ecmo bridge to recovery
DESCRIPTION
Extracorporeal Membrane OxygenationTRANSCRIPT
ECMO ndash A BRIDGE TO RECOVERY
Dr SK Varma MS FRCS(Ed) MCh DNB FIACS
Chief Cardiothoracic Surgeon
KG Hospital Coimbatore 641018
wwwskvarmacom
What is ECMO
bull Extra corporeal
bull Membrane
bull Oxygenation
bull (Pump)
When Is ECMO Used
bull Support the failing heart and or lungs by temporarily taking over their functions allowing rest and repair and rejuvenation
bull Bridge to recovery
bull Bridge to transplant
Pumps
bull Centrifugal
bull Roller
Membranes
bull Silicone rubber
bull Microporuspolypropylene
bull Polymethyl pentene
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
What is ECMO
bull Extra corporeal
bull Membrane
bull Oxygenation
bull (Pump)
When Is ECMO Used
bull Support the failing heart and or lungs by temporarily taking over their functions allowing rest and repair and rejuvenation
bull Bridge to recovery
bull Bridge to transplant
Pumps
bull Centrifugal
bull Roller
Membranes
bull Silicone rubber
bull Microporuspolypropylene
bull Polymethyl pentene
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
When Is ECMO Used
bull Support the failing heart and or lungs by temporarily taking over their functions allowing rest and repair and rejuvenation
bull Bridge to recovery
bull Bridge to transplant
Pumps
bull Centrifugal
bull Roller
Membranes
bull Silicone rubber
bull Microporuspolypropylene
bull Polymethyl pentene
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Pumps
bull Centrifugal
bull Roller
Membranes
bull Silicone rubber
bull Microporuspolypropylene
bull Polymethyl pentene
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Membranes
bull Silicone rubber
bull Microporuspolypropylene
bull Polymethyl pentene
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
ECMO Cannulae
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
ECMO Machines
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
History of ECMOhellip = hellipHistory of CPB
Pump ndash heart substitute
Gas exchange mechanism ndash Lung Substitute
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
History of ECMOhellip
bull 1953
bull John Heysham Gibbon Jr
bull Jefferson Medical College Hospital (Philadelphia)
bull First successful use of Cardiopulmonary bypass
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
History hellip
bull Atrial Septal Defect Closure
bull Cecelia Bavolek 18F
bull 45 minutes
bull 26 minutes
Next 3 patients died
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Historyhellip
bull 1954
bull Clarence Walton Lillehei
bull University of Minnesota
bull Controlled cross circulation (VSD Closure 1M child connected to fathers circulation)
bull 19 minutes
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
History helliphellip
bull 1970
bull Theodore Kolobow
bull Membrane Lung (no direct contact between blood and gas)
bull Silicone rubber (Kolobowrsquos orginal)
bull Microporus polypropylene
bull Polymethyl pentene
bull Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung
bull Patent number 4093515bull Abstract A blood-compatible gas-permeable laminated
carbon-containing silicone rubber membrane for use in a membrane artificial lung The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion
bull Type Grantbull Filed March 1 1976bull Issued June 6 1978bull Assignee Government of the United Statesbull Inventor Theodor Kolobow
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Historyhellip
bull 1972
bull Dr J Donald Hill
bull SanFransisco (CA)
bull First successful adult ECMO
bull 24M Polytrauma with ARDS
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
History hellip
bull 1975
bull Robert Bartlett
bull Orange County Hospital
Los Angeles CA
bull First successful neonatal ECMO
(I day old Mexican immigrant)
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Historyhelliphellip
bull Baby ldquoEsperenzardquo(Baby of hope)
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Historyhelliphellip(ELSO Registry 1989)
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Historyhelliphellip (Cesar Trial 2006)
BMC Health Serv Res 2006 6 163CESAR conventional ventilatory support vs extracorporeal membrane
oxygenation for severe adult respiratory failureGiles J Peek1 Felicity Clemens2 Diana Elbourne2 Richard Firmin1 Pollyanna
Hardy23 Clare Hibbert5 Hilliary Killer1Miranda Mugford4 MariammaThalanany4 Ravin Tiruvoipati1 Ann Truesdale2 and Andrew Wilson6
An estimated 350 adults develop severe but potentially reversible respiratory failure in the UK annually Current management
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
TYPES OF ECMO
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Veno Arterial ECMO (V-A ECMO)
bull Cardiac Support
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Veno Venous ECMO (V-V ECMO)
bull Lung Support
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Indications for V-A ECMO
bull Inability to wean off CPB after cardiac surgerybull e CPRbull Post MI Cardiogenic shock (refractory to IABP) ndash MR
- VSD- Free wall rupture
- Refractory arrhythmiasbull Post sepsis cardiogenic shockbull Acute viral myocarditisbull Massive bilateral pulmonary embolismbull Cardiac or major vessel blunt traumabull Peripartum cardiomyopathy
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Indications for V-V ECMO
bull ARDSbull Massive bilateral extensive pneumoniabull e CPR (drowning)bull Neonates (meconium aspiration HMD)bull Aspiration pneumoniabull Massive lung contusion after chest traumabull Smoke inhalation injurybull Intractable status asthmaticusbull Pulmonary alveolar protienosis (some forms)
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Criteria for ldquoLung Failure needing ECMOrdquo
bull Murray score gt3 (PaO2FIO2 ratio CXR PEEP Compliance)
bull Hypercarbia pCO2 gt70mm
bull Hypoxia pO2 lt50mm
bull Acidosis pH lt72
bull pAO2 FIO2 ratio lt75
bull Lung compliance lt05ml cmH2O Kg
bull Ventilation index gt40
bull FIO2 requirement of 100 gt6hrs
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Unable to wean off CPB despite optimal inotropes and IABP
bull Cardiac arrest in hospital ( CPRgtgt 30 min)
bull ECHO EF lt20
Aortic velocity time index lt8cm
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Criteria for ldquoCardiac Failure needing ECMOrdquo
bull Systemic index lt18LminM2
bull PCWP gtgt25mm
bull Serum Lactate gt10mmolsL
bull Mixed venous O2 sat ltlt65
bull Inotrope score of gtgt20 (sum of all inotropes in mcgkgmin at peak infusion rate)
bull Mean arterial pressure lt60mm adults (lt40mm infants) for more than 6hrs
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Exclusion Criteria
bull Primary disease is irreversible (disseminated malignancy)
bull Age gt75 years
bull On ventilator gt15 days
bull Irreversible indeterminate neurological prognosis
bull Any immunosupressed state
bull Already in multiorgan failure
bull Pre-existing coagulopathy
bull Severe pulmonary hypertension
bull Severe aortic regurgitation
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
ECMO Management
bull Anticoagulation (around 200 secs)
bull Top up transfusion (platelets RBCs)
bull Sepsis prevention
bull Nutrition
bull Prevent LV distension
bull Monitor recovery
bull Rx of underlying cause
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
How Longhellip
bull ELSO Data 117 days
bull Average V-V ECMO 14-21days
bull V-A ECMO 5-14 days
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Complications
bull Hemolysisbull Thrombocytopenia (mechanical heparin
induced)bull Bleeding bull Sepsis (access site and systemic)bull Intracerebral hemorrhage bull Intracerebral micro infarctsbull Oedemabull Malnutrition hypoalbuminemiabull Limb ischemia
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Results
bull V V ECMO 65-70
bull V A ECMO 50
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Practical Difficulties
bull Very labour intensive
bull Very cost intensive
bull Experienced team
bull Reliable blood bank support 247
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
bull When all else fails helliphelliphellipwhen life is sure to ebb awayhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
bull Cometh the hour helliphelliphelliphellip cometh the man
bull ECMO
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Future of ECMO
bull Increased accessibility and use
bull Reduction in costs
bull Insurance government support
bull Smaller lines volumes oxygenators
bull Coated ldquostealthrdquo tubings
Thank You
Thank You