cannulation concepts and strategies - cecentral
TRANSCRIPT
10/23/2019
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Cannulation Concepts and Strategies
Raj Malyala, M.D.
Assistant Professor of Surgery
Disclosures
No financial disclosures
Many slides are not my own
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Learning Objectives
Upon completion of this educational activity, you will be able to:
• Indicate appropriate cannulation method based on clinical scenario
• Assess when to use hybrid cannulation
Active ECLS Centers
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ELSO Registry January 2017
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ELSO Registry January 2017
Overall Patient Outcomes
Total Runs Survived ECSL Survived to DC
Neonatal
Pulmonary 29,942 25,205 84% 21,948 73%
Cardiac 7,170 4,643 64% 2,938 40%
ECPR 1,532 1,028 67% 627 40%
Pediatric
Pulmonary 8,071 5,424 67% 4,633 57%
Cardiac 9,363 6,404 68% 4,758 50%
ECPR 3,400 1,958 57% 1,414 41%
Adult
Pulmonary 12,350 8,242 66% 7,157 57%
Cardiac 10,991 6,255 56% 4,469 40%
ECPR 3,487 1,382 39% 993 28%
Total 86,306 60,541 70% 48,937 56%
ELSO Registry January 2017
Adult Cases by Diagnosis
Runs % Surv
1 Viral pneumonia 1,275 65
2 Bacterial pneumonia 1,460 61
3 Aspiration pneumonia 193 66
4 ARDS 1,545 56
5 Acute resp fa i lure, non‐ARD 2,105 57
6 Other 5,028 56
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ELSO Registry January 2017
Adult Diagnoses and Survival
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Bacterialpneumonia
Aspirationpneumonia
ARDS ARF, non-ARDS
Other
Died 434 564 65 665 903 2210Surv 841 896 128 880 1202 2818
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Temporary Mechanical Support
• CPB was invented by F. John Gibbon and used in 1953
• Current circuits are for more long term support and use centrifugal pumps
• ECMO was originally developed for Neonates by Bartlett
• Initial role was predominantly respiratory
• Now used for respiratory and cardiac support
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ECMO Schematic
Gas Exchange
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ECMO: Pump and Tubing
A CentriMag Pump
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Rotaflow Pump
Types of Pumps
• Roller Pumps: Move blood forward by compression and displacement
• Centrifugal Pumps: convert mechanical energy into hydraulic energy by virtue of centrifugal force
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Terminology
• ECMO
• ECLS
• RVAD
• LVAD
• Rotoflow
• CentriMag
Putting it all together: When to use which support
• “Blood does not know where it goes”
• Device depends on cannula position, and use of the oxygenator
• If an oxygenator is used, we have ECMO rather than a pure RVAD or LVAD
• If a particular ventricular chamber of the heart is bypassed, then it is an assist device of that chamber
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ECMO/ECLS
• Extracorporeal Membrane Oxygenation/
Extracorporeal Life Support
• Technique to provide cardiac and/or respiratory support in cases of severe acute organ failure
• Commonly subdivided into– Cardiac (venoarterial)• ECPR
– Respiratory (venovenous)
Range of ECMO Patients
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Goals of ECMO Therapy
• Initiate early prior to onset of multi organ dysfunction
• Halt cycle, and restore organ perfusion
• Formulate definitive plan which may includetransfer to a tertiary care facility
• Bridge to a decision regarding treatment or withdrawal of life support
Technical Points
• Use Ultrasound Guidance
• Do not push cannulas if not sliding over wires
• May need to change to an extra stiff wire
• Change to a smaller cannula
• Suture cannulas well and immediately after insertion
• Be careful with air, during insertion and later with procedures
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Anticoagulation
• Heparin
– 5,000 U IV prior to cannulation
– Continuous infusion (PTT goals) unless contraindicated
• If HIT+
– Bivalirudin
– Argatroban
Weaning
• Lots of variables
• Lots of personal preferences
• Need to stabilize, and then support while affected organ(s) recover
• Weaning VA and VV are very different
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Decannulation
• VV
– Clamp cannula(s)
– Stop circuit
– Return blood from circuit
– Remove cannula(s)
– Hold pressure
– Place stitch
Other Studies
• Numerous propensity matched case controlled retrospective series have demonstrated robust survival benefits
• This was shown with H1N1‐associated ARDS patients
• Also with various etiologies of ARDS
• While this is encouraging, it is not the highest level of evidence to demonstrate survival benefit
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Bleeding Complications
• Can occur anywhere from Cannula insertion sites, surgical incisions, lung, gi tract, nose, mouth, thorax, abdomen, and brain.
• Causes: Heparin effect, overdose, coagulopathy, thrombocytopenia, platelet dysfunction, acquired VWS, Hyperfibrinolysis.
Intracranial Bleeding
• Wide range with a frequency between 1.8% to 21%. Higher incidence occurs with routine CT scans
• Increase is associated with prolonged duration, antithrombotic therapy, altered intrinsic coagulation, renal failure, need of blood products.
• In the H1N1 pandemic in Australia and Newzealand, ICH was the most common cause of death among ECMO treated patients.
• In large series, relative risk of death is 1.48 to 2.91.
• However, modality of ECMO does not seem to make a difference
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Reducing ICH
• Unproven:• 1. Lowering ACT goals, prophylactic correction of coagulation factor dificiencies, possible use of Enoxaparin exclusively, low dose anticoagulation
• 2. There is evidence in pediatric and neonatal patients that certain biomarkers may be elevated prior to imaging detection of ICH (S100B, NSE, GFAP and others).
• 3. One Swedish study found that pre admission antithrombotic therapy and low plt count were independently associated with a high mortality with ICH
G.I. Bleeding
• Kiefer et al from Maryland found a 13.6% incidence of GI bleeding• Duration of ECLS (12 days vs 7 days) was a factor• Higher inhospital mortality (83% vs 44%). Odds ratio of 5.91 for in
hospital mortality• Most frequent diagnosis was stress gastritis. • Cause thought to be coagulopathy, systemic inflammation, non
pulsatile blood flow• In a Canadian paper by Cook et al., regarding stress ulcer
prophylaxis, studying 2252 critically ill patients, patients with respiratory failure (odds ratio of 15.6) and coagulopathy (odds ratio of 4.3) were most likely to encounter gi bleeding.
• ECMO patients seems to be thus the highest risk population for gibleeding
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Acquired VW Syndrome in ECLS Patients
• AVWS associated with loss of HMW multimers of VWF, leading to impaired binding of VWF to platelets
• This was studied in 32 patients with ECLS and 19 without.
• Ratios of ristocetin cofactor activity and collagen binding capacity to VWF antigen and multimericanalysis were performed
• 31/32 ECLS patients presented with AVWS, but none of the patients without it.
Thrombotic Complications
• High fibrinogen, Factor VIII levels, heparin resistance, and platelet activation
• LV thrombus may occur in cases of VA ECMO if there is minimal ejection
• Interaction between PVWF and PfHb may explain thrombosis
• Circuit Clots
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Renal Failure
• Incidence is 30‐40%
• In a review of multiple studies, OR for mortality of ECMO and CRRT was about 6.
Survival with Kidney Injury C. Delmas et al. / Journal of Critical Care 44 (2018) 63–71
Patients' outcome at 30 days and 3 months (M3) according to groups 1 and 2. Group 1: No AKI, AKI KDIGO stages 1 and 2 patients (n = 31); group 2: AKI KDIGO stage 3 patients
(n = 29) * and α p b 0.05.
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Uncommon Complications
• Massive Air Embolism
• Can Occur even during routine care of the central line
• Air can enter the venous system, and then the oxygenator, and the arterial line, resulting in immediate shut down of the circuit, and air embolism to the arterial side
• Can also result from a PFO or a Bubble Study
Air Embolism from a Central Line
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Conclusions
• 1. Use of ECLS is expanding world wide• 2. Survival even in patients requiring E CPR far exceeds conventional modalities
• 3. Percutaneous ECMO is flexible and powerful due to rapidity of access and ability to reverse organ dysfunction
• 4. Transport of ECMO patients is safe and is desirable to regional centers with specialized services
• 5. Enables access to tertiary care to patients who cannot be stabilized till definitive treatment