Hope (2)

HOPE for ARDS patients
Dr.Hossam Al-Afify
associate consultant intenisvist KAMC
hossamafify23@yahoo.com

Cause of death
DeathDeviceDisease

Disease

Device

Disease + Device = Death

THE HOPE !!!!!!!!!!!! Is
Stop the
Disease
process
Protect the
lung from the
Device
Support the
patient till
recovery

protect

PROTECT
• LOW tidal volume
• OPTIMAL PEEP
• LOWER plateau

↓ VT  ↓ MORTALITY
Protective
Ultra-protective
rest
VT
Survival &
CO2

Optimum strategy ….
•Effective gas exchange
•Comfortatable patient
•Lung protection ( no VILI)
•Sedation and NMBS ( NILL)
Extra Corporeal Life Support

VVVA
Single cannulation :
internal jagular or
rt atrium
Double cannulation
Jugular – femoral
Femro – femoral
Sapheno - saphenous
Vein :-
Internal jagular
Femoral
Artery:-
Rt common carotid
Axillary
Aorta
femoral
Cannulation
ModerateHighOxygen capacity
No direct support ( ↑O2)Partial to completeCardiac support
Respiratory bridge !Cardiac bridge !Indications

vvVa
1- bridge to cure (
intractable heart failure
and arrhythmia )
2- bridge to discion (
post cardiac arrest )
3- bridge to transplant
Indications

Respiratory ECLS

Avalon catheter

Physiological points :-

FACTORS affecting O2 delivery
Pump out put ×
• Pre-load dependent
• RPM × volume
• After-load sensitive
O2 content
• HB
• Fio2
• saturation

HISTORY OF ECMO
• 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

Dr & Mrs Gibbon
with their CPB
machine

HISTORY OF ECMO
• 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

Esperanza …. The HOPE

Indications
1- refractory hypoxemia
indicatedconsidered
80%50 %mortality
< 100on
FiO2 >90%
< 150 on
FiO2> 90%
p/f
3-4 despite
optimal
care for 6 h
2-3Murray
2- others
2- CO2 retention on mechanical
ventilation despite high Pplat (>30 cm
H2O)
3. Severe air leak syndromes
4. Need for intubation in a patient on
lung transplant list
5. Immediate cardiac or respiratory
collapse (PE, blocked airway,
unresponsive to optimal care)

Contraindications
• There are no absolute contraindications
to ECLS, as each patient is considered
individually with respect to risks and
benefits.
• There are conditions, however, that are
associated with a poor outcome despite
ECLS, and can be considered relative
contraindications

Poor outcomers
1. Mechanical ventilation at high settings (FiO2 > .9, P-plat > 30)
for7 days or more
2. Major pharmacologic immunosuppression (absolute neutrophil
count <400/mm3)
3. CNS hemorrhage that is recent or expanding
4. Non recoverable co morbidity such as major CNS damage or
terminal malignancy
5. Age: no specific age contraindication but consider increasing
risk with increasing age

• Several considerations must be weighed
- Likelihood of organ recovery
- Cardiac re-recovery
- Disseminated malignancy
- Advanced age
- Graft vs . Host disease
- Known severe brain injury
- Unwitnessed cardiac arrest
- Aortic dissection or aortic incompetence

www.respscore.com

So ECLS is not a curative tool
• It is a bridge :-
1. Bridge to cure ( ARDS )
2. Bridge to decision
3. Bridge to transplantation

Complications
Falls into one of three major categories
1) Bleeding associated with heparinization
2) technical failure
3) neurologic sequelae

Complications of ECMO
• Bleeding/Hemolysis
– Out of proportion to the degree of coagulopathy and patient
platelet count
• Coagulopathy
– Continuous activation of contact and fibrinolytic
systems by the circuit
– Consumption and dilution of factors within
minutes of initiation of ECMO

• Thrombocytopenia
– Platelets adhere to surface fibrinogen and are activated
– Resultant platelet aggregation and clumping causes
numbers to drop
• Non-pulsatile perfusion to end organs
– Kidneys
– Splanchnic circulation seems to be particularly susceptible
– GI bleeding, ulceration and perforation
– Liver impairment

• Mechanical Complications
– Tubing rupture
– Pump malfunction
– Cannula related problems
• Local complications: Leg ischemia
– Particularly at peripheral insertion site of VA
• Air embolism/Thromboembolism
• Neurological: Intracerebral bleeds
– Largely associated with sepsis
– Manifest as seizures or brain deathhossamafify23@yahoo.com

• So it is not only bridge ( not
curative )
• But also had a lot of the
complications
• And need specialized center

Debatable issues
• Mechanical ventilation
• ECPR ( during the cardiac arrest)
• Pregnancy
• Pharmacokinetics
• CRRT use

EOLIA ( trial still in progress)

Suggestive protocol
PCV
• 10 – rate and PEEP
• 20 -- PIP
• 30 – FiO2
Associated with …..
• To obtain high-flow ECMO sufficient to
perform ultra-protective ventilation, ECMO
cannulas with high diameter are essential
• Similarly, diuresis to dry weight and
• restrictive transfusion strategies should be
attempted
• tracheotomy is frequently done safely under
ECMO in this population exposed to pro-
longed MV
• Sedation and analgesia should be titrated
as low as possible to conciliate protective
ventilation with comfort and tolerance of the
cannula.

ECMO or not ……..

Trials of VV ECMO for ARDS

Trials of VV ECMO for ARDS
• The first multicenter, randomized trial to evaluate ECMO for ARDS was
conducted by the National Institutes of Health in the United States in the 1970s
on 90 patients with severe ARDS refractory to conventional ventilation
techniques .
• WHAT the found ?
1. Patient survival in that trial was extremely low (<10%) and
2. no improvement with ECMO was demonstrated.
• WHAY ?.
1. the mode of ECMO support was only veno-arterial and when no improvement
was observed after 5 days, ECMO was removed, which precluded the
possibility of late clinical improvement.
2. Because the ECMO group did not receive lung-protective ventilation, severe
complications related to barotrauma occurred and
3. since ECMO circuitry was not heparin-coated at that time, a very high
percentage of patients had severe hemorrhagic complications due to excessive
anti-coagulation.

• In the 1990s, Morris et al. in Utah conducted another
randomized, controlled trial, which was a single-center study
using a device eliminating CO2.
• The study was stopped for futility after only 40 patients had
been enrolled, and once again, the results did not advocate the
use of this form of respiratory assistance.

• CESAR
• The most recent trial (CESAR)
was conducted in the United
Kingdom from 2001 to 2006
• 180 patients ( 18-65)
• Lancet 2009.

• Inclusion criteria :-
sever ARDS ;-
1. Hypercapnic acidosis , and /or
2. Lung injury score > 3
• Exclusion criteria :-
1. High pressure ( peak > 30 ) or high FiO2 >
0.8 ventilation for more than 7 days
2. Contraindications to anticoagulation

• The patients randomized to receive ECMO support
were transferred to a single center (Glenfield,
Leicester), whereas the patients randomized to the
control group were treated conventionally at
designated treatment centers.
• Mortality or severe disability 6 months after
randomization, the primary end-point, was lower for
the 90 patients randomized to the ECMO group (37
vs. 53%, P ¼ 0.03).

• However, that trial had two limitations that merit
attention.:-
1-First, 22 patients randomized to the ECMO arm did
not receive ECMO (died before or during transport,
improved with conventional management at the referral
center or had a contraindication to heparin).

• 2-The other major methodological problem is the
absence of a standardized protocol for mechanical
ventilation in the control group, for which it was
merely recommended that the treating physicians
adopt a strategy of lung-protective ventilation with-
out further specifications

SO WHAT is the cause of decrease the
mortality reduction
Protection
By instrument
Protocol
By institute

May be the answer is
EOLIAExtracorporeal Membrane Oxygenation for Severe Acute
Respiratory Distress Syndrome (EOLIA)

Summary
• Select ( early ,young , single organ
failure , H1N1)
• Early transferor to ECMO center
• Protect : LOW VT & ( 10 - 20 -30 )
• Protocolized approach
• MORE RCT needed

Thank you

Hope (2)

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