MO Orientation ECMO

(Extracorporeal Membrane
Oxygenation) & ECLS
(Extracorporeal Life Support)
Ong Boon Hean
11/7/13
 Introduction
l Modification of CPB circuit to provide
prolonged support to patients with acute
cardiac/respiratory failure
l Blood is extracted from venous system to be
oxygenated and warmed
l Blood is then returned to the body via
mechanical pump
l Systemic heparinisation is required to ensure
patency of the entire circuit
 Introduction
l Venous arterial (VA) provides both cardiac
and respiratory support
l Peripheral venous cannula in femoral
vein, arterial cannula in femoral artery
l Central venous cannula in right atrium,
arterial cannula in aorta
l Venous venous (VV) provides only
respiratory support
 VA ECMO
l For VA ECMO, there is flow competition in the aorta
between blood from recovering heart and blood from
ECMO pump
l Blood from heart is relatively deoxygenated (very
deoxygenated if lung function compromised) compared
to blood from ECMO pump
l This deoxygenated blood from heart is directed to the
heart, brain and upper part of the body while oxygenated
blood from ECMO pump is directed to lower part of the
body
l This is lessened in central compared to peripheral VA
ECMO
l SpO2 probe should be placed on right upper limb / ABG
should be taken from right radial artery to measure O2 of
blood going to heart and brain (increase ventilator FiO2 if
not adequate)
 VA ECMO
l Pro
l Provides circulatory support
l Con
l Coronary arteries perfused by relatively
hypoxic blood from the LV
l Increases afterload to the heart (decreases
cardiac output)
l Requires arterial cannulation
l Higher risk of emboli (increased neurological
events)
 VV ECMO
l Pro
l Improves coronary oxygenation to the heart
l Decreases afterload (improves cardiac output)
l Avoids arterial cannulation
l Air and emboli filtered by lungs (decreased
neurological events)
l Con
l Does not provide circulatory support
 VA ECMO Indications
l Potentially reversible, acute cardiac failure
refractory to conventional therapy (fluids,
inotropic support, IABP)
l Cardiogenic shock (ischemic, myocarditis, failure to
wean post-CPB)
l Massive pulmonary embolism
l Sepsis with profound cardiac depression
l Anaphylactic shock
l Overdose of cardiac depressant medication
l Acute graft failure after heart transplantation
 VV ECMO Indications
l Potentiallyreversible, acute respiratory
failure refractory to conventional therapy
(mechanical ventilation)
l ARDS
l Pulmonary contusion
l Status asthamaticus
l Airway obstruction
l Inhalational injuries
l Acute graft failure following lung transplant
 Absolute Contraindications
l Progressive, irreversible cardiac/lung disease
l Chronic severe pulmonary hypertension with RV failure
l Advanced malignancy
l Chronic organ dysfunction
l Multi-organ failure / irreversible brain damage
l Unwitnessed cardiac arrest
l Contraindication to anticoagulation (bleeding, recent
surgery, recent ICH)
l For VA ECMO
l severe AR
l aortic dissection
 Relative Contraindications
l High pressure mechanical ventilation for
>7 days
l Age >70 years
l Body weight >120kg
l CPR >15 minutes
l Trauma with multiple bleeding sites
l Significant immunosuppression
 Complications
l Cannulation related
l Vessel perforation with hemorrhage
l Arterial dissection
l Distal ischemia
l Bleeding
l Due to heparin and thrombocytopenia
l May occur at any site (intracranial, pulmonary, GI,
retroperitoneal, etc.)
l Thromboembolism
l Due to clot formation within the circuit
l Can cause oxygenator failure or systemic/pulmonary
embolism
 Complications
l Thrombocytopenia
l Due to blood trauma or heparin-induced
l Linesepsis
l Coronary/cerebral hypoxia in peripheral
VA ECMO
l Due
to selective preferential perfusion of
lower extremities in peripheral VA ECMO
compared to blood ejected by heart
 Initiation
l Usually percutaneously via femoral artery/vein
using aseptic Seldinger technique
l Occasionally may require surgical cutdown
l Occasionally may be inserted into other vessels
(IJ / subclavian) or directly into RA / aorta
l Positioning of venous drainage cannula should
be confirmed on CXR (tip of cannula should be
in RA, just past IVC, if cannulating femoral vein)
 Management
l Keep flow > 50 ml/kg/min
l Keep mixed venous saturation 60-80%
l Keep Hb > 10 g/dL
l Drop
in Hb may be due to bleeding, hemolysis
or hemodilution
l Keep Platelet > 100,000 x 109/L
l Keep ACT 180-200s (hourly until reach
target, then Q4-6H)
l Stop heparin if excessive bleeding occurs
 Management
l Sedate and paralyze
l Ventilator settings as appropriate
l Low FiO2 (but remember coronary perfusion) avoid oxygen toxicity
l Low PIP and tidal volumes avoid barotrauma, aids cardiac filling/
ejection
l High PEEP avoid atelectasis (but too high may compromise cardiac
function)
l Can tolerate some degree of hypercapnia
l Avoid high airway pressures
l NG or parenteral nutrition
l IV antibiotics (normally IV cefazolin)
l IV pantoprazole
l Lower limb circulation chart (KIV distal perfusion cannula if required)
 Weaning
l VV ECMO
l CXR improving
l ABG improving with decreasing ventilatory support
l Lung compliance improving

l VA ECMO
l Increasing blood pressure
l Return of pulsatility to arterial pressure waveform
l Decreasing pO2 from right radial arterial line (in
peripheral VA ECMO)
l Decreasing CVP/pulmonary artery pressure
l Echocardiography shows improving LVEF
 Weaning
l Weaning trial done in OT with TEE for VA
ECMO (as repair of artery required) but
can be done at bedside for VV ECMO
l Progressive reduction of ECMO flows for
VA ECMO
l Disconnection of gas supply for VV ECMO
l Look at MAP/SpO2/TEE