Extracorporeal membrane oxygenation, also known as extracorporeal life support (ECLS), is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life. The technology for ECMO is largely derived from cardiopulmonary bypass, which provides shorter-term support with arrested native circulation. This intervention has mostly been used on children, but it is seeing more use in adults with cardiac and respiratory failure. ECMO works by removing blood from the person's body and artificially removing the carbon dioxide and oxygenating red blood cells. Generally, it is used either post-cardiopulmonary bypass or in late stage treatment of a person with profound heart and/or lung failure, although it is now seeing use as a treatment for cardiac arrest in certain centers, allowing treatment of the underlying cause of arrest while circulation and oxygenation are supported.

1. CLINICAL TEACHING
ON
EXTRACORPOREAL MEMBRANE OXYGENATION
BY RAJEE RAVINDRAN

3. HISTORY
John Heysham Gibbon
1937- successful on cats
1953- first successful open heart
surgery by using cardiopulmonary
bypass
Robert Bartlett
1976- First neonatal survivor of ECMO
(Esperanza)

4. DEFINITION
 ECMO is a form of extracorpeal life support where an external artificial
circulator carries venous blood from the patient to a gas exchange device
(oxygenator) where blood becomes enriched with oxygen and has carbon
dioxide removed. This blood then re-enters the patient’s circulation. Circuit
flow is achieved using a pump either centrifugal or a roller pump.
ECMO is evolved from cardiopulmonary by-pass.

5. INDICATIONS
Guidelines that describe the indications and practice of ECMO are published by the
Extracorporeal Life Support Organization (ELSO). Criteria for the initiation of ECMO
vary by institution, but generally include acute severe cardiac or pulmonary failure
that is potentially reversible and unresponsive to conventional management.
Respiratory failure
ALI/ARDS
Aspiration Pneumonia
Asthma
Post lung transplant
Lung contusion
Cardiac Failure
Post cardiac arrest
Pulmonary embolus
Drug overdose
Post cardiac surgery
Bridge to transplant
Post heart transplant
Cardiogenic shock

6. CONTRAINDICATIONS
Absolute Contraindications
 Severe irreversible neurological condition
 Encephalopathy
 Cirrhosis with ascites
 History of variceal bleeding
 Moderate-severe chronic lung disease
 Terminal malignancy
 HIV
VENO-
VENOUS ECMO
Severe left
ventricular
failure EF
<25%
Cardiac arrest
VENO –
ARTERIAL ECMO
Aortic
dissection
Severe aortic
regurgitation

7. CONTRAINDICATIONS
VENO-
VENOUS ECMO
High pressure/
high Fio2 IPPV
for > 1 week
VENO –
ARTERIAL ECMO
Severe
peripheral
vascular
disease
Relative Contraindications
 Age >65
 Multiple trauma with uncontrolled haemorrhage
 Multi-organ failure

8. TYPES
VENOVENOUS ECMO
VENOARTERIAL ECMO

9. VENO ARTERIAL CANNULATION
APPROACH
PERIPHERAL CENTRAL

10. FEMORAL AXILLARY CAROTID

12. VENO VENOUS CANNULATION APPROACH
SINGLE
CANNULATION
DOUBLE
CANNULATION

15. ECMO CIRCUIT

16. ECMO EQUIPMENT
ECMO CANNULA OXYGENATOR
GAS EXCHANGE DEVICE

17. ECMO EQUIPMENT
FLOW SENSOR CENTRIFUGAL PUMP

18. ECMO EQUIPMENT
PUMP CONSOLE

19. ECMO EQUIPMENT
PRESSURE MONITORING

22. COMPLICATIONS
 Neurologic
*neurological injury which may include intracerebral hemorrhage, subarachnoid hemorrhage, ischemic infarctions
in susceptible areas of the brain, hypoxic-ischemic encephalopathy, unexplained coma, and brain death.
*Bleeding (occurs in 30 to 40 percent) due to both the necessary continuous heparin infusion and platelet
dysfunction.
 Blood
Heparin-induced thrombocytopenia
Thrombosis.
 Bridge to assist device
A variety of complications can occur during cannulation, including vessel perforation with bleeding, arterial
dissection, distal ischemia
 In Children, there is high risk for intraventricular hemorrhage

23. NURSING MANAGENMENT
The ECMO patient must NOT be left unattended at any time. Relief for breaks should be
arranged so that a suitably experienced member of staff is monitoring the patient and
ECMO circuit at all times.
Patient should be nursed in the supine position. Head of bed can be elevated to 30 degrees.
Pressure relieving mattress should be insitu (because of decreased mobility and perfusion
these patients are often at high risk for pressure areas)

24. NURSING MANAGENMENT
Hourly observations include
 Pump flow rate
 Nursing ECMO observation chart must be maintained
 Haemodynamic observations- Continuously monitor patient and ECMO set for drop in BP/ CVP
 Evidence of hypovolaemia in the form of fluctuating flow rates and ‘shaking’ of ECMO tubes
 Hypovolaemia (relative or absolute) may result in disrupted blood flow through the circuit
 Sucking down of the access cannula against the vessel wall may occur in hypovolaemia
potentially causing trauma to vessel endothelium and haemolysis
 Blood flow through the ECMO circuit is essential for maintenance of gaseous exchange, and also
to maintaining haemodynamic stability
 Oxygen flow to oxygenator
 Patient temperature

25. NURSING MANAGENMENT
 Access & return cannula for bleeding
 Observe for oozing of blood, and maintain secure dressings
 Secure dressings are required to maintain cleanliness of cannula sites, and also to help stabilise
the cannula
 Circulation observations especially on lower limbs
 Limb temperature
 Limb colour
 Pedal pulses
 Capillary refill -Due to the large bore cannula distal arterial perfusion may be compromised in A-
VECMO, while the venous cannula may lead to DVT formation
 Input & output-Haematuria is often present when there is haemolysis, and therefore should be
reported and investigated appropriately

26. RESEARCH AND ABSTRACT
Yun Zhan, Chun-Sheng Li, XiaoLi Yuan, JiYang Ling, Qiang Zhang, Yong Liang, Bo Liu, Lian-Xing Zhao: Bioscience Reports
Jul 19, 2019,39(7)
ECMO attenuates inflammation response and increases ATPase activity in brain of swine model with cardiac arrest compared
with CCPR
Abstract
Extracorporeal membrane oxygenation (ECMO) could increase survival rate and neurological outcomes of cardiac arrest (CA)
patients compared with conventional cardiopulmonary resuscitation (CCPR). Currently, the underlying mechanisms how ECMO
improves neurological outcomes of CA patients compared with CCPR have not been revealed. A pig model of CA was established
by ventricular fibrillation induction and then underwent CCPR or ECMO. Survival and hemodynamics during the 6 h after return
of spontaneous circulation (ROSC) were compared. The levels of inflammatory cytokines and Ca2+-ATPase and NA+-K+-
ATPase activities were detected. Brain tissues histology and ultra-microstructure in CCPR and ECMO groups were also
examined.

27. RESEARCH AND ABSTRACT
Results suggested that ECMO significantly improved the survival of pigs compared with CCPR. Heart rate (HR) decreased
while cardiac output (CO) increased along with the time after ROSC in both ECMO and CCPR groups. At each time point, HR
in ECMO groups was lower than that in CCPR group while CO and mean arterial pressure in ECMO group was higher than
CCPR group. In ECMO group, lower levels of IL-1, IL-1β, IL-6, TNFα, and TGFβ, especially IL-1, IL-6, TNFα, and TGFβ,
were found compared that in CCPR group while no difference of IL-10 between the two groups was observed. Similar with the
results from enzyme-linked immunosorbent assay, decreased expressions of IL-6 and TGFβ were also identified by Western
blotting. And Ca2+-ATPase and NA+-K+-ATPase activities were increased by ECMO compared with CCPR. Hematoxylin and
eosin staining and ultra-microstructure examination also revealed an improved inflammation situation in ECMO group
compared with CCPR group.

28. SUMMARY
Extracorporeal membrane oxygenation, also known as extracorporeal life support (ECLS), is an
extracorporeal technique of providing prolonged cardiac and respiratory support to persons
whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion
to sustain life. The technology for ECMO is largely derived from cardiopulmonary bypass, which
provides shorter-term support with arrested native circulation.
This intervention has mostly been used on children, but it is seeing more use in adults with
cardiac and respiratory failure. ECMO works by removing blood from the person's body and
artificially removing the carbon dioxide and oxygenating red blood cells. Generally, it is used
either post-cardiopulmonary bypass or in late stage treatment of a person with profound heart
and/or lung failure, although it is now seeing use as a treatment for cardiac arrest in certain
centers, allowing treatment of the underlying cause of arrest while circulation and oxygenation
are supported.

29. CONCLUSION
Even though ECMO is used for a range of conditions with varying
mortality rates, early detection is key to prevent the progression of
deterioration and increase survival outcomes. ECMO has also seen
its use on cadavers as being able to increase the viability rate of
transplanted organs.

30. BIBLIOGRAPHY
 Guyton, AC & Hall, JE 2010, Textbook of Medical Physiology, 12th edition, W.B. Saunders Company,
Philadelphia
 Luo, Wang, Hu, Gao, Long, Song,(2009). Extracorporeal membrane oxygenation for treatment of cardiac
failure in adult patients. Interactive CardioVascular and Thoracic Surgery, 9: 296-300.
 Tortora, G. & Grabowski, S.R., 2003, Principles of Anatomy and Physiology, 10th ed, John Wiley & Sons,
Inc, New York.
 https://www.aci.health.nsw.gov.au
 https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation
 https://www.annalsthoracicsurgery.org/article/S0003-4975(03)01816-2

32. EVALUATION

33. THANK YOU