Hergen Buscher is an Intensivist from St Vincent's hospital in Sydney. He has extensive experience with ECMO, in both veno-venous and veno-arterial contexts. Listen to this talk he gave on the most recent developments in ECMO and where things are heading. This talk was given live in September 2014 for an Intensive Care Network (ICN) NSW meeting. Go to www.intensivecarenetwork.com for more.

1. What’s new in extracorporeal life
support
Hergen Buscher

3. Definition
• External artificial circuit carries venous blood from the patient to an
oxygenator.
• Blood becomes enriched with oxygen and has carbon dioxide removed.
• The blood is than returned to the patient via a central vein or an artery.

5. Allow time to recovery
It most cases recovery is seen between 7 to 14 days

6. 16 year old boy with goodpasture syndrome
On admission 28 days later

7. 51 year old patient with
polypharmacy overdose
No pulsatility Same patient 6 days later

10. Cannulation

11. Cannulation

12. Cannulation

13. Cannulation

14. Cannulation

15. Cannulation

16. Cannulation

17. Cannulation

18. Cannulation

20. Indications VV
Inability to maintain SaO2 > 88 or pH > 7.20 with safe mechanical ventilation
• Plateau pressure < 35cmH2O and
• Tidal volume <6ml/Kg predicted body weight
• Need for inter-hospital transport in severe respiratory failure
Despite
• Trial of high PEEP (18-22)
• Prone positioning
• Nitric Oxide or alternative pulmonary vasodilators

21. Conditions VV
Good:
• ARDS with primary lung injury (infection, aspiration or direct trauma)
• Primary graft dysfunction following lung transplantation (within 7 days)
• Pulmonary vasculitis (Goodpasture’s, ANCA-associated, other Autoimmune)
Variable:
• ARDS from secondary lung injury (from non-pulmonary sepsis, burns or pancreatitis)
• Lung transplant recipients 7-30 days post transplant
• Age >70

22. Conditions VA
Good
• Acute fulminate myocarditis
• Cardiomyopathy (first presentation)
• Chronic cardiomyopathy (suitable for VAD)
• Primary Graft Failure post heart transplant
• AMI (with early revascularisation)
• Drug overdose
• Pulmonary Embolism
Variable
• Multiple organ failure
• Late revascularisation
• Septic shock
• Post cardiotomy

23. Contraindications
• Age: > 70 years
• Active malignancy
• Severe brain injury
• Previous Bone marrow transplant, previous transplant (>30 days), AIDS
• End stage chronic organ failure (hepatic, renal)
• End stage cardiomyopathy (except for bridge to VAD/transplant)
• Chronic lung disease (except for bridge to transplant)
• Multi organ failure
• Severe mitral or aortic valvular insufficiency or aortic dissection (VA only)

24. ARE THESE PROVEN
INDICATIONS?

25. • ECMO (n=90 patients)
• Conventional management (n=90)
• 68 (75%) patients actually received
ECMO
• 63% of patients consideration for
treatment by ECMO survived
• 47% of patients on conventional
management survived
• Relative risk 0.69; 95% CI 0.05–0.97,
p=0.03
• Quality-adjusted life-year: ￡19 252

26. Research
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) FOR SEVERE
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
A multicenter, randomized, controlled open trial
EOLIA : ECMO to rescue Lung Injury in severe ARDS
Promoter:
Département de la Recherche Clinique et du Développement (DRCD)
Assistance Publique–Hôpitaux de Paris

28. Research cooperation

29. ISICEM Brussels March 2014
Brussels presentations

30. Paradigm shift in extracorporeal life
support
Should it be
done?
How should it be done?
When should it be done?

31. Key points of modern ECMO management

34. Subclavian Artery Cannulation for
Ambulatory VA ECMO
Javidfar, ASAIO 2012

35. Proning patients on ECMO

36. Mobile ECMO
• More experience -> more confidence
• Less sedation
• Better cannulation
• Team approach
 ECMO Patient -> Patient with ECMO

37. Mobile ECMO
• More experience -> more confidence
• Less sedation
• Better cannulation
• Team approach
 ECMO Patient -> Patient with ECMO

38. New Generation ECMO Consoles

39. Mobile ECMO

40. Pharmacokinetics ex vivo
Shekar, Crit Care 2012

41. Pharmacokinetics in vivo

42. ASAP –ECMO: Antibiotic, Sedative and Analgesic Pharmacokinetics during Extracorporeal
Membrane Oxygenation: A multi-centre study to optimise drug therapy during ECMO
Authors:
Kiran Shekar1
Jason A Roberts2
Susan Welch3
Hergen Buscher3
Sam Rudham3
Sussan Ghassabian4
Steven C Wallis2
Bianca Levkovich5
Vin Pellegrino5
Shay Mcguinness6
Rachael Parke6
Paul Forrest6
Adrian G Barnett8
James Walsham9
Daniel V Mullany1
Maree T Smith4
John F Fraser1
Affiliations:
1Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital and The
University of Queensland, Brisbane, Queensland, Australia
2Burns Trauma and Critical Care Research Centre, Royal Brisbane and Women’s Hospital and The
University of Queensland, Brisbane, Queensland, Australia
3 Intensive Care Services, St Vincent’s Hospital, Sydney, New South Wales, Australia
4Centre for Integrated Preclinical Drug Development, University of Queensland, Brisbane, Queensland,
Australia
5 Intensive Care Services, The Alfred Hospital, Melbourne, Victoria, Australia
6 Intensive Care Services, Auckland City Hospital, Auckland, New Zealand
6 Intensive Care services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
8Institute of Health and Biomedical Innovation, School of Public Health & Social Work, Queensland
University of Technology, Queensland, Australia
9Intensive Care Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
Day/Month/Year Footnote to go here Page 42

43. Clotting, bleeding and anticoagulation

45. Catastrophic circuit clotting

49. Complications - Bleeding
Zapol et al: Extracorporeal membrane oxygenation in severe acute
respiratory failure. A randomized prospective study. JAMA (1979)
Morris et al: Randomized clinical trial of pressure-controlled inverse ratio
ventilation and extracorporeal CO2 removal for adult respiratory distress
syndrome. Am J Respir Crit Care Med (1994)

50. How to anticoagulate and how to treat
bleeding
• As higher the flow as lower the heparin
• APTT targets of 1.5 to 2 times normal
• Low dose heparin??
• Heparin free ECMO is possible (in adults)
• Longest reported run without heparin: 25 days
• But higher risk during VA-ECMO
• Point of care testing to manage bleeding

51. J. Fraser, 2013 Asio-Pacific ELSO Meeting

52. ECMO and Blood Management
• 52 ECMO runs in St Vincent’s Hospital
• 363 ECMO days
• Daily median (interquartile range) transfusions
(unpublished data)

53. When to do it
NEW AND EVOLVING
INDICATIONS

54. Evolving indications
EXTRACORPOREAL CO2
REMOVAL (ECCOR)

55. 55

56. 56

57. Novalung
Passive arterio-venous System Active veno-venous System

58. Maquet PALP

59. Hemolung RAS
59

60. Hemolung Catheter 15.5 Fr
60
26 cm Femoral Catheter
350 – 450 ml/min flow
Infusion Lumen (Red)
Drainage Lumen (Blue)
17 cm Jugular Catheter
450 - 550 ml/min flow
Drainage Port
Infusion Port
Infusion Lumen (Red)
Drainage Lumen (Blue)
Drainage Port
Infusion Port

61. • Blood Flow
350-450 ml/min
• CO2 Removal
30% - 50% of total CO2 production

62. Indications
• To avoid intubation
• To facilitate extubation
• To reduce invasiveness of ventilation (ultraprotective ventilation)
Contraindications:
• Whenever oxygenation failure is that severe that more support is
used for that reason alone
62

63. Carbon Dioxide and
Mechanical Ventilation
Christopher Reeve Stephen Hawking
1995 to 2004 ~1985 to present

64. A real case
64
• 59 year old male with exacerbation of COPD
• Admission to ICU after respiratory arrest in the ward

65. Admission and
Intubation
65
Extubation New onset
dyspnoe
ECCOR
Off
BiPAP
Had full
dinner
pH

66. One hour after
Day/Month/Year Footnote to go here Page 66

67. 67
Europe: 21 patients with hypercapnic respiratory failure (Novalung)
• Now >500 patient entered in registry

68. Kluge et al. ICM 2012

69. NIV IMV
0 10 20 30 40 50 60 70 80
Page 69
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
hours
Abrams et al. Ann Am Thorac Soc 2013

70. NIV IMV pre ECCOR ECCOR
0 10 20 30 40 50 60 70 80
Page 70
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
hours
Abrams et al. Ann Am Thorac Soc 2013
ECCOR to facilitate extubation

71. Extubation was possible after
a few hours
Page 71
NIV IMV pre ECCOR ECCOR Time to extubation post ECCOR
21.5
2
1.5
5
4
0 10 20 30 40 50 60 70 80 90
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
hours
Abrams et al. Ann Am Thorac Soc 2013

72. 3 to 11 days on ECCOR
post extubation
NIV IMV pre ECCOR ECCOR Time to extubation post ECCOR ECCOR and extubated
0 50 100 150 200 250 300 350 400
Page 72
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
hours
Abrams et al. Ann Am Thorac Soc 2013

73. Mobilizing patients on ECCOR
NIV IMV pre ECCOR ECCOR Time to extubation post ECCOR ECCOR and extubated
Page 73
150 ft
450 ft
70 ft
600 ft
240 ft
0 50 100 150 200 250 300 350 400
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
hours
Abrams et al. Ann Am Thorac Soc 2013

74. Page 74

75. Where to use it: ARDS
• Mortality rate up to 45% despite lung protective ventilation
• Lung hyperinflation in 30%
• TV<4 ml/kg (ultraprotective ventilation)
• Hypercapnia
• Immunosuppression
• impairs pulmonary epithelial repair
• worsens right heart function
• barrier to achieve LPV

76. Ventilator Induced Lung Injury
76

77. ECCOR reduces IL-6 Levels
Training Guide 77

78. Xtravent trial
Bein, ICM 2013

79. Cardiac Support

80. What we used to do
severe
moderate
ECMO
IABP
Inotropes
Recovery
Tandem Heart, Impella, Levitronix…..
OR
Death
Durable VADs
Heart Transplantation
acute chronic
Heart Failure

81. What we are doing now
severe
moderate
ECMO-Tandem Heart-Impella …..
IABP
Inotropes
Durable VADs
Heart Transplantation
acute chronic
Heart Failure

82. What we are doing now
severe
moderate
ECMO-Tandem Heart-Impella …..
IABP
Inotropes
Durable VADs
Heart Transplantation
acute chronic
Heart Failure

83. IABP-Shock2
Trial, NEJM 2012
What’s the Standard of Care?
… IABP ?

84. Incidence and Mortality of Cardiogenic
Shock Post Myocardic Infarct
Mann, Nolan: Current Opinion in Critical Care 2006

85. Incidence of Cardiogenic Shock (CS)
Compared to ECMO runs
30000
25000
20000
15000
10000
5000
0
ECMO runs CS post MI CS on admission post MI
Total ECMO runs (ELSO)
Cardiogenic Shock from MI (NRMI)
(US data 1995-2004)

86. LVAD* vs IABP: 3 RCTs
*Tandem Heart and Impella

87. Should there be a RCT on cardiac extracorporeal life support
on patients with an expected mortality of 50-80%?

88. Prophylactic ECMO for interventional
aortic valve replacement
Before
• 8/131 (6%) needed rescue ECMO
• 2/8 (25%) died
After
• 9/83 (11%) had prophylactic ECMO
• 0% Mortality
• 1 needed Rescue ECMO and died
Husser, Regensburg Medical Center

89. ECMO Implantation to Optimize Renal
Function as a Bridge to Decision
ECMO Implantation
72 hours
Creatinine improved
to normal values
3 days after
ECMO implantation

90. ECMO could be more than a rescue
treatment in cardiogenic shock

91. What if the patient does not recover?
severe
moderate
IABP
Inotropes
Durable VADs
Heart Transplantation
acute chronic
Heart Failure
ECMO-Tandem Heart-Impella …..

92. Bridge-to-Bridge Therapy

93. … But is Heart Transplantation
an Option?
In the US
• 5.000.000 people have heart failure
• 500.000 are newly diagnosed each year
• 200.000 are refractory to standard treatment
• 2.200 will have a heart transplant

94. “TREATING CONGESTIVE HEART
FAILURE WITH CARDIAC
TRANSPLANTATION IS
ANALOGOUS TO TREATING
POVERTY WITH LOTTERY
TICKETS”
R. Robbins
Director of the Stanford Institute of Cardiovascular Medicine

95. QUESTION
Who should be offered a VAD as a
destination therapy?

96. Progress in durable VAD development
2000
2014

97. Rose, NEJM 2001
LVAD support Improves Short-term
survival in Stage 4 Heart Failure

98. Survival has improved Further with
modern Continuous Flow Devices
Miller, NEJM 2007

99. Quality of Life Improves Significantly
in Survivors

100. Costs are High (still)

102. 33% 60%

103. Get ECMO in less than 45 min from collapse
Non-survivors are not expensive

104. One of our cases
• 58 year old male presented to ED on a Sunday morning
• Found on the street, GCS 12, hypothermia (32.1 C)
• 08:01 VF cardiac arrest in ED
• 08:10 call for E-CPR
• 08:15 team arrives, 5 shocks, now asystolic
• 08:20 start of cannulation
• 08:38 total of 37 min of CPR, 5 shocks, 10mg adrenalin total
• 08:39 start of ECMO, CPR ceased
• 08:44 patients localized to the ETT, still asystolic, sedation given
• 08:51 temperature up to 34.5 C, VF
• 08:52 one shock, ROSC
• 24 hrs of temperature control at 36.0 C
• Pt. decannulated, extubated on day 1
• Ward the next day

105. Summary
• ECMO has been used as rescue therapy for many indications and has
shown to be safe and to improve outcome
• Extracorporeal life support devices become less invasive and more
integrated in general patient care
• Durable VADs evolve rapidly and become safer for long term treatment and
destination therapy
• Further studies are needed to investigate the rule of ECMO (and other
mechanical support devices) for high risk patients
• Patient selection and ethical considerations remain essential