung in a Box

Transplantation

Neonates, Children, Adults Acute Severe Respiratory failure Acute Cardiac support

ER Transport Resuscitation/Shock

Will play for drinks and tips

You should ALWAYS listen to a harmonica player

ECMO: Choice/Technique

Joseph B. Zwischenberger MD Johnston-Wright Professor

Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare

859-229-6635 (mobile)jzwis2@uky.edu

The University of KentuckyLexington, Kentucky

ECMO: Cannulation Techniques

Joseph B. Zwischenberger MD Johnston-Wright Professor

Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare

859-229-6635 (mobile)jzwis2@uky.edu

The University of KentuckyLexington, Kentucky

42

Cannulae choiceOxygen Consumption determines

DeliveryNewborn: 5-8 cc O2/kg/minChild: 4-6 cc O2/kg/minAdult: 3-5 cc O2/kg/min

Translated into flow (for normal Hgb)Neonate 100 to 150 mL/min/kgPediatric 75 to 100 mL/min/kgAdult 50 to 75 mL/min/kg

43

Cannulae choiceVenous drainageDetermines the flowDrains bloodPassivelyActively

Venous Drainage will be the most important factor in determining the maximum flowBiggest and Shortest cannula practical

44

Cannulae choiceHagen-Poiseuille:

laminar pipe flowIncreasing diameter

is best way to increase flow

Minimize lengthCannulaeCircuit

4

128dPQ

Lπ

µ⋅

=⋅ ⋅

∆

45

Percutaneous Cannulation• Percutaneous method

• Seldinger technique• Non-surgical

• Preferred for venovenousLow incidence of bleeding complications

• Sizes to 31+ French• Decannulation is non-surgical

• Withdrawal and suture of tract or quick close

46

Internal Jugular Cannulation

47

Femoral Vein Cannulation

48

Avalon Dual Lumen

Courtesy R Firmin, Leicester, UK

49

Two-cannula single-lumen cannulation

Venousreturn

Venousdrainage

InternalJugular/SVC

Blood pump

Membraneoxygenator

Femoralvein

50

Three-cannula single-lumen cannulation

Venousdrainage

Venousreturn

Femoralvein

IVC

Blood pump

Membraneoxygenator

Femoralvein

51

VVA - Hybrid VV and VAPartial cardiac supportAssures oxygenated

blood to brain and coronariesAll percutaneousCan convert VV to VVA if

more cardiac support is needed

Venousdrainage

Venousreturn

Femoralvein

IVC

Blood pump

Membraneoxygenator

Femoralartery

Arterialreturn

Internaljugular/SVC

52

Avalon dual-lumen: 13-31 Fr sizes

Unconventional Institutional Volume Outcome Associations in

Adult ECMO in the US

No significant survival difference between Low, Medium and High volume ECMO programs in bridge to Heart or Lung transplant patients

McCarthy et.al. Presented at STSA 11/15

Goal: Ambulatory Paracorporeal Artificial Lung

Grant Concept 2003

56

Disclosures

Check

xCheck

x

• No Relevant Financial Interests to Report

• Products discussed for patient use are FDA approved

• Many products discussed are used “extended label”

57

Learning Objectives

CannulationHow to choose a cannulaeHow to put it in

Initiation Process

58

Cannulation: Achilles' heel of ECMO

Venousreturn

Venousdrainage

InternalJugular/SVC

Blood pump

Membraneoxygenator

Femoralvein

59

Cannulation

The first of many opportunities to kill your patient Choices

Venous cannulaeDiameterLengthWhich veinHow many

ArterialDiameterLengthWhich arteryProtect the limb

60

Cannulae choice

• What are we doing?– Supporting tissue level

perfusion– Function of metabolism– Metabolism requires fuel-

oxygen• The “fire of life”

– Oxygen delivery is a function of:

• Oxygen content– Sats– Hgb

• Blood flow rate

61

Cannulae choice

OK, I can determine flow.Which cannulae do I use?

62

Cannulae choice

Mode of cannulationWhy are we doing this again?Tissue level perfusionGas exchange failure?

Venovenous Venoarterial

Perfusion failure? Venoarterial

63

Cannulae choice Single lumen Double lumen Arterial Venous Various lengths Various diameters

64

Cannulae choice• How much flow do you

want?– Almost always more then you

get

• Pressure Flow relationship• “M” number

– Experimentally measured per cannulae

65

Cannulae choice

Finally, you can choose your cannulae.About time!

66

Now, you only have to choose your: Pump? Oxygenator? Tubing diameter? Tubing length? How many connectors? What kind of access? What kind of monitors Bladder? Bridge? Protocols Training Education Competencies Data base Quality Order sets Labs? Transfusion strategies Counseling sessions

67

Cannulation techniques“how to put it in”

PercutaneousPrimary technique for adult venovenous support

Semi-open (surgically-guided percutaneous)Visual guidance of percutaneous insertionDeveloped for neonatal VV cannulationAn option for adult cannulation

Open (surgical venotomy)Traditional approach to cannulationRequires vessel ligationBackup option for failed percutaneous technique

68

Percutaneous Cannulation

Courtesy of Jonathan Haft

69

Surgical Cannulation

Distalligatures

Carotidartery

Internaljugularvein

Drainagecannula

Reinfusioncannula

Vagusnerve

Proximalligatures

69

70

Introducer Comparison

71

Vessel Dilatation

72

Pharmacologic management during cannulation

Deep sedation with intravenous analgesiaLocal infiltration anesthesia at cannulation

siteElevated airway pressuresUsually not a problemShort-acting neuromuscular blockade

during cannula insertionPrevention of air embolism

73

Tips for percutaneous technique 2

• Guidewire kinking– Occurs when advancing dilator– Usually in the tissue outside of the vessel

• Prevention– Patient positioning – ‘straight shot’– Long tapered dilators (Coon’s dilators)– Rotational motion >> forward motion– No more than 4 Fr increments – retreat if needed– Ensure adequate dilatation at each step– Adequate tension on guidewire

• Minimize skin incision – snug fit = less bleeding

74

Typical cannula sizes for percutaneous use

• Internal Jugular– Vein size usually about 40 to 50 Fr (I’ve seen 75 Fr!)– 23 to 24 Fr short– 27 to 31 Fr dual lumen

• Femoral vein– Vein size usually 35 to 45 Fr– 23 to 24 Fr short– 24 to 28 Fr long

• Femoral artery– 16 to 17 Fr

75

UltrasoundRight Internal Jugular

Courtesy of Jonathan Haft

RIJV

SCM

RIJV

CA

CA

SCM

76

UltrasoundRight Femoral

Courtesy of Jonathan Haft

77

Measuring vessel size

Fr size = diameter * 3

Fr size ≅ circumference in mm

78

Jugular cannula placement

79

Femoral cannula placement

Courtesy R FirminLeicester, UK

80

Avalon Placement

81

Positioning of the dual lumen cannula

82

Correct insertion depth

IVC Port Infusion PortCourtesy of Mark Ogino, MD

83

Insufficient insertion depth

Infusion PortCourtesy of Mark Ogino, MD

84

Deep insertion depth

Liver DiaphragmCatheter Tip Liver DiaphragmCatheter Tip

Courtesy of Mark Ogino, MD

85

Circuit priming

Isotonic crystalloid with extracellular fluid compositionNormosol-R pH 7.4, PlasmalyteNa 140 mEqCl 98 mEqAcetate 27 mEqK 5 mEqMg 3 mEqGluconate 23 mEq

OptionalAlbumin 25% to bring final concentration 4 to 5%

86

Initiation

• Your second opportunity to kill your patient– “Crashing on”

• VA• You can only look good

– Elective• VV• VA• You can only look bad

– Be prepared– Have a plan in your head– Have a plan outside of your head

» Say it “out loud” to each other» “closed loop communication”

87

Initiation• “Crashing on”

– Chaotic– CPR– Cannulator cannulates

• VA• Cut down• Percutanous

– Team manages the patient– Team readies the circuit– Focus on your job– Go on fast– Air– Connecting “backwards”

88

Initiation

ElectiveWhenAlways after midnightAlways for about 6 hours

WhereFluroCath labORICU

Should simulate the processElevator big enough?E h t bi l th t t i t ?

89

Initiation• How

– Commence support slowly• Hypotension with VV• Prepare with pressors

– Make sure blood is going the right direction– Watch for air– Double check each other

• Trust no one• Giving heparin is everyone’s job

– Change nothing until supports established– Stabilize– Evaluate circuit

• Maximum flow?• Evaluate support

– Minimize the unnecessary– Define support goals

• Tissue level perfusion

90

InitiationCommencing support Mix prime in slowlyIncrease pump speed slowly to achieve max flowDecrease flow to lowest level to provide adequate supportArterial saturation > 85% (lower if necessary)Physiologic goalsHemodynamicsTissue perfusionOrgan function

Blood flow regulated over time to meet goals

91

Thank youQuestions?

“To clinicians who have witnessed first-hand ECMO’s ability to salvage anunstable life that would presumably belost without it, today’s study will representthe sentinel paper on adult ECMO foryears to come. After all, 63% of patients who were dying survived to 6 months withECMO referral…”

Zwischenberger JB, Lynch JE; Will CESARanswer the adult ECMO debate? The Lancet 2009; 374

CESAR Trial

ECMO: When, Where, and by Whom?

Joseph B. Zwischenberger MD Johnston-Wright Professor

Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare

859-229-6635 (mobile)jzwis2@uky.edu

The University of KentuckyLexington, Kentucky