1. Whats new in extracorporeal lifesupportHergen Buscher

2. Definition External artificial circuit carries venous blood from the patient to anoxygenator. Blood becomes enriched with oxygen and has carbon dioxide removed. The blood is than returned to the patient via a central vein or an artery. 3. Allow time to recoveryIt most cases recovery is seen between 7 to 14 days 4. 16 year old boy with goodpasture syndromeOn admission 28 days later 5. 51 year old patient withpolypharmacy overdoseNo pulsatility Same patient 6 days later 6. Cannulation 7. Cannulation 8. Cannulation 9. Cannulation 10. Cannulation 11. Cannulation 12. Cannulation 13. Cannulation 14. Cannulation 15. Indications VVInability to maintain SaO2 > 88 or pH > 7.20 with safe mechanical ventilation Plateau pressure < 35cmH2O and Tidal volume 70 17. Conditions VAGood Acute fulminate myocarditis Cardiomyopathy (first presentation) Chronic cardiomyopathy (suitable for VAD) Primary Graft Failure post heart transplant AMI (with early revascularisation) Drug overdose Pulmonary EmbolismVariable Multiple organ failure Late revascularisation Septic shock Post cardiotomy 18. Contraindications Age: > 70 years Active malignancy Severe brain injury Previous Bone marrow transplant, previous transplant (>30 days), AIDS End stage chronic organ failure (hepatic, renal) End stage cardiomyopathy (except for bridge to VAD/transplant) Chronic lung disease (except for bridge to transplant) Multi organ failure Severe mitral or aortic valvular insufficiency or aortic dissection (VA only) 19. ARE THESE PROVENINDICATIONS? 20. ECMO (n=90 patients) Conventional management (n=90) 68 (75%) patients actually receivedECMO 63% of patients consideration fortreatment by ECMO survived 47% of patients on conventionalmanagement survived Relative risk 0.69; 95% CI 0.050.97,p=0.03 Quality-adjusted life-year: 19 252 21. ResearchEXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) FOR SEVEREACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)A multicenter, randomized, controlled open trialEOLIA : ECMO to rescue Lung Injury in severe ARDSPromoter:Dpartement de la Recherche Clinique et du Dveloppement (DRCD)Assistance PubliqueHpitaux de Paris 22. Research cooperation 23. ISICEM Brussels March 2014Brussels presentations 24. Paradigm shift in extracorporeal lifesupportShould it bedone?How should it be done?When should it be done? 25. Key points of modern ECMO management 26. Subclavian Artery Cannulation forAmbulatory VA ECMOJavidfar, ASAIO 2012 27. Proning patients on ECMO 28. Mobile ECMO More experience -> more confidence Less sedation Better cannulation Team approach ECMO Patient -> Patient with ECMO 29. Mobile ECMO More experience -> more confidence Less sedation Better cannulation Team approach ECMO Patient -> Patient with ECMO 30. New Generation ECMO Consoles 31. Mobile ECMO 32. Pharmacokinetics ex vivoShekar, Crit Care 2012 33. Pharmacokinetics in vivo 34. ASAP ECMO: Antibiotic, Sedative and Analgesic Pharmacokinetics during ExtracorporealMembrane Oxygenation: A multi-centre study to optimise drug therapy during ECMOAuthors:Kiran Shekar1Jason A Roberts2Susan Welch3Hergen Buscher3Sam Rudham3Sussan Ghassabian4Steven C Wallis2Bianca Levkovich5Vin Pellegrino5Shay Mcguinness6Rachael Parke6Paul Forrest6Adrian G Barnett8James Walsham9Daniel V Mullany1Maree T Smith4John F Fraser1Affiliations:1Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital and TheUniversity of Queensland, Brisbane, Queensland, Australia2Burns Trauma and Critical Care Research Centre, Royal Brisbane and Womens Hospital and TheUniversity of Queensland, Brisbane, Queensland, Australia3 Intensive Care Services, St Vincents Hospital, Sydney, New South Wales, Australia4Centre for Integrated Preclinical Drug Development, University of Queensland, Brisbane, Queensland,Australia5 Intensive Care Services, The Alfred Hospital, Melbourne, Victoria, Australia6 Intensive Care Services, Auckland City Hospital, Auckland, New Zealand6 Intensive Care services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia8Institute of Health and Biomedical Innovation, School of Public Health & Social Work, QueenslandUniversity of Technology, Queensland, Australia9Intensive Care Services, Princess Alexandra Hospital, Brisbane, Queensland, AustraliaDay/Month/Year Footnote to go here Page 42 35. Clotting, bleeding and anticoagulation 36. Catastrophic circuit clotting 37. Complications - BleedingZapol et al: Extracorporeal membrane oxygenation in severe acuterespiratory failure. A randomized prospective study. JAMA (1979)Morris et al: Randomized clinical trial of pressure-controlled inverse ratioventilation and extracorporeal CO2 removal for adult respiratory distresssyndrome. Am J Respir Crit Care Med (1994) 38. How to anticoagulate and how to treatbleeding As higher the flow as lower the heparin APTT targets of 1.5 to 2 times normal Low dose heparin?? Heparin free ECMO is possible (in adults) Longest reported run without heparin: 25 days But higher risk during VA-ECMO Point of care testing to manage bleeding 39. J. Fraser, 2013 Asio-Pacific ELSO Meeting 40. ECMO and Blood Management 52 ECMO runs in St Vincents Hospital 363 ECMO days Daily median (interquartile range) transfusions(unpublished data) 41. When to do itNEW AND EVOLVINGINDICATIONS 42. Evolving indicationsEXTRACORPOREAL CO2REMOVAL (ECCOR) 43. 55 44. 56 45. NovalungPassive arterio-venous System Active veno-venous System 46. Maquet PALP 47. Hemolung RAS59 48. Hemolung Catheter 15.5 Fr6026 cm Femoral Catheter350 450 ml/min flowInfusion Lumen (Red)Drainage Lumen (Blue)17 cm Jugular Catheter450 - 550 ml/min flowDrainage PortInfusion PortInfusion Lumen (Red)Drainage Lumen (Blue)Drainage PortInfusion Port 49. Blood Flow350-450 ml/min CO2 Removal30% - 50% of total CO2 production 50. Indications To avoid intubation To facilitate extubation To reduce invasiveness of ventilation (ultraprotective ventilation)Contraindications: Whenever oxygenation failure is that severe that more support isused for that reason alone62 51. Carbon Dioxide andMechanical VentilationChristopher Reeve Stephen Hawking1995 to 2004 ~1985 to present 52. A real case64 59 year old male with exacerbation of COPD Admission to ICU after respiratory arrest in the ward 53. Admission andIntubation65Extubation New onsetdyspnoeECCOROffBiPAPHad fulldinnerpH 54. One hour afterDay/Month/Year Footnote to go here Page 66 55. 67Europe: 21 patients with hypercapnic respiratory failure (Novalung) Now >500 patient entered in registry 56. Kluge et al. ICM 2012 57. NIV IMV0 10 20 30 40 50 60 70 80Page 69Patient 5Patient 4Patient 3Patient 2Patient 1hoursAbrams et al. Ann Am Thorac Soc 2013 58. NIV IMV pre ECCOR ECCOR0 10 20 30 40 50 60 70 80Page 70Patient 5Patient 4Patient 3Patient 2Patient 1hoursAbrams et al. Ann Am Thorac Soc 2013ECCOR to facilitate extubation 59. Extubation was possible aftera few hoursPage 71NIV IMV pre ECCOR ECCOR Time to extubation post ECCOR21.521.5540 10 20 30 40 50 60 70 80 90Patient 5Patient 4Patient 3Patient 2Patient 1hoursAbrams et al. Ann Am Thorac Soc 2013 60. 3 to 11 days on ECCORpost extubationNIV IMV pre ECCOR ECCOR Time to extubation post ECCOR ECCOR and extubated0 50 100 150 200 250 300 350 400Page 72Patient 5Patient 4Patient 3Patient 2Patient 1hoursAbrams et al. Ann Am Thorac Soc 2013 61. Mobilizing patients on ECCORNIV IMV pre ECCOR ECCOR Time to extubation post ECCOR ECCOR and extubatedPage 73150 ft450 ft70 ft600 ft240 ft0 50 100 150 200 250 300 350 400Patient 5Patient 4Patient 3Patient 2Patient 1hoursAbrams et al. Ann Am Thorac Soc 2013 62. Page 74 63. Where to use it: ARDS Mortality rate up to 45% despite lung protective ventilation Lung hyperinflation in 30% TV