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ECMO - PowerPoint PPT Presentation


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ECMO. EXTRA CORPOREAL MEMBRANE OXGENATION PROVIDES PROLONGED RESPIRATORY AND CARDIAC SUPPORT DOES NOT TREAT UNDERLYING PATHOLOGY ALLOWS SUPPORT WHILST DISEASE RESOLVES OR REVERSES ONLY APPROPRIATE IF UNDERLYING PATHOLOGY IS POTENTIALLY REVERSIBLE. Aspiration pneumonia ARDS trauma

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slide1
ECMO
  • EXTRA CORPOREAL MEMBRANE OXGENATION
  • PROVIDES PROLONGED RESPIRATORY AND CARDIAC SUPPORT
  • DOES NOT TREAT UNDERLYING PATHOLOGY
  • ALLOWS SUPPORT WHILST DISEASE RESOLVES OR REVERSES
  • ONLY APPROPRIATE IF UNDERLYING PATHOLOGY IS POTENTIALLY REVERSIBLE
pathologies potentially treatable by ecmo
Aspiration pneumonia

ARDS trauma

ARDS sepsis

ARDS obstetric

Pneumonia

viral

bacterial

atypical

Pancreatitis

Drowning

Burns - smoke inhalation

Pulmonary embolus

Tricyclic Antidepressant OD

Viral myocarditis

Post CPB failure to wean

PATHOLOGIES POTENTIALLY TREATABLE BY ECMO
ards effects on the lung
ARDSEffects on the Lung
  • Capillary leak
  • Hyaline membranes
  • Surfactant depletion
  • Collapse/consolidation
  • VQ mismatch
  • Reduced compliance
  • Neutrophil infiltration and cytokine release
history of ecmo 1
HISTORY OF ECMO -1
  • 1916 - MACLEAN - HEPARIN (JH)
  • 1930 - JOHN GIBBON - FIRST INVESTIGATION INTO ECLS
  • 1944 - KOLFF AND BERK - BLOOD OXYGENATION IN CELLOPHANE CHAMBERS OF ARTIFICIAL KIDNEY
  • 1950 - EARLY DEVELOPEMENTS OF CPB
  • 1956 - CLOWES - INVENTED MENBRANE OXGENATOR
  • 1957 - KAMMERMEYER - INVENTED SILICONE - MEMBRANE LUNG
history of ecmo 2
HISTORY OF ECMO - 2
  • 1960 - EXPERIMENTS INTO PROLONGED CPB
  • 1972 - HILL - FIRST ADULT ECMO - AORTIC RUPTURE
  • 1975 - BARTLETT - FIRST SUCCESSFUL NEONATAL ECMO
  • 1986 - USA 18 CENTRES ECMO
  • 1986 - GATTINONI - 50% SURVIVAL IN ADULT ECCO2R
  • 1989 - ELSO REGISTRY
  • 2001 - 120 CENTRES WORLD WIDE
ecmo in leicester uk
ECMO in Leicester UK
  • Neonatal ~ 40 cases per year
  • Paediatric ~ 20 cases per year
  • Adult ~ 40 cases per year
  • Cardiac (v.small number)
differences with cpb
DIFFERENCES WITH CPB
  • NO RESERVOIR; BLADDER SERVOREGULATOR
  • NO CENTRIFUGAL PUMP (haemolysis)
  • NO MICROPROUS OXYGENATOR
  • VENO-VENOUS PREFERRED WITH ADEQUATE CARDIAC FUNCTION
  • NORMOTHERMIA
  • HEPARIN ACT 160-200 NOT 500+
  • NO ARTERIAL FILTER
  • NOT HAEMODILUTED HB 14g/dl;HCT @ 40
  • NO AUTOTRANSFUSION
cannulation
Cannulation
  • Veno-venous (v=28Fr ; a= 21 to 28Fr)
  • Veno-arterial
  • Percutaneous
  • Open
  • Semi-Seldinger
  • Double lumen
  • Single lumen
vvadvantages disadvantages
Pulmonary vasodilation (corr. Of hypoxia and acidosis

Myocardial oxygenation

Maintained pulmonary blood flow

Minimally invasive

Not affected by PDA

More difficult

Slower stabilisation

No circulatory support

Re-circulation

VVAdvantages & Disadvantages
va advantages disadvantages
Easy to use

Circulatory support

Instant stabilisation

Huge experience

Right heart offloaded and rested

Carotid ligation

Jugular ligation

Raised LV afterload

Reduced pulmonary blood flow

Hypoxic coronary perfusion

Stun- high LV afterload

Duct

VA Advantages & Disadvantages
pt management on ecmo 1 lung rest
PT MANAGEMENT ON ECMO 1LUNG REST
  • FIO2 - 0.3
  • PEEP 10cm H20
  • PEAK INSPIRATORY PRESSURE 20cm H2O
  • RATE 5- 10/min
  • THEREFORE REDUCE:
    • BAROTRAUMA
    • VOLUTRAUMA
    • OXYGEN TOXICITY
    • MYOCARDIAL DEPRESSION
patient managment on ecmo 2 fluid balance
PATIENT MANAGMENT ON ECMO 2FLUID BALANCE
  • MULTIPLE TRANSFUSION
  • HYPOALBUMINAEMIC - SEPSIS, DILUTION
  • CAPILLARY LEAK SYDROME
  • RENAL FAILURE - SEPSIS
  • FLUID OVERLOAD FROM CIRCUIT PRIME
  • DIURESIS TO ‘DRY’ WEIGHT
      • DOPAMINE
      • FRUSEMIDE INFUSION
      • AMINOPHYLLINE
      • 40% CVVHF
patient management on ecmo 3
PATIENT MANAGEMENT ON ECMO -3
  • Percutaneous Veno-venous Cannulation.
  • Low range heparinisation; ACT 160-200
  • Lung Rest (20/10, RR10, FIO2 30%).
  • Normothermia.
  • Diuresis to dry weight.
  • Hb ~ 14g/dl.
rcts of ecls in adults
RCTs of ECLS in Adults
  • NIH Adult ECMO Trial

Zapol et al JAMA 242:2193-96,1979

  • PCIRV vs ECCO2R

Morris et al, Am J Respir Crit Care Med 1994;149:295-305.

early adult ecmo ecco 2 r trials
Early Adult ECMO/ECCO2R Trials
  • Zapol, : (NIH Trial) (VA ECMO +ventilation and ventilation only)Severe ARF. A Randomized Prospective Study. JAMA 1979:242:2193-6)
  • 90 patients, 9 US centres, 1974 - 77
  • Survival < 10% in both arms
  • Criticism:
    • 1. VA ECMO used (prone to microthrombi in lungs)
    • 2. High anticoagulation and bleeding complications
    • 3. High pressure ventilation used even DURING ECMO
    • 4. Mean duration of ventilation prior to ECMO was 9 days
  • Little experience, varying technique in different centres
early adult ecmo ecco 2 r trials33
Early Adult ECMO/ECCO2R Trials
  • Morris, et.al: Randomized Trial of PCIRV and ECCO2R in ARDS. AJRCCM,1994;149:295-305
  • 40 patients, severe ARDS (paO2/FiO2 63 mmHg) in one US centre
  • 33% survival in 21 patients ECCO2R + LFPPV
  • 42% survival in 19 patients PCIRV
  • P = 0.8, no significant difference
  • Little previous experience in centre with technique in humans
  • High pressure ventilation before and DURING ECCO2R (PEEP > 20, Peak 45 - 55 cmH2)
  • Frequent severe bleeding complications (leading to discontinuation of ECCO2R in 7/19 cases)
cohort studies of ecls other
Cohort Studies of ECLS - Other
  • LFPPV with ECCO2R in severe acute respiratory failure, Gattinoni L et al, JAMA 1986 256;7:881-6 (50% survival)
  • ECLS for 100 adult patients with severe respiratory failure.PaO2/FiO2 = 55mmHg Kolla S et al, Ann Surg 1997;226:544-64 (survival 54%)
results
Results
  • Conventional patients

8/28 Survived (28.5%)

  • ECMO patients

39/57 Survived (68.4%)

  • p=0.001
however time has passed and things have changed since
However, time has passed and things have changed since ...
  • Some centres in the US and Europe have been quite successful at providing ECMO for severe adult respiratory failure (Ann Arbor, Michigan, Berlin, Marburg, Munich, Glenfield Hospital, Leicester etc.)
  • ECMO has become ‘standard’ treatment for severe Neonatal Respiratory Failure and Persistent Pulmonary Hypertension of the Newborn
survival for ards with ecmo
Survival for ARDS with ECMO
  • Michigan - 66%
  • Leicester - 80%
  • Berlin -77%
  • Vienna -80%
advanced conventional itu treatments
ADVANCED CONVENTIONAL ITU TREATMENTS
  • HF JET VENTILATION - Romand 1995
  • HF OSCILLATING - Moller 1995
  • INHALED NITIC OXIDE - Gerlach 1993
  • NEBULISED PROSTACYCLIN - Zwissler 1996
  • PCIRV - Morris 1994
  • PERMISSIVE HYPERCAPNOEA - Gentilello 1995 (91%n=11, survival in trauma pts )
  • PRONE VENTILATION - Stoller 1990; Pappert 1994
  • LIQUID VENTILATION - still experimental
improved survival in severe ards with protective ventilatory strategies
Improved survival in severe ARDS with protective ventilatory strategies:
  • Hickling, Walsh, Henderson, Jackson: Low mortality rate in adult respiratory distress syndrome using low-volume, pressure limited ventilation with permissive hypercapnia: A prospective study.Crit Care Med1994,22:1568-78
  • 74 % survival (= 40 of 53 patients with severe ARDS, ie. Murray Lung Injury score > 2.5, paO2/FiO2 < 150 mmHg), 1988 - 1992, one centre
  • Mean Murray score 3.1 survivors, 3.2 non-survivors(3.4 first 50 adult VV ECMO Glenfield)
  • Mean PaO2/FiO2: 91+/-29 survivors, 81+/- 46 non-survivors (65 first 50 adult VV ECMO Glenfield)
recent improved survival in severe ards
Recent improved survival in severe ARDS
  • Abel, Finney, Brett, Keogh, Morgan, Evans: Reduced mortality in association with ARDS. Thorax 1998; 53: 292 - 294
  • 66%survivalin moderate to severe ARDS78 patients 1993-97 at Brompton Hospital (vs 34% survival in 41 patients 1990-93)
  • mean Murray score 2.8, mean PaO2/FiO2 90 mmHg/12 kPa

(First 50 adult VV ECMO patients Glenfield Hospital, Leicester, 1989 - 1995: Murray lung injury score 3.4, PaO2/FiO2 65 mmHg, (66%survival)

improved survival in severe ards with protective ventilatory strategies47
Improved survival in severe ARDS with protective ventilatory strategies:
  • Amato, Barbas, Medeiros et al: Effect of a Protective-Ventilation Strategy on Mortality inARDS. NEJM;1998;338:347-54
  • 53 patients, two ICU’s in Brazil, 1990 - 1995, early ARDS + 2 - 3 extrapulmonary organ failures
  • 62% 28 day survival with protective ventilation (n = 29, mean PaO2/FiO2 112, mean LIS 3.4) mean PEEP 16 >> 13, Vt < 6 ml/kg (360-390 ml), pressure limited ventilation with peak pressure < 30 cmH2O, permissive hypercapnoea
  • vs 29% survival and more deaths from progressive respiratory failure in low PEEP high Vt (12 ml/kg) group
improved survival in severe ards with protective ventilatory strategies48
Improved survival in severe ARDS with protective ventilatory strategies:
  • The ARDS Network: Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and ARDS.NEJM 4 May 2000;342:1301-8
  • 861 patients in 10 US university centres ALI/ARDS, ie. paO2/FiO2 < 300 mmHg, 80% < 200, mean 136
  • 69% survival and less ventilator days with 6ml/kg tidal volume (mean paO2/FiO2
  • 60% survival with 12 ml/kg Vt
  • 22% mortality difference, P = 0.007
  • No data on subgroup with paO2/FiO2 < 100)
estimated mortality of most severe ards pao2 fio2 100 mmhg
Estimated mortality of most severe ARDS (paO2/FiO2 < 100 mmHg):
  • US: NIH ARDSnet database: 70 %
  • UK:
  • Intensive Care National Audit & Research Centre (ICNARC): 62%(1506 patients with paO2/FiO2 < 100 mmHg)
  • Phone survey Glenfield/Heartlink ECMO centre: ~ 72% mortality in patients referred for but not receiving ECMO (no bed/staff)
vasilyev 1995 chest 1995 107 1083 8
VASILYEV (1995)Chest 1995;107:1083-8
  • International multicentre prospecttive study of hospital survival in acute respiratoryfailure defn /Fio2 0.5 for >24hrs
  • 1426 patients from 25 centres (USA11; Europe 14)
  • Overall survival 55%
  • Survival only 33% in hypoxic and hypercarbic pts ie more like ECMO pts
criteria for acceptance
CRITERIA FOR ACCEPTANCE
  • Age <65 years
  • Reasonable long term outlook
  • No contraindication to anticoagulation
  • IPPV < 7 days
  • Reversible pathology
  • Optimum conventional treatment tried
inclusion criteria
Inclusion Criteria
  • Potentially reversible respiratory failure
  • Murray score > 3.0
  • hypercapnoea pH <7.20
  • aged 18-65 years
inclusion criteria55
Inclusion Criteria
  • duration of high pressure and high FIO2 ventilation < 7 days
  • no contra-indication to limited heparinisation
  • no contra-indication to continuation of active treatment
sample size
Sample Size
  • Assuming a 10% risk of severe disability among survivors in both trial arms
  • a = 0.05 (2 sided test)
  • b = 0.2
  • Sample size of 120 patients in each group would be required to detect a reduction in the rate of primary outcome from 73% to 55%
cesar trial conventional treatment
CESAR Trial: Conventional Treatment
  • “.. Any treatment which relies on the patient’s lungs to provide gas exchange…”
  • Can include any treatment modality thought appropriate by patient’s intensivist, eg prone, NO, HFOV
  • Low (6ml/kg) tidal volume strategy (as in ARDSnet trial) and PIP < 40 cmH2O recommended, but not mandatory
  • Not standardized (no consensus)
  • (Analogous to UK Neonatal ECMO trial)
cesar trial outcome measures
CESAR Trial: Outcome measures
  • Primary: death or severe disability at six months
  • Secondary:

- Nature and duration of ventilation and other

organ system support

- Length of ICU and hospital stay

- Blood product use

- Cost/cost effectiveness to health and social

services, patients and their families

(by methods adopted from neonatal ECMO trial)

cesar trial potential referring conventional treatment hospitals so far 28
Bristol Royal Infirmary

St James Leeds

Royal Liverpool University Hospitals (3)

University of WalesCardiff

South Manchester

Royal Infirmary, Edinburgh

Morriston, Swansea

North Devon District

Gloucester Royal

Walsgrave

Queen Elizabeth, Gateshead

Royal Chesterfield

Derby Royal Infirmary

Derby City

Milton Keynes General

Crosshouse, Kilmarnock

Pilgrim, Boston

Cheltenham

Queen’s, Burton-on Trent

Llandough, Penarth

Macclesfield

North Staffordshire, Stoke-on-Trent

Wrexham Maelor

West Suffolk

Chase Farm, Enfield

CESAR TRIAL: Potential Referring/conventional treatment hospitals - so far: 28
conclusions
CONCLUSIONS.
  • ECMO with lung rest is a rational treatment.
  • Survival with conventional treatment remains poor in most centres.
  • Only an RCT can determine the best treatment.
slide61

Ventilation with lower tidal volumes for acute lung injury and the acute respiratory distress syndromeThe Acute Respiratory Distress Syndrome NetworkN Engl J Med 2000;342:1301-8

  • 6ml/Kg (PIP<30) vs. 12ml/Kg (PIP<50)
  • 861 patients
  • Age 51 + 17 vs. 52 + 18
  • PaO2/FIO2 138 + 64 vs. 134 + 58
slide62

Ventilation with lower tidal volumes for acute lung injury and the acute respiratory distress syndromeThe Acute Respiratory Distress Syndrome NetworkN Engl J Med 2000;342:1301-8

RESULTS

  • TV 6.2 + 0.8 vs. 11.8 + 0.8 ml/kg
  • PIP 25 + 6 vs. 33 + 8 cm/H2O
  • Mortality 31.0% vs. 39.8% (p=0.007)
  • Days without organ failure also lower (p=0.006)
adult ecmo patient status at referral
PaO2/FIO2 65mmhg

Murray Score=3.4

Time Vent=76.5 hrs

Time on 100% O2= 14 hrs.

PAP = 39.6 cmH2O.

PEEP = 10 cmH2O.

MV = 12.6 L/min.

MAP = 82 mmHg.

MPAP = 29 mmHg.

CVP = 12 mmHg.

PAWP = 12 mmHg.

CO = 127 ml/kg/min.

UO = 1.4 ml/kg/hr.

Age = 30.1 yrs.

Wt = 71.9 Kg.

Hb = 10.8 Kg.

Adult ECMO,PATIENT STATUS AT REFERRAL.
cost implications of ecmo
COST IMPLICATIONS OF ECMO
  • Median length of stay of adult ECMO pts is 14 days (range 0-41days). ELSO recommend 2:1 specialist to patient ratio
  • Daily cost for conventional care for severe respiratory failure is £1500 -£2300 (Sheffield Health care costing system)
  • Total cost per case £27000 - £63000
cardiac ecls at glenfield
Cardiac ECLS at Glenfield
  • 40 pediatric cardiac
  • 10 adult cardiac
adult cardiac ecls diagnoses
Post op MVR

Pulmonary Emboli (2)

Loefflers syndrome

CABG (2)

Viral Myocarditis

Pericardectomy

septic shock post removal of infected pacing wire / vegative mass

Post infarct VSD

Adult Cardiac ECLSDIAGNOSES
cardiac ecls at glenfield68
Cardiac ECLS at Glenfield
  • Between July 1991 and Sept 1998
  • 505 patients received ECMO
  • 152 adult respiratory
  • 182 neonatal respiratory
  • 121 pediatric respiratory
adult cardiac ecls
Adult Cardiac ECLS
  • 10 patients, 5 survived
  • age 39.6 (19)
  • Run time 188 (220) hours
  • PaO2/FIO2 = 81 (20) mmHg