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2. ecmo indications #beach2019 (bouchez)

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This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.

Published in: Health & Medicine
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2. ecmo indications #beach2019 (bouchez)

  1. 1. ECMO Indications Stefaan Bouchez, MD, FASE
  2. 2. Damn, ECMO again….
  3. 3. 1 september 1935 The Lindbergh Perfusion Pump Life without risks is not worth living
  4. 4. 1 september 1935 The Lindbergh Perfusion Pump
  5. 5. Gibbon 1953
  6. 6. Willem Johan Kolff 1944 Blood oxygenation during dialysis
  7. 7. Hill and Bramson 1971
  8. 8. Indications for ECMO - No absolute indications - Institution specific - Multiple studies with variable indications
  9. 9. Indications for ECMO - Immediate improvement of hemodynamics - Oxygenation & metabolic restauration - Technical not difficult - Bedside - Compared to other options : $ Advantages of ECMO - No absolute indications - Institution specific - Multiple studies with variable indications
  10. 10. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Etiology ?
  11. 11. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Reversible process ? Etiology ? Within reasonable time? Organ replacement ? Bridge to recovery (surgery) Bridge to decision Bridge to Transplant / LVAD
  12. 12. 1. 80% mortality risk - PaO2/FiO2 < 100 on FiO2> 90% - +/- Murray score 3-4, AOI >80, APSS 8 despite optimal care for 6 hours or less VV-ECMO
  13. 13. Oxygenation and ventilation : FiO2, PaO2, Airway pressures
  14. 14. Oxygenation and ventilation: - PaO2 < 80 & FiO2 100% - pH< 7,2 with hypercarbia unresponsive to conventional management
  15. 15. APPS POINTS 1 2 3 Age < 47 47- 66 > 66 PaO2/FiO2 > 158 105 -158 < 105 Plateau P < 27 27 - 30 > 30 Murray et al. 1988 Villar et al. 2016 OI = MAP x FiO2% PaO2 MAP: mean airway pressure OI < 5 = normal OI > 40 = ECMO ? Dechert et al. 2014
  16. 16. 1. 80% mortality risk - PaO2/FiO2 < 100 on FiO2> 90% - +/- Murray score 3-4, AOI >80, APSS 8 despite optimal care for 6 hours or less 2. CO2 retention despite high Pplat (> 30mmHg) 3. Other - Severe air leak syndromes - Respiratory collapse ( blocked airways…) - Surgery (trachea…) VV-ECMO
  17. 17. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Reversible process ? Etiology ? Within reasonable time? Organ replacement ? Bridge to recovery (surgery) Bridge to decision Bridge to Transplant / LVAD
  18. 18. Cardiogenic shock - Acute coronary syndrome - Myocarditis - Pulmonary embolism - Post-cardiotomy Periprocedural support - PCI - Surgery Sepsis (in some centers) VA-ECMO
  19. 19. Heartteam Hajjar et al. Crit Care 2019 Refractory Shock
  20. 20. Heartteam Hajjar et al. Crit Care 2019 Refractory Shock Shock: Chest pain Hypotension Altered mental state Metabolic changes Poor perfusion – low PP Sweating RV dysfunction
  21. 21. Thiele et al. Eur Heart J 2019 A/ At risk no signs B/ Pre-shock hypotension wo hypoperfusion C/ Classic CS Inotropes / MCS D/ Doom Deterioration / MCS +/- ECMO E/ Extremis CPR / ECMO
  22. 22. ECPR
  23. 23. ECPR CPR started immediately < 5 minutes Collapse to ECPR < 60 minutes (45 min) Holmberg et al. Resuscitation 2018
  24. 24. Cardiogenic shock - Acute coronary syndrome - Myocarditis - Pulmonary embolism - Post-cardiotomy Periprocedural support - PCI - Surgery Sepsis (in some centers) VA-ECMO
  25. 25. Falk et al. Crit Care Med 2019 Sepsis VV-ECMO : - ECMO output < Patient CO - Improvement of DO2 – reversal of hypoxia VA-ECMO : - Myocardial depression ++ (septic cardiomyopathy) - VAV-ECMO + immunoabsorption techniques
  26. 26. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Reversible process ? Etiology ? Within reasonable time? Organ replacement ? Disseminated malignancy Severe brain injury / bleeding Severe chronic organ dysfunction Unwitnessed cardiac arrest Advanced age ? Severe peripheral vascular disease ?
  27. 27. Salna et al. Eur J CardioThor Surg 2018 In-Hospital Mortality in VA-ECMO 72 y
  28. 28. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Etiology ? Selection of the right patient at the right time When to start and stop ECMO Avoid Bridge to nowhere

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