Ecmo bridge to recovery
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ECMO (extracorporeal membrane oxygenation) is a technique that uses pumps and a artificial lung to support heart and lung function. It can be used to support failing organs while allowing time for recovery or as a bridge to transplant. The history of ECMO began in the 1950s with the development of cardiopulmonary bypass and its use has expanded to support both children and adults with heart and lung failure. While intensive, ECMO can save lives that would otherwise be lost to critical illness.
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Ecmo bridge to recovery
- 1. ECMO – A BRIDGE TO RECOVERY Dr. S.K. Varma, MS, FRCS(Ed), MCh, DNB, FIACS Chief Cardiothoracic Surgeon KG Hospital, Coimbatore 641018 www.skvarma.com
- 2. What is ECMO • Extra corporeal • Membrane • Oxygenation • (Pump)
- 3. When Is ECMO Used • Support the failing heart and or lungs by temporarily taking over their functions allowing rest and repair and rejuvenation • Bridge to recovery • Bridge to transplant
- 4. Pumps • Centrifugal • Roller
- 5. Membranes • Silicone rubber • Microporus polypropylene • Polymethyl pentene
- 8. History of ECMO…. = ….History of C.P.B Pump – heart substitute Gas exchange mechanism – Lung Substitute
- 9. History of ECMO…. • 1953 • John Heysham Gibbon Jr • Jefferson Medical College Hospital (Philadelphia) • First successful use of Cardiopulmonary bypass
- 10. History ….. • Atrial Septal Defect Closure • Cecelia Bavolek 18/F • 45 minutes • 26 minutes Next 3 patients died
- 11. History….. • 1954 • Clarence Walton Lillehei • University of Minnesota • Controlled cross circulation (VSD Closure 1/M child connected to fathers circulation) • 19 minutes
- 12. History …… • 1970 • Theodore Kolobow • Membrane Lung (no direct contact between blood and gas) • Silicone rubber (Kolobow’s orginal) • Microporus polypropylene • Polymethyl pentene • Laminated carbon-containing silicone rubber membrane for use in membrane artificial lung • Patent number: 4093515 • Abstract: A blood-compatible gas-permeable laminated carbon-containing silicone rubber membrane for use in a membrane artificial lung. The membrane is composed of at least two layers wherein the first layer is of silicone rubber compounded with silica filler and the second layer is of silicone rubber compounded with carbon black filler. The second layer may be sandwiched between the first layer and a third layer of either silicone rubber compounded with silica filler or filler-free silicone rubber. Utilizing such membrane for extracorporeal blood gas exchange in a membrane artifical lung results in elimination of thrombosis without the necessity for maintenance anticoagulant treatment during perfursion, and enables elimination of leukopenia and granulocytopenia or inhibition of blood platelet count decreases during perfusion. • Type: Grant • Filed:March 1, 1976 • Issued: June 6, 1978 • Assignee: Government of the United States • Inventor: Theodor Kolobow
- 13. History….. • 1972 • Dr J Donald Hill • SanFransisco (CA) • First successful adult ECMO • 24/M Polytrauma with ARDS
- 14. History ….. • 1975 • Robert Bartlett • Orange County Hospital Los Angeles CA • First successful neonatal ECMO (I day old Mexican immigrant)
- 15. History……. • Baby “Esperenza”(Baby of hope)
- 17. History……. (Cesar Trial 2006) BMC Health Serv Res. 2006; 6: 163. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure Giles J Peek,1 Felicity Clemens,2 Diana Elbourne,2 Richard Firmin,1 Pollyanna Hardy,2,3 Clare Hibbert,5 Hilliary Killer,1Miranda Mugford,4 Mariamma Thalanany,4 Ravin Tiruvoipati,1 Ann Truesdale,2 and Andrew Wilson6 An estimated 350 adults develop severe, but potentially reversible respiratory failure in the UK annually. Current management
- 18. TYPES OF ECMO
- 19. Veno Arterial ECMO (V-A ECMO) • Cardiac Support
- 20. Veno Venous ECMO (V-V ECMO) • Lung Support
- 22. Indications for V-A ECMO • Inability to wean off CPB after cardiac surgery • e CPR • Post MI Cardiogenic shock (refractory to IABP) – MR - VSD - Free wall rupture - Refractory arrhythmias • Post sepsis cardiogenic shock • Acute viral myocarditis • Massive bilateral pulmonary embolism • Cardiac or major vessel blunt trauma • Peripartum cardiomyopathy
- 23. Indications for V-V ECMO • ARDS • Massive bilateral extensive pneumonia • e CPR (drowning) • Neonates (meconium aspiration / HMD) • Aspiration pneumonia • Massive lung contusion after chest trauma • Smoke inhalation injury • Intractable status asthmaticus • Pulmonary alveolar protienosis (some forms)
- 24. Criteria for “Lung Failure needing ECMO” • Murray score >3 (PaO2/FIO2 ratio, CXR, PEEP, Compliance) • Hypercarbia pCO2 >70mm • Hypoxia pO2 <50mm • Acidosis pH <7.2 • pAO2 / FIO2 ratio <75% • Lung compliance <0.5ml / cmH2O / Kg • Ventilation index >40 • FIO2 requirement of 100% >6hrs
- 25. Criteria for “Cardiac Failure needing ECMO” • Unable to wean off CPB despite optimal inotropes and IABP • Cardiac arrest in hospital ( CPR>> 30 min) • ECHO EF <20% Aortic velocity time index <8cm
- 26. Criteria for “Cardiac Failure needing ECMO” • Systemic index <1.8L/min/M2 • PCWP >>25mm • Serum Lactate >10mmols/L • Mixed venous O2 sat <<65% • Inotrope score of >>20 (sum of all inotropes in mcg/kg/min at peak infusion rate) • Mean arterial pressure <60mm adults (<40mm infants) for more than 6hrs
- 27. Exclusion Criteria • Primary disease is irreversible (disseminated malignancy) • Age >75 years • On ventilator >15 days • Irreversible / indeterminate neurological prognosis • Any immunosupressed state • Already in multiorgan failure • Pre-existing coagulopathy • Severe pulmonary hypertension • Severe aortic regurgitation
- 28. ECMO Management • Anticoagulation (around 200 secs) • Top up transfusion (platelets / RBCs) • Sepsis prevention • Nutrition • Prevent LV distension • Monitor recovery • Rx of underlying cause
- 29. How Long…..? • ELSO Data 117 days • Average V-V ECMO 14-21days • V-A ECMO 5-14 days
- 30. Complications • Hemolysis • Thrombocytopenia (mechanical / heparin induced) • Bleeding • Sepsis (access site and systemic) • Intracerebral hemorrhage • Intracerebral micro infarcts • Oedema • Malnutrition / hypoalbuminemia • Limb ischemia
- 31. Results • V V ECMO 65-70% • V A ECMO 50%
- 32. Practical Difficulties • Very labour intensive • Very cost intensive • Experienced team • Reliable blood bank support 24/7
- 33. • When all else fails, ………when life is sure to ebb away………………………………… • Cometh the hour …………. cometh the man • ECMO
- 34. Future of ECMO • Increased accessibility and use • Reduction in costs • Insurance / government support • Smaller lines / volumes / oxygenators • Coated “stealth” tubings
- 35. Thank You