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Adult ECMO

Dennis Disney, RRT-ACCS

Cardiovascular Clinical Specialist

ECMO Clinician

Respiratory Care

Indiana University Health - Methodist Hospital

Objectives

• Review history of ECMO.

• Describe different types of ECMO and the

indications for each.

• Understand how ECMO works.

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“Father of ECMO”

• Dr. Robert Bartlett

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History of ECMO

• First Heart/Lung machine used in 1956.

• Prolonged life support began in 1960’s.

• ECMO initially studied for adult use.

• First successful case in 1971.

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NIH Study of Adult ECMO

in early 1970’s

• Patients critically ill with acute respiratory

failure from a variety of causes (pneumonia,

pulmonary emboli, shock lung) were randomly

assigned treatment with conventional

ventilation or ECMO.

• Trial halted after 90 patients due to a mortality

rate of 90% in both groups.

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NIH Study – early 1970’s

• Although ECMO could support patients in the

short term, most developed irreversible

pulmonary fibrosis from their primary disease

process or the deleterious effects of the high

ventilatory settings they had been on before

ECMO.

• Authors concluded that there was no benefit of

ECMO in terms of survival.

• Use of ECMO in adults all but ceases.

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Neonatal ECMO

• 1974 – Desperately poor, illiterate peasant

farmer in Baja, Mexico discovers she is

pregnant, decides her child will have a better

life as a US Citizen and crosses into Los

Angeles.

• During journey her membrane ruptures, she

exits freeway ASAP and enters Orange County

Medical Center, where her daughter is born.

• Complications due to meconium aspiration, and

despite maximum ventilator settings, it appears

the child will not survive.

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• When the babies pO2 was 12 the situation was

considered hopeless.

• Orange County Medical Center thoracic

surgeon Dr. Robert Bartlett brings a device

from the lab called ECMO. At that time,

approximately 150 adults have been tried with

a 10% – 15% survival rate.

• No neonates had ever been attempted.

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• “Consent” obtained through an interpreter.

Mother signs with an “X” and disappears.

• Baby is named Esperanza (Hope) by the staff.

• After 3 days of ECMO, Esperanza completely

recovers.

• Esperanza (age 34) and Dr. Bartlett in 2008.

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• Dr. Bartlett continues to treat neonates.

• Despite a 90% predicted mortality, 75% survive.

• Why the improvement over adult survival?

1. Reversible causes.

2. Neonatal lung may be inherently more

capable of repair.

3. Neonates were placed on ECMO much

earlier than adults.

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What about Adult ECMO

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All hail CESAR

• Conventional Ventilation or ECMO for Severe

Adult Respiratory Failure

• United Kingdom

• July 2001 – August 2006.

• Published in February 2009

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CESAR

• ECMO patients transferred to an ECMO center.

• Conventional Therapy patients treated at

outlying hospitals.

• 180 patients total – 90 Conventional, 90 ECMO

• Conventional survival = 47%

• ECMO survival = 63%

• Successful study – right?????

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CESAR

• Of the 90 patients selected for ECMO, 22 did

not receive ECMO because they improved with

conventional therapy.

• Therefore ECMO survival = 51% (51% vs 47%).

• Suspect evidence, but we think ECMO works.

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What Revived Adult ECMO

H1N1 Influenza Virus

• April 15, 2009 – first US case.

• April 21, 2009 – CDC working on vaccine.

• April 26, 2009 – US declares H1N1 a public

health emergency.

• By June, 18,000 US cases, mostly young

previously healthy patients.

• CDC estimates 43 – 89 million people had

H1N1 between April 2009 and April 2010 with

8,870 – 18,300 deaths. 15

ECMO

• Due to the severity of the patients, ECMO was

tried at centers capable of providing the

therapy.

• There are about 40 Adult ECMO centers world

wide with a patient survival rate of 50%.

• Indiana University Health is the only ELSO

registered Adult ECMO program in Indiana.

• ECMO does not “treat” the lungs or heart. We

are allowing them time to heal.

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ECMO Team

• ECMO Physicians : Thoracic Surgeons and

Pulmonary/Critical Care Physicians

• Perfusionists

• ECMO Clinician (RN’s & RRT’s)

• RN

• RRT

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ECMO Team

• Communication is CRITICAL!!

• Each team member must be aware of

responsibilities in the event of an emergency.

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Types of ECMO

• V-V

Venous blood drained and returned to the

venous system. Supports the lungs only.

• V-A

Venous blood drained and returned to the

arterial system. Supports both heart and lungs.

• ECPR

V-A access initiated during CPR.

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Patient Selection

V-V

• ARDS

• IPF

• Pneumonia

• TRALI

• PGD

• Bridge to Lung Transplant

• Transition through Transplant

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Patient Selection

V-V

• ECMO used after all available “lung salvage”

modalities have been tried.

o ARDSnet protocol

o Prone Positioning

o Inhaled pulmonary Vasodilators

o HFOV

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Timing of ECMO consideration for

ARDS

• Three phases of ARDS

I. Exudative (inflammatory) phase (0-7 days)

II. Proliferative phase (7-21 days)

III. Fibrotic phase (after 7-10 days)

ECMO must be initiated during the exudative

phase to be effective

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Patient Selection

V-A

• Refractory Cardiogenic Shock.

• Cardiac Arrest.

• Failure to wean from Cardiopulmonary Bypass

after Cardiac Surgery.

• Bridge to either cardiac transplant or placement

of a Ventricular Assist Device.

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Patient Selection

• Must be a reversible process.

• Patient should be placed on ECMO within first 5

days.

• Have an “exit strategy”.

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VA ECMO Cannulation

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VA ECMO Cannulation

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VV ECMO Cannulation

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Avalon Elite Double Lumen

Catheter

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Avalon

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Avalon Malpositioned

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ECMO Circuit

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ECMO Pump & Oxygenator

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Quadrox Oxygenator

• The Quadrox has a surface area of 1.8 m2

• Oxygen added via blender

• CO2 removal determined by “sweep”

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ECMO Management

• Maintain ABG.

• In V-A, may assist maintaining blood pressure.

• Maintain hemostasis (ACT/aPTT).

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Weaning ECMO

• Begin thinking about weaning as soon as you

initiate ECMO.

• Decrease support from ECMO as patient is able

to take on the workload.

• Particularly V-V, watch CXR.

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Ambulatory ECMO

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Ambulatory ECMO

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Ambulatory ECMO

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• 68 total ECMO runs

• 62 patients 63 patients supported on ECMO

• V-V: pts = 31; runs = 34

• V-A: pts = 27; runs = 29

• eCPR: pts = 4; runs = 5

• V-V Survival off ECMO = 29/32 (91%) – 60% Nat’l.

– Survival to discharge = 24/28 (86%) – 50% Nat’l.

• V-A Survival off ECMO = 12/28 (43%) – 55% Nat’l.

– Survival to discharge = 11/28 (39%) – 36% Nat’l.

• eCPR Survival off ECMO = 2/5 (40%) – 40% Nat’l.

– Survival to discharge = 1/5 (20%) – 25% Nat’l

2015 Data (as of 09/08/2015)

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• 214 ECMO Runs

• 198 patients Supported with ECMO

• V-V: pts = 123; runs = 133

• V-A: pts = 66; runs = 68

• eCPR: pts = 10; runs = 13

• V-V Survival off ECMO = 117/131 (89%) – 60% Nat’l.

– Survival to discharge = 101/127 (80%) – 50% Nat’l.

• V-A Survival off ECMO = 35/67 (52%) – 55% Nat’l.

– Survival to discharge = 25/67 (37%) – 36% Nat’l.

• eCPR Survival off ECMO = 6/13 (46%) – 40% Nat’l.

– Survival to discharge = 3/13 (23%) – 25% Nat’l.

Overall Program Data –

2011 to 2014 (as of 09/08/2015)

Case Study

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Brief History – A.C.

• 18 yr old male post

MVA with prolonged extrication.

GCS = 3

• Diffuse Axonal Injury

• Cerebral Edema

• Pulmonary Contusion

• Scalp & Left hand Laceration

• Foreign Bodies in Nasopharynx

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Day 1 CXR

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Day 1 Data

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ABG Vent ECMO

7.40 PRVC

37 550

250 20

22.5 60%

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Day 2 CXR

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Day 2 Data

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ABG Vent ECMO

7.39 PRVC

38 550

256 16

22.9 40%

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Day 7 CXR

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Day 7 Data

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ABG Vent ECMO

7.33 BiVent

42 Phigh 22 /Peep 5

61 Thigh 3.2/Tlow0.8

22.3 RR 15

70%

Day 8 CXR

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Day 8 Data

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ABG Vent ECMO

7.29 BiVent - Prone

53 Phigh 22 /Peep 5

76 Thigh 4.5/Tlow0.6

25.6 RR 12

100%

Day 10 CXR

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Day 10 Data

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ABG Vent ECMO

7.38 BiVent Flow 4.6

45 Phigh 30 /Peep 0 RPM 4100

64 Thigh 4.5/Tlow0.6 FiO2 100%

26.3 RR 12 Sweep 2.0

Post ECMO 60% Initiate @ 1715

Day 12 CXR

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Day 12 Data

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ABG Vent ECMO

7.38 BiVent Flow 4.8

45 Phigh 28 /Peep 5 RPM 4300

75 Thigh 2.3/Tlow0.5 FiO2 100%

26.3 RR 21 Sweep 3.5

100%

Day 14 CXR

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Day 14 Data

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ABG Vent ECMO

7.44 BiVent Flow 4.9

39 Phigh 28 /Peep 5 RPM 4400

84 Thigh 3.0/Tlow0.5 FiO2 100%

26.6 RR 17 Sweep 5.0

60%

Day 16 CXR

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Day 16 Data

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ABG Vent ECMO

7.48 PRVC Flow 4.27

37 500 RPM 3800

64 20 FiO2 100%

27.6 50% Sweep 3.0

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Day 18 CXR

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Day 18 Data

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ABG Vent ECMO

7.42 PRVC Flow 4.43

42 700 RPM 4000

95 20 FiO2 60%

27.1 50% Sweep 2.0

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Day 20 CXR

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Day 20 Data

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ABG Vent ECMO

7.49 PRVC Flow 4.39

42 600 RPM 4000

77 20 FiO2 30%

32.2 50% Sweep 1.5

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Day 23

• Off ECMO @ 1235

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Day 24 CXR

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Day 24 Data

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ABG Vent ECMO

7.47 PRVC

52 550

134 20

37.3 50%

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Day 29

• Discharged to rehab facility

• And then …….

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