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ECMO Update - ICN NSW 2014
The document discusses advancements in extracorporeal life support (ECLS), particularly focusing on ECMO applications for various patient conditions, including severe acute respiratory distress syndrome and cardiogenic shock. Key points include the criteria for patient selection, indications and contraindications for treatment, and emerging technologies in ECLS. The document emphasizes the need for ongoing research to optimize patient outcomes and ethical considerations in treatment selection.
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ECMO Update - ICN NSW 2014
- 1. What’s new inextracorporeal life support Hergen Buscher
- 3. Definition • Externalartificial 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 torecovery It most cases recovery is seen between 7 to 14 days
- 6. 16 year oldboy with goodpasture syndrome On admission 28 days later
- 7. 51 year oldpatient with polypharmacy overdose No pulsatility Same patient 6 days later
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- 20. Indications VV Inabilityto 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=90patients) • 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 MEMBRANEOXYGENATION (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
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- 29. ISICEM Brussels March2014 Brussels presentations
- 30. Paradigm shift inextracorporeal life support Should it be done? How should it be done? When should it be done?
- 31. Key points ofmodern ECMO management
- 34. Subclavian Artery Cannulationfor Ambulatory VA ECMO Javidfar, ASAIO 2012
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- 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 ECMOConsoles
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- 40. Pharmacokinetics ex vivo Shekar, Crit Care 2012
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- 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 andanticoagulation
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- 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 anticoagulateand 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, 2013Asio-Pacific ELSO Meeting
- 52. ECMO and BloodManagement • 52 ECMO runs in St Vincent’s Hospital • 363 ECMO days • Daily median (interquartile range) transfusions (unpublished data)
- 53. When to doit NEW AND EVOLVING INDICATIONS
- 54. Evolving indications EXTRACORPOREALCO2 REMOVAL (ECCOR)
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- 57. Novalung Passive arterio-venousSystem Active veno-venous System
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- 60. Hemolung Catheter 15.5Fr 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 • Toavoid 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: 21patients with hypercapnic respiratory failure (Novalung) • Now >500 patient entered in registry
- 68. Kluge et al.ICM 2012
- 69. NIV IMV 010 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 preECCOR 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 possibleafter 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 11days 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 onECCOR 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
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- 75. Where to useit: 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 LungInjury 76
- 77. ECCOR reduces IL-6Levels Training Guide 77
- 78. Xtravent trial Bein,ICM 2013
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- 80. What we usedto do severe moderate ECMO IABP Inotropes Recovery Tandem Heart, Impella, Levitronix….. OR Death Durable VADs Heart Transplantation acute chronic Heart Failure
- 81. What we aredoing now severe moderate ECMO-Tandem Heart-Impella ….. IABP Inotropes Durable VADs Heart Transplantation acute chronic Heart Failure
- 82. What we aredoing now severe moderate ECMO-Tandem Heart-Impella ….. IABP Inotropes Durable VADs Heart Transplantation acute chronic Heart Failure
- 83. IABP-Shock2 Trial, NEJM2012 What’s the Standard of Care? … IABP ?
- 84. Incidence and Mortalityof Cardiogenic Shock Post Myocardic Infarct Mann, Nolan: Current Opinion in Critical Care 2006
- 85. Incidence of CardiogenicShock (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 bea RCT on cardiac extracorporeal life support on patients with an expected mortality of 50-80%?
- 88. Prophylactic ECMO forinterventional 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 toOptimize Renal Function as a Bridge to Decision ECMO Implantation 72 hours Creatinine improved to normal values 3 days after ECMO implantation
- 90. ECMO could bemore than a rescue treatment in cardiogenic shock
- 91. What if thepatient does not recover? severe moderate IABP Inotropes Durable VADs Heart Transplantation acute chronic Heart Failure ECMO-Tandem Heart-Impella …..
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- 93. … But isHeart 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 shouldbe offered a VAD as a destination therapy?
- 96. Progress in durableVAD development 2000 2014
- 97. Rose, NEJM 2001 LVAD support Improves Short-term survival in Stage 4 Heart Failure
- 98. Survival has improvedFurther with modern Continuous Flow Devices Miller, NEJM 2007
- 99. Quality of LifeImproves Significantly in Survivors
- 100. Costs are High(still)
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- 103. Get ECMO inless than 45 min from collapse Non-survivors are not expensive
- 104. One of ourcases • 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 • ECMOhas 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
Editor's Notes
- #8 How much is the nonpulsatile ECMO flow and how much is the heart contributing? There are other clues besides just echo. Here is an extreme example of what is potentially possible with ECMO. Still alive? See the CO2 trace, also the difference in oxygenation (color difference of the 2 cannula with O2 extraction that continues if still alive)
- #33 The Avalon catheter is frequently used in MSICU. With this cannula correct positioning is vital-we will see why with the next slide.
- #34 The blood gets taken in from the IVC and SVC ports and returned through a single port that needs to be positioned in the central part of the RA.
- #76 The reported incidence of acute respiratory distress syndrome ranges from 7 to 59 per 100,000 people with an associated with a mortality rate of 40 to 45%. This rate remains unacceptably high despite the introduction of lung protective. When surveyed, health care providers reported that hypercapnia or its related effects were significant barriers to achieving LPV. Studies have shown that while 6 ml.kg-1 is superior to 12 ml.kg-1 and <4 ml.kg-1 might be superior to 6 ml.kg-1 [9-11]. Hypercapnia harms injured lung through immunosuppression and impaired pulmonary epithelial repair. Furthermore, hypercapnia worsens right heart failure and is undesirable in patients with elevated intracranial pressure.