Ecmo

ecmo

1. How would you ventilate your ECMO patient. A glance at the literature. Abdalmohsen Ababtain CCM Grand round.

2. Disclosure No disclosure

3. Objectives A brief on ECMO ECMO Indications Time to ECMO PEEP individualization Ventilating ARDS patients on ECMO.

4. ECMO in ARDS

5. 10% survival!

6. Randomized 40 patients with severe ARDS Prospective, randomized comparison of ECCO2R and conventional management The main outcome measure was survival at 30 days after randomization. Survival was not significantly different in the 19 mechanical ventilation (42%) and 21 new therapy (extracorporeal) (33%) patients (p = 0.8 )

7. Retrospective review. January 1990 and July 1996, 142 patient had severe ARF 41 patients improved on Conventional treatment 100 patients required ECLS (94 Hypoxic) Survival 54%

8. How did they Ventilate? Lung rest protocol PCV Plateau pressure < 35 cm water PEEP 10-15. Fio2 <50 % with arterial sat 80-90 %. Rate 4-6/min Maintaining Co2 around 40mmHg Hematocrit 45-48%. Tracheostomy done in the first or second day.

9. Retrospective chart review for the first 50 patients received ECMO at Glenfield Hospirtal Survival Rate 66%

10. Does ECMO increase 6 months survival without severe disability in patients with severe respiratory failure compared to conventional ventilation? And is it cost effective?

11. Randomized control trial N=180 ECMO (n=90) Conventional Manamgement (n=90) Setting: 92 Conventional Treatment Centers, 11 Referral Hospitals and 1 ECMO center in the UK. If included in the trial participants were transferred to either a conventional treatment center or to the ECMO center. Enrollment: July 2001 to August 2006 Mean follow-up: 6 months Analysis: Intention-to-treat Primary outcome: Death or severe disability at 6 months .

12. Inclusion Criteria: Adult 18-65 Severe resp failure with Murray score >=3 or uncompensated hypercapnia with PH<7.20 Exclusion criteria: >7 days of high pressure or Fio2 ventilation Contraindication to heparin Moribund patients

13. PCV at 30 cm H2O PEEP titrated to optimum SaO2 FiO2 titrated to maintain SaO2 at more than 90% Diuresis to dry weight Target packed cell volume of 40%, Prone positioning F ull nutrition

14. If the patient doesn’t respond in 12 hours Install ECMO PCV with peak pressure 20 PEEP 10 Rate 10 Fio2 30%

15. Results: ECMO is cost effective and does increase survival without severe disability at 6 months in patients with severe reversible respiratory failure compared to conventional management in the UK.

16. H1N1 experience

17. Observational study Of 68 adult and pediatric patients who were treated with ECMO between June 1 and August 31, 2009 patient with H1N1 in 2009 outbreak

18. Prospective cohort study

19. ECMO Indications Heart and lung Support Emergent or elective Mortality of 40% ELSO Guidelines August 2017

20. Respiratory failure indications Refractory Hypoxia : Consider ECMO with mortality >50%:P/F ratio < 150 on Fio2 >90% Murray score 2-3. Do it for Mortality >80%: P/F ratio <100 on Fio2 >90% with Murray score 3-4. CO 2 retention on mechanical ventilation despite high Pplat (>30 cm H 2 O) Severe air leak syndromes Need for intubation in a patient on lung transplant list

21. ECMO contraindications Mechanical ventilation at high settings (FiO2 >.9, P-plat >30) for7 days or more. Conditions incompatible with normal life if the patient recovers . P reexisting conditions which affect the quality of life (CNS status, end stage malignancy, risk of systemic bleeding with anticoagulation ) . A ge and size of patient Futility ELSO Guidelines August 2017

22. How early?

23. Circuit Type Heart support V-A BF (60 ml/kg/min) Lung support V-V/V - A

24. How would you ventilate? ELSO: Lung rest: Low rate with long inspiratory time, low plateau inspiratory pressure (< 25 cm H2O) low FiO2 (under 30%) APRV and CPAP are other acceptable options. First 24-48 hours: PC 25/15 I:E 2:1 Rate 5 Fio2 50% Pplt <25 PEEP as high s tolerated! After 48 hours PC 20/10 Plus spontaneous breaths Fio2 20-40% ELSO Guidelines August 2017

25. Recruitment maneuvers? No. Till CXR improves and Vt > 4cc/kg and Cilley test is positive. Cilley test is increase Fio2 to 100% and watch for how fast Spo2 changes. Positive = Fast. How to do it? CPAP of 25cmH2o, or PSV 25/10, Rate 5, I:E 3:1 10min/ hr

26. O2 Sat? Spo2 around 80% Giving Normal heart function and Hematocrit > 40% Fio2 <40% on vent

27. PEEP? A multicenter randomized controlled trial of 767 adults