Emergency ECMO

Emergency ECMO/E-CPRSam Phillips

CasePC29 yr old male out of hospital witnessed VF arrest.

HPCCall from St John Ambulance to say they had a 29 year old male complaining of central chest pain.ECG performed on route.

ECG from ambulance

Cath lab activated and decision to go straight up on arrival.

Call back from SJA to say patient has now had a VF arrest without ROSC and they are 5 mins away.Using the lucas for chest compressionsPatient now to come through ED.

Further hx from ambulance staff and familyPatient was well this am.Went out of the house for a couple of hours and may have used methamphetamines.Arrived back and then developed central chest pain and diaphoresis. (around 12.30pm).Sister called the SJA who arrived within 10 mins.

Further collateral hxPatient has no known medical problems other than intermittent meth use.No medicationsStrong FHx of cardiac disease father died age 37 of an MI!mother had first MI age 50

1st ECG by SJA at 1253.VF arrest at 1310 on route.6 cycles of CPR with 6 shocks in total given for refractory VF. Also given amiodarone.On arrival in ED at 1335 now in PEA.

Would this patient be a potential candidate for ECMO?

Ongoing ManagementContinuation of PEA algorithm, intubated patient.I felt good candidate for ECMO, cardiologist (Michael Muhlman) present and agreed.Called intensivist Dave Moxon and cardiothoracic surgeon down to ED to help to try to facilitate this.After a further 10mins PEA, established ROSC but required adrenaline infusion at 10mls/hr.Treatment as per STEMI protocol.

Transferred straight up to the cath lab where he had another VF arrest on arrival which reverted with one shock.Found blocked prox LAD with one stent inserted.IABP inserted to support BP.Transferred to ICU on 5mls/hr adrenaline.

Clinical courseDay 1 post arrest;increasing lactate and abdominal distension. CT confirmed an ischaemic gut involving the caecum and proximal small bowel.Had bowel resected.Required haemo-filtration for acute kidney injury.Day 4Extubated, obeying commands, sedation still wearing off.Day 7No neurological deficit however still requiring haemo-filtration for acute kidney injury.Day 10Off haemo-filtrationDay 14D/C home neurologically intact.

ECMO OverviewWhat is it?Who patient selectionWhat equipmentWhy what is the evidenceWhat can we expect at Charlies

ELSO ECMO DefinitionECMO (Extracorporeal Membrane Oxygenation)is defined as the use of a cardiopulmonary bypass circuit for temporary life support for patients with potentially reversible respiratory and/or cardiac failure failing to respond to maximal medical therapy.E-CPR (Extracorporeal Cardiopulmonary Resuscitation) is the initiation of bypass during resuscitation of the arresting patient.

ELSO extracorporeal life support organisation14

Two types of ECMOVV = Veno-venousVA = Veno-arterial

VV ECMOMost common mode used in the ICU.Provides respiratory but no haemodynamic support.Venous drainage from large central veins oxygenator and CO2 remover venous system near RA. Proven to improve survival at 6 months (63% vs 47%) with acute severe respiratory failure. (CESAR trial-Conventional Ventilatory Support vs Extracorporeal membrane oxygenation for Severe Acute Respiratory Failure)

CESAR trial randomly assigned 180 patients with Severe ARDS (defined by hypercapnic resp acidosis PH 3 (quantifies severity of lung disease based onPaO2/FiO2, PEEP, lung compliance and CXR ,to be referred to the ECMO centre in the UK vs continued conventional management. NB Exclusion criteria age 65, intubation >7 days, CI to anticoagulation.16

VV ECMO

VA ECMO/E-CPRPerformed in the ED setting.Provides both respiratory and haemodynamic support.Venous drainage from the right atrial inlet via the CFV and infusion into the iliac artery via the FA.Establishment of the circuit is therefore retrograde.

VA ECMO

Femoral backflow cannula19

Alfred Indications for ED ECMOPatients with out-of-hospital cardiac arrest which is refractory to standard ACLS treatment AND:The patient meets all of the following criteria:Likely primary cardiac or respiratory cause.Witnessed arrest.Duration of arrest (collapse to arrival in ED )