ECMO - Part 1 by Dr.Tinku Joseph

Extracorporeal Membrane Oxygenation
Part-1
Dr.Tinku Joseph
DM Resident
Department of Pulmonary medicine
AIMS, Kochi
Email: tinkujoseph2010@gmail.com

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

ECMO - Part 1 by Dr.Tinku Joseph

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-1975
“The Hope”

ESPERANZA-at 21 years
First Neonatal ECMO survivor..

 1989-: Over 100 ECMO centers across the world
established Extracorporeal Life Support Organization
(ELSO).
 Platform of communication and research.
Evolution of ECMO

ECMO Society of
India 2010 in
Mumbai

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)

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
failure- Adults

 ARDS
 Pneumonia
 Status asthmatics
 Chemical pneumonitis
 Inhalational pneumonitis
 Near drowning
 Bronchiolitis
 Persistent air leak sydrome
 RSV infection post CHD surgery.
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

 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

Advantages and Disadvantages
Advantages Disadvantages
Both 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

 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)

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

Cannulation in
jugular vein
not possible.
Higher risk for
femoral
vein/caval
thrombosis(?)

Pedersen et al., Ann Thorac Surg 1997

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

– Less Recirculation.
– Single access.
– Possible ambulation.
– Bigger cannula and
smaller lumen.
– Image guidance is
mandatory.

 Mobilization is possible .
 It probably reduces critical illness
polyneuropathy, delirium and
muscle atrophy.
 It may reduce time on ventilation
and improve outcome post lung
transplantation.

 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.
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).

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

• To be continued…
• Part 2 Next week

ECMO - Part 1 by Dr.Tinku Joseph

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ECMO - Part 1 by Dr.Tinku Joseph