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ECMO in Cardiac Arrest
ECMO is a form of extracorporeal life support that oxygenates and removes carbon dioxide from the blood. It is being considered in the emergency department for patients experiencing refractory ventricular fibrillation during cardiac arrest. ECMO may improve survival rates and neurological outcomes compared to conventional CPR. There are indications and contraindications for its use in acute, severe reversible respiratory or cardiac failure. The two main types are veno-venous ECMO for respiratory failure and veno-arterial ECMO for cardiac failure. Proper patient selection, cannulation technique, and circuit management are important considerations for ECMO in cardiac arrest.
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ECMO in Cardiac Arrest
- 1. ECMO in CardiacArrest Johnny iliff
- 2. references LITFL AlfredHospital ECMO Project
- 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. Why are weconsidering 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. Indications acute, severeREVERSIBLE 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. Absolute Contraindications progressivenon-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. Relative Contraindications age> 75 multi-trauma with multiple bleeding sites CPR > 60 minutes multiple organ failure CNS injury
- 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. VV ECMO mostcommon 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
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- 11. Pathology pneumonia ARDS -acute GVHD pulmonary contusion smoke inhalation status asthmaticus airway obstruction aspiration bridge to lung transplant drowning
- 12. VA ECMO venousdrainage from large central veins -> oxygenator -> arterial system in aorta support for cardiac failure (+/- respiratory failure)
- 14. Pathology graft failurepost 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
- 15. 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
- 16. The patientis 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
- 17. STEPs 1. Identify potentialpatient 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
- 18. Cannulation It’s centralaccess, what’s the big deal?
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Editor's Notes
- #5 RETROSPECTIVE CHART REVIEW STUDY over 2 years of 60 patients who had VF refractory to CPR for more than 10mins
- #12 ----- Meeting Notes (13/04/16 16:08) ----- ADVANTAGES normal lung blood flow oxygenated lung blood pulsatile blood pressure oxygenated blood delivered to root of aorta must be used when native cardiac output is high VENTILATION no need to ventilate at normal level must maintain alveolar volume and oxygenation
- #14 Advantages of periperhal good Q can create high oxygen tensions Disadvantages relative lung ischaemia non-pulsatile blood flow possible poor perfusion of coronaries and cerebral vessels distal limb ischaemia risk of lung overventilation -> tissue alkalosis (monitor with ETCO2) Advantages of Central no preferential perfusion to lower body no possibility of hypoxic perfusion of cerebral vessels can use very large cannulae (high flows)