2. ecmo indications #beach2019 (bouchez)
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1. The document discusses indications for extracorporeal membrane oxygenation (ECMO) support, including respiratory failure or circulatory failure that is potentially reversible and where ECMO may provide a "bridge" until recovery. 2. Specific indications mentioned include severe hypoxemia or hypercapnia unresponsive to conventional management for VV-ECMO, and acute coronary syndrome, myocarditis, pulmonary embolism, or post-cardiotomy shock for VA-ECMO. 3. It emphasizes the importance of patient selection and initiating ECMO at the right time to avoid bridging patients to poor long-term outcomes or death.
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2. ecmo indications #beach2019 (bouchez)
- 1. ECMO Indications Stefaan Bouchez, MD, FASE
- 3. 1 september 1935 The Lindbergh Perfusion Pump Life without risks is not worth living
- 4. 1 september 1935 The Lindbergh Perfusion Pump
- 5. Gibbon 1953
- 6. Willem Johan Kolff 1944 Blood oxygenation during dialysis
- 7. Hill and Bramson 1971
- 8. Indications for ECMO - No absolute indications - Institution specific - Multiple studies with variable indications
- 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. Respiratory failure Circulatory failure VV-ECMO VA-ECMO Etiology ?
- 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. 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. Oxygenation and ventilation : FiO2, PaO2, Airway pressures
- 14. Oxygenation and ventilation: - PaO2 < 80 & FiO2 100% - pH< 7,2 with hypercarbia unresponsive to conventional management
- 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. 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. 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. Cardiogenic shock - Acute coronary syndrome - Myocarditis - Pulmonary embolism - Post-cardiotomy Periprocedural support - PCI - Surgery Sepsis (in some centers) VA-ECMO
- 19. Heartteam Hajjar et al. Crit Care 2019 Refractory Shock
- 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. 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. ECPR
- 23. ECPR CPR started immediately < 5 minutes Collapse to ECPR < 60 minutes (45 min) Holmberg et al. Resuscitation 2018
- 24. Cardiogenic shock - Acute coronary syndrome - Myocarditis - Pulmonary embolism - Post-cardiotomy Periprocedural support - PCI - Surgery Sepsis (in some centers) VA-ECMO
- 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. 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. Salna et al. Eur J CardioThor Surg 2018 In-Hospital Mortality in VA-ECMO 72 y
- 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
Editor's Notes
- Journal of experimental medicine
- Journal of experimental medicine
- OR
- Figure 1 Cardiogenic shock pyramid according to recent proposal. Five categories of cardiogenic shock. Stage A: At risk: Patients ‘At risk’ for cardiogenic shock development but not currently experiencing signs/symptoms of cardiogenic shock. Stage B: Patients with clinical evidence of relative hypotension or tachycardia without hypoperfusion being at ‘Beginning’ of cardiogenic shock. Stage C: Patients in the state of ‘Classic’ cardiogenic shock. Stage D: Cardiogenic shock signals deteriorating or ‘Doom’. Stage E: Patients in ‘Extremis’ such those experiencing cardiac arrest with ongoing cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation cardiopulmonary resuscitation. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
- Figure 1 Cardiogenic shock pyramid according to recent proposal. Five categories of cardiogenic shock. Stage A: At risk: Patients ‘At risk’ for cardiogenic shock development but not currently experiencing signs/symptoms of cardiogenic shock. Stage B: Patients with clinical evidence of relative hypotension or tachycardia without hypoperfusion being at ‘Beginning’ of cardiogenic shock. Stage C: Patients in the state of ‘Classic’ cardiogenic shock. Stage D: Cardiogenic shock signals deteriorating or ‘Doom’. Stage E: Patients in ‘Extremis’ such those experiencing cardiac arrest with ongoing cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation cardiopulmonary resuscitation. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
- Figure 1 Cardiogenic shock pyramid according to recent proposal. Five categories of cardiogenic shock. Stage A: At risk: Patients ‘At risk’ for cardiogenic shock development but not currently experiencing signs/symptoms of cardiogenic shock. Stage B: Patients with clinical evidence of relative hypotension or tachycardia without hypoperfusion being at ‘Beginning’ of cardiogenic shock. Stage C: Patients in the state of ‘Classic’ cardiogenic shock. Stage D: Cardiogenic shock signals deteriorating or ‘Doom’. Stage E: Patients in ‘Extremis’ such those experiencing cardiac arrest with ongoing cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation cardiopulmonary resuscitation. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
- Figure 1: Odds ratios and probability of in-hospital mortality in patients on VA-ECMO. Purple lines represent observed probability of death based on 10-year interval age cohorts (median age of each cohort is presented above the lines). The shaded grey region represents the 95% confidence interval of the predicted probability of death model. The blue line represents the unadjusted odds ratios for in-hospital mortality by age. VA-ECMO: venous–arterial extracorporeal membrane oxygenation. Unless provided in the caption above, the following copyright applies to the content of this slide: © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)