ECMO (Extracorporeal

Membrane Oxygenation
)

ECMO in Adults? Isnt this a Peds

thing?

1000 patients supported on ECMO at the University of Michigan were

reviewed (retrospectively)

VV-ECMO for respiratory failure provided survival to discharge:

88% of 586 cases of respiratory failure in neonates

70% for 132 cases of respiratory failure in children

56% for 146 cases of respiratory failure in adults

Introduction

Mechanical circulatory support has evolved markedly over recent years.

ECMO (extra corporeal membrane oxygenation) has become more

reliable with improving equipment, and increased experience, which is
reflected in improving results.

Introduction

ECMO is instituted for the management of life threatening pulmonary

or cardiac failure (or both), when no other form of treatment has
been or is likely to be successful.

ECMO is essentially a modification of the cardiopulmonary bypass

circuit which is used routinely in cardiac surgery.

Introduction

Instituted in an emergency or urgent situation after failure of other

treatment modalities.

It is used as temporary support, usually awaiting recovery of organs.

Dynamics of ECMO

Blood is removed from the venous system either peripherally via

cannulation of a femoral vein or centrally via cannulation of the right
atrium,

Oxygenate

Extract carbon dioxide

Blood is then returned back to the body either peripherally via a

femoral artery or centrally via the ascending aorta.

Indications for ECMO

Divided into two type

Cardiac Failure

Respiratory Failure

Indications Cardiac Failure

Post-cardiotomy

Post-heart transplant

when unable to get pt off cardiopulmonary bypass following cardiac

surgery

usually due to primary graft failure

Severe cardiac failure due to almost any other cause

Decompensated cardiomyopathy

Myocarditis

Acute coronary syndrome with cardiogenic shock

Profound cardiac depression due to drug overdose or sepsis

Indications Respiratory Failure

Adult respiratory distress syndrome (ARDS)

Pneumonia

Trauma

Primary graft failure following lung transplantation.

ECMO is also used for neonatal and pediatric respiratory support

This is where most of the research on ECMO has been done

Decision to Institute ECMO

Several considerations must be weighed:

Likelihood of organ recovery.: only appropriate if disease process is

reversible with therapy and rest on ECMO

Cardiac recovery: to either wait for further cardiac recovery to allow

implant of device (LVAD) or to list for transplantation.

Disseminated malignancy

Advanced age

Graft vs. host disease

Known severe brain injury

Unwitnessed cardiac arrest or cardiac arrest of prolonged duration.

Technical contraindications to consider: aortic dissection or aortic

incompetence

Configurations for ECMO

ECMO can be inserted in 2 configurations:

Veno-venous

Veno-arterial

Veno-arterial (VA) configuration

Blood being drained from the venous system and returned to the arterial
system.

Provides both cardiac and respiratory support.

Achieved by either peripheral or central cannulation

Central ECMO Cannulation

Veno-Venous (VV) configuration

Provides oxygenation

Blood being drained from venous system and returned to venous system.

Only provides respiratory support

Achieved by peripheral cannulation, usually of both femoral veins.

Peripheral ECMO Cannulation

Central vs. Peripheral Cannulation

Advantages

Flow from Central ECMO is directly from the outflow cannula into the aorta
provides antegrade flow to the arch vessels, coronaries and the rest of the
body

In contrast, the retrograde aortic flow provided by peripheral leads to mixing

in the arch.

Disadvantages

Previously insertion of central ECMO required leaving chest open to allow

the cannulae to exit.

Increased the risk of bleeding and infection

Newer cannulae are designed to be tunneled through the subcostal abdominal

wall allowing the chest to be completely closed.

Central cannula are costly (approximately 4 times as much as peripheral)

Things to Think About

Mechanical ventilation must be continued during ECMO support to try to

maintain oxygen saturation of blood ejected from the left ventricle to at
least above 90%.

ECMO flow can be very volume dependent

ECMO flow will drop:

Hypovolemia

Cannula malposition

Pneumothorax

Pericardial tamponade.

Weaning of ECMO VV ECMO

Actual ECMO flows do not need to be altered to assess native

respiratory function

Done by altering gas flow through the ECMO circuit

Pt may be weanable:

Gas exchange is able to be maintained with a low FiO2 (<30%)

Low fresh gas flow rates into the circuit (<2 L/min)

Caveat: RR and PEEP set on ventilator are not too high (e.g. <25
breaths/min and <15cmH2O, respectively).

Weaning of ECMO VA ECMO

Depends on cardiac recovery, Factors:

Increasing blood pressure

Return or increasing pulsatility on the arterial pressure waveform

Falling pO2 by a right radial arterial line

indicating more blood is being pumped through the heart which may be less well
oxygenated,

Falling central venous and/or pulmonary pressures.

It is important to note that cardiac outputs from pulmonary artery

catheter are inaccurate on ECMO

Most of the circulating blood volume is bypassing the pulmonary circulation

Complications

Falls into one of three major categories

1) Bleeding associated with heparinization
2) technical failure
3) neurologic sequelae

Complications of ECMO

Bleeding/Hemolysis

Out

of proportion to the degree of coagulopathy and

patient platelet count

Coagulopathy

Continuous activation of contact and fibrinolytic systems by the circuit

Consumption and dilution of factors within minutes of initiation of ECMO

Complications of ECMO

Thrombocytopenia

Platelets adhere to surface fibrinogen and are activated

Resultant platelet aggregation and clumping causes numbers to drop

Non-pulsatile perfusion to end organs

Kidneys

Splanchnic circulation seems to be particularly susceptible

GI bleeding, ulceration and perforation

Liver impairment

Complications of ECMO

Mechanical Complications

Tubing
Pump

rupture

malfunction

Cannula

related problems

Local complications: Leg ischemia

Particularly at peripheral insertion site of VA

Air embolism/Thromboembolism

Neurological: Intracerebral bleeds

Largely associated with sepsis

Manifest as seizures or brain death

Management of Complications

Regular measurements of blood tests (Q6-Q8h)

Coagulation Profile

Platelet Count

Hemoglobin

Creatinine to evaluate for renal insufficiency

Aggressive replacement of clotting factors, electrolytes, PRBC

Outcomes of ECMO

Good quality RCT of ECMO outcomes in adult population are lacking

There are very promising studies in the Pediatric populations,

however it is hard to know if this translates into the adult population.

Completed yet unpublished CESAR Trial shows some potential impact

in ECMO research

CESAR

Conventional Ventilation or ECMO for Severe Adult Respiratory Failure

Preliminary results released at 37th Society of Critical Care Medicine

Congress in Honolulu February 2008

CESAR

Randomized controlled trial to assess the impact of ECMO on survival

without severe disability by 6 months in patients with potentially
reversible respiratory failure

Severe disability was defined as confined to bed and unable to dress

or wash oneself

CESAR

Conducted from 2001-2006

Adults were randomized either to VV ECMO at Glenfield Hospital,

Leicester, England (90 patients) or continuing conventional care at
referral hospitals (90 patients).

The conventional group underwent standard clinical practice in the

UK

Conventional Ventilator

CESAR

ECMO

57 of 90 met primary endpoint

Conventional ventilation group

41 of 87 met primary endpoint

CESAR

RRR 0.69 (95% CI, 0.050.97; P = 0.03)

Benefit of ECMO seen regardless of age, duration of high-pressure

ventilation, primary diagnosis at trial entry, and number of organs
failing.

Further Studies

CESAR study shows potential impact for VV ECMO, however studies

to evaluate impact for VA ECMO are lacking

This is where potential studies can be done

Summary

ECMO is instituted for the management of life threatening pulmonary

or cardiac failure (or both), when no other form of treatment has
been or is likely to be successful.

ECMO is essentially a modification of the cardiopulmonary bypass

circuit which is used routinely in cardiac surgery.

ECMO can be inserted in 2 configurations: Veno-venous & Venoarterial

Completed yet unpublished CESAR Trial shows some potential impact

in ECMO research

Questions??

Bibliography

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Fiser S, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, Kron IL. When to discontinue ECMO
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Glauber M, Szefner J, Senni M, Gamba A, Mamprin F, Fiocchi R, Somaschini M, Ferrazzi P.

Reduction of haemorrhagic complications during mechanically assisted circulation with the use
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