Presentation by Professor Akram Abdel Bary, Professor of Critical care medicine, Cairo University

1. Extracorporeal
membrane Oxygenation
In Critical Care
Akram Abdelbary, MD
Professor of Critical Care
Cairo University
Chairman of research committee, ELSO-SWAC

2. What is ECMO
ECMO Definition & History

3. ECMO - Definition
 Temporarily partially or completely
replaces the circulatory and or the
respiratory systems.
 Shifting part of the circulation outside the
body.
 In Extra-corporeal membrane oxygenation
(ECMO) Blood is Actively oxygenated and
decarboxylated using a membrane lung.
An Extracorporeal life support system:

4. Blood
Drainage
Blood
Treatment
Blood
Reinfusion
ECMO
Add Oxygen
Remove
CO2

5. ECMO - History
1930 John Gibbon – First investigation into ECLS
1950 Early CPB
1956 Clowes invented membrane oxygenator
1957 Kammermeyer invented Silicone membrane lung

6. Dr & Mrs Gibbon
with
their CPB machine

7. ECMO - History

8. ECMO - History
1968: Kolobow and Zapol develop the first
membrane oxygenator permitting prolonged
extracorporeal oxygenation
1972: HILL – First Adult ECMO
1975: Bartlett – First successful neonatal ECMO
1986: Gattinoni - Adult ECCO2R

9. NEJM, 1972
Bramson
ECMO
machine

10. What are ECMO
components?
ECMO Circuit

11. ECMO - Circuit (Cannulae)

12. Arterial cannulae Venous cannulae
12
HLS Cannulae
Art and Venous Cannulae

13. MCP-TP-90000083-EN-01
13
2010-10-18
HLS Cannulae
HLS Cannulae & Insertion kit

14. DRAINAGE
RETURN
TO RV through
TRICUSPID valve
FROM SVC
FROM IVC

15. MCP-TP-90000083-EN-012010-10-18
15
Bi-Caval Cannula

16. MCP-TP-90000083-EN-012010-10-18
16
Bi-Caval Cannula

17. •Roller Pump
 Positive displacement pump.
 By compressing a segment of blood filled tubing .
 Output of a roller pump is determined by
revolution per minute (rpm), the size of the
tubing, and the length of the raceway.
 The roller pump belongs to the occlusive pump
units.
 Disadvantage: Destruction of red blood cells
(hemolysis)
ECMO Challenges

18. •Centrifugal Pump
ECMO Challenges

19. •Centrifugal Pump Component
ECMO Challenges

20. No central shaft or
seals
Spiral flow channel
outlet continuously
increasing from 4mm
 to 9,6mm 
Rotor
Shrouded impeller
with 4 flow channels.
central open
1-point ball-bearing
Designed according the
Gyro Principle, bearing
made of an artificial
sapphir (Al2O3))
Permanent magnets (6pcs.)
for optimal drive and
stabilization;of the rotor
Housing
Due to the inclined
design, no stagnant
zones
DESIGN
•Centrifugal Pump
ECMO Challenges

21.  A negative pressure is at the inlet,
positive pressure at outlet.
 Less priming volume
 NON occlusive pump units.
 Advantage: Less Hemolysis
•Centrifugal Pump
ECMO Challenges

22. ECMO - Circuit (Pump)
 Electrical.
 Centrifugal pump
 0 - > 4000 RPM.
 Can deliver flows
up to 8 L/min.
 Very reliable
 Up to 21 days.

23. ECMO - Circuit (Controller)

24. ECMO - Circuit (Oxygenator)
 Hollow fiber membrane
oxygenator.
 Polymethylpentene.
 Heparin – coated.
 High performance.
 CO2 elimination.
 Blood oxygenation.
 Low pressure drop.
 Long duration 15-21 d.

26. Oxygenator (Artificial lung)
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26
•Blood Flow
Gas (O2)
Water from HCU
Blood from patient
(Low in oxygen)
Blood to patient
(Rich in oxygen)
Membran
(hollow fibres)

27. Oxygenator (Artificial lung)
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27
•Oxygen Flow
Gas (O2)
Water from HCU
Blood from patient
(Low in oxygen)
Blood to patient
(Rich in oxygen)
Membran
(hollow fibres)

28. Oxygenator (Artificial lung)
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28
•Oxygen & water flow for Gas & Heat Exchange
Gas (O2)
Water from HCU
Blood from patient
(Low in oxygen)
Blood to patient
(Rich in oxygen)
Membran
(hollow fibres)

29. 1972 2014

30. Concept and
configurations
ECMO Circuit

31. ECMO – Concept of Use
 RECOVERY
 TRANSPLANTATION
 BRIDGE
 NOWHERE
Bridge

32. ECMO – Organs Supported
 Partial or complete
 Organ Support or
Replacement
 Heart, Lungs or Both
 (Configuration)
Temporary

34. •Respiratory failure &
•Hemodynamic
Stability
VV ECMO
•Heart or Respiratory
Failure &
•Hemodynamic instability
VA ECMO
ECMO - Configurations

35. J Am Coll Cardiol. 2014;63(25_PA):2769-2778. doi:10.1016/j.jacc.2014.03.046

36. Date of download:
1/7/2015
Copyright © The American College of Cardiology.
All rights reserved.

38. Date of download:
1/7/2015
Copyright © The American College of Cardiology.
All rights reserved.
From: Extracorporeal Membrane Oxygenation in Cardiopulmonary Disease in Adults
J Am Coll Cardiol. 2014;63(25_PA):2769-2778. doi:10.1016/j.jacc.2014.03.046
Femoral Venoarterial ECMO
When extracorporeal membrane oxygenation (ECMO) is implemented via femoral venous drainage and femoral arterial return in
patients with residual native cardiac function and impaired lung function, reinfused oxygenated blood (red arrow), flowing
retrograde through the aorta, may meet resistance from poorly oxygenated blood flowing antegrade from the left ventricle (purple
arrow). Depending on the amount of cardiac function, the location of the interface between antegrade and retrograde flow will vary,
and the reinfused oxygenated blood may not reach the cerebral and coronary vascular beds.
Figure Legend:

39. How ECMO Works
ECMO settings

40. Glucose Metabolism
AEROBIC ANAEROBIC
TCA
CO2 + H2O
Lot of Energy / Oxygen Dependant Little Energy / Oxygen Independant
GLYCOLYSIS
LACTATE

41. Main Target
Oxygen Delivery Above
the critical DO2/VO2.

42. Determinants of Arterial Blood
Oxygenation and Decarboxylation
on VV ECMO

43. Influence of
ECMO flow

44. Influence of ECMO FiO2

45. Influence of Sweep Gas Flow
25
30
35
40
45
50
55
60
65
70
75
90
100
110
120
130
140
150
PaCO2(mmHg)O2(mmHg)
P < 0.001
25
30
35
40
45
50
55
60
65
50
60
70
80
90
100
110
120
130
140
150
20
25
30
35
40
45
50
55
60
65
PaCO2(mmHPASP(mmHg)PaO2(mmHg)
10 8 6 4 2
Sweep gas flow (L.min-1 )
P < 0.001

46.  Cardiopulmonary bypass:
 Reduction in RV preload.
 Reduction in pulmonary blood flow.
 Reduction in pulsatility.
 Increases systemic perfusion:
 Combination of native cardiac output and extracorporeal
flow.
 Heterogeneity of perfusion:
 Arterial cannulation site dependent.
 Competing circulations.
 Regional hypoxemia.
 Imposed afterload:
 LV dilatation.
Overview of physiology during VA support

47. VA ECMO Flow Patterns

48. Pulsatile Blood Flow
ECLS circuit produces non-
pulsatile flow:
 Pulsatility diminished
with VA ECLS.
 Inadequate flow (< 40 –
60) results in organ
dysfunction and shock.
 Pulsatility is protective
when compared with
non-pulsatility but only
at low flow.

49.  Flow range:
 2.5 L/min/m2.
 50 ml/kg/min.
 Metabolic assessment:
 Venous drainage oxygen saturation (70-75%, > 65%).
 Lactate.
 Peripheral perfusion assessment:
 NIRS.
 Clinical assessment:
 Urine output.
 Mental status.
Determining Adequacy of Support

50.  LV support:
 Pulse pressure.
 Arterial waveform (dicrotic notch).
 Echocardiography (TTE, TEE).
 CXR.
• If pulmonary involvement, may need decompression
or hybrid support.
 RV support:
 PA tracing (+/-) [pressure = flow vs resistance].
 Liver and renal function.
 Splanchnic and peripheral congestion: edema, ascites,
 Echocardiography.
Determining Adequacy of Cardiac Rest

51.  ECLS system drains ~ 80% from RA, 20% or more goes
to lungs and LA.
 Inadequate LV function with inability to eject against
systemic pressure results in distension of LA and LV:
 Cardiac support with severe LV dysfunction.
 Respiratory support with myocardial stunning.
 PDA can decompress LV in neonates.
 LV decompression may be required.
Left Ventricular Function in VA ECLS

52. Who needs ECMO?
Indications of VV and VA ECMO

53. ECMO - Respiratory
Severe ARDS
Which?
Severe ARDS not responding to
ARDS net protocol + Prone.
When? As Early as possible before organ damage.

54. ECMO - ARDS (Berlin def)

56. Murray Score
Mortality > 80%3-4
 PaO2/FIO2 in mmHg.
 PEEP in cm H2O.
 Lung Compliance, TV/(PIP-PEEP), in ml/cm
H2O.
 Number of quadrants with infiltration on
chest X-ray.
 Total score = ∑ 4 parameters / 4.

57. ECMO - Other Respiratory
Indications
 Vasculitis.
 Post traumatic ARDS.
 Severe Pneumonia.
 Waiting lung
transplantation.
 Air leak syndromes.
 Pulmonary Embolism? VA

58. Extracorporeal Life Support
Organization-Guidelines

59. Mortality
Predictors on
ECMO
Can we
avoid Futile
patients?

60.  To Identify the patients who will likely
survive on ECMO.
 Used by most centers to select patients
that need to be supported and to exclude
futile patients.
 Many ethical considerations specially
regarding disconnection.
VV ECMO - Mortality Predictors

61. ECMO - Mortality Prediction

62. VA ECMO

63. • Acute:
 Complicating ACS.
 Myocarditis.
 Drug induced
 Takatsubu.
 Difficult weaning
from bypass
ECMO in Cardiogenic
Shock- Indications
• Cardiac Arrest.
• Transplantation
Rejection.
• Sepsis induced
Myocardial depression.

64. •As Early As Possible
•Before permanent
Organ damage.
Protect the Brain
before protecting the
heart
Therapeutic Strategy

65. • Parameters to evaluate:
 Etiology/Time course of the disease
 Treatments administered
 Rapid increase in inotropes
 Clinical status, in particular neurological status:
 Is it futile to insert a device?
• Other clinical signs associated with rapid
deterioration of cardiac function:
 Nausea, abdominal pain, Alteration of consciousness, skin
mottling
 Tachycardia, rhythm disturbances
 Ionic disturbances, Acidosis
 Hepatic / Renal failure
• Doppler-Echocardiography +++
 LVEF <20%
 Signs of low cardiac output, Ao VTI <7-8cm
Therapeutic Strategy

67. PatientCircuit
• Infections
• Hemorrhage
• Thrombosis
• Neurologic
• Other
• Cannula
• Oxygenator
• Gas blender
• Tubing
Combined
• Recirculation
• Harlequin
• Pulmonary Edema
• Limb ischemia
Complications

68. We need an
Algorhytm…
ECMO referral

70. Acute
•Recently shocked
•Myocardial depression
Manage
•Cardiogenic shock refractory
•Inotropes and pressors /pacing +/- IABP
ECMO
•SAVE score accepted
•Veno-arterial.

71. Resp
Faiure
•Hypoxic
•No pneumothorax or hemothorax
Manage
•Acute Respiratory failure
•Mechanical ventilation strategies
ECMO
•RESP score accepted
•Veno-venous.

72. Arrest
•Witnessed cardiac arrest
•Myocardial depression
Manage
•Cardiac arrest refractory (30 min)
•Signs of life?
ECMO
•Available ECPR program
•Veno-arterial.

73. Take Home Message
• There are patients with cardiogenic shock and
respiratory failure who are refractory to
conventional intensive care measures.
• ECMO support can serve as a bridge for recovery
for these patients provided initiated within a
suitable time before multi-organ failure.
• ECMO-CPR in certain patients may provide hope if
available.

74. Any further
Readings?
Special issue