laboratory of biological structure mechanics technical and biological advances in ecmo new...

LABORATORY OF BIOLOGICAL STRUCTURE MECHANICS

www.labsmech.polimi.it

Technical and biological advances in ECMO

New Perspective in ECMO 2012III International Meeting

Milan, 5 October 2012

Maria Laura Costantino


ECMO is the use of a modified extracorporeal circuit to provide temporary mechanical support (respiratory and/or cardiac) to patients failing conventional intensive therapy.

ECMO has brought the technology of cardiopulmonary bypass to bedside under the management of ECMO specialists and intensive care physicians.

Extracorporeal Membrane Oxygenation(ECMO)


HistoryHistory

1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938).

1930 – JH Gibbon - First extracorporeal circulation system.


Dr & Mrs Gibbon with their CPB machine

HistoryHistory




HistoryHistory



1950 – Early Developements of CPB.

1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator.

1957 – K Kammermeyer – Use of thin Silicone Membranes.

Early ’60s – T Kolobow designed his “Membrane Lung”.

1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO


HistoryHistory









1975 – RH Bartlett - First Successful Neonatal ECMO

1986 – L Gattinoni - 50% Survival in Adult ECCO2R

1989 – ELSO Registry

HistoryHistory









1975 – RH Bartlett - First Successful Neonatal ECMO

1986 – L Gattinoni - 50% Survival in Adult ECCO2R

1989 – ELSO Registry

HistoryHistory

From then on, over and over increasing number of centres are performing either

adult or neonatal ECMO


The type of ECMO depends on the patient’s underlying cardiac function.

• Provides support for severe respiratory failure when reasonable heart function is assessed.

• Induces low hemodynamic disturbances.

• 1 or 2 access cannulae can be used depending on the bypassed blood flow.

• Provides support for severe cardiac and respiratory failure, most commonly after cardiac surgery.

• Induces high hemodynamic disturbances depending on the chosen return access sites.

• Can be used as a bridge to cardiac recovery or to another destination therapy.

Veno-Venous (V-V) ECMOVeno-Venous (V-V) ECMOVeno-Arterial (V-A) ECMOVeno-Arterial (V-A) ECMO

ECMO Types


ECMO Types

SecondAccess Cannula

SVC

Return Cannula IVC

Access CannulaIVC

Return CannulaFA Access

CannulaFV

Veno-Venous (V-V) ECMOVeno-Venous (V-V) ECMOVeno-Arterial (V-A) ECMOVeno-Arterial (V-A) ECMO


ECMO Circuit

• Outflow cannula• Inflow cannula• Pump• Oxygenator• Lines

EquipmentEquipment

Main IssuesMain Issues

• Efficacy• Priming Volume• Haemolysis• Compatibility• Duration

Membrane Lung

Pump

Gas Source

PatientPatient


ECMO main technical advances are in 4 areas

1) A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae.

Return (arterial) lumen

Outflow (venous) lumen

DL VV catheter




2) A move from roller to centrifugal pumps that do not damage the red cells (most main pump manufacturers have systems).

Roller Pump HeadCentrifugal Pump

HeadCentrifugal Pump

Console

Roller Pump Console

Centrifugal Pump Drive Unit




2) A move from roller to centrifugal pumps that do not damage the red cells - most main pump manufacturers have systems.

3) A switch from silicone membrane oxygenators to polymethylpentene hollow fibre ones.

Silicone membrane oxygenator unravelled




2) A move from roller to centrifugal pumps that do not damage the red cells - most main pump manufacturers have systems.

3) A switch from silicone membrane oxygenators to polymethylpentene hollow fibre ones.

4) Miniturisation of circuits: all the above have allowed circuit miniturisation, have facilitated transport on ECMO and have allowed us to run with much less Heparin, thus reducing bleeding risk.


Thank you for your attention

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