ECMO.pptx

Brief description of ECMO sitting in CCL and type of ECMO and selection criteria.

1. Muhammad Naveed Saeed BSc. RCIS. Cardiac Cath Lab Hamad Medical Corporation. Heart Hospital

2. Extracorporeal Membrane Oxygenation (ECMO): Indications and Management Strategy Muhammad Naveed Saeed BSc. RCIS. Cardiac Cath Lab Hamad Medical Corporation. Heart Hospital

3. OBJECTIVES Understand the clinical indications for ECMO therapy Identify procedural strategies and techniques of ECMO therapy Discuss management strategy of ECMO in the ICU Brief about the ECMO experience at Heart Hospital

4. PHYSIOLOGY of ECMO Basic principle : De-saturated blood is drained via a venous cannula, CO2 is removed, O2 added through an “extracorporeal” device (an oxygenator), and the blood is then returned to systemic circulation via another vein (VV ECMO) or artery (VA ECMO)

5. TYPES OF ECMO: Veno -arterial bypass - supports the heart and lungs Veno -venous bypass – supports the lungs only

6. VV ECMO Perfusate blood returned to systemic circulation via venous cannula – travels into right ventricle and next pulmonary vasculature and is returned to the systemic circulation Volume removed = volume returned; therefore no net effect on CVP, ventricular filling, or hemodynamics CO2/O2 content in arterial blood supply is that of the blood arriving to right ventricle + any effects from gas exchange from remaining pulmonary function

7. VA ECMO Replaces/augments both pulmonary and cardiac function Perfusate mixes in the aorta with blood from left ventricle (arriving from compromised lungs); thus O2/CO2 content = content of blood returning from the circuit + that of pulmonary source; Systemic blood flow = ECMO flow + pt’s own CO

8. Role of ECMO in Cardiogenic Shock Bridge to recovery (BTR) Bridge to decision (BTD) Bridge to surgery Bridge to long-term VAD Bridge to transplant (BTT)

9. IABP in Cardiogenic Shock Can initially stabilize patient May not provide enough support Requires a certain level of LV function Limited by persistent tachycardia / arrhythmias Does not unload the RV Provides some pulsatile flow with ECMO

10. BRIDGE TO RECOVERY Indications Acute MI Acute decompensated HF Post- cardiotomy syndrome Acute myocarditis Severe rejection in transplant Takotsubo’s Massive PE Respiratory failure and ARDS

11. BRIDGE TO SURGERY Indications Mechanical complications of AMI VSD Severe MR from papillary muscle rupture CAD requiring CABG Massive PE with heparin failure

12. BRIDGE TO Long-term VAD Indications Unable to wean off ECMO Difficult donor match for transplant Not a transplant candidate => LVAD as Destination Therapy

13. BRIDGE TO TRANSPLANT Indications Unable to wean off ECMO Transplant candidate Easy donor match for transplant

14. Predictors of Poor Outcomes Multiorgan dysfunction ARDS with sepsis Severe neurological injury Long time interval between shock and initiating ECMO

15. How long does ECMO last? Advances in life-support technologies and expertise are making it possible for patients to remain on ECMO for much longer.

16. VA Advantages & Disadvantages Easy to use Circulatory support Instant stabilisation Huge experience Right heart offloaded and rested Carotid ligation Jugular ligation Raised LV afterload Reduced pulmonary blood flow Hypoxic coronary perfusion Stun- high LV afterload Duct

17. CONTRAINDICATIONS Major CNS injury Severe anoxia Embolic or hemorrhagic stroke Intracerebral hemorrhage Multiorgan failure Metastatic disease Overwhelming sepsis

18. Equipment: Cannulas VV ECMO: Jugular vein, femoral vein VA ECMO Vein: femoral Artery: Femoral Axillary Aorta

19. Axillary vs Femoral Cannulation AXILLARY Side-arm graft sewn on Antegrade perfusion better for cerebral and aortic root oxygenation, especially when lungs not oxygenating Increased afterload Risk of arm hyper-perfusion FEMORAL Percutaneous Need antegrade stick for forward perfusion Retrograde perfusion increases atheroembolic risk Ad-mixing with cardiopulmonary circulation => indequate cerebral and aortic root oxygenation if lungs not oxygenating

20. Equipment: Pump, Oxygenator Thoratec Centrimag pump & motor Centrimag console Maquet Quadrox oxygenator

21. ECMO Management

22. Anticoagulation IV Heparin, target ACT of 200-240 seconds to prevent clotting upon interference of blood with prosthetic surfaces and in stagnant areas. If high bleeding risk, ACT 180-220 s Watch for platelet drop and heparin induced thrombocytopenia (HIT)

23. Monitoring an ECMO patient Continuous cerebral SaO2 CVP, PAP, CO CXR – assess pulmonary edema SvO2: 75% in VA ECMO and 85-90% on VV ECMO considered adequate as long as CO normal EtCO2 – measures return of native lung function aBG , lactate – tissue perfusion Urine output, fluid balance – renal function Labs: renal, hepatic function Platelet count

24. POTENTIAL RISKS Infection Bleeding Brain Surgical site Non-pulsatile flow Renal insufficiency Peripheral ischemia Limb complications Arm hyperperfusion Leg ischemia Air in circuit Pump malfunction Clots in the circuits Heat exchanger malfunction Cannula dislodgement

25. Criteria for Weaning ECMO Pulmonary edema resolved Minimal inotropes / pressors End-organ dysfunction nearly recovered

26. ECMO Weaning Protocol ICU ECMO flow down to 1-1.5 L/min for 5 min Assess CVP, PAP, CO TTE to assess LV, RV function OR 3000-5000 U heparin ECMO flow down to 1 L/min Assess CVP, PAP, CO TEE to assess LV, RV function, septal position Explant ECMO if appropriate

27. Past & Next steps for ECMO at Heart Hospital

28. CONCLUSIONS

29. Thank You.