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ECMO

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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ECMO

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  1. 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

  2. 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

  3. NORMAL LUNG

  4. CONSOLIDATED LUNG

  5. CONSOLIDATED LUNG

  6. ARDSEffects on the Lung • Capillary leak • Hyaline membranes • Surfactant depletion • Collapse/consolidation • VQ mismatch • Reduced compliance • Neutrophil infiltration and cytokine release

  7. 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

  8. Dr & Mrs Gibbon with their CPB machine

  9. 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

  10. ECMO in Leicester UK • Neonatal ~ 40 cases per year • Paediatric ~ 20 cases per year • Adult ~ 40 cases per year • Cardiac (v.small number)

  11. The Circuit

  12. 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

  13. TECHNICAL ASPECTS

  14. Cannulation • Veno-venous (v=28Fr ; a= 21 to 28Fr) • Veno-arterial • Percutaneous • Open • Semi-Seldinger • Double lumen • Single lumen

  15. 21F percutaneous return cannula in adult Rt femoral vein

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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.

  21. DOES ECMO WORK

  22. 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.

  23. 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

  24. 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)

  25. BOTH TRIALS HAVE LITTLE RELEVANCE TO CURRENT ECMO REGIMENS

  26. OBSERVATIONAL STUDIES

  27. Cohort studies of ECMO- Leicester 1997.PaO2/FIO2 65mmhgMurray Score=3.4

  28. 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%)

  29. OUTCOME IN ADULTS WHEN ECMO IS UNAVAILABLE

  30. Results • Conventional patients 8/28 Survived (28.5%) • ECMO patients 39/57 Survived (68.4%) • p=0.001

  31. 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

  32. Survival for ARDS with ECMO • Michigan - 66% • Leicester - 80% • Berlin -77% • Vienna -80%

  33. The Sceptics’ Perspective

  34. 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

  35. 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)

  36. 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)

  37. 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

  38. 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)

  39. 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)

  40. 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

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