ECMO.pptx
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This document discusses extracorporeal membrane oxygenation (ECMO), including its indications, types (veno-arterial and veno-venous), management strategies, and the experience with ECMO at Heart Hospital. ECMO can be used as a bridge to recovery, decision-making, surgery, long-term devices like LVADs, or transplant. It involves draining blood from the body, removing carbon dioxide and adding oxygen through an external oxygenator before returning the blood. Management involves anticoagulation and monitoring various patient parameters. Complications can include bleeding, infection, and organ dysfunction. Criteria and protocols are discussed for weaning patients off ECMO support.
ECMO.pptx
- 1. Muhammad Naveed Saeed BSc. RCIS. Cardiac Cath Lab Hamad Medical Corporation. Heart Hospital
- 2. Extracorporeal Membrane Oxygenation (ECMO): Indications and Management Strategy Muhammad Naveed Saeed BSc. RCIS. Cardiac Cath Lab Hamad Medical Corporation. Heart Hospital
- 3. OBJECTIVES Understand the clinical indications for ECMO therapy Identify procedural strategies and techniques of ECMO therapy Discuss management strategy of ECMO in the ICU Brief about the ECMO experience at Heart Hospital
- 4. PHYSIOLOGY of ECMO Basic principle: De-saturated blood is drained via a venous cannula, CO2 is removed, O2 added through an “extracorporeal” device (an oxygenator), and the blood is then returned to systemic circulation via another vein (VV ECMO) or artery (VA ECMO)
- 7. TYPES OF ECMO: Veno-arterial bypass - supports the heart and lungs Veno-venous bypass – supports the lungs only
- 10. VV ECMO Perfusate blood returned to systemic circulation via venous cannula – travels into right ventricle and next pulmonary vasculature and is returned to the systemic circulation Volume removed = volume returned; therefore no net effect on CVP, ventricular filling, or hemodynamics CO2/O2 content in arterial blood supply is that of the blood arriving to right ventricle + any effects from gas exchange from remaining pulmonary function
- 11. VA ECMO Replaces/augments both pulmonary and cardiac function Perfusate mixes in the aorta with blood from left ventricle (arriving from compromised lungs); thus O2/CO2 content = content of blood returning from the circuit + that of pulmonary source; Systemic blood flow = ECMO flow + pt’s own CO
- 12. Role of ECMO in Cardiogenic Shock Bridge to recovery (BTR) Bridge to decision (BTD) Bridge to surgery Bridge to long-term VAD Bridge to transplant (BTT)
- 13. IABP in Cardiogenic Shock Can initially stabilize patient May not provide enough support Requires a certain level of LV function Limited by persistent tachycardia / arrhythmias Does not unload the RV Provides some pulsatile flow with ECMO
- 14. BRIDGE TO RECOVERY Indications • Acute MI • Acute decompensated HF • Post-cardiotomy syndrome • Acute myocarditis • Severe rejection in transplant • Takotsubo’s • Massive PE • Respiratory failure and ARDS
- 15. BRIDGE TO SURGERY Indications • Mechanical complications of AMI • VSD • Severe MR from papillary muscle rupture • CAD requiring CABG • Massive PE with heparin failure
- 16. BRIDGE TO Long-term VAD Indications • Unable to wean off ECMO • Difficult donor match for transplant • Not a transplant candidate => LVAD as Destination Therapy
- 17. BRIDGE TO TRANSPLANT Indications • Unable to wean off ECMO • Transplant candidate • Easy donor match for transplant
- 18. Predictors of Poor Outcomes Multiorgan dysfunction ARDS with sepsis Severe neurological injury Long time interval between shock and initiating ECMO
- 19. How long does ECMO last? Advances in life-support technologies and expertise are making it possible for patients to remain on ECMO for much longer.
- 20. VA Advantages & Disadvantages Easy to use Circulatory support Instant stabilisation Huge experience Right heart offloaded and rested Carotid ligation Jugular ligation Raised LV afterload Reduced pulmonary blood flow Hypoxic coronary perfusion Stun- high LV afterload Duct
- 21. CONTRAINDICATIONS Major CNS injury Severe anoxia Embolic or hemorrhagic stroke Intracerebral hemorrhage Multiorgan failure Metastatic disease Overwhelming sepsis
- 22. Equipment: Cannulas VV ECMO: Jugular vein, femoral vein VA ECMO Vein: femoral Artery: Femoral Axillary Aorta
- 23. Axillary vs Femoral Cannulation AXILLARY Side-arm graft sewn on Antegrade perfusion better for cerebral and aortic root oxygenation, especially when lungs not oxygenating Increased afterload Risk of arm hyper- perfusion FEMORAL Percutaneous Need antegrade stick for forward perfusion Retrograde perfusion increases atheroembolic risk Ad-mixing with cardiopulmonary circulation => indequate cerebral and aortic root oxygenation if lungs not oxygenating
- 25. Equipment: Pump, Oxygenator Thoratec Centrimag pump & motor Centrimag console Maquet Quadrox oxygenator
- 26. ECMO Management
- 27. Anticoagulation IV Heparin, target ACT of 200-240 seconds to prevent clotting upon interference of blood with prosthetic surfaces and in stagnant areas. If high bleeding risk, ACT 180-220 s Watch for platelet drop and heparin induced thrombocytopenia (HIT)
- 28. Monitoring an ECMO patient Continuous cerebral SaO2 CVP, PAP, CO CXR – assess pulmonary edema SvO2: 75% in VA ECMO and 85-90% on VV ECMO considered adequate as long as CO normal EtCO2 – measures return of native lung function aBG, lactate – tissue perfusion Urine output, fluid balance – renal function Labs: renal, hepatic function Platelet count
- 29. POTENTIAL RISKS Infection Bleeding Brain Surgical site Non-pulsatile flow Renal insufficiency Peripheral ischemia Limb complications Arm hyperperfusion Leg ischemia Air in circuit Pump malfunction Clots in the circuits Heat exchanger malfunction Cannula dislodgement
- 30. Criteria for Weaning ECMO Pulmonary edema resolved Minimal inotropes / pressors End-organ dysfunction nearly recovered
- 31. ECMO Weaning Protocol ICU ECMO flow down to 1-1.5 L/min for 5 min Assess CVP, PAP, CO TTE to assess LV, RV function OR 3000-5000 U heparin ECMO flow down to 1 L/min Assess CVP, PAP, CO TEE to assess LV, RV function, septal position Explant ECMO if appropriate
- 32. Past & Next steps for ECMO at Heart Hospital
- 33. CONCLUSIONS
- 34. Thank You.
Editor's Notes
- #2: Not in my mind what have to present and which one is easily present because of some other business atually I don’t have time to prep slides. So 5 days before finally decided present some thing out from cath lab and out of my mind. So today finally presenting ECMO and we will learn together in today session .
- #3: ECMO is an advanced form of temporary life support, to aid support respiratory and/or cardiac function.
- #6: Gibbon was the first to use artificial oxygenation and perfusion support for the first successful open-heart surgery in 1953.
- #7: Ten years later in 1963, Kolobow described the construction and evaluation of an alveolar membrane artificial heart lung . This was “the embryo” of the ECMO, which was first successfully used in treatment by Hill in 1971.
- #8: The two most common forms of ECMO are veno-venous (VV) and veno-arterial (VA). In VV-ECMO, used to support gas exchange, oxygenated blood is returned to a central vein. In VA-ECMO, used in cases of cardiac or cardiorespiratory failure, oxygenated blood is returned to the systemic arterial circulation, bypassing both the heart and lungs.
- #9: ECMO circuit consists of specialized cannulae attached to tubing connected to a centrifugal pump. Venous blood is siphoned into an extracorporeal artificial membrane oxygenator, and oxygenated blood is returned to the systemic venous circulation. The oxygenator consists of numerous low-resistance, hollow, fibers that allow for oxygen transfer across membrane from gas to blood interphase. VV ECMO improves systemic oxygenation and provides for a reduction in ventilatory inflation pressures, thereby decreasing ventilator-induced lung injury and facilitation of lung recovery.
- #10: majority of cases using VV ECMO, in this type right femoral vein is used for venous drainage and the internal jugular vein is used for venous return If patients were unable to lie down for intubation due to dyspnea or a high risk of respiratory arrest during induction, femoral vein drainage and femoral return to the right atrium was performed in the sitting position If additional heart support was necessary during VV ECMO, we added a return cannula to the femoral artery and employed veno-arterial ECMO (VA ECMO If cardiac arrest occurred due to breath-holding, we initially used VA ECMO. For VA ECMO 5000 heparin immediately before cannulation. ACT was maintained for approximately 180-240 s.
- #11: When conventional ventilatory therapies aren’t enough that time use VV ECMO VV ECMO does not support systemic circulation or alter hemodynamics,
- #12: V-A ECMO. V-A, or veno-arterial ECMO, supports both heart and lung function. The surgeon will place two cannulae, one in a large vein and one in a large artery so that blood can be taken out of a vein and returned into an artery.
- #13: ECMO is a life support for patients with severe life-threatening condition will that’s mean will significant affects on heart or lungs. What is the main job of ECMO. keeps blood moving through the body and keeps blood gasses in balance (oxygen and carbon dioxide) …….Just clear ECMO does not treat lung or heart failure, but does the jobs of the heart and lungs temporarily ― allowing them to “rest.”
- #14: IABP use in ECMO for increase coronary perfuison ,
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- #20: The duration of ECMO treatment depends on the underlying problem with the person’s heart or lungs. ECMO treatment may last only a few hours or days, but in some cases, ECMO might continue for weeks. Before the COVID-19 pandemic, according to Dr. Glenn Whitman director of the cardiovascular surgical intensive care unit. at Johns Hopkins the average ECMO treatment lasted about 10 days, In Hamad Hospital one patient keep on ECMO for 10 months. Credit goes to management team making it possible for patients to remain on ECMO for much longer.
- #22: Metastatic disease example of stage IV cancer cells spread to other parts of the body is called metastasis. Sepsis is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death.
- #23: Cannulation based on patient BSA for adult standard BSA use 2.4 and for children BSA 2.8
- #24: Peripheral cannulation in femoral or axillary artery is generally preferred over central cannulation in ascending aorta. No cannulation strategy for VA-ECMO is perfect. Surgeons should make individualized decisions on the appropriate arterial cannulation site and revise to an alternate cannulation site when required.
- #25: Femoral cannula configuration illustration (left) and intraoperative photograph (right): femoral artery vascular graft (1) was used for arterial perfusion; a regular 25F venous cannula (2) was introduced up to the inferior vena cava-right atrium junction from the femoral vein; and an extra 14F cannula (3) was inserted into the distal femoral vein.
- #28: INR 1.5 to 2.0 ACT 180 to 240 APPT 50-60
- #30: Infections can be associated with the devices used in medical procedures, such as catheters or ventilators. These healthcare-associated infections (HAIs) include central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia.
- #33: In November 2019, HMC set up a Heart and Lung Transplant Taskforce team, led by Professor Takahiro Oto, an internationally renowned expert in lung transplantation., Previous announcement in early 2021 as per Medical Director of Hamad General Hospital and Director of Qatar Center for Organ Transplantation, Dr. Yousef Al Maslamani. The first heart transplant is expected to take place in the current year of 2022 Heart Hospital planning to start Heart transplant Programm very soon and Heart Hospital management working on it closely. So far successfully done 3 Lungs transplant in HMC which covered by Heart Hospital Perfusionist team. We believe that our dedicated ECMO team, part of multidisciplinary team and approach and commitment to provide maximize the chances of successful achieved Qatar MOPH milestone.
- #34: Rapidly evolving technology Increasing array of indications Excellent “tool” for ACS with cardiogenic shock Shifting the paradigm of “bridge to recovery” Presently investigating the “science” behind the clinical results
- #35: I'd like to thank you for your time and attention today. Thank you so much for your interest and attention.