overview of ecmo

1. Extracorporeal membrane oxygen
ation
ECMO
Dr Himaaldev
Consultant intensive care

2. ARDS
1. Lung protective
ventilation
2. Prone ventilation
3. ECMO
Severe ARDS
Pao2/Fio2 ratio <100
PEEP >5cm
Mortality 45%
2

3. Evolution of ventilators
Negative pressure – positive pressure

4. NPV
4

5. PPV
5

6. PRONING

7. ECMO

8. •ECMO-extracorporeal circuit to provide
temporary respiratory or cardiac support to
patients failing conventional therapy
TECHNOLOGY OF CARDIOPULMONARY
BYPASS TO BEDSIDE
Extracorporeal Membrane Oxygenation
(ECMO)

9. How ECMO works
• External artificial circuit carries venous blood from the patient
to a gas exchange device (oxygenator) where blood becomes
enriched with oxygen and has carbon dioxide removed.
• The blood is then returned to systemic circulation
via another vein (VV ECMO) or artery (VA ECMO).

10. ECMO Types
Veno-Arterial (V-A) ECMOVeno-Venous (V-V) ECMO
SVC
Return Cannula
IVC
Access Cannula
IVC
Return Cannula
FA Access
Cannula
FV

11. Veno Venous ECMO Indications
Primary
1. Severe pneumonia
2. ARDS
3. Acute lung (graft) failure following transplant
4. Pulmonary contusion -trauma
Others
1. Smoke inhalation
2. Status asthmaticus
3. Airway obstruction
4. Aspiration

12. Veno Arterial ECMO Indications
1. Cardiogenic shock: AMI and complications (wall ruptu
re, papillary muscle rupture, refractory VT / VF)
2. Post cardiac surgery: unable to wean safely from cpb
3. Sepsis with profound cardiac depression
4. Drug overdose with profound cardiac depression
5. Myocarditis
6. Chronic cardiomyopathy: as a “bridge” to longer term
ventricular assist device or transplant

13. Ecmo principle
• Patient care during ECMO has focused on the end organ
perfusion and thus preventing further injury and also
improving or maintaining end organ functions
• Bridge to Decision and to Recovery

14. HISTORY
• First successful implantation of ECMO dates
from 1972
• 1975 – RH Bartlett - First Successful Neonatal ECMO

15. ECMO History

16. ECMO History

17. From this…
TO THIS!!

18. Ecmo circuit

19. 18F (6.0mm)
20F (6.7mm)
22F (7.3mm)
24F (8.0mm)
28F (9.3mm)
Cannulation …
55 cm (21.6”)
68 cm (26.8”)
16F (5.3mm)
18F (6.0m
20F (6.7mm)
22F (7.3mm)

20. ECMO technical advances
A move from roller to centrifugal pumps that do
not damage the red cells
Roller Pump Head
Centrifugal Pump He
ad
Centrifugal Pump Co
nsole
Roller Pump C
onsole
Centrifugal Pum
p Drive Unit

21. ECMO technical advances
A switch from silicone membrane oxygenators to
polymethylpentene hollow fibre ones
Silicone membrane ox
ygenator unravelled

22. Oxygenators
Quadrox D – Safeline Coating
Mini Max
Silicones

23. New Cannula

24. ECMO technical advances
Miniturisation of circuits - transport on ECMO
run with much less Heparin, thus reducing bleeding risk.

25. 26
Downside
Complications
BLEEDING, COAGULOPATHY AND HAEMOLYSIS
MECHANICAL COMPLICATIONS (e.g. oxygenator failure, circuit disruption,
pump malfunction, problems with cannula placement/removal)
HIT, INFECTION
AIR EMBOLISM, THROMBOEMBOLISM AND NEUROLOGICAL SEQUELAE
COMPARTMENT SYNDROME AND LEG ISCHEMIA

27. Contraindications
• Irreversible neurological injury
• Malignancy with limited survival
• Multiple trauma/hemorrhage
• Multi organ failure
• Coagulopathy
• Severe aortic valve regurgitation
• Aortic dissection

28. How do we do it ?
• Ecmo team discussion
• Family counselling
• Cannulation and anticoagulation
• Ecmo circuit establishment and maintainance
• Ventilation and ICU measures
• Daily team discussion and prognostication
• Weaning

29. THE ECMO TEAM
• CTVS team
• Perfusionist
• Primary care physician
• Intensive care team
• Pulmonologist
• Nursing team
• Respiratory therapist
• Physiotherapist

30. When to start?
• Severe, life threatening hypoxemia –P/F less than 100
• Lack of recruitment response
inadequate SpO2/PaO2 response to increasing PEEP
• Failure of prone ventilation
• Murray score of more than 2.5 to 3
• Oxygenation index >40 x 2 hours-indicates ecmo
• Ventilator days pre-ECMO
• Compliance < 0.5 ml/cmH2O/kg

31. Murray Score

32. Oxygenation Index
OI=
Mean airway pressure x Fi O2 x 100
PaO2

33. Ecmo pronevs.
Selection of Technique

34. VA
ECMO
VVvs.
Selection of Technique

35. “The key to the success of ECMO may be the time
of initiation”
Basic goals:
»
» Decrease further lung damage
»
» Reduce oxygen toxicity
» “Lung Rest”
» Maintain end organ perfusion
»

36. REST THE LUNG
• Tolerate pCO2 55-65, SpO2 > 88%, Sao2 > 90%
REST LUNG SETTINGS
Limit Plateau pressures <30 cm H2O
Delivered tidal volumes 4 ml/kg
Rate 8-10 breaths/minute
PEEP 12-14 cm H2O
Inspiratory time longer
Goal FiO2 0.4-0.6

37. Circuit management
• Blood flow litres per minute
• Transmembrane pressure ,Circuit check for clots
• Venous chattering-HYPOVOLEMIA
• Normothermia
• ACT Target 160-200 sec

38. ECMO maintainance
1. ABG ,ACT– 6hourly
2. Blood Investigations : Complete blood count, RFT,LFT,
LDH and Plasma free HB
3. Doppler examination
4. Antibiotics and septic screening, Sedation holiday
5. Additional procedures
1. Tracheostomy
2. Dialysis on ECMO (CVVHD)
3. Chest physiotherapy
4. Repeated bronchoscopy

39. Adjunctive therapy
• Fluids/nutrition: Feed ‘em!
• Sedation/analgesia: wake ‘em!
• Antibiotics: Hold ‘em!
• Invasive procedures: Bronch/trach ‘em!
• Weaning: Wean ‘em!
• Decannulation: Cap ‘em!
• Post-ECMO: Rehab ‘em!

40. Weaning
• Turning off the gas flow to the oxygenator and
simultaneous reestablishing full ventilation is required- VV ECMO
• Circuit flows must be reduced to assess native heart function
(≤ 1.5 LPM) –VA ECMO
• Lower limb arterial /venous Doppler studies
-following decannulation as to prevent distal limb
ischaemia and distal DVT formation

41. Cost burden

42. PRONING

43. THANKYOU