Extracorporeal Life Support - McGill University...23 Overall Patient Outcomes 1971-2018 ELSO...

Extracorporeal Life Support

Montreal 2019

Disclosure

• Dr Bartlett is consultant to MC3 and Cytosorbents

• No conflict related to this presentation

SR, 6yo

SR 2/6/2011

SR 6yo healthy girl H1N1 influenza and streptococcal pneumonitis Septic shock, 3 pressors SaO2 60 ,PCO2 50 on Maximal ventilator settings She is dying: Mechanical Life Support?

CO2 Production

Ventilation CO2 Clearance

Severe cardiopulmonary failure (inadequate oxygen delivery)

DO2:VO2 < 2

• Treatment: • 100% O2 • Pplat>25 • Vasopressors • Inotropes • Anesthesia and paralysis

CO2 Production

Ventilation CO2 Clearance

Severe cardiopulmonary failure (inadequate oxygen delivery)

DO2:VO2 < 2

• Treatment: ECLS • 100% O2 Spontaneous breathing • Pplat>25

• Vasopressors No vasopressors • Inotropes

• Anesthesia, paralysis Awake, ambulatory

Phil Drinker PhD Drinker and Bartlett 4 day ECC in dogs 1968

ECLS: Lab Development

Ted Kolobow and Warren Zapol, 1969

ECLS: Lab development

First cardiac case First newborn case(Esperanza) 1971 1972 1975

ECLS: First Clinical Cases

First sucessful case, ARDS

University of Michigan Medical Center

Michigan ECMO Courses 1980-1990 Cannulating and managing ECMO in sheep

ECMO worldwide 1985--

1975-1980, UCI

Extracorporeal Life Support ( ECLS, ECMO)

Support of heart or lung function with mechanical devices which:

•is temporary (days to weeks), •can be partial or total, •avoids ongoing iatrogenic injury, •and sustains life while bridging to organ recovery or replacement.

Indications for ECLS

• Acute, severe, cardiac or pulmonary

failure unresponsive to optimal management, with recovery expected in 2-4 weeks

Venoarterial ECMO in a neonate

Veno-venous ECLS with a double lumen cannula

Original ECMO Registry Report 1988

ELSO Member Centers 2018

23

Overall Patient Outcomes 1971-2018

ELSO Registry January 2019

Total Runs Survived ECLS Survived to DCNeonatal

Pulmonary 31,591 27,779 87% 23,119 73%Cardiac 8,252 5,684 68% 3,529 42%ECPR 1,864 1,315 70% 775 41%

PediatricPulmonary 9,487 6,797 71% 5,573 58%

Cardiac 11,377 8,155 71% 5,980 52%ECPR 4,361 2,628 60% 1,858 42%

AdultPulmonary 19,482 13,453 69% 11,565 59%Cardiac 19,627 11,628 59% 8,381 42%ECPR 6,190 2,580 41% 1,827 29%

Total 112,231 80,019 71% 62,607 55%

24

Overall Outcomes 2014-2018

ELSO Registry January 2019

Total Runs Survived ECLS Survived to DCNeonatal

Pulmonary 3,956 3,295 83% 2,686 67%Cardiac 2,335 1,664 71% 1,150 49%ECPR 745 508 68% 315 42%

PediatricPulmonary 2,960 2,210 74% 1,868 63%Cardiac 3,920 2,978 75% 2,277 58%ECPR 1,997 1,200 60% 877 43%

AdultPulmonary 13,413 9,325 69% 8,156 60%Cardiac 14,580 8,627 59% 6,366 43%ECPR 4,691 1,965 41% 1,399 29%

Total 48,597 31,772 65% 25,094 51%

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ECMO I, 1990-2008 ECMO II, 2008 -

ECLS Techniques • Cardiac Support, ECPR, EDCD

V-A access via neck, groin V-A access for postop cardiac failure

• Respiratory Support VA or VV access via neck or groin VV Double lumen cannulas

• ECLS Management Lung and cardiac rest and recovery Hemoglobin 12-15 gm/dL Weaning ECMO specialists and nurses Routine ICU procedure

Patient Management: ECMO II

ECMO I ECMO II Sedation, Paralysis

Awake, Spontaneous breathing

Intubated Tracheostomy Rest vent settings CPAP, extubate? Specialist 24/7 ICU Nurse, ECMO Team

role Lung recruitment? Watch and wait Bleeding: major Bleeding: minor

Cardiac ECLS algorithm

Day2-3: CNS OK? Cardiac Function returning? NO: Transplant candidate? YES: Bridge to recovery Yes: Donor list ,bridge to VAD No: Futility: Stop, Organ donation?

VA support, no cardiac function Bridge to LVAD, then cardiac recovery

Cardiac VA support Special considerations

• Some cardiac function ( pulsatility) Lung function/ harlequin syndrome

• No cardiac function Vent left side, septostomy, Impella • Leg perfusion

before leaving the bedside • Femoral vs proximal perfusion subclavian, carotid • Central access post cardiotomy, high flow sepsis

U.K. Neonatal ECMO Study(1993-95)

180 Patients Randomized

90 Conventional 90 ECMO

41% surv. - p <.01 - 72% surv

1 year disability 28% both groups

Clinical Research 13 prospective trials of ECMO in respiratory failure

ECLS in ARDS (CESAR) Prospective Randomized Trial 2007

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Conventional ECMO

Kaplan-Meier survival estimates, by allocation

Giles Peek CESAR 2007

Noah. H1N1 ECMO vs control. Matched pairs trial JAMA 2011, 366:1659

EOLIA trial 2012-2018 Alain Combes NEJM 2018

• Severe ARDS (1015 pts) Randomize ( 249 pts) Early ECMO ( 1.5d) Conventional Care+ late ECMO

Survival: 65% Survival: 58%

Late ECMO (6d)

Survival 43%

Day 1-2:VV Blood Flow max, sedated, Vent P 20/10. rate 5, FiO2 30% Goal SaO2>80%, PaCO2 40mmHg, DO2>3xVO2 Day 3+: Awake, Spontaneous breathing, CPAP VV Blood Flow lowest to meet goals Trach or extubate, watch and wait Day 14-21: Lung recovery: Wean VV blood flow to meet goals When <50% support trial off on low vent settings Off ECMO,wean vent

Respiratory Support algorithm

Irreversible lung injury, no recovery with ECLS after:

• 7 days ( 1975-80) • 14 days (1980-1990) • 21 days (1990-2000) • 28 days 2000-2008, with some exceptions

• 2008-2012, new circuits, ECMOII • 2012-2017 lung recovery or transplant after

months of no lung function.

Palle Palmer, Stockholm 1997 Why should ECMO patients be asleep?

Tidal volumes long run ECMO

40 yo, viral ARDS, Awake alert on ECMO, total consolidation for 50 days courtesy of Palle Palmer, Karolinska

Ambulatory VV bridge to XP: Hoopes, Why should ECMO patients be in bed?

Lung recovery or replacement after prologed ECMO support

• Registry: Hundreds of cases >21d, adult and pediatric

• Pediatric: ( Brogan): 289 cases > 21d, 38% survival

• Univ Maryland (Kon): 11 cases >21d, 72% survival • Shock-Trauma, Baltimore 27 cases >21d, 87% survival • Case reports:

35,38,42,45,50,52,59,65,67, 73,104,107,117,155,193, 605 days

Redefining irreversible lung injury

• Lung has unexpected regenerative capacity, during prolonged mechanical support,

• Recovery can take months • Late follow up: minimal disability • New scientific opportunities ( How, why,

when,) • New practical problems, RV support, long ICU stay, expense (where?)

Late Recovery in Acute Lung Disease with ECMO (A New Phenomenon)

• Pathophysiology: O2, RV Failure, CO2 equally important • Clinical trials: Late recovery (1-2 years) vs. transplant

• ECMO out of ICU: Wearable artificial lungs • Application: Late recovery in ECMO cases > 1 month • Vascular access: VV ECMO, RA→PA (pump), PA-LA • Paracorporeal with transcutaneous conduits • Devices: 1.5 m2, 6 L/min blood flow, • Duration: 2 Months-2 Years

ECLS Research: Implantable Lungs, 2000--

MICHIGAN OSAKA MICHIGAN

Ambulatory Lung Assist PA-LA implantation, 5 weeks, bridging to transplant Alois Philippe, Regensberg, 2007

ECLS 605 days with full recovery VA, VV, RA-PA, 15 months ECCOR, 2 months s

RA-PA vascular access. Bart Griffith Kris Nelson, JASAIO 2018

Livanova- Tandemlife “Protek Duo”

Wearable Artificial Lung with VV access RA double lumen cannula or RA-PA

Portable RA-PA Total support Univ Pittsburgh Univ Maryland

ECMO 2025: Respiratory

Acute Lung Failure Chronic Lung Failure ICU ICU recovery 50% ECMO 7d ECMO 1d recovery 50% LUNG FAILURE CENTER ECMO Extubate,ambulate Recovery 21d 50% Home, Implant Late recovery 30% Transplant Destintion

ECLS FUTURE: Respiratory Support Acute Respiratory Failure Neonatal, Prematurity Acute RDS, pediatric and adult Status asthmaticus, Airway Post transplant Chronic Respiratory Failure Pediatric BPD, CDH Bridge to transplant

Acute to chronicECMO(months) Lung Centers , home ECMO, Wearable lungs ,ESLD/COPD palliation

ECMO FUTURE: Circulation support ( VA)

Acute Cardiac Failure Post Op MI, Myocarditis, Toxins, PE ECPR for cardiac arrest Acute Circulatory Failure Septic shock, anaphyllaxis Trauma, hemorrhage Organ Donation and Transplantation EDCD Organ perfusion, organ banks

ECMO III( 2025)Patient Mangement

• Awake breathing extubated • Indications 50% mortality risk based on

algorithms for cardiac , respiratory failure • No systemic anticoagulation • Automation, servo regultion • Cardiac, Shock: bridge to recevery, ECPR, EDCD, bridge to VAD • Respiratory: ECMO bridge to recovery,

Lung centers, home ECMO, implant lungs

Future of ECLS Technology

• Simple, automated devices

• Modular components • No systemic

anticoagulation

• Ex vivo organ perfusion, Organ banks

• Lung Failure Units

Applications • ARDS algorithm • Awake patients • Bridge to lung

transplant • DCD Organs • ECPR • Sepsis • Placenta • Implantable Chronic

Lungs

SR 3/2/ 11

EC32 ECMO Day 32

SR 3/11/11

ECMO Day 40

SR Going home 3/29/11

SR 3/28/11