Upload
drtinku-joseph
View
2.339
Download
5
Embed Size (px)
Citation preview
Extracorporeal Membrane Oxygenation
Part-1
Dr.Tinku JosephDM Resident
Department of Pulmonary medicineAIMS, Kochi
Email: [email protected]
Contents in ECMO part 1
What is ECMO ? Evolution of ECMO Types Indications Veno-venous V/S veno-Arterial
ECMO. Cannulation and Circuit
Contents in ECMO part 2
Monitoring ECMO patients Ventilatory strategies Sedation and pain control Anticoagulation Complications Weaning Various ECMO trials. ELSO guidelines. Recent advances
Introduction
Mechanical circulatory support has evolved markedly over recent years.
ECMO (extra corporeal membrane oxygenation) has become more reliable with improving equipment, and increased experience, which is reflected in improving results.
ECMO is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful.
ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery.
Introduction
Instituted in an emergency or urgent situation after failure of other treatment modalities.
It is used as temporary support, usually awaiting recovery of organs.
Introduction
Dynamics of ECMO
Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, – Oxygenate– Extract carbon dioxide
Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.
Extra corporeal Life Support is
achieved by :
- Draining venous blood
- Removing CO2
- Adding oxygen
- Returning to circulation
- Through either a vein or artery
Introduction
• The physiologic goal is to improve tissue oxygen delivery , remove CO2 and allow normal aerobic metabolism whilst the lung rests
• ECMO circulation: - Dual circulation - Nonpulsatile flow
Evolution of ECMO
1953-: Gibbon used 1st artificial oxygenation and perfusion support for the first successful open heart operation.
Direct exposure of anticoagulated blood to oxygen was successful.
Direct gas interface oxygenators -: Dennis, Morrow, Cross, Dewall and Rygg.
Kolobow T-: First attempt at ECMO
BARTLETT –Father of ECMO 1975-: Successfully applied bed
side ECLS device to treat newborn with meconium aspiration.
Developed of better membrane oxygenators.
Evolution of ECMO
First successful ECMO patient, 1971
J Donald Hill MD and Maury Bramson BME, Santa Barbara, Ca, 1971. (Courtesy of Robert Bartlett, MD)
First Neonatal ECMO survivor..
Esperanza, Age 1 day 1975
ESPERANZA-1975
“The Hope”
Esperanza, age 21ESPERANZA-at 21 years
First Neonatal ECMO survivor..
FROM THIS
TO THIS
1989-: Over 100 ECMO centers across the world established Extracorporeal Life Support Organization (ELSO).
Platform of communication and research.
Evolution of ECMO
Summary of History of ECMO
ECMO Society of India 2010 in
Mumbai
Modes of ECMO
Modes of ECMO
ECMO can be categorized according to the circuit used
– Veno-arterial - VA ECMO provides both gas exchange and circulatory support (Heart & Lung failure)
– Veno-venous –VAECMO allows gas exchange only (Isolated Lung failure)
INDICATIONS FOR ECMO
Indications for ECMO-VA
Indications for ECMO-VV
Proposed indications of ECMO in ARDS patients
Indications of ECMO for Respiratory failure- Adults
ARDS Pneumonia Trauma Primary graft failure post lung transplant Status asthmaticus Chemical pneumonitis Inhalational pneumonitis Near drowning
Post traumatic lung contusion Bronchiolitis obliterans Autoimmune lung disease-: Vasculitis, Goodpasture
syndrome. Airleak syndrome
Indications of ECMO for Respiratory failure- Adults
ARDS Pneumonia Status asthmatics Chemical pneumonitis Inhalational pneumonitis Near drowning Bronchiolitis Persistent air leak sydrome RSV infection post CHD surgery.
Indications of ECMO for Respiratory failure- In Pediatric
Inclusion criteria
• Presence of any two of the criteria from the following observed over a period of 4 to 6 hours after maximum medical resuscitation.
PaO2/FiO2 <75% Oxygen index >40% Murrays Score of >3 aA gradient >600 Hypercapnia with PH of
<7.2 observed over more than 3 hours.
Lung compliance <0.5 cc/cmH2O/kg
Irreversibile disease- eg:malignancy Age >75 years Patient on ventilator for >15 days IC bleed Active bleeding from noncompressive
site Irreversible neurological status Unwitnessed arrest or arrest
>30minutes Gross multi organ failure
Exclusion criteria
Absolute Contraindications to all forms of ECMO
Age: > 70 years
Active malignancy
Severe brain injury
Previous Bone marrow transplant, previous
transplant (>30 days).
AIDS
End stage chronic organ failure (hepatic, renal)
End stage cardiomyopathy (except for bridge to VAD/transplant)
Chronic lung disease (except for bridge to transplant)
Multi organ failure
Severe mitral or aortic valvular insufficiency or aortic dissection
(VA only)
Weight >140kg
Unwitnessed cardiac arrest or CPR >60minutes
Absolute Contraindications to all forms of ECMO
Relative Contraindications to all forms of ECMO
Trauma with multiple bleeding sites
Multiple organ failure
VV ECMO-: Absolute contraindications
Anticoagulation issues Severe PAH Severe Rt or Lt heart failure Cardiac arrest
VV ECMO-: Relative contraindications
High pressure ventilation (peak insp pressure >30 cm of H2O) for >7days.
High FiO2 requirement (>0.8) for >7days
Limited vascular access. Refusal to accept blood products
Aortic dissection Severe aortic valve
regugitation Anticoagulation issues
VA ECMO-: Absolute contraindications
– Blood being drained from the venous system and returned to the arterial system.
– Provides both cardiac and respiratory support.– Achieved by either peripheral or central
cannulation.
VA ECMO
VA ECMO
Decreases cardiac work Reduces cardiac oxygen consumption Provides adequate systemic organ perfusion with
oxygenated blood. Prevents over distension of ventricles. Helps in
cardiac recovery. Indications: Already discussed.
VA ECMO
VA ECMO
VA ECMO
Advantages and Disadvantages
Advantages DisadvantagesBoth cardiac and pulmonary support.Instant haemodynamic support
Cannulation of major artery and sacrifice of one carotid in newborn
No mixing of arterial/venous blood. Poor coronary and pulmonary perfusion
Good oxygenation at low ECMO flows
Systemic thromboembolism
No recirculation. Nonpulsatile flow
Oxygenated blood returns to patients arterial circulation
Increased incidence of neurological events
– Provides oxygenation – Blood being drained from venous system and
returned to venous system.– Only provides respiratory support – Achieved by peripheral cannulation, usually of
both femoral veins.
VV ECMO
VV ECMO
Drainage from SVC, IVC, Femoral vein. Flow is determined by the size and placement of the
drainage catheter Centrifugal pump Membrane oxygenator Oxygenated blood returned to the right heart.
VV ECMO
Advantages Pulmonary
circulation/oxygenation is maintained.
No carotid ligation. Pulsatile waveform maintained.
Efficient CO2 removal.
Disadvantages No control of BP. Inefficiency
(recirculation). Hypoxemia (low PO2).
VV ECMO
Cannulation
The establishment and maintenance of adequate vascular access is essential for ECMO
- Patient age and size- Underlying disease & condition- Cause of the cardiorespiratory compromise- Type of support:
– Veno-venous (VV) ECMO – Veno-arterial (VA) ECMO
- Time of the event in relation to the peri-operative period
- Location
Cannulation
For each modality, there are different kinds and sizes of cannulae that can be used
Target ACT should be accomplished before ECMO (heparin 100 units/kg)
3 minutes before cannulation.
Cannulation
Cannulation-VV
Venous cannula should be with the largest lumen and shortest length possible.
Venous cannula should have side holes. Resist kinking Smallest double lumen cannula is size 12 Fr ( for V V ecmo in neonate)
Options For Cannulation in VV ECMOTwo Cannulas One double-lumen cannula
D Brodie, M Bacchetta; N Engl J Med 2011; 365:1905-14.
Drainage cannula– As central as possible– Not too close to the
return cannula Return cannula
– Close to the tricuspid valve
– But not too close to the drainage cannula
Cannula Placement
Fem – Fem Cannulation
Indication
Cannulation in jugular vein not possible.
Higher risk for femoral vein/caval
thrombosis(?)
Cannula Choice
Pedersen et al., Ann Thorac Surg 1997
Hemolysis & Cannula Diameter
Q =DP p r4
8 h L
Flow is proportional to the power of 4 of radius
inversely proportional to tubing length and viscosity
1797-1869
Poiseuille’s Law
Double Lumen Cannula
– Less Recirculation.– Single access.– Possible ambulation.
– Bigger cannula and smaller lumen.
– Image guidance is mandatory.
Double Lumen Cannula
Avantages:
Drawbacks:
Cannulation
Two Cannulas
Double-lumen
Mobilization: ECMO DevicesMobilization is possible .
It probably reduces critical illness polyneuropathy, delirium and muscle atrophy.
It may reduce time on ventilation and improve outcome post lung transplantation.
Insertion
Percutaneous insertion
Guide-wire – Dilators – Cannulas: Use the right tools
188 cannulation attempts.
11 cannulation failures.
3 arterial punctures.
• One leading to distal necrosis.
1 SVC laceration .
1 fatal hemothorax.
• SVC perforation by Reinfusion Cannula.
Venovenous Extracoporeal Life Support Via Percutaneous Cannulation in 94 Patients*
Thomas Pranikoff, MD; Ronald B. Hirschl, MD’; ‘Robert Remenapp, RRT; Fresca Swaniker, MD and Robert H. Bartlett, MD, FCCP
Chest 1999; 115:818-822.
Transesophageal Echocardiographic Guided Placement of a Right Internal Jugular Dual-Lumen
Venovenous Extracorporeal Membrane Oxygenation (ECMO) Catheter
Mazzeffi M J Cardiothorac Vasc Anesth, 2013
Mid-esophageal four-chamber TEE view with white arrow
showing improperly positioned cannula in the
right ventricle.
Modified mid-esophageal bicaval TEE view using color Doppler
compare mode showing return blood flow in the center of the
right atrium directed towards the tricuspid valve. (Color version of
figure is available online).
Dolch et al, ASAIO, 2011.
Always use ultrasound guidance…
Ultrasonic locating devices for central venous cannulation: meta-analysis
Daniel Hind, Neill Calvert, Richard McWilliams, Andrew Davidson, Suzy
Paisley, Catherine Beverley, Steven Thomas
Cannulation-VA
• Through neck vessels(RCC artery and RIJV and or an additional vein)
• Central cannulation
or
• Cannulation of groin vessels
Access and return cannula sites
Access Return
RA Aorta
Femoral Vein Femoral Artery
Subclavian Vein Axillary artery
Internal Jugular Vein Carotid artery
Circuit
• To be continued…• Part 2 Next week