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ECMO in Cardiac Arrest

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ECMO in Cardiac Arrest

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ECMO in Cardiac Arrest

  1. 1. ECMO in Cardiac Arrest Johnny iliff
  2. 2. references  LITFL  Alfred Hospital  ECMO Project
  3. 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. 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. 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%
  6. 6. Absolute Contraindications  progressive non-recoverable cardiac disease (not transplant candidate)  progressive and non-recoverable respiratory disease (irrespective of transplant status)  chronic severe pulmonary hypertension  advanced malignancy  GVHD  >120kg  unwitnessed cardiac arrest
  7. 7. Relative Contraindications  age > 75  multi-trauma with multiple bleeding sites  CPR > 60 minutes  multiple organ failure  CNS injury
  8. 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. 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
  10. 10. VV ECMO
  11. 11. Pathology  pneumonia  ARDS  -acute GVHD  pulmonary contusion  smoke inhalation  status asthmaticus  airway obstruction  aspiration  bridge to lung transplant  drowning
  12. 12. VA ECMO  venous drainage from large central veins -> oxygenator -> arterial system in aorta  support for cardiac failure (+/- respiratory failure)
  13. 13. 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
  14. 14. 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
  15. 15.  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
  16. 16. 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
  17. 17. Cannulation  It’s central access, what’s the big deal?
  18. 18. The Circuit
  19. 19.  https://www.youtube.com/watch?v=OM27HovykWY

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