respiratory ecmo
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Respiratory ECMO
Sachin ShahAdult Intensive Care UnitRoyal Brompton HospitalLondon
Disclosures
Objectives
• Respiratory ECMO service
• Referrals
• Practical aspects
• Case discussion
Respiratory ECMO Service
Single adult centre (Glenfield, Leicester) 1989-2011
H1N1 pandemic, temporary commissioning:
2009-10 3 extra centres (RBH, Papworth, Aberdeen)
2010-11 5 extra centres
2011 - contracts awarded to 5 hospitals in England
Geographical service - based on critical care networks
Referral criteria similar to CESAR study
Centres expected to collaborate to provide national service
ECLS in ICU
Modality PumpBlood flow
rate (l/min)Physiological effects
VA - ECMO Yes 4 - 6oxygenation, CO2 removal
cardiac support
VV - ECMO Yes 2 - 6 oxygenation & CO2 removal
AV - ECCO2R
‘Novalung’No 0.7 - 1.5 partial CO2 removal
VV - ECCO2R Yes 0.2 - 0.5 partial CO2 removal
Technical
difficulty
Rescue therapies
Development of ECMO
1967 Description of ARDS
Ashbaugh
1970 Injured lungs susceptible to over-distension (VALI)
Mead
1972 First successful ECMO in adult ARDS patient
Hill
1979 RCT of ECMO for adult ARDSZapol
1990s Positive UK collaborative RCT - neonatal ECMO
Adult case series - enthusiastic centres
Rationale for vv ECMO
Maintain oxygen deliveryPatients with severe hypoxamia
Control respiratory acidosisPatients with severe hypercarbia
Lung protective ventilation (rest settings)Decrease FiO2
Decrease Vt, Paw and respiratory rate
Improved haemodynamic stability
Buy timeTreatment of primary disease
Optimisation of supportive care
Indications
WythenshaweGlenfieldPapworthGSTTRoyal Brompton
London
NHS England adult respiratory ECMO centres
• Minimum 20 adult cases per year
• ECMO units must have
– capability for ECMO retrieval
– based in a cardiothoracic hospital
– provide surge capacity
– ability to provide all modes of advanced respiratory support
– clear referral & repatriation networks
• Joint audit & service development
• Service started on December 1st 2011
UK ECMO Commissioning
UK H1N1 ECMO service 2009-10
3 additional ECMO centres commissioned
Royal Brompton, London
Papworth, Cambridge
Aberdeen, Scotland
Royal Brompton H1N1 experience
20 adult patients referred for ECMO and
admitted
10 patients managed with ECMO
80% overall survival to home
http://www.elso.med.umich.edu/
ELSO
160 member institutions
Multidisciplinary
ECLS registry: > 40,000 cases
Meetings
Education
Support research & regulatory agencies
http://www.elso.med.umich.edu/
ASAIO Journal 2013;59:202–210
Adult Respiratory Outcomes - ELSO
Overall survival: 55% 2011 - 58%
Evidence for ECMO in severe acute respiratory failure
• Many case series
• One older randomised controlled trial (1970s)
• One recent randomised controlled trial (CESAR)
• One recent cohort study (H1N1)
• Randomised controlled trial currently underway (EOLIA, NCT01470703) – due 2015
The first randomised controlled trial of ECMO for severe acute respiratory failure
Zapol et al. JAMA 1979; 242: 2193-96
Inclusion criteriaPaO2 <50mmHg on fiO2 1.0 for 2 hours and PEEP ≥5cmH2O
or PaO2 <50mmHg on fiO2 0.6 for 12 hours and PEEP ≥ 5cmH2O
Exclusion criteriaAge <12 or >65 years
Duration of pulmonary insult > 21 daysPulmonary capillary wedge pressure > 25mmHg
Chronic or irreversible systemic disease
ECMO therapyNine centres
Veno-arterial bypass
Cessation of ECMO supportPaO2 ≥70mmHg on FiO2 0.6, PEEP 5cmH2O, ECMO flow 0.5L/min for 6 hours
Technical complications, excessive bleedingNo improvement after 5 days ECMO
Results
• 90 patients randomised to veno-arterial (VA) ECMO or conventional management
• 4 survivors in each group
Zapol et al. JAMA 1979; 242: 2193-96
Why was outcome so poor?
• Inexperienced centres (<5 patients treated at each centre)
• VA (not VV) ECMO
• Excessive bleeding
• Duration of ventilation pre-ECMO >9 days(7 of the 8 survivors ventilated <7 days)
• No lung rest
Zapol et al. JAMA 1979; 242: 2193-96
Potential effects of high volume and high pressure ventilation
Fu et al. J Appl Physiol 1992; 73: 123-33
PneumothoracesPneumomediastinumSubcutaneous air
Rupture of alveolar capillaries
ARDSnet ARMA trial
• 861 patients with ARDS
• Randomised to tidal volume 6ml/kg vs 12ml/kg PBW
• Actual tidal volume 6.2±0.8 vs 11.8±0.8 ml/kg PBW
• Actual Pplat 25±6 vs 33±8 cmH2O
First 50 adult ECMO patients at Glenfield Hospital
• 1989 to 1995, veno-venous ECMO
• ‘Lung rest’• Peak inspiratory pressure 20cmH2O
• PEEP 10cmH2O
• Rate 10 breaths/min
• FiO2 0.3
• Survival to hospital discharge 66%
• Mean duration of ECMO support >8 days
• Improved survival compared with historical controls
Peek et al. Chest 1997; 112: 759-764
Other case series of ECMO in ARDS
Author
(location)
Reference Years n Diagnoses Outcome
Peek
(Leicester)
Chest 1997; 112: 759-64 1989-1995 50 Pneumonia and ARDS 66% hospital discharge
Lewandowski
(Berlin)
Intensive Care Medicine 1997;
23: 819-835
1989-1995 49 ARDS 55% ICU survival
Ullrich
(Vienna)
Anaesthesiology 1999; 91:
1577-86
1995-1997 13 ARDS 62% ICU survival
Kolla
(Ann Arbor)
Ann Surg 1997; 226: 544-64 1990-1996 100 Pneumonia and ARDS 54% hospital survival
Frenckner
(Stockholm)
Minerva Anestesiol 2002; 86:
381-6
1995-2002 38 Respiratory failure
(mainly pneumonia)
66% 30d survival
Hemmila
(Ann Arbor)
Ann Surg 2004; 240: 595-607 1989-2003 255 Severe ARDS 52% hospital survival
What did we learn from case series?
• Survival of patients receiving VV ECMO improving
• Duration of ventilation pre-ECMO
• Age
• Bleeding/transfusion
• Cannot reach firm conclusions regarding efficacy of ECMO without RCT...
Conventional ventilatory support vs
ECMO for
Severe
Adult
Respiratory failure
71 % discharged home6 (8%) remained in patients
• 1972 – first report of successful use of extracorporeal circulation to treat acute hypoxaemia respiratory failure in an adult patient
Hill JD et al. J Thorac Cardiovasc Surg 1972; 64: 551-562
ECMO during CESAR
ECMO cart
ECMO - complications
HaemorrhageIntracranial (CESAR 4.5%, ANZ 9%)
Gastrointestinal
Nasal
Circuit problemsCircuit clotting
Circuit air
Motor failure
Cannulation problems
RBH activity 2014 – commissioned pathway
N
Referrals 159
AdmissionsECMO / ECCO2RVA ECMONovalungNo extracorporeal support
4339413
Patients not admittedFutility“Too well”Referrer wants to keepLack of capacity(transferred by RBH)
60136
284
Demographics
• Age 43 yrs mean Range 17-66 yrs
• Sex 55% male
Definitive microbiology diagnosis in 46% patients
Percentage Percentage on total Associated infections
Pneumococco 15% 7% - Influenza B 2%
Influenza A 15% 7% - Influenza B 2%
Legionella 11% 5%
PCP 8.7% 4% - HIV 75%- Staph aureus 25%
Pseudo aeruginasae 8.7% 4% - CF 50%
TB 8.7% 4%
Influenza B 8.7% 4% - MRSA 25%- MSSA 25%- Pneumococco 25%- Influenza A 25%
Staph aureus 8.7% (25% MRSA) 4%
E.Coli in BAL (aspiration
pneumonia)
2% 1%
Percentage Percentage on total Associated infections
Adenovirus 2% 1%
Coliforms in BAL 2% 1%
Human Metapneumovirus
2% 1%
K. pneumoniae in TA(aspiration
pneumonia)
2% 1%
Mycoplasma 2% 1%
PVL 2% 1%
RSV 2% 1%
VRE sepsis inaspiration
pneumonitis
2% 1%
Diagnosis with no positive microbiology in 54% patients
ECMO patients 2014
0
5
10
15
20
25
30
35
40
45
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Min
ECMO
ECMO bed-days
0
100
200
300
400
500
600
700
800
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Cu
mu
lati
ve b
ed
day
s o
n N
HSE
pat
hw
ay
Beds used
+ 480 standard bed days
Retrievals2013-14 2014
Retrievals 37 40
Median distance round trip, miles 32 75
Total distance, miles 3978 5230
Mobile ECMOMobile VA ECMO
24 352
Plus 9 retrievals for non-NHSE ECMO pathway:
2014
Retrievals 9
Median distance round trip, miles 28
Total distance, miles 1621
Mobile ECMOMobile VA ECMO
53
Referrals
http://www.rbht.nhs.uk/healthprofessionals/clinical-departments/critical-care/ecmo/
Management at local hospital
• Haemodynamically stable
• Cardiac output monitoring
• Echo
• Consider proning
• Fluid management
Preparing for retrieval
• Checking equipment
• Call team (ECMO consultant, perfusionist, ECMO fellow)
• Call ambulance
• Communication
Preparation locally
• Next of Kin
• At-least two units packed cells cross matched and available
• Imaging transfer (IEP)/CD’s
• Anaesthetic Team
• Transfer patient on ICU ventilator
• Theatre space with scrub nurse
• Radiographer with image intensifier
Theatre preparation
• Standard trolley
• Fenestrated drape used for central cannulation
• Total body drape
• Swabs
• Jug with normal saline
• Ultra-sound for central access
Returning
• Will carry cross matched blood with us
• Use your front line ambulance service
Guidance for ambulance
• Compatible with Stryker locking device fitted to LAS 5 series ambulances
• Vehicle with tail lift
• 240V power inverter with standard three pin UK plug
• Full oxygen supply
Summary
• ECMO referral pathway
• Evidence
• Logistic
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