ECMO

1. EXTRACORPOREAL LIFE
SUPPORT-
PULMONOLOGIST’S
PERSPECTIVE
Dr AMITH SREEDHARAN MD DNB IDCCM EDIC
CONSULTANT PULMONOLOGY AND CRITICAL CARE MEDICINE,ASTER
MIMS,KANNUR

2. Extracorporeal Life Support
Systems’ Nomenclature
 ECLS: ExtraCorporeal Life Support
 ECMO: Extracorporeal Membrane
Oxygenation
 iLA: Lung Assist
 ECCO2R: Extracorporeal CarbonDioxide
Removal
 VAD: Ventricular Assist Device

3. ECMO is a Type of ECLS
2 Main Physiologic Functions
Pulmonary Gas Exchange through an artificial
‘lung’ or MEMBRANE
1. O2 delivery to meet metabolic needs
2. Removal of CO2
Care of patient on ECMO involves exposure to
anticoagulation and transfusion therapy

5. Indications: Purpose > Diagnosis
1. Bridge to organ recovery
• To provide time needed for recovery of
function
• To facilitate therapy: surgery or medical
2. Bridge to receive organ transplant
3. Bridge to decision:
• To palliative care

8. Need: Modes & Configurations
Cardiopulmonary failure
• Cardiac or cardiopulmonary support
• Veno-Arterial VA ECMO
Respiratory failure
• Respiratory Support
• Veno-venous or VV ECMO
Respiratory Support with Right Heart Failure
• Pulmonary artery- to left atrium iLA

12. Considerations > Contraindications
 Irreversible lung or heart disease
• And organ transplantation is not an option
 Massive active hemorrhage
 Uncorrectable coagulopathy
 Major acute intracranial hemorrhage
 Multi-organ failure

13.  CESAR TRIAL 2009
 180 patients – ECMO / Conventional
 63% survival at 6months in ECMO group Vs
47% in conventional group
 Technically flawed due to different levels of
care
 Summary : Mortality difference observed
cannot be attributed to ECMO

14.  AUSTRALASIAN 2009 H1N1 EXPERIENCE
 ECMO found a 21% survival rate at 3 months
 Mortality in Non – ECMO group only 13%

15.  EOLIA TRIAL 2018
 NO MORTALITY DIFFERENCE – ECMO VS
CONVENTIONAL VENTILATION
 CONTROLS – 90% PRONE VENTILATED
 PRONE VS ECMO
 28% OF CONTROLS (SICKER AT
RANDOMISATION) MIGRATED TO ECMO WHICH
MADE RESULTS DIFFICULT TO INTERPRET
 SUMMARY(HARDIN &HIBBERT 2018,NEJM)):
TRIAL SUPPORTS USE OF ECMO WHO HAVE
CLEARLY EXCEEDED CONVENTIONAL VENTILATION
AND PRONE POSITION

19. Cannulation
Vascular access:
• Peripheral: neck and femoral
• Central
Sites:
• Single or dual or more
Cannula Types:
• Lumens: single, dual, multiple
• Flow rate capacity (L/min)

24. COMPLICATIONS
• Bleeding
Cerebral hemorrhage or stroke Surgical site
hemorrhage
• Ischemia & end organ multi-organ failure
• Stroke & Limb Ischemia
• Renal failure
• Lung injury or failure of lung recovery
• Skin ulcerations
• Infection & systemic inflammatory syndrome
• Exposure to transfusions and other blood
products
• Pain, delirium, fear, awareness if awake &
NMB

25. Complications - Mechanical
• Pump
• Membrane failure
• Air embolism
• Catheter related vascular or cardiac
perforation
• Circuit clotting & Haemolysis