Ecmo ( extracorporeal membrane oxygenation )

A BRIEF ACCOUNT ON THE ECMO MODES , USES, INDICATIONS

1. ECMO ( Extracorporeal Membrane Oxygenation ) Chairperson - DR VENKATAMURTY Moderator - DR PAVAN Presenter - DR HARSHAVARDHAN DEPT OF PEDIATRICS –AIMS – SAH & RC

2. Introduction History Modes of ECMO Circuit & components Indications Contraindications Mechanism Complications Outcome

3. introduction Extracorporeal membrane oxygenation (ECMO) is the application of a modified cardiopulmonary bypass for neonates in cardiac or respiratory failure not responding to conventional measures or treatments. The term extracorporeal membrane oxygenation (ECMO) has generally been replaced by ECLS – extracorporeal life support , reflecting an expanded role beyond oxygenation . ECMO has been offered to 35,000 neonates worldwide till date.

4. ECMO - A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. In simple words it is called a ~ HEART - LUNG MACHINE ~ SOURCE : ECMO guidelines Alfred Health Update nov 2015

5. Hi s t o r y of E CMO…. John H e y sha m Gi bbo n Jr - 1953 J ef f e r so n Medi c al Co lle g e Hospi t al (Ph iladel p hia) F i r s t succe s s fu l us e of Ca r d i opu lm o na r y b ypass

6. 1972 - D r J Dona ld H i ll San F r ans i s c o (CA) F i r s t succes s fu l adu l t E CMO 24/M - P o lyt r auma with ARDS

7. 1975 - R ober t Bart l e t t ELSO LOGO – elso estb . In 1989

8. Extra corporeal Life Support is achieved by - Draining venous blood - Removing CO2 - Adding oxygen - Returning to circulation - Through either a vein or artery

9. Modes of ecmo ECMO can be categorized according to the circuit used – Veno -arterial - VA ECMO provides both gas exchange and circulatory support (Heart & Lung failure) – Veno -venous –VA ECMO allows gas exchange only (Isolated Lung failure)

10. 25 25 Di f f e r e n t C ON F I G U R A T I ON S in E CMO Mo s t c ommo n c o n f ig u r a ti o n s: V en o - V eno u s E CMO ( V V - E CM O ): Us ed t o supp ort p a ti e n ts with s e v e r e r esp i r a t o r y f ail u r e r e f r ac t o r y t o c o nv e n ti ona l the r api e s Bl o o d is d r a wn f r o m a c e n t r al v ei n , p a s s ed th r oug h an E CMO m a c h i n e an d then r e turned ba c k via a c e n t r al v ein . V en o -Ar t er i al E CMO ( V A - E CMO): Us ed t o supp ort p a ti e n ts with s e v e r e c a r d i ac f ail u r e (w ith or with o ut r esp i r a t o r y f ail u r e) Bl o o d is d r a wn f r o m a c e n t r al v ei n , pas s th r oug h an E CM O ma c h i n e and then r et u rne d b a ck via a c e n t r al a r t e r y . E CM O gu i de l ine s Al fredHea lth Upda t e n o v 2015

11. Ar t er i o - V eno u s E CMO ( A V E CM O ) : An ar t er io v enous ( A V ) e x t r a c orpo r eal ci r cuit th a t use s the p a tie n t ’ s ow n ar t er i al p r essu r e o r i n c orpo r at es a pum p t o dr i v e bloo d a c r os s an o x y g en at o r c an part ia l l y suppor t the r esp i r at o r y s y s t em b y ef f ecti v ely r em o v in g c arbon di o x i d e ( C O2 ) ( e xt r a c or p o r eal C O 2 r em o v al [ E C C O2 R]). E CM O gu i de l ine s Al fredHea lth Upda t e n o v 2015

12. ECMO serves as a BRIDGING THERAPY and not a curative therapy. Used as a - bridge to recovery :– i.e., buying time for patient to recover - bridge to decision :- provide temporary support to patient and allow clinicians to decide on the next step. - bridge to transplant :- provide support to patient while awaiting suitable donor organ.

13. E C M O C I R C U I T & C O M P ON E N T S Th e bas ic c ompone n ts o f E CMO ci r cu it i n clu des - a b l oo d pump - memb r ane o x y g en at o r & he a t e x chan g er - c o n t r o ll er - c annu l as - tu b i n gs

14. F RO M THIS TO THIS

15. CEN T RIFUGAL PUM P S : R o l ler p u m p s a r e n o w be i ng r ep l a c ed b y ce n tr ifu g al pum p s. Th e perfusio n p r essu r e i s c o n t r o l led b y R PM ( -4000 RPM) Ca n del i v er f l o w u p t o 8 L/m in V ery r eliable u p t o 21 d a y s.

16. M e m b r an e O x y g en a t o r : E CM O c i r cuits h a v e a g as e x chan g e d e v i ce c al l ed o x y g en a t o r , t o a d d O x y g en and r em o v e C O 2 f r o m blood.

17. P r e v i ous l y , s i l i c o n me m b r ane o x y g en a t o r s w e r e u se d wh ich a r e b ei n g r ep l a c ed b y Ho l l o w f i b r e PM P ( pol y m e t h yl pe n t ene) me m b r ane o x y g en a t o r s. Thes e a r e e x t r eme l y e f f ic i e n t a t g as e x chan g e and demon s t r at e m i n imal p lasma l e a k a g e, l o w r es i s t ance t o b l oo d f l o w .

18. G A S E X C HA N G E : O X Y GEN e x chan g e depends on : T y p e o f memb r ane & d i f fus i on cha r ac t er i s t i cs Th ickness o f the b l oo d p a t h w a y Sur f a c e a r ea o f the memb r ane F i O 2 in the g as phase R a t e o f b l oo d f l o w C O2 e x chan g e depends on : D i f f e r ence i n C O 2 c onc . b e t w een b l oo d and g as S i z e o f mem b r ane F r esh g as f l o w Bl oo d p a t h w a y thi ck n ess Bl oo d f l o w r at e

19. H E A T E X C HA N G E R : In adul t s , i t i s us u all y bu i l t with i n the o x y g en a t o r . In paedi a tr i c c ases, i t i s c on n ec t ed se p a r at e l y a f t er the o x y g en at o r i n the ci r cuit. It i s use d f o r t empe r a tu r e r egul a ti o n o f the e x t r a c orpo r eal blood.

20. Co n t r o ll er pane l f o r p r essu r e mon i t orin g and b l oo d g as mo n i t or i n g

21. V E N O - V E N O U S E C M O ( V V E C M O ) V enous bloo d i s a c c essed f r o m l a r g e ce n t r al v ei n s , pu m pe d th r ough the o x y g en a t o r and r e tur n ed t o the v enous s y s t em nea r r i g h t a tr ium. The r e a r e 4 c o n f ig u r a ti o n s o f VV - E CM O depend i n g o n the c annu l a ti on s i t es. F emo r o- f emo r al hi gh f l o w f emo r o - jugu lar dou b l e l u men s i n gle c anu l a ( A v al on) E CM O gu i de l i ne s Al fre d Health Upda t e n o v 2015

22. F e m o r o - F e m o r a l : Access c ann u l a i s i nser t ed v i a the f emo r al v ein with the tip s i t ed with i n the IVC . R e tu r n c ann u l a i s i nser t ed v i a c o n t r al a t e r al f emo r al v ein with the t i p i n r i g h t a tr ium. Ad v a n t a g es : qu i ck and s a f e t o i nser t, ea s y t o secu r e c ann u l a e . D isad v a n t a g es : l i m i t ed m a x im u m f l o w r at es, of t en r equ i r es c o n v e r s i o n t o a hi gh f l o w c o n f ig u r a ti o n .

23. H i g h F l o w : U s es the sam e b i - f emo r al c annu l a ti o n . An addi ti ona l shor t a c c e s s c annula i s i nser t ed via the rig h t i n t ernal jugu l ar v ei n with tip i n s v c. Ad v a n t a g es : all o w s h ig h er ci r cuit blood f l o w s a s th e y d r a w b l oo d f r o m the g r e a t v ei n s ( sv c & i v c). - It i s r equ i r ed i n s e v e r e c ases of r esp i r at o r y f ail u r e when s i n gle a c cess c anu la ci r cu it f l o w i s i n adeq uat e t o mai nt ain su f f ic i e n t l e v els o f g as e x chan g e.

24. D i sad v a n t a g es : -oc c up i es 3 v ei n s. r el a ti v ely c omp l e x t o se c u r e and d r ess the jugu lar c annu l a. p a tie n t r ema i n s be d bou n d. po t e n tial sou r ce o f a i r embo li s m and p r essu r e i n jur y . E CM O gu i de l ine s Al fredHea lth Upda t e n o v 2015

25. F e m o r o - J u g u l a r : A c cess c annu l a – v i a f emo r al v e i n with tip s i t ed ju s t be l o w the i n f eri or c a v o - a tr i al junct i on. R e turn c annula – i n t o r i g h t i n t ernal jugu l ar v ei n with the tip in l o w er SVC . Ad v a n t a g e s : nearl y c an p r o v ide adequ at e suppor t ( 5 -7 l / m i n ).

26. D i sad v a n t a g es : r el a ti v ely c omp l e x t o se c u r e and d r ess the jugu lar c annu l a. r equ i r es t w o s t er i l e f i el d s t o b e don e du r i n g E CMO c ann u l a t i on . a c cess i ns u f f ic i ency c an b e mo r e di f ficu l t t o i de n ti fy i n early st a g es w i t h ou t ne g a ti v e p r essu r e mon i t or i n g. E CM O gu i de l ine s Al fredHea lth Upda t e n o v 2015

27. D o u b l e l u m e n / T w o s t a g e s i n g l e c an nu l a ( Av a l o n ) : S i n gle c annu l a with t w o l umen s f or a c cess a n d r e turn i n ser t ed v i a the r i g h t i n t ernal jugu lar v ei n . Ad v a n t a g es : s i ngl e v e i n c annu l a ti o n . All o w s m o v eme n t f r o m be d a n d ambu l a ti o n . D i sad v a n t a g es : c a r e o n i nser t i o n t o a v o id r i g h t v e n tr i cular pl a c eme n t/ru p tu r e. D i f ficu l t t o posi ti o n r e turn por t t o w a r d s the tr i cusp i d v al v e.

28. V E N O - A R T E R IA L E C M O ( V A - E C M O ) V eno u s b l oo d i s ac c essed f r o m the l a r g e ce n t r al v e ins , p u mp ed th r ough o x y g en at o r and r e tur n ed t o the s y s t emi c ar t er i al s y s t em i n the aor t a. It p r o v ide s su p por t f o r s e v e r e c a r di ac f ail u r e with o r without asso c i a t ed r es p i r at o r y f ai l u r e. D i f f e r e n t c o n f i g u r a ti o n s of V A E CMO a r e : - st anda r d F emo r o- F emo r al - eme r g ency F emo r o - F emo r al -Hi gh F l o w -Ce n t r al : spec ia l i s e d c annu l a -Ce n t r al : B y p ass c ann u l a

29. S t a nd a r d F e m o r o - F e m o r a l : Access c ann u l a i s i nser t ed v i a f emo r al v e i n with tip i n r i g h t a tr ium. R e turn c annu l a : v i a c ommo n f emo r al ar t ery with t i p l y i n g in c ommo n i l i ac ar t ery or l o w er aor t a. Ad v a n t a g es : p r o v ide s fu l l o r part i al c a r di ac su p port. D i sad v a n t a g es : r i s k o f d i f f e r e n t i al h y p o x i a – m a y nee d c o n v e r s i o n t o h igh f l o w c o n f ig u r a ti o n i f n a ti v e c a r di ac funct i on i m p r o v es i n the s e t ti n g o f s ign i f i c a n t r es p i r at o r y f ai l u r e.

30. E m e r g en c y F e m o r o - F e m o r a l : S i m i lar t o st anda r d f emo r o - f emo r al b u t us e s SMALLER c ann u l a wh ich a r e q ui c k er t o i nser t i n an eme r g enc y . S t anda r d c annu l a : 2 1 -2 5 Fr Eme r g ency c annu l a : 19 -2 1 Fr Ad v a n t a g es : f a s t er t o i nser t. Used f o r E CM O -CPR o r i n peri -ar r e s t p a tie n ts. D isad v a n t a g es : r is k o f d i f f e r e n tial h y p o x ia. E CM O gu i de l ine s Al fredHea lth Upda t e n o v 2015

31. H i g h F l o w : Uses the sam e b i - f emo r al c ann u l a t i o n with add i t i ona l ac c ess c annu l a i n ser t ed v i a the r i g h t i n t ernal jugu lar v ein with tip i n s v c. Ad v a n t a g es : us e d t o min i m i s e di f f e r e n tial h y p o x ia when n a ti v e c a r di ac funct i o n i m p r o v es.

32. T U B I N G S : Depe n din g o n the hepari n c o a ti n g , th e y a r e o f 2 ty p es : - r egular - hepari n c o at ed

33. INDICATIONS ECLS primarily used for critically ill term & late preterm newborns with reversible respiratory/cardiac failure who have failed appropriate maximum medical management with ventilatory support ( conventional/high frequency),volume expansion,inotropic /vasopressor support.

34. indications Meconium aspiration syndrome Congenital diaphragmatic hernia Respiratory distress syndrome Persistent pulmonary HTN of newborn Sepsis Pneumonia Barotrauma ( air leak syndromes ) Perinatal asphyxia - Supportive in – cardiac failure owing to CHD, Post cardiotomy heart failure, cardiomyopathy.

35. Weight > 1.6 - 1.8kg, gestational age >32 -34 weeks. The cannula size is determined by infants wt. A. Respiratory failure. The indications for neonatal ECMO are ( i ) reversible respiratory failure and (ii) a predicted mortality with conventional therapy great enough to warrant the risks of ECMO. ECMO is also considered in patients with life-threatening air leaks not manageable with optimal ventilatory support and chest drainage.

36. Oxygenation index (OI) is a measure of the severity of respiratory failure and is calculated as follows: OI = mean airway pressure (MAP) × FiO2/PaO2 × 100 . It is essential to document OIs from serial blood gases over time because the OI may vary. ECMO indications vary among different centers . Commonly used criteria include two OIs of >40 within 1 hour, one OI of 60 on high-frequency ventilation, or one OI of 40 combined with cardiovascular instability .

37. For infants hospitalized where ECMO is not available, an OI of 20 should prompt early outreach to an ECMO center for potential transfer because prolonged ventilation at high ventilator settings may worsen ventilator-induced lung injury and worsen the overall outcome.

38. Total anomalous pulmonary venous return (TAPVR) may mimic neonatal respiratory distress syndrome (RDS), resulting from lung congestion in the setting of inadequate drainage of the pulmonary veins in the left atrium. In any neonate with respiratory failure, hypoxia, and bilateral opacities on chest radiograph, TAPVR should be excluded prior to initiating ECMO support. Once veno -arterial ECMO support is initiated, pulmonary blood flow is reduced and the diagnosis of TAPVR may be difficult to make using echocardiography alone; these patients may require cardiac catheterization on ECMO to demonstrate presence or absence of pulmonary veins entering the left atrium .

39. B. Cardiac failure. ECMO provides biventricular support for neonates with cardiac failure. General indications are low cardiac output (CO) despite maximal hemodynamic support or cardiac arrest with a potentially reversible underlying condition. ECMO for congenital heart defects can be offered as a bridge to definitive treatment until the newborn's condition has stabilized. Other cardiac indications are failure to wean from cardiopulmonary bypass, cardiomyopathy, and pulmonary hypertension .

40. C. Rapid-response ECMO (ECMO-cardiopulmonary resuscitation [E-CPR] . In the setting of a witnessed cardiorespiratory arrest, ECMO can be offered in centers with a rapid response team. A readily “clear-primed circuit” (an ECMO circuit primed with normal saline rather than with blood products) and an ECMO team must be available 24 hours per day in order to offer E-CPR. Effective cardiopulmonary resuscitation (CPR) before cannulation is essential for a favorable outcome during rapid-response ECMO.

41. D. Ex utero intrapartum treatment (EXIT) to ECMO procedure . The vessels are cannulated during a cesarean section while the newborn remains on placental support. Indications include severe congenital diaphragmatic hernia (CDH), lung tumours, and airway obstructing lesions such as large neck masses and mediastinal tumours .

42. ECMO in c lu s io n cr i ter i a - Murray sc o re = a v era g e s c or e o f al l 4 par a meters P a ra m e t e r / Score 1 2 3 4 P a O 2 /Fi O 2 ≥3 0mmHg 225 - 299 175 - 224 100 - 174 <100 (On 100 % Ox y g e n) ≥4 kPa 30 - 40 23 - 30 13 - 23 <13 CXR n o rm a l 1 po i nt p e r q u a d ra n t i n f i l t ra t ed PEEP( c m H 2 O) ≤5 6 -8 9 - 11 12 - 14 ≥15 Com p li a n c e (m l / c m H 2 O) ≥80 60 - 79 40 - 59 20 - 39 ≤19

43. Contraindications. ECMO should only be offered for reversible conditions. Contraindications are considered to be lethal – Chromosomal disorder (including trisomies 13 and 18 but not 21) Irreversible brain damage, Grade 3 or greater Intraventricular hemorrhage (IVH) Intraparenchymal hemorrhage .

44. E x cl us i o n Cr i t eria P r ima r y d i seas e is i r r e v e r s i b le (d i ssem i n a t ed ma l ignancy) O n v e n til a t o r >1 5 d a y s Ir r e v e r s i b l e / i nd e t ermi n a t e neu r o l og i c al p r ogn o s is A n y i m m unosup r essed s t a t e Al r eady in mu l ti o r g an f ai l u r e P r e - e x i s ti n g c oagu l op a t h y S e v e r e pu lmona ry h yper t ens ion S e v e r e aorti c r egu r gi t a ti on Gestational age <32 weeks & b.wt <1600 gms . - IVH - severe coagulopathy, - progressive chronic lung disease

45. E C M O M E C H A N I S M It i nc l u de s : - INITI A TION - MAINTENANCE - DIS C O N T I N U A T I ON

46. INIT I A TION Onc e i t ha s bee n decide d t o i n i t i at e E CM O , the p a t i e n t i s a n t i c oagu l a t ed with i / v hepari n and c annu l ae a r e i n s er t ed a c c o r din g t o t h e E CMO c o n f ig u r a ti o n ( V V o r V A E CMO) F o l lowi n g c ann u l a t i on , p a t i e n t i s c on n ec t ed t o E CM O ci r cu it, the pump s t ar t ed with the f l o w o f 20 ml /k g /m in and g r adual l y i n c r eased e v ery 5 - 10 min b y 10 ml /k g /m in t o r each the desi r ed f l o w . Gas f l o w t o b l oo d f l o w r a tio i s adju s t ed t o 0.5 : 1 & st art with F i O 2 of 21%  100% F i O 2. Onc e desi r ed f l o w a c hi e v ed, v e n ti l at o r s e t ti n gs a r e b r oug h t d o wn t o bas e l i ne. S OU R C E : E CM O U P T O D A T E 201 5

47. Saline priming - Patients who are placed on ECMO emergently can be started on a saline-primed circuit. Instead of blood products, the circuit is primed with NS . In centers with rapid-response ECMO, a saline primed, sterile circuit is always available, minimizing the time to initiate ECMO therapy. The neonate's own blood volume is initially diluted with the normal saline from the ECMO circuit. This causes a drop in hematocrit and a transient decrease in oxygen-carrying capacity. The hematocrit is later restored by using ultrafiltration and transfusing packed red blood cells (PRBCs)

48. Blood priming. Patients who are placed on ECMO nonemergently are started on a blood-primed circuit. Orders for the initial prime of a neonatal circuit are as follows: 500 mL of PRBC (cytomegalovirus [CMV] negative, <7 days old), 200 mL of fresh frozen plasma (FFP), 2 units of cryoprecipitate, and 2 units of platelets (not concentrated). Heparin and Tris-hydroxymethyl-aminomethane (THAM, also “Tris”) buffer and calcium gluconate are added to the circuit .

49. R easonab l e t a r g e ts a r e : - an ar t erial o x y H b s a tu r a ti o n o f- >90% f o r V A E CM O , >75% f o r V V E CMO - A v enous o x y H b s a tu r a ti o n o f 70- 80% f o r V A E CMO - Adequ at e ti ssu e perfus i o n as d e t ermi ne d b y ar t erial b l oo d p r essu r e, v enous o x y g en s a tu r a ti o n and bloo d l ac t at e l e v el . ECMO therapy - ECMO pump flow rate is generally 100 to 120 mL/kg/minute in newborns . Sweep gas flow rate is 1.0 to 2.5 L/minute for a 0.8 m2 and 1.0 to 4.5 L/minute for 1.5 m2 membrane.

50. A safety check is conducted every 4 hours. This safety check includes searching for blood clots and circuit inspection for leaks. Normothermia is maintained and temperature is regulated by adjustments in the heat exchanger water temperature. schedule for laboratory studies : ( i ) activated clotting time hourly (ii) lactate levels twice daily (iii) complete blood count, platelets, whole blood electrolytes, ionized calcium, and creatinine twice daily

51. (iv) antithrombin III (AT III) twice daily and prior to FFP administration and 3 hours post-FFP administration (v) liver function tests, alkaline phosphatase, lactate dehydrogenase (LDH), bilirubin, albumin, pre-albumin, and total protein every week .

52. M A I N T E N A N C E & M O N I T O R I N G : Onc e the i n i t i al r esp i r at o r y and hemodynam ic g oa ls h a v e bee n a c hi e v ed, bloo d f l o w i s m a i n t ai ne d a t th a t r at e. Co n ti n uou s v enous o xym e tr y , P r essu r e mon i t or i n g (MA P , p r epu m p P , p r e and po s t o x y g en a t o r P), v i t al pa r am e t e r s (HR , R R , TEMP) , F l o w r at es (b l oo d f l o w r at e a t 6 -150 m l/k g /m i n ) , neu r o l og i c al s t a tus, v as c ul ar s t a tus t o b e mon i t o r ed. A n ti c oa g ul a ti o n i s su st ai ne d du r i n g E CM O w i th a c o n ti n uou s i n fus i o n of u n f r acti on a t ed he p ar in , t it r at ed wi t h acti v at ed cl o t t i n g t i me( A C T ) o f 18 - 210 sec.

53. W E AN I N G & TR I A L O F F O F E C M O INDIC A TION S : - F o r p a tie n ts with R espi r at o r y f ai l u r e, i mp r o v eme n ts i n r adi o g r aphic appea r ance, p u l m onar y c ompl i a n ce and ar t er i al o xy H b s a tu r a t i on. - With c a r d iac f ai l u r e, enhanced a ortic pu l s a ti l i ty c or r el a t es with i m p r o v ed l e f t v e n tr i cular outp u t. - On e o r mo r e tri al s o f t aki n g the p a ti e n t o f f o f E CM O shoul d be per f orme d pr i o r t o d i s c o n ti n u i n g E CM O permane n tl y . S OU R C E : ELS O General Gu i de li ne s V ers io n 1.3 De c ember 2 1 5

54. De c r ease f l ow in st e p s t o 1 L/m in a t F i O 2 1 % or de c r ease f l ow t o 2L / min then dec r ease sweep gas F i O 2 t o mai nt ain SaO 2 >9 5 % When SaO 2 st abl e o n these s e t ti ngs, VV E CMO trials a r e p er f orme d b y e limi n a ti n g all c ou n t e r cur r e n t s w e e p g as th r ou g h o x yg en at o r . Bl o o d f l ow r em a i n s c on st a n t, bu t g as t r an s f er doesn ot occu r . V e n til a t or s e t ti ng s a r e adju s t ed. V A E CMO trials ne e d t em po r a r y clamp in g o f bot h d r ai na g e and i n fus i o n li nes , whil e all o wi n g t o ci r cul a t e th r ou g h a br i d g e bet w e e n the ar t e r ial and v enous li mb s. - V A E CM O trials a r e g en e r all y sh or t er du r a ti on than VV E CM O trials be c ause o f h i g her r i s k o f th r omb u s f orm a ti o n . S OU R C E : ELS O General Gu i de li ne s V ers io n 1.3 De c ember 2 1 5

55. SPECIAL SITUATIONS DURING EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT ECMO-circuit change ( change in premembrane pressure, extensive thrombosed/clotted circuit) Lung biopsy ( If pulmonary function does not improve after a prolonged period (usually 1 to 2 weeks of ECMO support), a lung biopsy can be performed through a thoracotomy Left-sided heart failure and left atrial decompression ( If left ventricular contractility is severely impaired, increase in both left ventricular end-diastolic pressure and left atrial pressures - significant pulmonary edema from left atrial hypertension and to intravascular and intracardiac thrombosis secondary to stasis. LA-decompressed (“vented”) into the venous side of the ECMO circuit.

56. C O M P L I C A T I O N S Mechanical causes Systemic causes Blee d i n g Th r omboe m bo l i s m Hepari n i n duce d th r omboc y t open i a (HIT) VV E CM O sp e ci f i c c ompl i c a t i ons V A E CM O spec i f ic c omp l i c a ti o n s Ne u r o l og i c al c omp l i c a ti o n s

57. Mechanical causes include clots in the circuit (most common in oxygenator, bladder, and bridge) cannula problems oxygenator failure air in the circuit Causes for poor venous return from the patient to the ECMO circuit include hypovolemia, pneumothorax. Poor catheter position, small venous catheter diameter, excessive catheter length, kinked tubing, and insufficient hydrostatic column length

58. Cardiovascular - Hemodynamic instability during ECMO may be a result of hypovolemia,vasodilation during septic inflammatory response,arrhythmias , and pulmonary embolism, Volume overload. Renal - Renal failure may warrant dialysis, whereas fluid overload may require hemofiltration during the ECMO run Neurologic - Sequelae resulting in neurologic damage often originate from acidosis and hypoxia before commencement of ECMO - Intracranial haemorrhage (most common)

59. BLE E DIN G : Occu r s i n 30- 40% o f p a tie n ts o n E CMO Du e t o c o n ti n uou s hepari n i n fus i o n and pl at el e t d y s fu n cti on. T r e a tme n t : -mai nt ai n i n g pl at el e t c ou n t > 1 l akh/m m 3, t a r g e t A C T r educes the r is k o f b lee d i n g. su r gi c al e xp l o r a t i o n if major b l e e d i n g oc c u r s. i f b l eed i n g oc c u r s , dec r ease hepar i n i n fus i o n & mai n t ain A C T a t 160 sec. p l asmino g en i n h i b i t o r s c an b e gi v en b u t m a y i nc r ease r is k of ci r cuit th r ombos i s.

60. T H R O M B O E M B O L I S M : It i s mo r e c ommo n with V A E CMO than V V E CM O a s i n fus i o n i s i n t o s y s t emi c ci r cul a ti o n . A su d de n chan g e i n p r essu r e g r adie n t i n di cat es th r ombus f orm a ti o n .

61. C A N N U L A T I O N RE L A T E D : V essel per f o r a ti o n with haemor r h a g e. Ar t er i al dissect i on Blee d i n g Di s t al ischemia i n V A E CMO - T r e a tme n t : i n sertin g di st al perfusio n c annu l a i n f emo r al ar t ery d i s t al t o E CM O c annu l a.

62. H E P AR I N I ND U C E D T H R O M B O C Y T O PE N I A HI T c an o c cur i n p a tie n ts r eceiv i n g E CM O . When HI T i s p r o v en, hepari n i n fus i o n shou l d b e r ep l a c ed b y no n -he p ar i n a n t i c oagu la n t. - If heparin induced thrombocytopenia (HIT) is confirmed, argatroban , a synthetic direct thrombin inhibitor, can be used as an alternative anticoagulant during ECMO .

63. V V E C M O S P E C I F I C C O M P LI C A T I ON S R E CI R CUL A TIO N : - He r e, r ei n fuse d bloo d i s w i t h d r a wn th r oug h the d r ai na g e c annu l a without passin g th r oug h the s y s t emi c ci r cul a ti o n . Th e deg r ee o f r eci r cu l a t i o n d et er m i n es the e f f i cie n cy o f E CM O in p r o v idin g o x y g en a ti o n . I NTE R VENTION : Inc r easi n g the d i s t ance b e t w een c ann u l ae Use of s i n gle s i t e doubl e l u men c annu l a Add i ti o n o f a nothe r d r ai na g e c annu l a S O U R C E : ELS O g u i de l i ne s f o r mana g e m e n t o f r eci r c u l a ti o n M a y 20 1 5

64. V A E C M O spe c ifi c c o m p l i c a tio n s P u l m onar y haemor r h a g e Ca r di ac th r ombosi s - r e t r og r ade bloo d f l o w i n the as c end i n g aor t a i n V A E CM O . - st asis o f b l oo d c an oc c u r if l e f t v e n tr i cu l ar out p u t i s no t mai n t ai n ed l ead i n g t o th r ombos i s. Co r ona r y or ce r eb r al h y p o x i a - c o r ona r y us u all y g e ts bloo d f r o m n a ti v e c i r cul a ti o n (f r o m L V) - W i th c omp r om i se d L V & L UNGS, r el a ti v ely h y p o x ic perfusion oc c u r s.

65. T H E H A R L E Q U I N S Y N D R O M E ( n o r t h so u t h s y nd r o m e ) S a tu r a ti o n o f u ppe r par t o f the bod y i s l o w er than th a t o f l o w er ha l f . Th i s i s d ue t o f l o w c omp e t i t i o n in the a or t a – r e c o v er in g hear t v s E CM O pump H i gh c a r di ac outp u t f r o m n a ti v e r e c o v er in g hear t p r e v e n ts the r e t r og r ade f l o w o f E CM O t o perf u s e u p pe r part. If p ulmona r y fu n cti o n i s i mpa i r ed : -”B L UE H E AD” : deoxygenated blood of upper part -”R ED L E G S ” : h ype r o x y g en at ed b l oo d t o l o w er par t

66. In cas e of re s pira t ory f a i l ur e , flow c ompe t ition in t h e a or t a b e t w ee n the re c o v erin g n a ti v e h e art and the e x tr a corpor e al circuit can le a d to a “ H a rlequin” or “Nor t h – South” s y ndro m e. Christop he r Lotz et al . Circulatio n . 201 4 ; 130 : 109 5 -1 10 4 Cop y righ t © A merica n Hear t Ass ocia t i on, Inc. A l l righ ts re s er v ed.

67. OUTCOME Survival - The ECLS database has reported the outcomes of ECMO therapies worldwide since 1985. A total of 28,271 ECMO runs (84% survival) for neonatal respiratory support were reported for neonatal respiratory disorders through July 2015 . For the most recently recorded year, the most common indication for ECMO therapy was CDH , followed by persistent pulmonary hypertension of the newborn (PPHN), meconium aspiration syndrome (MAS), sepsis, and neonatal RDS . Survival rates for these conditions at 7 years of age after completion of the UK Collaborative ECMO trial was 33% in the ECMO group and 59% in the conventional group

68. ECLS CENTERS There are 620 ECMO Centers in the world right now according to ECLS REGISTRY 2017. and in INDIA total of 8 ECMO centers are available 1. Fortis –Bangalore 2. Narayana institute of cardiac sciences-Bangalore 3. Manipal –Bangalore 4. Apollo hospitals- Chennai 5. KIMS –Hyderabad 6. Max Superspeciality - New delhi 7. Dayanand medical college- Ludhiana 8. Riddhi Vinayak hospitals -Mumbai

69. References- Tricia lacy Gomella – neonatology Cloherty manual of neonatology ELSO Guidelines 2015

70. Thank you