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Extracorporeal membrane oxygenation.
- 3. The Alfred Intensive Care Unit, Melbourne, Australia MCS in Cardiogenic Shock: Case 1 • Friday afternoon (!) • Tx waiting list (severe biventricular DCM) patient presents unwell (cold, shutdown) – BP 70 initially on CCU • Inotropes commenced – dobutamine, adrenaline…. • BP to 50, decreasing conscious state … Code called • Urgent echo
- 4. The Alfred Intensive Care Unit, Melbourne, Australia MCS in Cardiogenic Shock: Case 1
- 5. The Alfred Intensive Care Unit, Melbourne, Australia Cardiogenic Shock Defined When to consider MCS • Cardiac Index < 2.2L/min/m2 despite adequate filling • Evidence of hypoperfusion (eg CNS, renal, lactate>2) • SBP<90 mmHg – Despite catecholamines – Need to evaluate trajectory
- 6. The Alfred Intensive Care Unit, Melbourne, Australia Causes of Cardiogenic Shock Cooper & Panza Cardiol Clinics 2013
- 7. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes in Cardiogenic Shock 2000 2002 20062004 Mortality rate GRACE Registry – MI Outcomes No impact of IABP Ie SHOCK, SHOCK II
- 8. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes in Cardiogenic Shock • Proven predictors of outcome: – APACHE Score, cytokines (eg IL-6) – Cardiac indices (eg CI, BNP) not helpful Age GCS Temp MAP HR RR FiO2 PaO2 Art pH Na+ K+ Cr ARF (Y/N?) Hct WCC Pre-existing severe ilness??
- 9. The Alfred Intensive Care Unit, Melbourne, Australia Maximizing Outcomes in CS • Early recognition of definite CS – Inotrope refractory, emerging end-organ dysfn • Optimal timing of MCS deployment • Optimal form of MCS • Limiting the complications of MCS • Optimal timing of weaning from MCS or converting to long-term MCS
- 10. The Alfred Intensive Care Unit, Melbourne, Australia Timing of MCS • No randomized studies re timing • USpella Registry – cardiogenic shock + PCI AMI with Cardiogenic Shock (n=154) Impella 2.5 Pre-PCI (n=63) Impella 2.5 Post-PCI (n=91) O’Neil J Interv Cardiol 2013 Inotropes 81% Acidosis 74% Ventilated 66% Lactate >4mmol/L 57% Shock > 6hrs 53%
- 11. The Alfred Intensive Care Unit, Melbourne, Australia Emergency & Emergent MCS Chronic Worsening HF (Intermacs 2-3) Acute Cardiogenic shock CPR Nature of Heart Failure Presentation MCS Option Outcome Short Term MCS Eg ECMO VAD Long Term Recovery (+/- medical therapy) Destination Bridge to Transplant Elective/ semi-elective BTD
- 12. The Alfred Intensive Care Unit, Melbourne, Australia Comparative forms of MCS IABP Impella 2.5 ECMO Cannulae 7.9Fr 13Fr 21Fr venous 19 Fr arterial Insertion time 5-10 mins 10-15mins 10-15mins Support <1L/min 2.5L/min 4-6L/min Limb Ischemia risk Low-Interm Interm Interm NB Backflow Management complexities + ++ +++ Oxygenation Yes RV Support Yes
- 13. The Alfred Intensive Care Unit, Melbourne, Australia MCS Options in Cardiogenic Shock -acute VAD deployment in cardiogenic shock (INTERMACS 1) and particularly cardiac arrest/Bi-Ventricular failure is associated with poor outcome ISHLT 2013
- 17. The Alfred Intensive Care Unit, Melbourne, Australia ECMO in Cardiogenic Shock • Sheu et al retrospective review of outcomes in profound cardiac shock in MI (SBP<75mmHg on inotropes) Crit Card med 2010 Multiple Logistic Regrn OR p value ECMO 0.22 0.021 TIMI<2 4.07 0.036 CHF 13.37 0.028
- 18. The Alfred Intensive Care Unit, Melbourne, Australia STEMI N-STEMI ECMO in Cardiogenic Shock IABP alone IABP alone IABP+ECMO IABP+ECMO
- 20. The Alfred Intensive Care Unit, Melbourne, Australia ECMO: Emerging Populations Mechanical CPR • Increasingly utilized by hospitals and EMS • Two large randomized trials LINC & CIRC indicated safe and equivalent to good manual CPR • Potentially useful to facilitate prolonged CPR during transport • ? Management of these patients –a bridge to ECMO??
- 21. The Alfred Intensive Care Unit, Melbourne, Australia OHCA-CPR-ECMO (ECPR) First report: Resuscitation of the Moribund Patient Using Portable CPB. Mattox et al 1976
- 22. The Alfred Intensive Care Unit, Melbourne, Australia The Rise of ECPR • The ‘SAVE-J: Study of advanced life support for ventricular fibrillation with extracorporeal circulation in Japan’ commenced in 2008 > 30 hospitals • The key inclusion criteria are: 1) shockable rhythm on the initial ECG; 2) Persistent cardiac arrest on arrival at hospital 3) arrival at hospital within 45 min of the call for an ambulance or cardiac arrest; and 4) cardiac arrest remaining for more than 15 min after arrival at hospital.
- 23. The Alfred Intensive Care Unit, Melbourne, Australia 1) CPR to hospital • Automated CPR enabling safe transport to hospital with effective CPR 2) Hypothermia • Initiated pre-hospital for neuroprotection 3) ECMO • Manage Refractory Cardiac arrest 4) Early Reperfusion • Coronary Angiogram • Diagnose and treat underlying aetiology Melbourne Experience of ECPR in OHCA The CHEER study Refractory Out-Of-Hospital Cardiac Arrest Treated With Mechanical CPR, Hypothermia, ECMO And Early Reperfusion Aim: To study the feasibility and efficacy of a treatment pathway for patients with refractory cardiac arrest.
- 24. The Alfred Intensive Care Unit, Melbourne, Australia ECMO-CPR At the Alfred Hospital Melbourne Australia Resource Intensive / But no different to Trauma Response team in number § 2 ECMO Cannulators (Intensivists) § 1 doctor/tech ECHO (check wires in IVC/ aorta) § Dr for IV cooling fluid § ECMO nurse for circuit start § Dr / Nurse managing Autopulse § ER team for conventional resus Inclusion Criteria: • 18-65 years of age • with a suspected cardiac aetiology • chest compressions commenced within 10 minutes, • initial cardiac arrest rhythm of VF • automated CPR available • within 10 minutes ambulance transport time • Pilot phase during normal working hours (9am-5pm) • with the aim to commence ECMO within 60 minutes of the initial collapse
- 25. The Alfred Intensive Care Unit, Melbourne, Australia ECPR Results – Melbourne First 2 years Stub et al Resus Oct 2014
- 26. The Alfred Intensive Care Unit, Melbourne, Australia Outcomes and Complications Outcomes All N=26 Survivors N=14 Non Survivors N=12 Survival to Hospital Discharge, n(%) 14 (54) Good neuro outcome (CPC 1-2) 14 (54) 14 (100) Wean off ECMO* 13/24 (54) 12/12 (100) 1 (7) Median Time on ECMO Days (IQR) 2 (1-5) 3 (1.8-5) 1 (1-5) Median Time in ICU, Hours (IQR) 134 (39-291) 230 (118-320) 30 (4-134) Median Hospital length of stay, Days 13 (1.3-22) 20 (12-26) 1 (1-8) Bleeding, n(%) 18 (70) 10 (71) 8 (67) Renal Replacement Therapy, n(%) 10 (39) 4 (29) 6 (50) Peripheral Vascular Issues, n(%) 10 (39) 5 (36) 5 (42) Stroke, n(%) 6 (23) 2 (14) 4 (33) Stub et al Resus Oct 2014
- 27. The Alfred Intensive Care Unit, Melbourne, Australia ECMO Practical Issues • Neurologic assessment in the ECPR scenario – Wean sedation, CT brain/EEG, neuro consult – Always consider the appropriate exit strategy • Increased afterload – Aortic regurgitation (* must assess pre ECMO) – Persistently elevated LVEDP (pulm edema)/LV stasis • May require LV or LA venting: NB prove APO is due to high PCWP etc • Differential (upper body hypoxia) – Monitor R radial blood gases – Due to inadequate venous return: consider further cannulae options • Lower limb ischemia – Diligent monitoring, backflow cannulae • Weaning & conversion to LVAD
- 28. The Alfred Intensive Care Unit, Melbourne, Australia Summary • ECMO provides a cost-effective, rapidly achievable interim approach to ‘full’ MCS in the ‘right’ patient • ECMO MCS provides the clinical team with an opportunity to make considered decisions about the best clinical strategy for the patient (and family) • Positive long-term outcomes can be achieved when managed by multi-disciplinary MCS teams