3. What is it?
ECMO is extra-corporeal membrane oxygenation
extracorporeal life support (ECLS) may be a better term
The extracorporeal circuit allows for the oxygenation and
removal of carbon dioxide from blood
used as a supportive strategy in patients who have a high risk
of death despite conventional therapy
4. Why are we considering it in the ED for
CardiacArrest
“Patients with refractory ventricular fibrillation receiving E-
CPR tended to have higher survival rates and significantly
improved neurological outcomes when compared with those
receiving C-CPR”. Managing cardiac arrest with refractory ventricular fibrillation in
the emergency department:Conventional cardiopulmonary resuscitation versus
extracorporeal cardiopulmonary resuscitation -Fu-Yuan Siao et al. RESUSCITATION April
2015
Drive to start ECMO in SCGHED
5. Indications
acute, severe REVERSIBLE respiratory or cardiac failure with
a high risk of death that is refractory to conventional
management
poor gas exchange
compliance < 0.5mL/cmH2O/kg
P:F ratio < 100
shunt fraction > 30%
7. Relative Contraindications
age > 75
multi-trauma with multiple bleeding sites
CPR > 60 minutes
multiple organ failure
CNS injury
8. Types
VV = veno-venous
VA = veno-arterial: peripheral or central
Veno-pulmonary artery ECMO (provides short-term right
ventricular and respiratory support following LVAD insertion)
high (2 venous cannulae) vs low flow (1 venous cannula)
9. VV ECMO
most common mode
venous drainage from large central veins -> oxygenator ->
venous system near RA
support for severe respiratory failure (no cardiac dysfunction)
Proven to be improve survival @6months (63% vrs 47%) with
acute respiratory failure
12. VA ECMO
venous drainage from large central veins -> oxygenator ->
arterial system in aorta
support for cardiac failure (+/- respiratory failure)
13.
14. Pathology
graft failure post heart or heart lung transplant
non-ischaemic cardiogenic shock
failure to wean post CPB
bridge to LVAD
drug OD
Sepsis
PE
cardiac or major vessel trauma
massive pulmonary haemorrhage
pulmonary trauma
acute anaphylaxis
15. The ALFRED guidelines
Patients in the E&TC with out-of-hospital cardiac arrest which is refractory to
standard advanced cardiac life support (ACLS) treatmentAND:
The patient meets ALL the following criteria in regards to the characteristics of
the arrest:
Likely due to Respiratory or Cardiac cause
Witnessed arrest
Chest compressions started within 10 mins
Less than 60 mins duration in total
12-70 years old
No major co-morbidities
16. The patient is profoundly hypothermic (<32°C) due to
accidental exposure
The patient has taken a significant overdose of a vaso-active
drug(s) (i.e. β-Blocker, tricyclic acid, digoxin etc)
Any other cause where there is likely to be reversibility of the
cardiac arrest if an artificial circulation can be provided
In order to ensure that out-of-hospital cardiac arrest patients
arrive within a short time-frame, eligible patients will be
transported by ambulance with an AutopulseTM as soon as
possible after the initiation of ACLS
17. STEPs
1. Identify potential patient
2. US guided Line-Venous and Arterial (Training Required)
3. Prime Circuit (Training Required)
4. Attach Circuit
5. Intensive Care
6. Optimize and treat potential casues
RETROSPECTIVE CHART REVIEW STUDY over 2 years of 60 patients who had VF refractory to CPR for more than 10mins
----- Meeting Notes (13/04/16 16:08) -----
ADVANTAGES
normal lung blood flow
oxygenated lung blood
pulsatile blood pressure
oxygenated blood delivered to root of aorta
must be used when native cardiac output is high
VENTILATION
no need to ventilate at normal level
must maintain alveolar volume and oxygenation
Advantages of periperhal
good Q
can create high oxygen tensions
Disadvantages
relative lung ischaemia
non-pulsatile blood flow
possible poor perfusion of coronaries and cerebral vessels
distal limb ischaemia
risk of lung overventilation -> tissue alkalosis (monitor with ETCO2)
Advantages of Central
no preferential perfusion to lower body
no possibility of hypoxic perfusion of cerebral vessels
can use very large cannulae (high flows)