hồi sức

1. Extracorporeal Membrane Oxygenation
(ECMO) for Management of Cardiogenic
Shock: Initial Experience
Intensive Care Unit,
Department of Cardiac Surgery,
Bach Mai Hospital

2. Case study 1
A 52-year-old male patient suffered from cardiogenic shock complicating acute inferior myocardial infarction
Emergency Depar ICU
Before
ECMO
After 6 hours Day 2 Day 4 Day 5 Day 7 Day 10
Glasgow Score 3 Sedation Sedation 15 15 15 15
Noradrenalin dosage 0,45 Stop
Epinephrine dosage 0,15 Stop
Dobutamin dosage 10 Stop
Lactate 11,5 7,4 3,2 1,5 0,9 0,8
Urine output
(ml/hour)
0 160 180 280 190 138 100
SOFA score 11 9 5 5 1 0
-Ventricular Fibrillation
-Cardicac arrest
-CPR 45 minutes
Stent
intervention
Discharge
without
sequels
STOP
ECMO
Extubation
ECMO

3. Case study 2
A 52-year-old female patient suffered from cardiogenic shock complicating acute myocarditis
Emergency Dep ICU
-Ventricular Fibrillation
-Cardicac arrest
-CPR and set up ECMO
at the same time
STOP
ECMO
EXTUBATION
Before
ECMO
After 6
hours
Day 2 Day 4 Day 5 Day 7 Day 10
Glasgow Score 3 Sedation Sedation 15 15 15 15
Noradrenalin dosage
(µg/kg/minute)
0,6 Stop
Epinephrine dosage 1 Stop
Dobutamin dosage 10 Stop
Lactate 5,3 2,1 1,8 1,8 2,2 1,2 1,8
Urine output
(ml/hour)
0 300 125 180 150 112 100
SOFA score 9 9 8 5 4 2 0
Discharge
without
sequels
Fever, angina
Dyspnea
Cool extremities

5. Introduction: cardiogenic shock
- High mortality: 60%
- Etiology:
+ AMI
+ Acute myocarditis
+ Heart valve disease
MYOCARDIAL PATHOLOGY
* Steven M. Hollenberg (2012), ‘Cardiogenic Shock’, Critical care medicine principle of diagnosis and managment in
the adult, 4th edition published by Elsevier, 325-337.

6. Introduction
Circulation assist devices
ECMO V-A
• Survival rate: 20,8-65,4%**.
*Marc Licker, (2012), Ma age e t of wea i g fro ardiopul o ary ypass after ardia surgery”, Annals of Cardiac Anaesthesia
**Ri hard Che g, et al, 4 Co pli atio s of E tra orporeal Me ra e O ge atio for Treat e t of Cardioge i “ho k a d Cardiac Arrest:
A Meta-A al sis of ,866 Adult Patie ts , A Thora “urg.

7. INDICATION OF ECMO
VA-ECMO
• Cardiogenic shock
• Acute myocarditis
• AMI
• Poisoning
• Cardicac arrest
• Failure to wean from
cardiopulmonary bypass after
cardiac surgery
• As a bridge to either cardiac
transplantation or placement of
a ventricular assist device
V-V ECMO
• ARDS with PaO2/FiO2 <100 mmHg
despite optimization of the
ventilator settings

8. Peripheral ECMO V-A

9. OBJECTIVE
• Assess the efficacy of the Extracorporeal Membrane
Oxygenation (ECMO) in patients with severe
cardiogenic shock
• Describe complications of the technique during the
treatment

10. METHODS
Patients: who were severe cardiogenic shock
Criteria for diagnosing cardigenic shock*:
Clinical signs:
• Hypotension
• Oliguria
• Clouded sensorium
• Cyanotic, have cool skin and mottled extremities
Hemodynamic signs:
• SBP <90 mmHg for > 30 mins
• CI <2.2 L/min/m2
Exclude: shock due to the others causes (hypovolemia, septic, pulmonary embolism,
aortic dissection...), severe hypoxia, metabolic acidosis
* Steven M. Hollenberg (2012), ‘Cardiogenic Shock’, Critical care medicine principle of diagnosis and managment
in the adult, 4th edition published by Elsevier, 325-337.

11. METHODS
•A prospective study
•In the ICU, Bach Mai Hospital

12. ICU in Bach Mai hospital
01 Maquet machine (for VV ECMO) 02 Terumo machine (for VA ECMO)

13. Preparation

14. METHODS
• The V-A ECMO was establishes using the CAPIOX
emergent bypass system (TERUMO Inc. Tokyo,
Japan)
− V-A vascular access
− Blood flow was adjusted gradually to the target
cardiac index of 2.0 – 2.5l/min/m2; and to maintain
MAP above 65mmHg
− FiO2 100% and titrated based on arterial blood gas
and lactate
− Standard heparin was titrated to maintain the APTT
between 40-45s

15. Monitoring and Titration

16. Weaning

17. RESULTS
Demographic data:
25 cardiogenic shock patients were enrolled in the study from
2008 to 2014
o The median age was 49,4 ± 19,05 (years),
Maximum was 82 (years) ,
Minimum was 11 (years)
o Gender: Male 60% (n=15), Female 40%.
o 23 patients were used one ECMO membrane
o ECMO duration was 124,4 ± 57,97 (hours)

18. RESULTS
Characteristic (n=25)
Heart rate (beats/minute) 104,2 ± 33,81
CVP (mmHg) 15,4 ± 5,86
Epinephrine dosage (µg/kg/minute) 0,9 ± 1,03 (n=16)
Noradrenalin dosage (µg/kg/minute) 0,8 ± 0,68 (n=23)
Dopamin dosage (µg/kg/minute) 10 (n=1)
Dobutamin dosage (µg/kg/minute) 14 ± 9,9 (n=22)
Urine output (ml/hour) 23,8 ± 49,7
MAP (mmHg) 64,3 ± 24,76
APACHE II 17,2 ± 5,25
SOFA score 10,1 ± 4,27
Lactate (mmol/l) 7,5 ± 4,48
proBNP (pmol/l) 2314,0 ± 1627,27
EF (%) 35 (n=20)
Troponin T (nmol/l) 6,1 ± 3,95
Pacemaker 48%
Table 1: Clinical and subclinical characteristics of patients before ECMO

19. RESULTS
Acute myocarditis [VALUE]
n=13AMI [VALUE]
n=9
After surgery [VALUE]
n=3
FIGURE 1: THE ETIOLOGY OF CARDIOGENIC SHOCK

20. RESULTS
Figure 2: Mortality rate
Alain Combes, MD, et al 2008 , Out o es a d lo g-term quality-of-life of patients supported by
e tra orporeal e ra e o ge atio for refra tor ardioge i “ho k , Crit Care Med.
Non-survivors
52%
Survivors
48%

21. RESULTS
0
20
40
60
80
100
Viêm cơ tim NMCT “au Phẫu thuật
Figure 3: Mortality rate
“ố g Tử vo g
-2 cases died due to ruptured ligament
of mitral valve
-1 case died due to bladder bleeding
-1 case died due to nosocomial infection
n= 10
Acute myocarditis AMI After surgery
n= 3
n= 3 n= 6 n= 3
n= 0
*Kang-Hong Hsu, et al, (2012), E tra orporeal e ra ous o ge atio support for a ute ful i a t o arditis: a al sis
of a si gle e ter s e perie e , Europea Jour al of Cardio-thoracic Surgery.
** Alain Combes, MD, et al 2008 , Out o es a d lo g-term quality-of-life of patients supported byextracorporeal
e ra e o ge atio for refra tor ardioge i “ho k , Crit Care Med.
Non-survivorsSurvivors

22. RESULTS
0
20
40
60
80
100
TRƯỚC ECMO SAU ECMO 6 GIỜ SAU ECMO 12
GIỜ
NGÀY 2 NGÀY 3 NGÀY 5 NGÀY 7 NGÀY 10
ACHSENTITEL
FIGURE 4: MAP DURING ECMO
“ố g Tử vo g
P < 0,05 P < 0,05
P < 0,05 P < 0,05 P < 0,05
P < 0,05P < 0,05
mmHg Survivors Non-survivors
Before ECMO After 6 h After 12 h Day 2 Day 3 Day 5 Day 7 Day 10

23. RESULTS
0
20
40
60
80
100
120
140
160
180
200
TR C ECMO SAU ECMO 6
GIỜ
SAU ECMO 12
GIỜ
NGÀY 2 NGÀY 3 NGÀY 5 NGÀY 7 NGÀY 10
FIGURE 5: URINE OUTPUT
“ố g Tử vo g
p< 0,05
p< 0,05
p< 0,05
p< 0,05
p< 0,05
P< 0,05
Survivors Non-survivors
p< 0,05
ml/h
Before ECMO After 6 h After 12 h Day 2 Day 3 Day 5 Day 7 Day 10

24. RESULTS
0
1
2
3
4
5
6
7
8
Tr c ECMO N1 N2 N3 N4 N5 N6 N7
Figure 6: Lactate during ECMO
“ố g Tử vo g
P< 0,05
P< 0,05
P< 0,05
P< 0,05
P< 0,05
P< 0,05
P< 0,05
P < 0,05
P < 0,05 P < 0,05 P < 0,05 P < 0,05
P < 0,05 P < 0,05
mmol/l
Non-survivors
Before ECMO Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Survivors

25. RESULTS
0
2
4
6
8
10
12
14
Tr c
ECMO
N 1 N 2 N 3 N 4 N 5 N 6 N 7 N 8 N 9 N 10
“ố g Tử vo g
P< 0,05
P< 0,05P< 0,05 P< 0,05
Before ECMO Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10
Survivors
Figure 7: SOFA score
P < 0,05
P < 0,05
P < 0,05
P < 0,05
P < 0,05
P < 0,05
Non-survivors

26. RESULTS
Before ECMO Day 3 Day 5 Day 7 Day 10
PLT Survivors 141 ± 64,3 97 ± 15,2 113 ± 70,4 129 ± 44,5 314 ± 164
Non-survivors 189 ± 105 96 ± 65,8 85 ± 27,5 126 ± 100 100 ± 55,8
PaO2/ FiO2 Survivors 207 ± 135,7 286 ± 97,6 282 ± 122,2 245 ± 83,8 298 ± 122,6
Non-survivors 218 ± 196,6 285 ± 125,3 274 ± 144,3 161 ± 132,5 213 ± 0
Creatinin
µmol/l
Survivors 174 ± 139,8 134 ± 99,4 118 ± 181,1 101 ± 58,0 102 ± 56,4
Non-survivors 200 ± 92,4 222 ± 99,9 285 ± 147,6 239 ± 135,1 258 ± 194,0
Bilirubin
total
Survivors 19,4 ± 14,02 25,8 ± 18,6 22,1 ± 12,44 25,2 ± 14,03 22,7 ± 10,58
Non-survivors 39,2 ± 39,10 80,6 ± 73,19 64,7 ± 59,3 36,4 ± 24,5 73,6 ± 0
The others parameters during ECMO

27. COMPLICATION
CLINICAL COMPLICATIONS %
Bleeding 75 % (19 pts)
Disrupting differential hypoxia 8 % (2 pts)
Cannula site infection 8 % (2 pts)
Stroke 4 % (1 pt)
Femeroal venous thrombus 4 % (1 pt)
TECHNICAL COMPLICATION
(ECMO membrane)
Plasma leakage 8 % (2 pts)
Clots formed in the oxygenator 4 % (1 pt)
Table 2: complications of ECMO

28. CONCLUSION
• V-A ECMO: The survival rate in cardiogenic shock
patients were 52% in our study (higher – 77% - in acute
fulminant myocarditis group)
• The patients who used one ECMO membrane were 92 %,
duration of ECMO were 124,4 (hours).
• The frequent complications observed were bleeding,
infection, ischemia that are preventable with closely
monitoring

29. ECMO group
• 02 ICU doctors
• 02 cardiac surgeons
• 02 nurses

31. Thank you for your attention!